Urinary patho 2014

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Urinary Pathophysiology

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  • Gluconeogenesis during prolonged fasting – as we also saw in ANS modulation.Production of renin to help regulate blood pressureProduction of erythropoietin to stimulate red blood cell production in bone marrow given to CA pts – some studies dispute effectiveness / efficacy.Activation of vitamin D
  • Effects of gravity – huge contribution in collection of urine in the bladderMuscular composition of ureters – smooth muscle.Would urine still collect if we upside-down?
  • The Vas deferens looks like it is running through the bladder … it is not!
  • Change could be increased or decreased urinary frequency.PSA = (prostate specific antigen)
  • Push to increase awareness – as well as checking for PSA markers.
  • Digital Rectal Exam.
  • Begin to appreciate the level of vascularization.
  • Kids are heavily protected!Note the Anterior and posterior renal fascia.
  • Arterial flow in & venous flow out of the kidneys follow similar paths.
  • Is urine sterile?If myoglobin, hemoglobin or red blood cells in urine: red or brown urineIf pus, bacteria, lipids, or alkaline (higher pH): white cloudy urineFoamy urine: excessive protein in urine
  • Women have much shorter urethras. If repeated lwr UTIs – need to re-educate front to back wiping.
  • Lasix – excellent diuretic, cheap – but non-K sparing. Need to educate to increase your K intake.
  • Many other types as well.
  • Urinary patho 2014

    1. 1. The Urinary System
    2. 2.  Kidney functions  Other system organs  General system anatomy  Kidney str & fxn  Nephron – basic fxnal unit of the kidney Overview
    3. 3. Kidney Functions  Filter 200L blood/day to eliminate:  Toxins  Metabolic wastes  Excess ions  Regulate blood volume  ~ 5 L  Regulate chemical makeup of the blood  300 mmoL concentration of solutes (i.e. sodium, potassium, zinc)  Maintain the proper balance between H20 & salts, and acids and bases.
    4. 4. Other Kidney Functions  Gluconeogenesis  Production of renin  Production of erythropoietin  Activation of vitamin D
    5. 5. Other Urinary System Organs  Urinary bladder – provides temp. storage reservoir for urine  Paired ureters – transport urine from the kidneys to the bladder  Urethra – transports urine from the bladder out of the body
    6. 6. Ureters  Slender tubes-carry urine: kidneys to the bladder  Ureters enter the base of the bladder through the posterior wall  As bladder pressure increases (increased urine volume in bladder), distal ends of ureters get closed off & prevent backflow of urine into ureters.  Tri-layered wall  Epithelial mucosa  Smooth muscle  Fibrous connective tissue  Ureters actively propel urine to the bladder via response to smooth muscle stretch
    7. 7. Urinary Bladder  Smooth, collapsible, muscular sac that temporarily stores urine  Lies on the pelvic floor posterior to the pubic symphysis  Males – prostate gland surrounds the neck inferiorly  Females – anterior to the vagina and uterus  Trigone – triangular area outlined by the openings for the ureters and the urethra  Clinically important because infections tend to persist in this region
    8. 8. Urinary Bladder  The bladder wall has three layers  epithelium  muscular layer  fibrous layer  The bladder is distensible & collapses when empty  As urine accumulates, the bladder expands without significant rise in internal pressure
    9. 9. Bladder Cancer  60,000 cases a year in the US  13,000 deaths per year  4 times more likely to occur in men  Most frequently b/w 60-70 yrs of age  Causes ?  Environmental exposures High rates in employees in chemical and rubber plants  Prognosis for metastatic bladder cancer is poor  Spreads to bone, lymphatic system
    10. 10. Tissue engineering: Bladder  Bladder disease  Increased pressure in poorly functioning bladder leads to kidney damage  Reconstruction w/ small intestine tissue  Grow own bladder cells in culture for 7-8 weeks  Attached ‘new bladder’ to old bladder in 7, 4-19 yr old children  2-5 yrs later: improved bladder function in all subjects
    11. 11. Urethra  Muscular tube that:  Drains urine from the bladder  Moves urine out of the body
    12. 12.  Sphincters keep the urethra closed when urine is not being passed  Internal sphincter – involuntary sphincter at the bladder-urethra junction  External sphincter – voluntary sphincter surrounding the urethra as it passes through the urogenital diaphragm  Levator ani muscle – voluntary urethral sphincter
    13. 13.  The female urethra is tightly bound to the anterior vaginal wall  External opening lies anterior to vaginal opening and posterior to the clitoris  The male urethra has 3 named regions:  Prostatic urethra – runs within the prostate gland  Membranous urethra – runs through the urogenital diaphragm  Spongy (penile) urethra – passes through the penis and opens via the external urethral orifice
    14. 14. Prostate Gland Surrounds Urethra
    15. 15. Prostate Gland:  Size of walnut  Surrounds neck of urinary bladder and urethra  Secretes fluid that forms part of semen
    16. 16. Benign Prostate Disorders  Infection  Inflammation  Enlarged prostate  High blood levels of PSA  Impotence  Incontinence and or retention  S&S of prostate disorders  Interference of flow  Change in urinary freq. urination  Pain
    17. 17. Prostate CA  Increased likelihood with enlarged prostate (hypertrophy).  60% of prostate cancers discovered remain localized  5 yr survival = 100%  10 yr survival = 68%  15 yr survival = 52%  In past 20 yrs survival has increased from 67-93%
    18. 18. Other Considerations  PSA check annually after age 50  High risk males should begin screening earlier  Risk factors  Age  Race African Americans are 61% more likely to get prostate CA & 2.5x more likely to die from dx  Diet: high fat / low fiber  Obesity  Environmental exposures
    19. 19. Kidney Location & Structure  Bean-shaped  extends from T-12 to L-3.  R kidney hangs lower than left.  crowded by the liver
    20. 20. Layers of Tissue Support  Renal capsule – fibrous capsule surrounding kidneys that gives support & helps prevent infection  Adipose capsule – fatty mass that cushions the kidney and helps attach it to the body wall  Renal fascia – outer layer of dense fibrous connective tissue that anchors the kidney
    21. 21. Internal Structure of Kidney  Cortex – the light colored, granular superficial region  Medulla – exhibits cone-shaped medullary (renal) pyramids  Pyramids are made up of parallel bundles of urine- collecting tubules  Renal columns are inward extensions of cortical tissue that separate the pyramids  Pyramid plus its surrounding capsule, constitute a lobe
    22. 22. Large blood flow to kidney: ~25% (1200 ml) of BF from heart into systemic circulation, flows through the kidneys per minute.
    23. 23. The Nephron  Nephrons: stral & fxnal units of the kidneys that form urine:  Glomerulus: a capillary bed associated with a renal tubule  Bowman’s capsule: cup-shaped end of a renal tubule that surrounds glomerulus.  Renal corpuscle – the glomerulus and its Bowman’s capsule  Glomerular endothelium –epithelium that allows solute-rich, virtually protein-free filtrate to pass from the blood into the glomerular capsule
    24. 24. Renal Tubule  Proximal convoluted tubule (PCT):  Composed of cuboidal cells with numerous microvilli and mitochondria  Reabsorbs water and solutes from filtrate and secretes substances into it  Loop of Henle: a hairpin-shaped loop of the renal tubule  Distal convoluted tubule (DCT):  cuboidal cells w/o microvilli that function more in secretion than reabsorption
    25. 25. Nephrons  Cortical nephrons – 85% of nephrons; located in the cortex  Juxtamedullary nephrons:  Located at the cortex-medulla jxn  Have loops of Henle that deeply invade the medulla  Have extensive thin segments  Are involved in the production of concentrated urine
    26. 26. Capillary Beds of the Nephron  B/P in the glomerulus is high:  Kidney is very well vascularized  High density of blood vessels  Blood flow within nephron controlled by afferent arteriole  Fluids & solutes are forced out of the blood throughout the entire length of the glomerulus
    27. 27. Characteristics of Normal Urine • Complex watery (95%) solution of organic & inorganic wastes (5%) • Color: pale, straw to amber color – If highly concentrated: •Hematuria / orange color –‘milky’ / turbid : infection • Clarity: transparent • Odor: faintly aromatic; will change to ammonia if standing too long. Some drugs and vegetables (asparagus) alter the usual odor • pH: 5.5 – 7.0 – Will turn alkaline if left standing
    28. 28. Characteristics of Normal Urine  Specific Gravity:  Indicates concentration of urine (# of particles in it)  Normal values = 1.01 – 1.03 Measured by comparing the weight of pure water vs. urine  Urine should not contain:  Albumin  Glucose  Ketones  Blood / Pus / Bacteria  Calculi  Bile
    29. 29. Normal Output  Normal voiding: 250 – 500cc  Normal 24 hour voiding: 1000 - 1500cc  Normal hourly: 30 -120cc  < 30cc / hr may indicate renal pathology
    30. 30. Chemical Composition of Urine  Urine is 95% water and 5% solutes  Nitrogenous wastes include urea, uric acid, and creatinine  Other normal solutes include:  Na+, K+, phosphate, and sulfate ions  Calcium, magnesium, and bicarbonate ions  Abnormally high concentrations of any urinary constituents may indicate pathology
    31. 31. Trauma, Ischemia & Kidney Damage  Ischemia – decreased oxygen supply to nephron because there is decrease in blood flow  Decreased blood flow to nephron which is chronic can lead to Kidney Damage.  Anything that causes afferent arteriole prolonged constriction
    32. 32. Renal Clearance Diagnostic Test  The volume of plasma that is cleared of a particular substance in a given time  Clearance tests are used to:  Determine the GFR  Detect glomerular damage  Follow progress of renal dx
    33. 33. Renal Clearance RCR = UV/P RCR = renal clearance rate U = concentration (mg/ml) of the substance in urine V = flow rate of urine formation (ml/min) P = concentration of the same substance in plasma
    34. 34. Urinary Disorders: S&S  Changes in urinary frequency or volume  Dark urine  Pain with urination  Kidneys unable to regulate body H2O & Na+ balance  Edema (fluid retention) & or High B/P
    35. 35. Urinary Tract Patho  Urinalysis  General health of urinary sys  Drug testing  Proteinuria  Glomerular damage  Ketonuria  Diabetes or starvation  Glucosuria  Diabetes  Solids in urine - sediment examined.  Types of cells: RBCs ; WBCs  Ability of kidneys to concentrate urine  Administer ADH become more concentrated since more fluid should be retained
    36. 36. Urinary Tract Infections  Occurs in any portion of urinary tract  10 - 20% of all women in US have lower UTI at some time  Limited occurrence  Effects of urea (kill bacteria)  Acidic pH of urine  Washing out of bacteria during voiding  Minimize urine reflux
    37. 37.  Cystitis  Bladder inflammation Increased urination  frequency & urgency Pain Cloudy urine Blood in urine  Treatment: ABx thpy
    38. 38. Kidney Infection  Bacterial or viral  Urinary obstruction  causes backflow of urine from bladder to kidneys  From blood infection  Most cases in women  Symptoms  Pain / Fever  Increased urinary frequency  Treatment  Longer use of ABx thpy
    39. 39. Urolithiasis  Presence of stones in the urinary tract  Calculi formed by:  Calcium oxalate  Calcium phosphate  Uric acid  Calculi can pass through the urinary tract and/or cause an obstruction
    40. 40. Urolithiasis  Assessment:  Acute, sharp, intermitte nt pain (ureteral colic)  Dull, tender ache in the flank (renal colic)  N&V, Fever & chills  Hematuria / Pyuria  Abd. Distention  Diagnostic Findings:  KUB: visible calculi  IVP: size & loc of stones  Renal sonogram & Spiral CT scan  Stone Analysis – detection of type of stone
    41. 41.  Non-Surgical Procedures:  Extracorporeal Shock Wave Lithotripsy  Stone dissolution  Laser impulse technology  Surgical Procedures:  Cystoscopy  Ureterolithotomy; Pyelolithotomy; Nephrolithotomy
    42. 42. Polycystic Kidney Disease  Genetic disorder - 500,000 cases in US  Large cysts form in the kidneys  Kidney hypertrophy  Over time, decreasing kidney function as nephrons units are replaced by cysts  Dialysis or transplant  50% with PKD progress to kidney failure (end stage renal disease)  4th leading cause of kidney failure  No cure except kidney transplant
    43. 43. Polycystic Kidney Disease
    44. 44. Acquired Cystic Kidney Disease  From long-term kidney dialysis and end-stage renal disease  90% of people on dialysis for 5 yrs develop ACKD  Cysts may bleed  Increased risk of kidney cancer (very rare)  2 times as likely with ACKD
    45. 45. Diabetic Nephropathy  Diabetes - Abnormally high blood glucose  Causes major problems with blood chemistry including osmotic balance  Kidneys can remove all extra glucose from blood Kidneys must work extra hard to do this  Larger urine volume as kidneys must excrete excess glucose
    46. 46. Diabetic Nephropathy (con’t)  Prolonged high blood glucose causes nephropathy  Damage to the glomerulus and the filtering system  Proteins and blood cells that would normally not be filtered appear in the urine  Kidney function is compromised  Diabetic nephropathy is leading cause of kidney failure in United States
    47. 47. Diuretics  Chemicals that enhance the urinary output include:  Any substance not reabsorbed  Substances that exceed the ability of the renal tubules to reabsorb it At transport max  Substances that inhibit Na+ reabsorption Na+ drives the reabsorption of fluid
    48. 48. Osmotic diuretics include:  High glucose levels H2O carried out w/ glucose  Alcohol inhibits release of ADH  Caffeine and most diuretic drugs inhibit Na+ reabsorption  Lasix  inhibit Na+ associated transporters
    49. 49. Diuretics to Treat Urinary System Dx  Diuretics: increase urine volume  Aldosterone antagonists: block sodium retaining effect of aldosterone More sodium remains in renal tubule  More sodium excreted  Where sodium goes, water goes (increased fluid elimination  Sodium and chloride reabsorption inhibitors (thiazides) block reabsorption of sodium, potassium and chloride  Increased salt and water elimination
    50. 50. Treatment of Renal Failure  Will develop after both kidneys are damaged  Restrict water, salt and protein intake Minimizes volume of urine produced Prevent production of large amount of nitrogenous waste  Hemodialysis  Uses artificial membrane (replaces glomerular filtration) to filter blood. Diffusion of small ions Minimal loss of blood protein  Dialysis fluid K+, phosphate ions, sulfate ions, urea, creatinine, uric acid go into dialysis
    51. 51. Treatment of Renal Failure  Dialysis  15 hrs per week  Dialysis centers  Transplantation  15,000 transplants in 2003  1 yr success rate is 85-95%  Immunosupressive drugs to reduce transplant rejection
    52. 52. Urinary Incontinence – Multiple Etiologies  Normal effect of aging or pathology  Stretching of pelvic floor during childbirth  Incontinence during sneezing and coughing (stress incontinence)  Prostate removal  Neurogenic bladder dysfunction  Treatment  Kegel exercises: tightening pelvic muscles as if trying to stop urination
    53. 53. Did you know?  Infants have small bladders and the kidneys cannot concentrate urine, resulting in frequent micturition  Control of the voluntary urethral sphincter develops with the N System about age 1  E. coli bacteria account for 80% of all urinary tract infections  Sexually transmitted diseases can also inflame the urinary tract and result in urinary tract infections  Kidney function declines with age, with many elderly becoming incontinent

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