This document provides an overview of the seminar on the genitourinary system. It begins with an anatomical and physiological overview of the urinary system, including the kidneys, ureters, bladder, and urethra. It then discusses specific topics like urethral strictures, renal calculi, diagnostic evaluations, and treatment options for various urinary obstructions. Surgical and non-surgical management strategies are described for conditions like kidney stones. The document provides a comprehensive review of the genitourinary system and common issues.

1. SEMINAR ON GENITOURINARY
SYSTEM
-Suryakant Satpute
F.Y.M.Sc

2. Anatomic and Physiologic Overview
 The urinary system comprises the kidneys, ureters,
bladder, and urethra.
Kidneys
• The kidneys are a pair of brownish-red structures
located retroperitoneally
• The kidney consists of two distinct regions, the renal
parenchyma and the renal pelvis.
• The renal parenchyma is divided into the cortex and
the medulla.
• The cortex contains the glomeruli, proximal and distal
tubules, and cortical collecting ducts and their
adjacent peritubular capillaries.

4. Ureters, Bladder, and Urethra
 Urine, which is formed within the nephrons, flows into the
ureter, a long fibromuscular tube that connects each kidney to
the bladder.
 The ureters are narrow, muscular tubes, each 24 to 30 cm
long, that originate at the lower portion of the renal pelvis and
terminate in the trigone of the bladder wall.
 There are three narrowed areas of each ureter: the
ureteropelvic junction, the ureteral segment near the sacroiliac
junction, and the ureterovesical junction.
 The angling of the ureterovesical junction is the primary
means of providing antegrade, or downward, movement of
urine, also referred to as efflux of urine.
 This angling prevents vesicoureteral reflux, which is the
retrograde, or backward, movement of urine from the bladder,

5.  During voiding (micturition), increased intravesical
pressure keeps the ureterovesical junction closed and
keeps urine within the ureters. As soon as micturition is
completed, intravesical pressure returns to its normal low
baseline value, allowing efflux of urine to resume.
 Therefore, the only time that the bladder is completely
empty is in the last seconds of micturition before efflux of
urine resumes.
 The three areas of narrowing within the ureters have a
propensity toward obstruction because of renal calculi
(kidney stones) or stricture.
 Obstruction of the ureteropelvic junction is the most
serious because of its close proximity to the kidney and
the risk of associated kidney dysfunction

6. Nursing assessment: history, and physical
examination
 Multiparous women delivering their children vaginally
are at high risk for stress urinary incontinence
 Elderly women and persons with neurologic
disorders such as diabetic neuropathy, multiple
sclerosis, or Parkinson’s disease often have
incomplete emptying of the bladder with urinary
stasis, which may result in
 urinary tract infection
 increasing bladder pressure leading to overflow
incontinence,
 hydronephrosis,
 pyelonephritis,
 renal insufficiency.

7.  The patient’s chief concern or reason for seeking
health care, the onset of the problem, and its effect
on the patient’s quality of life
 The location, character, and duration of pain, if
present, and its relationship to voiding
 Factors that precipitate pain, and those that relieve it
 History of urinary tract infections, including past
treatment or hospitalization for urinary tract infection
 Fever or chills
 Previous renal or urinary diagnostic tests or use of
indwelling urinary catheters

8.  Dysuria and when it occurs during voiding (at
initiation or termination of voiding)
 Hesitancy, straining, or pain during or after urination
 Urinary incontinence (stress incontinence, urge
incontinence, overflow incontinence, or functional
incontinence)
 Hematuria or change in color or volume of urine
 Nocturia and its date of onset
 Renal calculi (kidney stones), passage of stones or
gravel in urine

9.  Female patients: number and type (vaginal or
cesarean) of deliveries; use of forceps; vaginal
infection, discharge, or irritation; contraceptive
practices
 Presence or history of genital lesions or sexually
transmitted diseases
 Habits: use of tobacco, alcohol, or recreational drugs
 Any prescription and over-the-counter medications
(including those prescribed for renal or urinary
problems)

10. ASSESSMENT
 During physical examination for
genitourinary dysfunction areas of
emphasis include the abdomen,
suprapubic region, genitalia and lower
back, and lower extremities.
 Direct palpation of the kidneys may
help determine their size and mobility
 The right kidney is easier to feel
because it is somewhat lower than the
left one
 Renal dysfunction may produce
tenderness over the costovertebral
angle, which is the angle formed by
the lower border of the 12th, or
bottom, rib and the spine.

11.  The abdomen is auscultated to assess for bruits (lowpitched
murmurs that indicate renal artery stenosis or an aortic
aneurysm).
 The abdomen is also assessed for the presence of peritoneal
fluid, which may occur with kidney dysfunction.
 The bladder should be percussed after the patient voids to
check for residual urine
 Percussion of the bladder begins at the midline just above the
umbilicus and proceeds downward.
 The sound changes from tympanic to dull when percussing
over the bladder.
 The bladder, which can be palpated only if it is moderately
distended, feels like a smooth, firm, round mass rising out of
the abdomen, usually at midline
 Dullness to percussion of the bladder following voiding
indicates incomplete bladder emptying.ich may occur with
kidney dysfunction.

12.  The prostate gland is palpated by digital rectal
examination (DRE)
 Blood is drawn for PSA before the DRE because
manipulation of the prostate can cause the PSA level to
rise temporarily.
 The inguinal area is examined for enlarged nodes, an
inguinal or femoral hernia, or varicocele (varicose veins
of the spermatic cord)
In female, the vulva, urethral meatus, and vagina are
examined
 The patient is assessed for edema and changes in body
weight. Edema may be observed, particularly in the face
and dependent parts of the body, such as the ankles and
sacral areas
 An increase in body weight commonly accompanies
edema. A 1-kg weight gain equals approximately 1,000

13. UROLOGICAL OBSTRUCTIONS
URETHRAL STRICTURES
A urethral stricture is a scar in or around the
urethra, which can block the flow of urine, and is a
result of inflammation, injury or infection.
Risk Factors
 Urethral strictures are more common in men
because their urethras are longer than those in
women.
 Thus men's urethras are more susceptible to disease
or injury.
 A person is rarely born with urethral strictures and
women rarely develop urethral strictures.

14. ETIOLOGY
 Stricture disease may occur anywhere from the bladder
to the tip of the penis.
 The common causes of stricture are trauma to the
urethra and infections such as sexually transmitted
diseases and damage from instrumentation.
 Trauma such as straddle injuries, direct trauma to the
penis and catheterization can result in strictures of the
anterior part of the urethra.
 In adults, urethral strictures from instrumentation trauma
may occur after prostate surgery and urinary
catheterization.
 In children, urethral strictures most often follow
reconstructive surgery for congenital abnormalities of the
penis and urethra, cystoscopy and occasionally may be
congenital.

15. Clinical Features
 Painful urination.
 Slow urine stream.
 Decreased urine output.
 Spraying of the urine stream.
 Blood in the urine.
 Abdominal pain.
 Urethral discharge.
 Urinary tract infections in men.
 Infertility in men.

16. Diagnostic Evaluation
 Evaluation of patients with urethral stricture includes a physical
examination.
 Urethral imaging (X-rays or ultrasound).
 The retrograde urethrogram is an invaluable test to evaluate and
document the stricture and define the stricture recurrence. Combined
with antegrade urethrogram, length of the stricture can be
determined.

17. Treatment
 Treatment options for urethral stricture disease are
varied and selection depends upon the length,
location and degree of scar tissue associated with
the stricture.
 The main treatment options include enlarging the
stricture by gradual stretching (dilation).
 Cutting the stricture with a endoscopic equipment
(urethrotomy) and surgical repair of the stricture with
reconnection and reconstruction called urethroplasty.
 Urethral Stents where a biocompatible hollow tube is
placed on the inside of the stricture to allow for free
passage of urine.

18. Renal Calculi
 Urolithiasis refers to stones (calculi) in the urinary tract. Stones
are formed in the urinary tract when urinary concentrations of
substances such as calcium oxalate, calcium phosphate, and uric
acid increase.
 This is referred to as supersaturation and is depen- dent on the
amount of the substance, ionic strength, and pH of the urine.
Incidence
 The occurrence of urinary stones occurs predomi- nantly in the
third to fifth decades of life and
 Affects men more than women.
 About half of patients with a single renal stone have another
episode within 5 years.
 Most stones contain calcium or magnesium in combination with
phosphorus or oxalate.

19. Types Of Stone
 Calcium stone
 Oxalate stone
 Cystiene stone
 Struvite stone

20. Calcium stone
 Most stones (75%) are
composed mainly of calcium
oxalate crystals.
 Increased calcium
concentrations in blood and
urine promote precipitation of
calcium and formation of
stones.
 Causes of hypercalcemia
(high serum calcium) and
hypercalciuria (high urine
calcium) include the following:
 Hyperparathyroidism
 Renal tubular acidosis
 Cancers
 Granulomatous diseases
(sarcoidosis, tuberculosis),
which may cause increased
vitamin D production by the
granulomatous tissue
 Excessive intake of vitamin D
 Excessive intake of milk and
alkali
 Myeloproliferative diseases
(leukemia, polycythemia vera,
multiple myeloma), which
produce an unusual
proliferation of blood cells
from the bone marrow

21. Uric acid stones
 5% to 10% of all stones
 Gout (inflammatory
arthritis)
 myeloproliferative
disorders
 Diet high in purines and
abnormal purine
metabolism
Cystine stones
 1% to 2% of all stones
 occur in patients with a
rare inherited defect in
renal absorption of cystine
(an amino acid).
Struvite stones
 15% of urinary calculi
 form in persistently
alkaline, ammonia-rich
urine
 caused by the presence of
urease splitting bacteria
such as Proteus,
Pseudomonas, Klebsiella,
Staphy- lococcus, or
Mycoplasma species.
 Predisposing factors for
struvite stones (commonly
called infection stones)
include neurogenic
bladder, foreign bodies,
and recurrent UTIs.

22. Causes and predisposing factors:
 Chronic dehydration, poor fluid intake, and
immobility
 Living in mountainous, desert, or tropical areas
 Infection, urinary stasis, and periods of immobility
 Inflammatory bowel disease and in patients with an
ileostomy or bowel resection because these patients
absorb more oxalate.
 Medications- antacids, acetazolamide (Diamox),
vitamin D, laxatives, and high doses of aspirin

23. •Location of
stones
•Kidney
•Ureter
•Bladder
•Urethra

24. Clinical Features
 Pain
 Heamturia
 Dysuria
 Oedema
 Pyuria (Obstruction in
urine flow, urinary
retention )
 Associated symptoms
 Nausea, vomiting,
diarrhea, abdominal
discomfort
 Chills and fever (may)
Diagnostic Evaluation
 History
 Physical examination
 Urinanalysis
 Blood
studies(Hyperuracemia,Hyperc
alcemia Neutrophilia )
 Stone chemistry
 Radiographic studies

25. NON SURGICAL MANAGEMENT
 Fluids are encouraged. This increases the hydrostatic
pressure behind the stone, assisting it in its downward
passage.
 A high, around-the-clock fluid intake reduces the
concentration of urinary crystalloids, dilutes the urine,
and ensures a high urine output.
 Cellulose sodium phosphate (Calcibind) may be effective
in preventing calcium stones
 Sodium and protein restriction diet
 Allopurinol (zyloprim,zyloric tbs)may be prescribed to
reduce serum uric acid levels and urinary uric acid
excretion.

26. NON SURGICAL MANAGEMENT
Ureteroscopy
 Ureteroscopy involves
visualizing the stone and then
destroying it.
 Access to the stone is
accomplished by inserting a
ureteroscope into the ureter
and then inserting a laser,
electrohydraulic lithotriptor, or
ultrasound device through the
ureteroscope to fragment and
remove the stones
ESWL (Extra Corporeal
Shock wave lithotripsy)
 ESWL is a noninvasive
procedure used to break up
stones in the calyx of the
kidney
 In ESWL, a high-energy
amplitude of pressure, or shock
wave, is generated by the
abrupt release of energy and
transmitted through water and
soft tissues.
 Repeated shock waves
focused on the stone eventually
reduce it to many small pieces.
These small pieces are
excreted in the urine, usually
without difficulty.

27. Endoscopic Procedures
 A percutaneous
nephrostomy or a
percutaneous
nephrolithotomy may be
performed, and a
nephroscope is introduced
through the dilated
percutaneous tract into the
renal parenchyma.
 Depending on its size, the
stone may be extracted with
forceps or by a stone
retrieval basket.
Alternatively, an ultrasound
probe may be introduced
through the nephrostomy
tube.
Electrohydraulic Lithotripsy
 an electrical discharge is used to
create a hydraulic shock wave to
break up the stone.
 A probe is passed through the
cystoscope, and the tip of the
lithotriptor is placed near the stone
 This procedure is performed under
topical anesthesia.
Chemolysis
 Chemolysis, stone dissolution
using infusions of chemical
solutions (eg, alkylating agents,
acidifying agents)
 A percutaneous nephrostomy is
performed, and the warm irrigating
solution is allowed to flow
continuously onto the stone.

28. Surgical Management
 Nephrolithotomy - Incision into the kidney with
removal of the stone
 Nephrectomy – removal of kidney
 Pyelolithotomy - removal of stone from renal pelvis
 Ureterolithotomy - removal of stone from ureter
 Cystostomy – removal of stone from bladder
 Cystolitholapaxy - an instrument is inserted through
the urethra into the bladder, and the stone is crushed
in the jaws of this instrument

29. GLOMERULONEPHRITIS ,ACUTE (ACUTE
NEPHRITIC SYNDROME )
Definition –
Acute glomerulonephritis refers to a group of kidney
diseases in which there is an inflammatory reaction in the
glomeruli. It is not an infection of the kidney, but rather
the result of the immune mechanisms of the body
Risk factors –
 Group A beta- hemolytic streptococcal infection of the
throat
 Impetigo (infection of the skin)
 Acute viral infections- upper respiratory tract infections,
mumps, varicella zoster virus, Epstein-Barr virus,
hepatitis B, and human immunodeficiency virus [HIV]
infection).
 Antigens outside the body (eg, medications, foreign
serum)
 In other patients, the kidney tissue itself serves as the
inciting antigen.

30. Categories –
 Primary: Disease is mainly in glomeruli
 Secondary: Glomerular diseases that are the consequence of
systemic disease
 Idiopathic: Cause is unknown
 Acute: Occurs over days or weeks
 Chronic: Occurs over months or years
 Rapidly progressing: Constant loss of renal function with
minimal chance of recovery
 Diffuse: Involves all glomeruli
 Focal: Involves some glomeruli
 Segmental: Involves portions of individual glomeruli
 Membranous: Evidence of thickened glomerular capillary walls
 Proliferative: Number of glomerular cells involved

31. PATHOPHYSIOLOGY OF
GLOMERULONEPHRITIS

32. CLINICAL FEATURES
 Hematuria - The urine may appear cola-colored be- cause of
red blood cells (RBCs) and protein plugs or casts; RBC casts
indicate glomerular injury.
 Edema and hypertension
 Oliguria
 Anemia from loss of RBCs into the urine
 In the more severe form of the disease, patients also complain
of headache, malaise, and flank pain.
 Elderly patients may experience circulatory overload with
dyspnea, engorged neck veins, cardiomegaly, and pulmonary
edema.
 Atypical symptoms include confusion, somnolence, and
seizures, which are often confused with the symptoms of a
primary neurologic disorder

33. Diagnostic Evaluation
 History
 On examination- kidney is large, tender, edematous and
congested
 Urinanalysis- protienuria, hematuria , oliguria
 Blood studies
 Serum creatinine, BUN increased
 Hypoalbuminemia, hyperlipidemia
 Elevated serum IgA level
 Antistreptolysin O titers are usually elevated in post
streptococcal glomerulonephritis
 Electron microscopy and immunofluorescent analysis help
identify the nature of the lesion
 Kidney biopsy may be needed for definitive diagnosis.

34. TYPES OF MANAGEMENT
Non pharmacological
management
 Complete bed rest – as
excessive activity may
increase the protienuria and
hematuria. It should be
encouraged until the urine
clears and BUN, creatinine
and BP return to normal.
 Strict intake out put charting.
 Fluid restrictions
 Plasmapheresis to
decrease the serum anti
body level
 Dialysis if, uremic symptoms
are severe.
Dietary management-
 Protein restricted diet as the
level of BUN and creatinine
is high in blood
 Low fat diet due to
hyperlipidemia
 Sodium restriction if
hypertension, edema or
congestive heart failure are
present.
 Increased carbohydrate diet
to provide energy and to
prevent the catabolism of
protein.

35. Pharmacological management-
 Residual streptococcal infection is suspected,
penicillin is the agent of choice.
 Diuretics and antihypertensive agents may be given
to control hypertension.
 Corticosteroids and cytotoxic agents are used to
reduce the inflammation.
 H2 blockers (to prevent stress ulcers)
 Phosphate binding agents (to reduce phosphate and
elevate calcium).

36. NURSING MANAGEMENT-
 Monitor vital signs, intake and
output, and maintain dietary
restrictions during acute phase.
 Encourage rest during the acute
phase as directed until the urine
clears and BUN, creatinine, and
blood pressure normalize. (Rest
also facilitates diuresis.)
 Administer medications as ordered,
and evaluate patient's response to
antihypertensives, diuretics, H2
blockers, phosphate-binding
agents, and antibiotics (if
indicated).
 Regular monitoring of blood
pressure, urinary protein, and BUN
concentrations to determine if there
is exacerbation of disease activity.
 Carefully monitor fluid balance
 Replace fluids according to the
patient's fluid losses (urine,
respiration, feces)
 Daily body weight as prescribed.
 Monitor pulmonary artery pressure
and CVP, if indicated.
 Monitor for signs and symptoms of
heart failure: distended neck veins,
tachycardia, gallop rhythm,
enlarged and tender liver, crackles
at bases of lungs.
 Observe for hypertensive
encephalopathy, any evidence of
seizure activity.
 Encourage patient to treat any
infection promptly. Tell patient to
report any signs of decreasing
renal function and to obtain
treatment immediately

37. ACUTE PYELONEPHRITIS
Definition-
Pyelonephritis is a bacterial infection of the
renal pelvis, tubules, and interstitial tissue of one or
both kidneys.
Commonest microorganism-
 Enteric bacteria, such as E. coli, is most common
pathogen
 other gram-negative pathogens include Proteus
species, Klebsiella, and Pseudomonas.
 Gram-positive bacteria are less common, but include
Enterococcus and Staphylococcus aureus

38. Clinical features-
 Fever, chills, headache, malaise
 Flank pain (with or without radiation to groin)
 Nausea, vomiting, anorexia
 Costovertebral angle tenderness
 Urgency, frequency, and dysuria may be present

39. DIAGNOSTIC EVALUATION-
 History – urinary obstruction, systemic infection
 Physical examination- pain and tenderness in the
area of the costovertebral angle
 Urinalysis- pyuria, bactriuria, RBCs and WBCs in
urine
 Hematology- elevated WBC count
 An ultrasound study or a CT scan may be performed
to locate any obstruction in the urinary tract.
 An IV pyelogram may be indicated with
pyelonephritis if functional and structural renal
abnormalities are suspected
 Urine culture and sensitivity tests

40. MANAGEMENT-
 For severe infections (dehydrated, cannot tolerate oral intake)
or complicating factors (suspected obstruction, pregnancy,
advanced age), inpatient antibiotic therapy is recommended.
 Usually immediate treatment is started with a penicillin or
aminoglycoside I.V. to cover the prevalent gram-negative
pathogens; subsequently adjusted according to culture results.
 An oral antibiotic may be started 24 hours after fever has
resolved and oral therapy continued for 3 weeks.
 Oral therapy antibiotic therapy is acceptable for outpatient
treatment.
 Co-trimoxazole (Bactrim, Septran) or a fluoroquinolone is
used; 10 to 14 days is the usual length of treatment.
 Repeat urine cultures should be performed after the
completion of therapy.
 Supportive therapy is given for fever and pain control and
hydration.

41. Nursing Management-
 Administer or teach self-administration of antibiotics as
prescribed, and monitor for effectiveness and adverse effects.
 Assess vital signs frequently, and monitor intake and output;
administer antiemetic medications to control nausea and
vomiting.
 Administer antipyretic medications as prescribed and
according to temperature.
 Report fever that persists beyond 72 hours after initiating
antibiotic therapy; further testing for complicating factors will
be ordered.
 Use measures to decrease body temperature if indicated;
cooling blanket, application of ice to armpits and groins, and
so forth.
 Correct dehydration by replacing fluids, orally if possible, or
I.V.
 Monitor CBC, blood cultures, and urine studies for resolving
infection

42. NEPHROTIC SYNDROME
Definition
Nephrotic syndrome is a clinical disorder
characterized by marked increase of protein in the
urine (proteinuria), decrease in albumin in the blood
(hypoalbuminemia), edema, and excess lipids in the
blood (hyperlipidemia).
 These occur because of increased permeability of
the glomerular capillary membrane.

43. Classification Of Nephrotic Syndrome
ETOLOGICAL CLASSIFICATION
 Primary NEPHROTIC syndrome. Disease limited to
kidney
 Secondary NEPHROTIC syndrome. Other systems
involved
HISTOLOGICAL CLASISIFICATION
 MCD (Minimal change disease )
 FSGN (Focal segmental glomerulosclerosis )
 MN (Membranous nephropathy)
 MPGN (membranous proliferative
glomerulonephrosclerosis)

44. Etiology
 Membranous nephropathy (MN)
 Hepatitis B
 Systemic lupus erythematosus (SLE)
 Diabetes mellitus
 Sarcoidosis
 Syphilis
 Drugs
 Focal segmental glomerulosclerosis (FSGS)
 Hypertensive Nephrosclerosis
 Human immunodeficiency virus (HIV)
 Diabetes mellitus
 Obesity
 Kidney loss
 Minimal change disease (MCD)
 Malignancy, especially Hodgkin's lymphoma

46. Clinical Features
 The major manifestation of nephrotic syndrome is edema.
 It is usually soft and pitting and commonly occurs around the eyes
(periorbital), in dependent areas (sacrum, ankles, and hands), and in
the abdomen (ascites).
 Patients may also exhibit irritability, headache, and malaise.
Diagnostic Evaluation
 Urinalysis- marked proteinuria, microscopic hematuria,
 24-hour urine for protein (increased) and creatinine clearance
(decreased)
 Protein electrophoresis and immunoelectrophoresis of the urine to
categorize the proteinuria
 Needle biopsy of kidney for histologic examination of renal tissue to
confirm diagnosis
 Serum chemistry- decreased total protein and albumin, normal or
increased creatinine, increased triglycerides, and altered lipid profile

47. COMPLICATIONS
 Complications of nephrotic syndrome include-
 Infection (due to a deficient immune response)
 Thromboembolism (especially of the renal vein)
 Pulmonary emboli
 ARF(due to hypovolemia)
 Accelerated atherosclerosis (due to hyperlipidemia)

48. MANAGEMENT
 Treatment of causative glomerular disease
 Diuretics (used cautiously) and angiotensin
converting enzyme inhibitors to control proteinuria
 Corticosteroids or immunosuppressant agents to
decrease proteinuria
 General management of edema
 Sodium and fluid restriction; liberal potassium
 Infusion of salt-poor albumin
 Dietary protein supplements
 Low-saturated-fat diet

49. Nursing Management
 Monitor daily weight, intake and output, and urine specific
gravity.
 Monitor CVP (if indicated), vital signs, orthostatic blood
pressure, and heart rate to detect hypovolemia.
 Monitor serum BUN and creatinine to assess renal
function.
 Administer diuretics or immunosuppressants as
prescribed, and evaluate patient's response.
 Infuse I.V. albumin as ordered.
 Encourage bed rest for a few days to help mobilize
edema; however, some ambulation is necessary to
reduce risk of thromboembolic complications.

50. ACUTE RENAL FAILURE
 Definition-
Acute renal failure is a sudden and almost
complete loss of kidney function caused by failure of
renal circulation or by glo
Etiology
 Pre – renal (hypoperfusion of kidney)
 Intra – renal (actual damage to the kidney tissue)
 Post – renal (obstruction to urine flow) merular or
tubular dysfunction.

51. ETIOLOGY
Pre – Renal
 Volume depetion
 Hemorrhage
 Renal loses
 GI losses
 Impaired cardiac efficiency
 Vasodilation
 sepsis
 Anaphylaxis
 Antihypertensive medications
Post – Renal
 Urinary tract obstructions
 Renal calculi
 Tumors
 BPH
 Blood clots
 Strictutres
Intra – Renal
 Prolonged renal ischemia
 Pigment nephropathy
 Myoglobinuria
 Hemoglobinuria
 Nephrotoxic agents
 Aminoglycosides agents
 Radiopaque contrast agents
 Heavy metals,Solvents and
chemicals

52. RISK FACTORS
 Advanced age
 Blockages in the blood
vessels in your arms or
legs
 Diabetes
 High blood pressure
 Heart failure
 Kidney diseases
 Liver disease

53. PHASES OF ARF
Initiating phase
 Begins with the initial insult and ends when oliguria
develops
Oliguric phase
 Urine output less than 400 ml/day
Diuretic phase
 Urine out put become normal but nitrogenous waste
products still remain elevated in blood
Recovery phase
 It signifies the improvement of renal function It takes 3-12
months to return normal

54. Clinical Features
 Vomiting and/or diarrhea, which
may lead to dehydration.
 Nausea.
 Weight loss.
 Nocturnal urination.
 pale urine.
 Less frequent urination, or in
smaller amounts than usual, with
dark coloured urine
 Haematuria.
 Pressure, or difficulty urinating.
 Itching.
 Anorexia
 Pruritus
 Seizures (if blood urea nitrogen
level is very high)
 Bone damage. Non-union in
broken bones.
 Muscle cramps (caused by low
levels of calcium which can cause
hypocalcaemia)
 Abnormal heart rhythms.
 Muscle paralysis.
 Swelling of the legs, ankles, feet,
face and/or hands.
 Shortness of breath due to extra
fluid on the lungs
 Pain in the back or side
 Feeling tired and/or weak.
 Memory problems.
 Difficulty concentrating.
 Dizziness.
 Low blood pressure.

55. PREVENTION
 Provide adequate hydration to patient at high risk for
dehydration
 Prevent and treat shock with blood and fluid replacement
therapy
 Manage hypotension
 Monitor critically ill patient for central venous and arterial
pressures and hourly urine output to detect the onset of renal
failure as early as possible.
 Continuously assess the renal function
 Prevent and treat infections
 Cautiously administer the blood
 Closely monitor the all medications that metabolized and
excreted by the kidney for dosage and blood levels for the
toxic effects.
 Pay special attention to wound, burns and other precursors of
sepsis.

56. COMPLICATIONS
ARF can affect the entire body in the form of –
 Infection
 Hyperkalaemia, Hyperphosphataemia, Hyponatraemia
 Water overload
 Pericarditis
 Pulmonary oedema.
 Reduced level of consciousness.
 Immune deficiency
MANAGEMENT
 To correct fluid and electrolyte balance.
 To correct dehydration.
 To Keep other body systems working properly

57. RENAL AGENESIS
 Bilateral renal agenesis
- both mesonephric
ducts fail to develop.
 Incompatible with life.
UNILATERAL RENAL
AGENESIS
 the mesonephric duct
fails to develop.
 Usually there is absent
ureter, trigone, kidney
and (in boys) vas
deferens.

58. Horseshoe Kidney •
 Both metanephros are
fused together.
 Both kidneys rotated &
their lower poles are
joined in the shape of a
horseshoe.
 As the fetus grows, the
joined kidneys are held
up by the inferior or
superior mesenteric
arteries at L3.

59. Pelviureteric Junction
Obstruction
 Obstruction of the junction
between the renal pelvis &
ureter.
Clinical Features
 may present at any time
(before birth, in childhood,
or in adulthood) by:
 abdominal mass.
 abdominal pain.
 Haematuria after fairly
minor abdominal trauma.

60. Diagnostic Evaluation
 IVU(intravenous urogram) - shows delay in appearance of
contrast and dilated renal pelvis and calices.
 Renal scan -shows differential renal function and confirms
obstruction
Management
Surgery is indicated for:
1. obstructive symptoms,
2. stone formation,
3. recurrent urinary infection,
4. progressive renal impairment.
 Pyeloplasty is the treatment of choice
 Nephrectomy is performed if the affected kidney is <10% of
total renal function.

61. Vesicoureteric Junction
Reflux
 Reflux can be defined
as the retrograde flow of
urine into upper urinary
tract. Incidence of reflux
is equal in both sexes.
 Reflux can be classified
into 5 grades

62. Diagnostic Evaluation
 Micturating cystourethrography is the gold standard
for diagnosis and evaluation of VUR grade.
 Diuretic Renal scan (DMSA) is used to visualize
scarring and quantify differential renal function.
Management
 antibiotic prophylaxis is recommended for children
with reflux of grades I-II.
 Surgery (uretro - vesical reimplantation or
endoscopic injection) is recommended in reflux of
grades III-V and persistent reflux despite a trial of
antibiotics.

63. Ectopic Ureter
 An ectopic ureter is one that
opens in some location other
than the bladder.
 80% associated with
duplicated system.
 20% associated with single
system.
 Most common sites (in
female): urethra, vestibule,
and vagina • In female
present as urinary
incontinence.
 Most common sites (in
male): posterior urethra and
seminal vesicles.

64. Uretrocele
 A congenital cystic
ballooning of the
terminal submucosal
ureter.
 It is classified as simple
or ectopic.
 Simple ( Orthotopic )
Ureterocele : in
trigone.
 Ectopic Ureterocele :
can obstruct bladder
neck or even prolapse
from female urethra.

65. Hypospadias
 It is a condition in which the
opening of the urethra is on the
underside of the penis, instead of
at the tip.
 congenital condition results in
underdevelopment of urethra.
 affects 3 per 1000 male infants.
 Consists of 3 anomalies:
1.Abnormal ventral opening of
the urethral meatus. 2.Ventral
curvature of the penis ( chordee
). 3.Deficient prepuce ventrally
Treatment
The child should be referred for
urological assessment and
surgical treatment.
The ideal age for surgery is 6–12
months.

66. Epispadias
 Congenital condition in
which the urethra opens on
dorsal surface of penis..
 Usually associated with
bladder extrophy (ectopia
vesicae).
Bladder Extrophy (Ectopia
vesicae)
 Failure of development of
the lower abdominal wall.
 Anomaly include defect in
anterior abdominal wall,
defect in anterior bladder
wall and epispadias (dorsal
penile opening).

67. CANCER OF KIDNEY
Incidence
 Cancer of the kidney accounts for about 3.7% of all
cancers in adults.
 It affects almost twice as many men as women.
 The most common type of renal tumor is renal cell or
renal adenocarcinoma, accounting for more than
85% of all kidney tumors.
 These tumors may metastasize early to the lungs,
bone, liver, brain, and contralateral kidney.
 The incidence of all stages of kidney cancer has
increased in last two decades.

68. Risk factors
 Gender: Affects men more than women
 Tobacco use
 Occupational exposure to industrial chemicals, such as
petroleum products, heavy metals, and asbestos
 Obesity
 Unopposed estrogen therapy
 Polycystic kidney disease
 regular use of NSAIDs such as ibuprofen and naproxen,
 faulty genes;
 a family history of kidney cancer;
 having kidney disease that needs dialysis;
 being infected with hepatitis C;

69. Clinical Features
 Many renal tumors produce no symptoms and are discovered
on a routine physical examination as a palpable abdominal
mass.
 The classic triad of signs and symptoms, comprises
hematuria, pain, and a mass in the flank.
 The usual sign that first calls attention to the tumor is pain-
less hematuria, which may be either intermittent and
microscopic or continuous and gross.
 There may be a dull pain in the back from the pressure
produced by compression of the ureter, extension of the tumor
into the perirenal area, or hemorrhage into the kidney tissue.
 Colicky pains occur if a clot or mass of tumor cells passes
down the ureter.
 weight loss, increasing weakness, and anemia.

70. Assessment and Diagnostic Findings
 The diagnosis of a renal tumor may require
 intravenous urography,
 cystoscopic examination,
 nephrotomograms,
 renal angiograms, ultrasonography,
 CT scan.
Management-Surgical management
 A radical nephrectomy is the preferred treatment if the tumor can be
removed. This includes removal of the kidney (and tumor), adrenal
gland, surrounding perinephric fat and Gerota’s fascia, and lymph
nodes.
 Radiation therapy, hormonal therapy, or chemotherapy may be used
along with surgery.
 Immunotherapy
 Nephron-sparing surgery

71. Pharmacological Management
 use of biologic response modifiers such as interleukin-2
(IL2) and topical instillation of bacillus Calmette-Guerin
(BCG)
 Patients may be treated with IL-2, a protein that regulates
cell growth. This may be used alone or in combination
with lymphokine-activated killer cells
 Interferon, another biologic response modifier, appears to
have a direct antiproliferative effect on renal tumors.
Renal Artery Embolization
 In patients with metastatic renal carcinoma, the renal
artery may be occluded to impede the blood supply to the
tumor and thus kill the tumor cells.

72. CANCER OF BLADDER
 Cancer of the urinary bladder is more common in
people aged 50 to 70 years.
 It affects men more than women (3:1)
 There are two forms of bladder cancer: superficial
(which tends to recur) and invasive. About 80% to
90% of all bladder cancers are transitional cell
(which means they arise from the transitional cells of
the bladder);
 the remaining types of tumors are squamous cell
and ade- nocarcinoma.

73. Risk Factors
 Cigarette smoking: risk proportional to number of packs
smoked daily and number of years of smoking
 Environmental carcinogens: dyes, rubber, leather, ink, or
paint
 Recurrent or chronic bacterial infection of the urinary tract
 Bladder stones
 High urinary pH
 High cholesterol intake
 Pelvic radiation therapy
 Cancers arising from the prostate, colon, and rectum in
males

74. Clinical Manifestations
 Bladder tumors usually arise at the base of the bladder and involve
the ureteral orifices and bladder neck.
 Visible, painless hematuria is the most common symptom of bladder
cancer.
 Infection of the urinary tract is a common complication, producing
frequency, urgency, and dysuria.
 Any alteration in voiding or change in the urine, however, may
indicate cancer of the bladder.
 Pelvic or back pain may occur with metastasis.
Assessment and Diagnostic Findings
 The diagnostic evaluation includes – cystoscopy (the mainstay of
diagnosis),
 excretory urography,
 a CT scan, ultrasonography,
 bimanual examination with the patient anesthetized.
 Biopsies of the tumor and adjacent mucosa

75. Management- Surgical
 Transurethral resection or fulguration (cauterization) may
be per- formed for simple papillomas (benign epithelial
tumors). eradicate the tumors through surgical incision or
electrical current with the use of instruments inserted
through the urethra.
 After this bladder-sparing surgery, intravesical
administration of BCG is the treatment of choice.
 A simple cystectomy (removal of the bladder) or a radical
cystectomy is performed for invasive or multifocal bladder
cancer.
 Radical cystectomy in men involves removal of the
bladder, prostate, and seminal vesicles and immediate
adjacent perivesical tissues.

76. Management- Pharmacological
 Chemotherapy with a combination of methotrexate, 5-fluorouracil,
vinblastine, doxorubicin (Adriamycin), and cisplatin
 Intravenous chemotherapy may be accompanied by radiation
therapy.
 Topical chemotherapy (intravesical chemotherapy or instillation of
antineoplastic agents into the bladder, resulting in contact of the
agent with the bladder wall) is considered when there is a high risk
for recurrence, when cancer in situ is present, or when tumor
resection has been incomplete.
 Topical chemotherapy de- livers a high concentration of medication
(doxorubicin, mitomycin, ethoglucid, and BCG) to the tumor to
promote tumor destruction.
 BCG is now considered the most effective intravesical agent for
recurrent bladder cancer because it enhances the body’s immune
response to cancer.
Management- Radiation Therapy
 Radiation of the tumor may be performed preoperatively to reduce
microextension of the neoplasm and viability of tumor cells,

77. THANK YOU