Pathophysiology - Urinary

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Location of Urinary disorders

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Anywhere between kidney and urethral opening

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Why can urinary disorders be lethal

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impedes the ridding f body toxins. Hydrogen ions build up along with byproducts of protein breakdown and electrolytes

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most common urinary disorder

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bladder infection

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kidney filtration rate

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125mL/minute

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kidney reabsorption rate

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670 mL/hour

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filtrate

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the part that is filtered out of the blood and into the tubules

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location of most water reabsorption

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proximal tubules

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size of kidneys

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11cm x 5cm

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kidney blood flow

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aorta - renal artery - renal vein - vena cava

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cortex

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outer portion with glomeruli

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Medulla

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Inner Portion – collecting tubules

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Glomerulli

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Filtering part of the nephrons

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Renal Pelvis

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Location of urine collection before peristolic movement in ureters

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ADH

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- secreted by posterior pituitary
- controls the re-absorption of water by changing the permeability of distal convoluted tubules

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Aldesterone

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- secreted by the adrenal cortex
- controls the re-absorption of Na
- more aldesterone – leads to more Na+ reabsortion – leads to more water retention – leads to increased BP

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How much blood from the heart is pumped through the kidneys

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25%

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Where in the kidneys does filtrtion occur

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Glomerulus

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Route through kidneys

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Afferent Arteriole - Glomerulous – Efferent Tubule – Bowman’s capsule - Tubules

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Location of reabsorption of glucose, amino acids, sodium, and Water

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Bowman’s Capsule

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Length of ureters

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30cm

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Detrusor Muscle

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Smooth muscle coat of the bladder
Involuntary control

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Urethra

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Mucus secreting
-internal and external spincters
- female – 4cm, male – 20 cm

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Bladder

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Sends signal when about 300 mL collects

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Voiding

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Relaxation of internal spincter
Contraction of Detursor muscle
Relaxation of external spincter

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Prostate Gland

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- plays a role in semen production
- wraps around the urethra at base of bladder

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GFR

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- Glomerular Filtration Rate
- 25% of cardiac output
- can be estimated through 24 hour urine collection
- systolic BP needs to be 70 mmHG for there to be enough pressure for filtration

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Anatomical Causes Urinary Tract Obstruction

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Structure
Stones
Tumor
prostate enlargement
pelvic organ prolapse

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Urinary Tract Obstruction Consequences

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UTI
Dilation of proximal area
Fibrosis of Nephron
-Decrease in GFR
HTN
Reversible tubular damage in a matter of hours

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Functional Cause Urinary Tract Obstruction

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- Incoordination between detrusor muscle and spincters

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Obstruction leads to

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Proximal dilation

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BPH -

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Benign prostatic hypertrophy
- The prostate sits on the base of the bladder blocking flow into the urethra

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Nephrolithiasis

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- Kidney Stones obstruction
- aka renal colic
- salts which are not flushed out by water flow

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Hydronephrosis

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Water collection above the site of the stone

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Composition of kidney stones -

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Most commonly made of calcium
- can be made of struvite of uric acid

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Kidney stone pH

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Calcium stones occur from a alkalie environement
Uric acid stones for in an acidic environment

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Struvite Stones

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-Mag, Ammonia, & Phos
- form during an infection
- may form into a staghorn (shaped like an antler)
- larger than 5 cm must be surgically removed

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Symptoms of Kidney stones

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- asymptomatic in kidney or bladder
- severe back and groin pain when travelling down the ureters

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Clinical Manifestations of nephrolithiasis n the back

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- Flank pain radiating to groin
- Lower Urinary problems
- Urgency
- Frequency
- rhino horn stabbing i

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Treatment for Nephrolithiasis -

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Large amounts of fluid
- Narcoticcs
- Increase in dietary fiber to rid of calcium
- Stone removal (PCNL)

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PCNL

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Percutaneous nephrolithotripsy
-Urologist passes a needle into collecting kidney or ureter. Laser lithotripto is used to break up and retrieve stones. Foley catheter and nephrostomy tubes are left in place so fragments don’t get stuck.

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Dyssynergia

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No motion

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Bladder neck dyssynergia

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Failure of the detrusor to funnel urine during micturation

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Urethral stricture

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Narrowing of the urethral lumen due to scar tissue
i.e. infectin or surgical manipulation

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Causes of urethral stricture

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- Injury (surgical, fall astride on bike)
- Infection – gonorrhoea, Chlamydia
- congenital
- cancer

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Neurogenic bladder dysfunction

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Lack of communication between bladder and nervous system.

-incoordination between detrusor contraction and sphincter relaxation caused by spinal cord injury

- can lead to over activity or under activity

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Evaluation of lower urinary tract obstruction

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- Voiding frequency
- Nocturia
- Poor force of stream
- Intermittent stream
- Incomplete Emptying
- Post-void residual volume

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Post void residual volume

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200mL remain in bladder after voiding.
Measured by emptying bladder via catheter

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Lower Urinary Tract Obstruction Treatment Surgery – TURP

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Pessary
PCNL
Dilation
Meds –abx , Meds to relax sphincter

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TURP

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Transurethral resection of the prostate

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Cystitis causes

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(UTI)
-usually bacterial – (80% e coli. 20% staph)
- decreased immune response
-alkaline urine
#1 iatrogenic is catheterzation

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Cystisis clinical manifestations

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Dysuria
Urgency
Frequency
Confusion and abdominal pain in elderly

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Cystitis evaluation

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High neutrophil count
Micro hematuria
100,000 + organisms per liter of urine

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Cystitis treatment

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Antibiotics
Follow-up UA in 4 weeks

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Non bacterial Cystitis

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Inflammation without evident pathogenic bacterial count due to inflamed glands near urethra
- more likely in females

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Interstital cystitis

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-walls of bladder irritated and inflamed
- often misdiagnoses as bladder infection
- 1 in 3000 people, 90% of which are women
- more likely in reproductive years

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Pyelonephritis

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- a climbing cysitits
- urinary tract pathogens climb from bladder up ureters into renal pelvis
- there is a danger of organisms entering blood stream leading to sepsis

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Pyelonephritis causes

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Stones
Refulx
Pregnancy
Neurogenic bladder
Catheters
Untreated cystitis

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Pyelonephritis manifestations

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Fever
Chills
Flank pain

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Pyelonephritis Evaluation

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- UA will show white casts (collection of WBC)
- Blood cultures needed

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Acute Renal Failure

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ARF
Abrupt and reversible shut down of the kidneys

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(Prerenal) Acute Renal Failure

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Most common – decreased perfusion to the kidneys due to decreased cardiac output

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(Intrarenal) Acute Renal Failure

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Sometimes just called renal, or acute tubular necrosis
Damage to tubules
Common causes – nephrotoxic medications or excess myoglobin from burn inuries

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Postrenal ARF

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- cause of problem lies below the kidney
- most common BPH

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Acute Renal Failure
Clinical Manifestations

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-change in urine output and levels of creatinine
-BUN/creatinin rise
-hydrogen ions retained, bicarb is lost
metabolic acidosis
potassium retained

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ARF – Treatment

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- Fix the underlying cause
- fluids
- remove nephrotoxins
- relieve obstruction

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ABG Balance

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- pH controlled by longs and kidneys
- Lungs are quick and kidneys are slow