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94 Cards in this Set

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Define the process of voiding, from bladder filling to actual micturition
The lower urinary tract has two discrete phases of activity: the storage phase, when urine is stored in the bladder; and the voiding phase, when urine is released through the urethra. The state of the reflex system is dependent on both a conscious signal from the brain and the firing rate of sensory fibers from the bladder and urethra. At low bladder volumes, afferent firing is low, resulting in excitation of the outlet (the sphincter and urethra), and relaxation of the bladder. At high bladder volumes, afferent firing increases, causing a conscious sensation of urinary urge. When the individual is ready to urinate, he or she consciously initiates voiding, causing the bladder to contract and the outlet to relax.
Detrusor muscle
Contracts when urinating to squeeze out urine. Otherwise, it remains relaxed to allow the bladder to fill.
Trigone
A smooth triangular region of the internal urinary bladder formed by the two ureteral orifices and the internal urethral orifice.

The area is very sensitive to expansion and once stretched to a certain degree, the urinary bladder signals the brain of its need to empty. The signals become stronger as the bladder continues to fill.
External Sphincter
Located at the bladder's distal inferior end in females and inferior to the prostate (at the level of the membranous urethra) in males is a secondary sphincter to control the flow of urine through the urethra. Unlike the internal sphincter muscle, the external sphincter is made of skeletal muscle, therefore it is under voluntary control of the somatic nervous system.
Internal Sphincter
located at the bladder's inferior end and the urethra's proximal end at the junction of the urethra with the urinary bladder. The internal sphincter is a continuation of the detrusor muscle and is made of smooth muscle, therefore it is under involuntary or autonomic control. This is the primary muscle for prohibiting the release of urine.
ANS control of the bladder: SNS (‘hold it’), PSNS (allows voiding) effects on internal sphincter
The internal sphincter is a continuation of the detrusor muscle and is made of smooth muscle, therefore it is under involuntary or autonomic control. This is the primary muscle for prohibiting the release of urine.
ANS control of the bladder: SNS (‘hold it’), PSNS (allows voiding) effects on detrusor
The smooth muscle of the bladder, known as the detrusor, is innervated by sympathetic nervous system fibers from the lumbar spinal cord and parasympathetic fibers from the sacral spinal cord.
What is the only anatomic part of voiding that is under somatic/voluntary control?
External urethral sphincter because it consists of skeletal muscle
Characteristics of urine (sterile)
Urine is an aqueous solution of greater than 95% water, with the remaining constituents, in order of decreasing concentration: urea chloride, sodium, potassium, creatinine and other dissolved ions, inorganic and organic compounds.

Urine is sterile until it reaches the urethra, where epithelial cells lining the urethra are colonized by Gram negative bacteria. Subsequent to elimination from the body, urine can acquire strong odors due to bacterial action and in particular the release of ammonia from the breakdown of urea.
Characteristics of urine (Specific Gravity)
The concentration of solutes in the urine relative to water

Normal= 1.010-1.030 (water=1.000)

The higher the solutes, the greater the specific gravity and vice
versa

-Dehydration = high specific gravity (concentrated)
-Overhydration = low specific gravity (dilute)


Protective mechanisms associated with urine
Act of voiding and the dilution of urine flushes out pathogens. Other factors include urine's acidic pH, osmolarity, and high concentration of UREA (protein metabolism end product). These characteristics of urine kill invading pathogens.
UTIs: compare gender anatomical differences for risk
Anatomically, women have a shorter urethera than men, which makes the bladder in shorter proximity to vaginal and perirectal areas, making for an easier colonization.
Risk factors for UTI for women
Sex, diaphragm, spermicides, pragnancy, HIV
Risk factors for UTI for men
Sex, uncircumcised, HIV, BPH, stones, or tumor
Risk factors for UTI for both genders…especially foley catheters
Diabetes, 50% of pts w/Foleys, stones, neurogenic bladder dysfuction (CVA, MS, spinal cord injury)
Signs/Symptoms of UTI
30% are without symptoms!

- Dysuria (painful urination), frequency, urgency, nocturia
- Fever is not a common presentation but can be present
- Low back pain, suprapublic discomfort
- Cloudy urine, “smells strong”
- Pyuria=WBCs in urine
Pyelonephritis: signs and symptoms—what is the HALLMARK symptom?
Infection of the renal pelvis, calices, parenchyma.

Hallmark: CVA tenderness (costovertebral angle tenderness)!!!

Others: Patient looks sick! Chills, fever, back pain, headache. Dysuria (painful urination), frequency, urgency, nocturia
UT obstruction: definition
Any interference with urine flow at any site along the urinary tract leading to accumulation of urine behind the obstruction
UT obstruction: hydronephrosis vs. hydroureter
Hydronephrosis: enlarged, swollen kidney from backed up urine

Hydroureter: complete obstruction of ureter; accumulation of urine, ureter distended
Consequences of obstruction
Both, hydronephrosis and hydroureter, can result in damage to the organ(s) involved.

Also, the consequence to any obstruction is back pressure into the kidney, which can decrease GFR, leading to renal failure.
Where do stones form?
Most stones are formed in the kidneys and are referred to as upper urinary tract stones

Other stones can form in the ureters or bladder and are called lower urinary tract stones
What is the most common type of kidney stone?
Calcium stones are the most common. About 80% of all kidney stones contain calcium.
Calcium Oxalate stones: risk factors for hypercalciuria
Several dietary factors besides calcium can contribute to hypercalciuria. These include animal protein, sodium, alcohol, caffeine, refined carbohydrates, fiber, oxalate, and fluids.
What characteristic of urine will favor calcium oxalate stone formation?
Since urine can be either basic or acidic, depending on hydration levels, an alkaline urine can favor calcium supersaturation and stone formation.
Uric Acid stones: significance of high purine diet
Formed due to high uric acid formation or decreased excretion

-Increased purine metabolism from high protein intake (rich meats, like liver) produces more uric acid.
What characteristic of urine will favor uric acid stone formation?
An acidic urine favors supersaturation and stone formation
What is a Staghorn calculus, and where does it commonly form?
Upper urinary tract stones that involve the renal pelvis and extend into at least 2 calyces are classified as staghorn calculi
What is the Staghorn calculus made from?
They are Struvite Stones, made up of magnesium-ammonium-phosphate mix and are generally caused by co-infection with Gram- bacteria.
Glomerulonephritis: definition
inflammation of the glomerulus
Glomerulonephritis is always accompanied by ____and ___
Low GFR and High creatinine
Cause of acute glomerulonephritis (organism)
Acute post-strep glomerulonephritis: Ab made to Strep pyogenes, standard strep throat pathogen
Mechanism of acute glomerulonephritis
Type III Hypersensitivity: Ag-Ab complex becomes trapped in the glomerulus, which kicks of an inflammatory reaction in the glomerulus:

- IgG-mediated, complement, histamine from mast cells, and damage from neutrophils releasing lysosomal chemicals
Glomerulonephritis “leakiness” allows what to happen?
- Glomerular integrity is compromised from the inflammatory reaction, which then activates the complement cascade, which further damages the glomerulus.

Glomerular damage allows for RBCs, WBCs, and protein to
appear in the urine (classic s/s). Blood cells can clump in specific renal vessels, taking the shape of that vessel becoming a cast.
Clinical Manifestations of glomerulonephritis
- Abrupt onset, 7-10 days s/p (status post or after) a common strep throat
- Hematuria, proteinuria
- Oliguria from lowered GFR (Oliguria= urine output <400mL/24 hours and Anuria= urine output <100mL /24 hours)
- RBC casts
- Edema from protein loss: periorbital, feet, ankles
- ↑ Lipids from reduced serum albumin
- HTN
- Increased BUN, creatinine
Why does edema happen in glomerulonephritis?
Less protein means less colloid osmotic pressure to hold fluid in vessels
Why are serum lipids raised in glomerulonephritis?
Liiver overproduces to compensate
Why does HTN happen in glomerulonephritis?
All the protein loss, provokes hypovolemia, which activates RAA. Thus, Na+ and water are retained.
Chronic Glomerulonephritis: definition
Fibrotic tissue development in the glomerulus leading to permanent decrease in GFR
Nephrotic syndrome: definition, clinical manifestations
Described as a loss of protein in the urine of >3-5gm/day. Mainly due from autoimmune problems: SLE glomerulonephritis, amylodosis, idiopathic glomerular injury
Nephrotic syndrome: clinical manifestations
- Hypovolemia
- Edema formation: Generalized from lack of oncotic pressure
- Protein malnutrition
- HTN
Where do casts form?
Urinary casts are formed only in the distal convoluted tubule (DCT) or the collecting duct (distal nephron)
Why do casts form?
Glomerular permeability results in plasma proteins developing proteinuria, a "glue" that cements urinary casts together.
What types of cells form casts?
RBC and WBC.

Tamm-Horsfall mucoproteins, albumin, & other globulins can form the glue.
Polycystic Kidney Disease: genetic, recessive or dominant?
Autosomal dominant pattern
What do the cysts do?
They are the leading causes of chronic renal failure
Where do the cysts form?
Development of renal cysts throughout cortex and medulla,
destroys normal nephrons.

Cysts swell and press against the renal capsule=extreme
pain.
Polycystic Kidney Disease: Clinical Manifestations
- Abdominal pain
- Hematuria, proteinuria, oliguria, anuria
- HTN – fluid retention
- Recurrent UTIs
- Anemia
ARF vs. CRF
Acute Renal Failure (ARF), rapid onset

Chronic Renal Failure (CRF), slow onset, develops over years
In ARF, what are 2 major problems that can kill your patient quickly?
Two major electrolyte problems that will kill your patient quickly :
- Hyperkalemia (high K+)
- Metabolic acidosis (high H+)
Pre‐renal ARF: what might cause it?
Etiology is “before” the kidney, 50% of all ARFs.

Generally caused by a decrease in renal perfusion, no tubular damage, but decreased GFR. It has multiple causes:

- Stenosis, embolism, thrombosis of the renal artery(ies) leads to renal hypoperfusion
- Congestive Heart Failure: LV not pushing enough blood forward into the kidneys
- MI, damaged LV, as above for CHF
- Cardiac dysrhythmias – poor rhythm, same as in CHF
- Hypovolemia from hemorrhage, vomiting, burns, anaphylaxis
- NSAIDS
What role does chronic NSAID use have in the potential development of pre‐renal ARF?
Renal PG maintains the vasodilation of the renal artery and the afferent arteriole. However, ibuprofen will inhibit this process causing vasoconstriction and hypoperfusion (only in patients predisposed to renal problems). The hypoperfusion kicks of RAA, angio II makes vasoconstriction worse.
Clinical Manifestations of pre‐renal ARF
- Decreased GFR
- Increased BUN, Creatinine (BUN, creatinine can be elevated in the face of dehydration or GI bleed). If BUN:creatinine ratio >15:1 the cause is prerenal ARF, Why? Decreased volume from vomiting, dehydration, diarrhea drops GFR. The decreased GFR causes an increased BUN reabsorption and increases
the ratio to creatinine
- Hyperkalemia, metabolic acidosis
- Tachycardia, decreased BP. Generally if ARF is from fluid, blood loss
- Decreased urine output. Oliguria , <400cc/day. Anuria, <100cc/day
- Azotemia
Intrarenal ARF: definition
Intrinsic to kidney itself. Generally caused by exposure to toxins, drugs, or autoimmune problems, such as SLE.
What is acute tubular necrosis? Definition and relation to hypoxia/ischemia
ATN is related to decreased GFR due to hypoxia/ischemia and tubular cell injury
Causes of ATN (esp. contrast media)
- Antibiotics: aminoglycosides, tetracyclines, penicillins
- Chemicals: carbon tetrachloride, methanol, ethylene glycol
- Heavy metal poisons: Hg, Pb, Chromium, arsenic
- Cyclosporine for transplant patients
- Rhabdomyelosis – from muscle crush injury, myoglobin released from muscles and can damage tubules
- Pesticides, fungicides
- X-ray contrast media, big cause!!
- Anesthetics
3 Stages of ARF
1. Oliguric: volume overload, ↑K+, metabolic acidosis
2. Diuretic: return of tubular patency
3. Recovery
Post‐renal ARF: definition, clinical manifestations
Postrenal Type, “beyond the bladder”, <5% of all ARFs

Usually related to a urinary tract obstruction that affects the kidneys bilaterally, i.e., urinary bladder cancer, stones, bladder
atony, cervical cancer, urethral stricture, BPH, prostate cancer
How does mental status change in ARF?
Mental status changes from hyponatremia
CRF: levels of GFR for renal insufficiency, renal failure
Progressive and irreversible loss of renal function, renal tissue
is often replaced with fibrotic scar tissue

First manifestation is renal insufficiency (GFR decreases by 75%)

Mild azotemia, polyuria, nocturia. It progresses to renal failure (GFR decreases by >90% of normal) and end-stage renal disease (ESRD) with a GFR <10ml/min

This is not adequate for the multiple body homeostatic functions

ESRD=>90% nephron loss or GFR lowers to 90%
What is ESRD?
End-stage renal disease (ESRD) with a GFR <10ml/min
2 major causes of CRF
Two major etiologies: HTN, DM
BPH: definition
Enlargement of the prostate (not cancer, but hyperplasia), as a result of age, exogenous drugs (testosterone) that puts increased pressure on the urethra. It causes decreased/interrupted urinary flow, inability to empty the bladder, increased frequency of elimination.

50% of men over 50 yrs have some degree of BPH.
BPH: symptoms
- Weak urinary stream
- Abdominal “pushing” to move urine
- Urinary hesitancy
- Incomplete bladder emptying
- Urgency, frequency, nocturia
- Urinary incontinence, retention
- Post renal ARF possible
Serum Creatinine
A break-down product of creatine phosphate in muscle, produced at a fairly constant rate by the body.

Creatinine is chiefly filtered out of the blood by the kidneys (glomerular filtration and proximal tubular secretion). There is little-to-no tubular reabsorption of creatinine. If the filtering of the kidney is deficient, creatinine blood levels rise. Therefore, creatinine levels in blood and urine may be used to calculate the creatinine clearance (CrCl), which reflects the glomerular filtration rate (GFR).
Serum BUN
Blood urea nitrogen measures the amount of nitrogen in the blood in the form of urea, and is a measurement of renal function. Urea is a by- product from metabolism of proteins by the liver and is removed from the blood by the kidneys.
Urinalysis: general things that should or should not be there (i.e., pyuria, bacteruria, hematuria)
If Pyuria (presence of WBCs) + bacteriuria +/- hematuria suspect a UTI

If hematuria, suspect stones.
UA for stones: what might be seen?
If hematuria, suspect stones and look for sedimentation/crystals to ID element. Also check pH to find reason for stone formation.

You may also find albuminuria, proteinuria, casts.
KUB
Kidney-Ureter-Bladder is a a plain frontal supine radiograph of the abdomen. It detects 90% of stones. They are radiopaque and can be seen on X-ray.
What is shock wave lithrotripsy?
Sound wave treatment to break stones in the kidney, bladder, or ureter.
PSA
Prostate specific antigen is often elevated in the presence of prostate cancer and in other prostate disorders.
Cystitis
A urinary bladder inflammation that results from any one of a number of distinct syndromes. It is most commonly caused by a bacterial infection in which case it is referred to as a urinary tract infection.
Pyelonephritis
An ascending urinary tract infection that has reached the pelvis of the kidney. It is a form of nephritis. Severe cases of pyelonephritis can lead to pyonephrosis (pus accumulation around the kidney), urosepsis (a systemic inflammatory response of the body to infection), kidney failure and even death.
Micturition
Urination is also known as micturition or voiding
Continence
The ability to voluntarily control urinary and fecal discharge.
Neurogenic Bladder
A problem in which a person lacks bladder control due to a brain or nerve condition.
Urolithiasis
Condition where urinary calculi are formed or located anywhere in the urinary system.The process of forming stones in the kidney, bladder, and/or ureters (urinary tract).
Dysuria
Painful urination described as a burning or stinging sensation.
Pyuria
Condition of urine containing pus.

Sterile pyuria is urine which contains white blood cells while appearing sterile by standard culturing techniques.
Frequency
Frequent, excessive urination.
Urgency
A sudden, compelling urge to urinate. It is often, though not necessarily, associated with urinary incontinence, polyuria, nocturia, and interstitial cystitis. It tends to increase with age. When uncontrollable, it causes urge incontinence.
Nocturia
The need to get up in the night to urinate, thus interrupting sleep. Its occurrence is more frequent in pregnant women and in the elderly.
CVA tenderness
Also known as Murphy's punch sign, is elicited when gently tapping the area of the back overlying the kidney producing pain in people with an infection around the kidney (perinephric abscess), pyelonephritis or renal stone.
Hydronephrosis
Distension and dilation of the renal pelvis and calyces, usually caused by obstruction of the free flow of urine from the kidney.
Hydroureter
Distention of the ureter with urine or watery fluid, due to obstruction.
Renal calculi
A kidney stone, also known as a renal calculus is a crystal aggregation formed in the kidneys from dietary minerals in the urine. Urinary stones are typically classified by their location in the kidney (nephrolithiasis), ureter (ureterolithiasis), or bladder (cystolithiasis), or by their chemical composition (calcium-containing, struvite, uric acid, or other compounds). Kidney stones are a significant source of morbidity. 80% of those with kidney stones are men.
Nephrolithiasis
Stone located in the kidney.
Nidus
A "nest" of crystals which grows, attracts other crystals to it, and continues to grow until it blocks an important channel, and obstructs urine flow.
Urine casts
They are cylindrical structures produced by the kidney and present in the urine in certain disease states. They form in the distal convoluted tubule and collecting ducts of nephrons, then dislodge and pass into the urine, where they can be detected by microscopy.

They form via precipitation of Tamm-Horsfall mucoprotein which is secreted by renal tubule cells, and sometimes also by albumin in conditions of proteinuria. Cast formation is pronounced in environments favoring protein denaturation and precipitation (low flow, concentrated salts, low pH). Tamm-Horsfall protein is particularly susceptible to precipitation in these conditions.
Oliguria
Low output of urine. It is clinically classified as an output below 300-500ml/day.
Anuria
Nonpassage of urine. In practice is defined as passage of less than 50 milliliters of urine in a day. Anuria is often caused by failure in the function of kidneys. It may also occur because of some severe obstruction like kidney stones or tumours. It may occur with end stage renal disease. It is a more extreme reduction than oliguria, sometimes called anuresis.
Proteinuria
Presence of an excess of serum proteins in the urine.

Up to 150 mg a day of protein may be excreted by a normal person, primarily the Tamm-Horsfall protein.
Hematuria
Presence of red blood cells in the urine. It may be idiopathic and/or benign, or it can be a sign that there is a kidney stone or a tumor in the urinary tract (kidneys, ureters, urinary bladder, prostate, and urethra), ranging from trivial to lethal. If white blood cells are found in addition to red blood cells, then it is a signal of urinary tract infection.
Azotemia
Medical condition characterized by abnormally high levels of nitrogen-containing compounds, such as urea, creatinine, various body waste compounds, and other nitrogen-rich compounds in the blood. It is largely related to insufficient filtering of blood by the kidneys.
Rhabdomyelosis
A condition in which damaged skeletal muscle tissue breaks down rapidly. Breakdown products of damaged muscle cells are released into the bloodstream; some of these, such as the protein myoglobin, are harmful to the kidneys and may lead to kidney failure.