PathoPhysiology Chapter 29

1. CHAPTER 29
DISORDERS OF THE LOWER
URINARY TRACT

2. LOWER URINARY TRACT
• Role is to transport urine formed by the
kidneys and allow removal from the body
• Urine movement due to the effect of gravity
and facilitated by peristaltic movement of
the ureters
• Released through the urethra; requires
integrity of ureters and bladder, competent
urethral sphincters, functioning nervous
system

3. LOWER URINARY TRACT (CONT.)
Diagnostic Tests
• Urinalysis: for diagnosis of infection
• Ultrasonography: visualization of the urinary
system
• Fluoroscopic voiding cystourethrography or
radionuclide voiding cystography: used to
identify reflux or urethral abnormalities
• Urodynamic testing: used for diagnosing
voiding dysfunctions

4. LOWER URINARY TRACT (CONT.)
Mechanics of Micturition
• Bladder innervation is supplied by the
sympathetic nerves that exit the spinal cord
at L1 and L2 and allow relaxation and filling
• Stimulation of parasympathetic nerves from
S1-S4 results in bladder contraction and
relaxation of the internal sphincter

5. LOWER URINARY TRACT (CONT.)

6. LOWER URINARY TRACT (CONT.)
Mechanics of Micturition
• The somatic pudendal nerve innervates the
external bladder sphincter
• The sympathetic system innervates blood
vessels via the hypogastric plexus
• Micturition requires central, autonomic, and
peripheral nervous system functioning
• It is a result of parasympathetic and voluntary
motor control

7. VOIDING DYSFUNCTION
• May be secondary to:
• Disorders of the lower urinary tract
• Pathologies affecting the central, autonomic, and
peripheral nervous systems
• A wide variety of factors affecting control of
micturition, including medication and access to
toileting facilities

8. VOIDING DYSFUNCTION (CONT.)
Incontinence
• Urge incontinence: may be idiopathic, due to
bladder infection, radiation therapy, tumors
or stones, or CNS damage
• Stress incontinence: due to weakening of
pelvic muscles or intrinsic urethral sphincter
deficiency
• Mixed incontinence: due to a combination of
stress and urge incontinence

9. VOIDING DYSFUNCTION
(CONT.)
• Neurogenic bladder: broad classification of
voiding dysfunction in which the specific
cause is a pathology that produces a
disruption of nervous communication
governing micturition
• Treatment options for voiding dysfunction are
behavioral, pharmaceutical, and surgical

10. VOIDING DYSFUNCTION
(CONT.)
Enuresis
• Inappropriate wetting of clothing or bedding
• Typically refers to incontinence in children,
particularly at night
• Primary cause is maturational delay
• Treatment: behavioral modification with or
without pharmaceutical intervention

11. CONGENITAL DISORDERS
Vesicoureteral Reflux
• Reflux of urine from the bladder to the ureter
and renal pelvis
• Due to incompetence of the valvular
mechanism at the ureter-bladder junction
• Classified as primary or secondary etiology
• Clinical manifestations may include recurrent
UTI, voiding dysfunction, renal insufficiency, or
hypertension in children

12. CONGENITAL DISORDERS
(CONT.)
• May resolve spontaneously or require surgery

13. VESICOURETERAL REFLUX

14. CONGENITAL DISORDERS
• Include misimplantation of ureters, strictures,
an extra ureter, and ureterocele
• Cause problems by obstructing normal urine
flow and predisposing to the retrograde flow
of urine, urine stasis, and secondary infection
• Usually treated with surgical interventions

15. CONGENITAL DISORDERS
(CONT.)
Obstruction of the Ureteropelvic Junction
• Blockage in urinary flow (partial or complete)
from the renal pelvis at the entry point of one
or both ureters
• Typically presents with hydronephrosis
• May be managed conservatively or require
surgical intervention

16. CONGENITAL DISORDERS
(CONT.)
Ureteral Ectopy
• Ectopic ureter is a single ureter implanted in
an abnormal location or a duplicate ureter
• Can increase risk of infection and reduction in
renal function
• Typically found with other genitourinary
pathologies
• Surgical interventions usually required

17. CONGENITAL DISORDERS
(CONT.)
Ureterocele
• Cystic dilation of the distal end of the ureter
• Obstruction in the collecting system results in
ureteral and renal calyx dilation; reflux and
infection
• Clinical manifestations include
hydronephrosis, UTIs, voiding dysfunction,
hematuria, urosepsis, or failure to thrive
• Surgical intervention is necessary

18. NEOPLASMS
Bladder Cancer
• Fourth most common cancer in males eighth
most common in females
• Risk increases with age; predisposing factors
include smoking and exposure to
carcinogenic chemicals
• Most tumors originate from the transitional
epithelium (urothelium) lining the urinary tract

19. NEOPLASMS (CONT.)
Bladder Cancer
• Primarily manifested as hematuria; frequency
and urgency may be present
• Cystoscopy used for diagnosis with tissue
biopsy and washings
• Treatment protocols based on type, grade
and stage of bladder cancer; primary options
are surgery, radiation therapy,
chemotherapy, and immunotherapy

20. INFLAMMATION AND
INFECTION
Urethritis
• Inflammation of the urethra
• Caused by infection from the bladder, STD-
related or from external factors
• STDs confined to the urethra; infection of
other etiologies may ascend to the bladder
before symptoms present
• Treatment depends on the cause

21. INFLAMMATION AND
INFECTION (CONT.)
Cystitis
• Inflammation of the bladder lining
• From infection, chemical irritants, stones,
trauma
• Most cases have an infectious etiology and
result from infection originating in the urethra
• Predisposing factors include female gender,
increased age, catheterization, DM, bladder
dysfunction, poor hygiene, and urinary stasis

22. INFLAMMATION AND
INFECTION (CONT.)
Cystitis
• Manifestations: frequency, urgency, dysuria,
suprapubic pain, and cloudy urine
• Symptoms in older adults may include
lethargy, anorexia, confusion, and anxiety
• Most female patients treated based on
symptoms; males and children or more
complicated cases may require urine culture
and/or further assessment

23. CYSTITIS

24. INFLAMMATION AND
INFECTION
Interstitial Cystitis/Painful Bladder
Syndrome
• Chronic condition consisting of bladder pain,
urgency, frequency, and nocturia
• Diagnosed based on symptoms
• Treatment: identifying contributory lifestyle
factors, such as some foods and beverages;
avoidance is primary intervention;
medications may be helpful in relieving
symptoms

25. OBSTRUCTION
Lower Urinary Tract Urolithiasis
• Most often caused by stones traveling to the
ureters, bladder, or urethra from the kidney
• Manifestations include ureteral colic,
hematuria, tachycardia, tachypnea,
diaphoresis, and N/V

26. OBSTRUCTION (CONT.)
Lower Urinary Tract Urolithiasis
• Bladder urolithiasis due to stones traveling
from ureters, but may form in bladder
because of urinary stasis
• Bladder stone symptoms include frequency
and dysuria; hematuria possible
• If infection: antimicrobial therapy based on
culture and sensitivity
• Stones that don’t pass spontaneously may
require endoscopic lithotripsy