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258 Cards in this Set

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Kidneys produce how many liters of fluid
180 L (45 gal)
How much of the filtrate is reabsorbed by the bloodstream?
99%
Where does most of the reabsorption of filtrate occur
proximal tubule and along the entire tubule
Where does filtrate become concentrated?
Distal tubule and collecting ducts
What causes the filtrate to become concentrated?
Hormonal influence
Becomes urine
What hormone is secreted by the posterior portion of the pituitary gland in response to changes in osmolality of the blood?
Antidiuretic hormone (ADH)
Antidiuretic hormone is also known as
vasopressin
What stimulates ADH release?
decreased water intake because the blood osmolality tends to increase
What suppresses ADH?
Excess water intake
Increased urine volume
diuresis
Pain
Dysuria
Early sign of kidney disease (Inability to concentrate and dilute urine) is a fixed specific gravity or fixed osmalality of
1.010 or 300 mOsm/L
Ratio of solute to water
osmolality
paramount for control of extracellular volume and both serum and urine osmolarity
regulation of salt and water
Filtrate in the glomerular capillary normally has the same osmolality as blood which is
280 to 300 mOsm/kg
Normal ingestion
1300 ml of oral and 1000 ml of water in food
how much water is lost
900ml through the skin and lungs (insensible), 50 ml through sweat and 200 ml through feces.
One pound
500 ml
Average american daily diet
6 to 8 gm of sodium chloride and potassium chloride (approx. same amounts excreted in urine).
Regulation of sodium volume depends on
Aldosterone
A hormone synthesized and released from the adrenal cortex
aldosterone
Less sodium is excreted in the urine, because aldosterone fosters renal reaborsption....what causes less sodium excretion
Increased aldosterone
Release of aldosterone from the adrenal cortex is under the control of
Angiotensin II
Agiotensin II levels are under the control of
Renin
An enzyme that is released from specialized cells in the kidneys
Renin
What happens when pressure in the renal arterioles falls below normal (shock, dehydration)
Renin, Angiotesin II
Activation of this system causes
the retention of water and expansion of the intravascular fluid volume
Normal serum pH
7.35 to 7.45
The kidneys maintain normal serum levels by
Reabsorbing and returning to the body any bicarbonate from the urinary filtrate
The kidneys also maintain normal serum levels by
excreting acid in the urine
Small ion, freely filtered in the glomerulus
Bicarbonate
Bicarbonate is actively reabsorbed by
the renal tubules
Replacement of lost bicarbonate
the renal tubular cells generate new bicarbonate
Body's acid production
Catabolism
Catabolism
breakdown of proteins producing acid compounds in particular phosphoric and sulfuric acids.
Cannot be eliminated by the lungs
Phosphoric and sulfuric acid
Accumulation of phosphoric and sulfuric acid
Lowers pH (making the blood more acidic) inhibiting cell function - must be excreted
A normal person excretes how much acid each day?
70 mEq
Excess acids are bound to chemical buffers known as
phosphate ions and ammonia
When buffered with acid ammonia becomes
ammonium
Phosphate is present in the
glomerular filtrate
Ammonia is produced by the
cells of the renal tubules
Ammonia is secreted into
the tubular fluid
Through this buffering process, the kidney is able to excrete large quantities of
acid in bound form (does not lower pH)
Regulation of blood pressure
important function of the kidney
What specialized cells in the kidney regulate bp?
Vasa Recta
What happens when the vasa recta detect a decrease in bp?
specialized juxtaglomerular cells called denta cells near the afferent, efferent and distal tubule - secrete renin
Renin converts
angiotensinogen to angiotensin I which is then converted to angiotensin II
Angiotensin II
most powerful vasoconstrictor known; increases blood pressure
When the vasa recta detect an increase in bp what happens
renin secretion stops
Renal clearance is the
ability of the kidneys to clear solutes from the plasma
One particular useful measure for renal clearance
creatinine
creatinine is an
endogenous waste product of skeletal muscle
where is creatinine filtered
at the glomerulus
where is creatinine excreted
rine
creatine is a good measure of
GFR
Adult GFR
125 mL/min
200 mL/min
When the kidney detect a decrease in the oxygen tension in renal blood flow they release
erythropoietin
Erythropoietin is a
glycoprotein from the kidney sthat simulates the blood marrow to produce RBC's to carry oxygen throughout the body
The kidneys are also responsible for the final conversion of which vitamin?
Vitamin D to its active form, 1,25-dihydroxycholecalciferol
The kidneys are also responsible to produce
prostaglandin E and prostacyclin
Prostaglandin E and prostacyclin have a
vasodilatory effect and are important in maintaining renal blood flow
Major waste product of protein metabolsim is
urea
how much urea is excreted daily?
25 to 30 g
What must be excreted daily?
Urea
Other waste products of metabolism that must be excreted are
creatinine, phosphates and sulfates and uric acid (a waste product of purine metabolism)
The kidneys serve as the primary mechanism for excreting drug
metabolites
Bladder
reservoir for urine
Bladder filling and emptying mediated by
coordinated sympathetic and parasympathetic nervous system control mechanism involving the detrusor muscle and the bladder outlet
Conscious awareness of bladder filling
sympathetic neuronal pathways that travel via the spinal cord to the level of T10 through T12.
Which nerve innervations allows for continued bladder filling?
Peripheral, hypogastric nerve
As the bladder fills, stretch receptors are activated in the bladder wall this information is relayed from
the detrusor muscle to the cerebral cortex via the parasympathic pelvic nerves at the level of S1 through S4.
Bladder compliance is due in part to
the smooth muscle lining of the bladder and collagen deposits within the wall of the bladder
Bladder compliance is also in part due to
neuronal mechanism that inhibit the detrusor muscle from contracting
What keeps the detrusor muscle from contracting?
adrenergic receptors that mediate relaxation
Bladder pressure during filling must remain lower than
40 cm H2O
The low pressure in the bladder allows
urine to freely leave the renal pelvis and enter the ureters
When is the sensation of bladder fullness transmitted to the CNS?
when the bladder has reached about 150 to 200 mL in adults
Marked sense of fullness occurs at
300 mL to 500 mL
What causes and absent sense to void?
neurologic changes to the bladder at the level of the supraspinal nerves, the spinal nerves or the bladder wall itself
Micturition
normally occurs approximately 8 times in a 24-hour period
What happens at night to decrease the production of urine
the release of vasopressin - makes urine more concentrated
Nocturia
decrease of vasopressin
Micturition is activated at the
micturition reflex arc within the parasympathetic and sympathetic nervous systems
Initiation of voiding occurs
when the efferent pelvic nerve, which originates in the S1 to S4 area, stimulates the bladder to contract, resulting in complete relaxation of the striated urethral sphincter.
After the inititation begins there is a decrease
in urethral pressure, contraction of the detrusor muscle, opening of the vesicle neck and proximal urethra and then a flow of urine.
This coordination effort to produce urine voiding is by the
parasympathetic system which is mediated by muscarinic and, to a lesser extent, cholinergic receptors within the detrusor muscle.
Pressure generated in female bladders is
20 to 40 cm H2O
Obstruction of the bladder outlet such as in
advanced benign prostatic hyperplasia (BPH) resulting in high voiding pressure - more difficult to start urine flow and maintain it.
GFR decreases between age
35 and 40 and then a yearly decline
Elderly acute and chronic renal failure:
sclerosis of the glomerulus and renal vasculature, decreased blood flow, decreased GFR, altered tubular function, and acid-base balance
Renal function is elderly remains normal but
renal reserve is decreased and may reduce the kidney's ability to respond effectively to drastic or sudden changes
Elderly also experience
decrease in glomerular filtration, combined with multiple medications in which metabolites are cleared by the kidneys placed elderly at risk for drug-drug interactions
Elderly decreased thirst may develop
hypernatremia - almost never occurs younger than 60
Elderly women
vaginal and urethral tissues atrophy (become thinner) due to decreased estrogen levels
Decreased estrogen levels causes
decreased blood supply to the urogenital tissues resulting in urethral and vaginal irritation and urinary incontinence
multiparous women delivering their children vaginally have a high risk for
stress urinary incontinence
elderly women and people with neurologic disorders such as diabetic neuropathy, multiple sclerosis (MS), or Parkinson's disease
often have incomplete emptying of the bladder and urinary stasis which may lead to urinary tract infection or increasing bladder pressure leading to overflow incontinence, hydronephrosis, pyelonephritis, or chronic kidney disease.
Anuria
decrease urine production
Kidney disease does not always involve
pain
Enuresis
involuntary voiding during sleep
polyuria
increased volume
oliguria
less than 500 mL/day
anuraia
less than 50 ml/day
anemia of chronic disease
a/k/a gradual kidney dysfunction...fatigue, shortness of breath, exercise intolerance
best test for gradual kidney dysfunction
hemoglobin level (better assessment of oxygen transport ability of the blood)
upper and lower urinary assessment
abdomen, suprapubic region, genitalia, lower back and lower extremities
Kidneys are not usually palpable, however,
palpation of the kidneys may detect enlargement that could prove to be very important
Palpation of kidney
place on hand under the patient's back with the fingers under the lower rib, place the palm of the other hand anterior to the kidney with fingers about the umbilicus, push the hand on top forward as the patient inhales deeply.
Renal dysfunction may produce tenderness over the
costovertebral angle (formed by the lower border of the 12th, or bottom, rib and the spine
Abdomen ausculated to assess for bruits
(low pitched murmurs that indicate renal artery stenosis or an aortic aneurysm)
Abdomen also assessed for the presence of
ascites (accumulation of fluid in the peritoneal cavity).
To check for residual urine
the bladder should be percussed after the patient voids
Percussion of the bladder begins at the
midline just above the umbilicus and proceeds downward...Sound changes from tympanic to dull
Dullness to percussion of the bladder after voiding indicates
incomplete bladder emptying.
In older men, BPH or prostatis can cause difficulty with
urination
Prostate gland palpated by
digital rectal examination (DRE)
Prostate gland exam
men over 40
prostate gland includes a blood specimen to test the
prostate-specific antigen (PSA).....PSA is checked before the DRE because manipulation of the prostate can cause the PSA level to increase temporarily.
Inguinal area is examined for
enlarged nodes, an inguinal or femoral hernia, and variococele (varicose veins of the spermatic cord)
Uretrha
palpated for diverticula
Vagina assessed for
adequate estrogen effect and any of 5 types of herniation
urethrocele
bulging of the anterior vaginal wall into the urethra
cystocele is
the herniation of the bladder wall into the vaginal vault
pelvic prolapse
bulging of the cervix into the vaginal vault
Enterocele
herniation of the bowel into the posterior vaginal wall
rectocele
herniation of the rectum into the vaginal wall
To assess the urethra's system of muscular and ligament support
the women is asked to cough and perform a valsalva maneuver
Marshall-Boney maneuver
when urine leakage occurs, the index and middle fingers are used to support either side of the urethra and the women repeats....if urine leakage, referral
urine culture
determines whether bacteria are present as well as their strains and concentrations
urine culture and sensitivity
identify the antimicrobial therapy that is best suited for the particular strains
Urine exams include the following:
urine color, clarity, odor, pH, specific gravity, protein, glucose, glycosuria, ketonuria
Microscopic examination of the urine sediment after centrifugation to detect
RBCs (hematuria), white blood cells (pyuria), casts (cylindruria, crystals (crystalluria, and bacteria (bacteriuria
additional studies possible (urine telomerase activity)
may detect bladder cancer in men
Normally about 1 million
RBCs pass into the urine daily (1 to 3 RBCs per high power field)
Hematuria
(more than three RBCs per high-power field)...more common in women
causes of hematuria
acute infection (cystitis, urethritis, or prostatitis, renal calculi, and neoplasm
other causes include systemic disorders
bleeding disorders, malignant lesions, medications (warfarin (coumadin) and heparin (heparin sodium)
Kidney protected by
renal fascia made of connective tissue
Renal parenchyma is divided into two parts:
cortex and medulla
Medulla contains the
loop of Henle, vasa recta, collecting ducts of the juxtamedullary nephrons
Collecting ducts from the juxtamedullary and the cortical nephrons connect the
renal pyramids
Each kidney contains how many pyramids
8-18
The pyramids drain into
minor calices
minor calices drain into
major calices
major calices open directly into the
renal pelvis
Cortex is located
farthest from the center of the kidney and around the outermost edges contains the NEPHRONS
Each kidney has how many nephrons
1 million located within the renal parenchyma
Proteinuria may be a benign finding or
may signifiy serious disease
Occasional loss of 150 mg/day of protein in the urine, primarily albumin and Tamm-Horsfall protein (also known as uromodulin) is considered
normal
Dipstick exam does not detect protein concentrations of less than 30mg/dL so this test cannot be used
for early detection of diabetic neuropathy
early sign of diabetic nephropathy
microalbuminuria (excretion of 20 to 200 mg/dL of protein in the urine)
causes of persistent proteinuria include
glomerular diseases, malignancies, collagen diseases, diabetes mellitus, preeclampsia, hypothyroidism, and use of meds (NSAIDS) non-steroidal anti-inflammatory drugs and angiotensin-converting enzyme (ACE) inhibitors.
Specific gravity
measures the density of a solution compared to the density of water
Specific gravity is altered by the presence of
blood, protein, and casts in the urine
Normal range specific gravity
1.010 to 1.025
Specific gravity methods
Multiple test dipstick, urinometer, refractometer (measures differences in speed of light)
Fluid increases or decreases causes what effect on specific gravity?
Decreased liquid, specific gravity increases. Increased liquid, specific gravity decreases.
Kidney disease (specific gravity) changes?
Specific gravity does not change known as fixed specific gravity
Kidney disease (specific gravity) changes?
Specific gravity does not change known as fixed specific gravity
Disorders decreased specific specific gravity
diabetes insipidus, glomerulonephritis, and severe renal damage
Disorders decreased specific specific gravity
diabetes insipidus, glomerulonephritis, and severe renal damage
Disorders increased specific gravity
diabetes mellitus, nephritis and fluid deficit
Disorders increased specific gravity
diabetes mellitus, nephritis and fluid deficit
Osmolality
most accurate measurement of the kidney's ability to dilute and concentrate urine
Healthy human osmolality
Serum: 280 to 300 mOsm/kg
Urine: 200 to 800 mOsm/kg
Osmolality
most accurate measurement of the kidney's ability to dilute and concentrate urine
24-hour urine sample normal value
300 to 900 mOsm/kg
Healthy human osmolality
Serum: 280 to 300 mOsm/kg
Urine: 200 to 800 mOsm/kg
Renal function tests
used to evaluate the severity of kidney disease and the pt's kidney function
24-hour urine sample normal value
300 to 900 mOsm/kg
Common tests of renal function include
renal concentration tests, creatinine clearance and serum creatinine and blood urea nitrogen levels and serum electrolyte levels
Renal function tests
used to evaluate the severity of kidney disease and the pt's kidney function
Ultrasonography is a
noninvasive procedure to detect abnormalities such as fluid accumulation, masses, congenital malformations, changes in organ size, and obstructions
Common tests of renal function include
renal concentration tests, creatinine clearance and serum creatinine and blood urea nitrogen levels and serum electrolyte levels
Ultrasonography requires a
full bladder
Ultrasonography is a
noninvasive procedure to detect abnormalities such as fluid accumulation, masses, congenital malformations, changes in organ size, and obstructions
Ultrasonography requires a
full bladder
Bladder ultrasonography
noninvasive method of measuring urine volume in the bladder
Bladder ultrasonography may be indicated for
urinary frequency, inability to void after removal of an indwelling catheter, measurement of postvoiding residual urine volume, inability to void postoperatively or assessment of the need for catheterization.
Computed tomography (CT) scans and magnetic resonance imaging (MRI) are noninvasive techniquest that provide
excellent cross sectional views of the anatomy of the kidney and urinary tract.
CT's and MRI's are used to detect
genitourinary masses, nephrolithiasis, chronic renal infections, renal or urinary tract trauma, metastatic disease and soft tissue abnormalities
Patches such as nicotine and nitroglycerine that have a metal backing must be
removed as they can cause burns
Cochlear implants are inactivated by
an MRI, therefore, other imaging procedures are considered
Prior to MRI the patinent must be informed to
avoid alcohol, caffeine-containing beverages, and smoking for at least 2 hours and no iron supplements
Nuclear scans require an injection of a
radioisotope into the circulatory system...the isotope is then monitored as it moves....the technetium scan provides info about kidney perfusion....the renal scan provides info about kidney function such as the GFR
Nuclear scans are used to evaluate
actue and chronic renal failure, renal masses, and blood flow before and after kidney transplantation.....the patient is encourage to drink fluids to promote excretion.
IV urography includes various tests such as
excretory urography, intravenous pyelography and infusion drip pyelography
A radiopaque contrast agent is administered by
IV
An IVP shows the
kidneys, ureter and bladder via x-ray imaging as the dye moves through the upper and lower urinary system
A nephrdyotomogram may be carried out as part of the studyto visualize
different layers of the kideny and the diffuse structures within each layer and to differentiate solid masses
IV urography may be used as the initial assessment of many urologic conditions
lesions in the kedneys and ureters, renal function, multiple x-rays are obtained to visualize drainage structures in the upper and lower urinary system
Infusion drip pyelography requires IV infusion of a large volume of a dilute contrast agent to
opacify the renal parenchyma and fill the urinary tract - used when prolonged opacification of the drainage structures is desires so that tomograms can be made.
In retrograde pyelography
catheters are advanced through the ureteres into the reanl pelvis by means of cystoscopy
cystography aids in evaluating
vesicoureteral reflux (backflow of urine from the bladder into one or both ureters)
In cystography, a catheter is
inserted into the bladder and a contrast agent is instilled to outline the bladder wall
The contrast agent may leak through a small bladder perforation
but such leakage is harmless
Voiding cystourethrography uses
fluoroscopy to visualize the lower urinary tract and assess urine storage in the bladder.
A radiopaque contrast agent is administered by
IV
An IVP shows the
kidneys, ureter and bladder via x-ray imaging as the dye moves through the upper and lower urinary system
A nephrdyotomogram may be carried out as part of the studyto visualize
different layers of the kideny and the diffuse structures within each layer and to differentiate solid masses
IV urography may be used as the initial assessment of many urologic conditions
lesions in the kedneys and ureters, renal function, multiple x-rays are obtained to visualize drainage structures in the upper and lower urinary system
Infusion drip pyelography requires IV infusion of a large volume of a dilute contrast agent to
opacify the renal parenchyma and fill the urinary tract - used when prolonged opacification of the drainage structures is desires so that tomograms can be made.
In retrograde pyelography
catheters are advanced through the ureteres into the reanl pelvis by means of cystoscopy
cystography aids in evaluating
vesicoureteral reflux (backflow of urine from the bladder into one or both ureters)
In cystography, a catheter is
inserted into the bladder and a contrast agent is instilled to outline the bladder wall
A radiopaque contrast agent is administered by
IV
The contrast agent may leak through a small bladder perforation
but such leakage is harmless
A radiopaque contrast agent is administered by
IV
An IVP shows the
kidneys, ureter and bladder via x-ray imaging as the dye moves through the upper and lower urinary system
Voiding cystourethrography uses
fluoroscopy to visualize the lower urinary tract and assess urine storage in the bladder.
An IVP shows the
kidneys, ureter and bladder via x-ray imaging as the dye moves through the upper and lower urinary system
A nephrdyotomogram may be carried out as part of the studyto visualize
different layers of the kideny and the diffuse structures within each layer and to differentiate solid masses
A nephrdyotomogram may be carried out as part of the studyto visualize
different layers of the kideny and the diffuse structures within each layer and to differentiate solid masses
IV urography may be used as the initial assessment of many urologic conditions
lesions in the kedneys and ureters, renal function, multiple x-rays are obtained to visualize drainage structures in the upper and lower urinary system
IV urography may be used as the initial assessment of many urologic conditions
lesions in the kedneys and ureters, renal function, multiple x-rays are obtained to visualize drainage structures in the upper and lower urinary system
Infusion drip pyelography requires IV infusion of a large volume of a dilute contrast agent to
opacify the renal parenchyma and fill the urinary tract - used when prolonged opacification of the drainage structures is desires so that tomograms can be made.
A radiopaque contrast agent is administered by
IV
Infusion drip pyelography requires IV infusion of a large volume of a dilute contrast agent to
opacify the renal parenchyma and fill the urinary tract - used when prolonged opacification of the drainage structures is desires so that tomograms can be made.
An IVP shows the
kidneys, ureter and bladder via x-ray imaging as the dye moves through the upper and lower urinary system
In retrograde pyelography
catheters are advanced through the ureteres into the reanl pelvis by means of cystoscopy
In retrograde pyelography
catheters are advanced through the ureteres into the reanl pelvis by means of cystoscopy
A nephrdyotomogram may be carried out as part of the studyto visualize
different layers of the kideny and the diffuse structures within each layer and to differentiate solid masses
cystography aids in evaluating
vesicoureteral reflux (backflow of urine from the bladder into one or both ureters)
cystography aids in evaluating
vesicoureteral reflux (backflow of urine from the bladder into one or both ureters)
IV urography may be used as the initial assessment of many urologic conditions
lesions in the kedneys and ureters, renal function, multiple x-rays are obtained to visualize drainage structures in the upper and lower urinary system
In cystography, a catheter is
inserted into the bladder and a contrast agent is instilled to outline the bladder wall
In cystography, a catheter is
inserted into the bladder and a contrast agent is instilled to outline the bladder wall
The contrast agent may leak through a small bladder perforation
but such leakage is harmless
Infusion drip pyelography requires IV infusion of a large volume of a dilute contrast agent to
opacify the renal parenchyma and fill the urinary tract - used when prolonged opacification of the drainage structures is desires so that tomograms can be made.
The contrast agent may leak through a small bladder perforation
but such leakage is harmless
Voiding cystourethrography uses
fluoroscopy to visualize the lower urinary tract and assess urine storage in the bladder.
In retrograde pyelography
catheters are advanced through the ureteres into the reanl pelvis by means of cystoscopy
Voiding cystourethrography uses
fluoroscopy to visualize the lower urinary tract and assess urine storage in the bladder.
cystography aids in evaluating
vesicoureteral reflux (backflow of urine from the bladder into one or both ureters)
A radiopaque contrast agent is administered by
IV
In cystography, a catheter is
inserted into the bladder and a contrast agent is instilled to outline the bladder wall
An IVP shows the
kidneys, ureter and bladder via x-ray imaging as the dye moves through the upper and lower urinary system
The contrast agent may leak through a small bladder perforation
but such leakage is harmless
Voiding cystourethrography uses
fluoroscopy to visualize the lower urinary tract and assess urine storage in the bladder.
A nephrdyotomogram may be carried out as part of the studyto visualize
different layers of the kideny and the diffuse structures within each layer and to differentiate solid masses
IV urography may be used as the initial assessment of many urologic conditions
lesions in the kedneys and ureters, renal function, multiple x-rays are obtained to visualize drainage structures in the upper and lower urinary system
Infusion drip pyelography requires IV infusion of a large volume of a dilute contrast agent to
opacify the renal parenchyma and fill the urinary tract - used when prolonged opacification of the drainage structures is desires so that tomograms can be made.
In retrograde pyelography
catheters are advanced through the ureteres into the reanl pelvis by means of cystoscopy
cystography aids in evaluating
vesicoureteral reflux (backflow of urine from the bladder into one or both ureters)
In cystography, a catheter is
inserted into the bladder and a contrast agent is instilled to outline the bladder wall
The contrast agent may leak through a small bladder perforation
but such leakage is harmless
Voiding cystourethrography uses
fluoroscopy to visualize the lower urinary tract and assess urine storage in the bladder.
A radiopaque contrast agent is administered by
IV
An IVP shows the
kidneys, ureter and bladder via x-ray imaging as the dye moves through the upper and lower urinary system
A nephrdyotomogram may be carried out as part of the studyto visualize
different layers of the kideny and the diffuse structures within each layer and to differentiate solid masses
IV urography may be used as the initial assessment of many urologic conditions
lesions in the kedneys and ureters, renal function, multiple x-rays are obtained to visualize drainage structures in the upper and lower urinary system
Infusion drip pyelography requires IV infusion of a large volume of a dilute contrast agent to
opacify the renal parenchyma and fill the urinary tract - used when prolonged opacification of the drainage structures is desires so that tomograms can be made.
In retrograde pyelography
catheters are advanced through the ureteres into the reanl pelvis by means of cystoscopy
cystography aids in evaluating
vesicoureteral reflux (backflow of urine from the bladder into one or both ureters)
In cystography, a catheter is
inserted into the bladder and a contrast agent is instilled to outline the bladder wall
The contrast agent may leak through a small bladder perforation
but such leakage is harmless
Voiding cystourethrography uses
fluoroscopy to visualize the lower urinary tract and assess urine storage in the bladder.