Urinary System Disorders

Dahler Bahrun,Sp A(K

Overview
Incontinence and
Retention
Diagnostic Tests
Urinalysis
Blood tests
Other tests

Diuretic Drugs
Dialysis
Disorders of the Urinary
System
Urinary Tract Infections
Inflammatory Disorders
Glomerulonephritis

Urinary Tract
Obstructions
Urolithiasis
Tumors

Renal Failure
Acute
Chronic

Incontinence and Retention

Loss of voluntary control
of bladder
Stress incontinence
Increase in intra-abdominal
pressure
Forces urine through
sphincter
Laughing
Coughing
Females weakened

Spinal cord injuries, brain

damage

Inability to empty bladder

May accomp overflow
incontinence
Spinal cord injury
Inability to control
managed by pads, briefs
Catheter
Tube inserted in urethra
Drains urine from bladder
to collecting bag
Common source of UTI

Catheter

Diagnostic TestsUrinalysis
Constituents, characteristics of urine vary w/
dietary intake, drugs, care of specimen
Normally clear, straw-colored; pH 4.5-8.0
Appearance
Cloudy
Presence of lg amts protein, blood cells, bacteria, pus

Dark color
Hematuria (blood), excessive bilirubin, high concentration of
urine

Unpleasant, unusual odor

infection

Diagnostic TestsUrinalysis

Abnormal constituents (high in numbers)

Blood (hematuria)
Small, microscopic amts
Infection, inflammation, tumors of UT

Lg # RBC
Increased glomerular permeability or hemorrhage in tract

Protein (Proteinuria)
Leakage of albumin into filtrate
Inflammation, increased glomerular permeability

Bacteria (Bacteriuria) and Pus (Pyuria)

Indicates UTI

Urinary casts
Microscopic mold of tubules
Consists of one or more cells, bacteria, protein

Inflammation of tubules

Specific gravity
Ability of tubules to concentrate urine
Low is related to renal failure

RBC Cast

Diagnostic TestsBlood Tests

High serum urea and creatinine

Indicate failure to excrete N wastes
Due to low GFR

Metabolic acidosis
Indicates low GFR, failure of tubules to control acid/base balance

Anemia
Indicates low erythropoietin secretion and/or bone marrow depression
Due to accumulating wastes

Electrolytes
Antibody level
Antistreptolysin O (ASO) or antistreptokinase (ASK)

Renin levels
Indicate cause of hypertension

Diagnostic TestsOther Tests

Culture and sensitivity tests

Urine specimens
ID organism and select drug treatment

Clearance tests
Creatinine, insulin clearance
Used to asses GFR

Radiologic tests

Intravenous pyelography (IVP)

Angiography
Ultrasound
CT, MRI
Used to visualize structures and abnormalities

Cytoscopy
Visualize lower UT
Can be used to perform biopsy or remove kidney stones

Biopsy
Acquire tissue specimen for microscopic analysis

IVP (Intravenous Pyelography)

Angiography, Ultrasound

CT

CT, MRI

Diuretic Drugs
Removes excess Na ion and water from body
Increase excretion of water thru kidneys and urinary vol

Take in morning
Prescribed for many disorders
Renal disease, hypertension, edema, CHF, pulmonary edema

Most commonly used drug group inhibits NaCl

reabsorption
Major side effect is excess loss of electrolytes
Many cause excessive loss of potassium
Cause muscle weakness or cardiac arrhythmias

Dialysis
Provides artificial kidney
Sustains life after kidney fails
Acute renal failure or end-stage renal failure (those
waiting for a transplant)

2 forms
Hemodialysis
Peritoneal dialysis

Hemodialysis
Hospital, dialysis center
Pts blood moves from implanted shunt in arm
artery tube machine exchange of
wastes, fluids, electrolytes
Semipermeable membrane separates pts blood from
dialysis fluid
Constituents move between the 2 compartments
Ex: wastes in blood dialysate
bicarbonate in dialysate blood
Blood cells, proteins remain in blood
Movement by ultrafiltration, diffusion, osmosis
Blood to pt vein

Hemodialysis
Heparin (anticoagulant)
Required 3Xs/week for 3-4 hrs
Potential complications
Shunt becomes infected
Blood clot forms
Blood vessels become damaged
Must move to new site

Increased risk of hepatitis, HIV

Peritoneal Dialysis

Administered in unit or at home

At night or continuously
CAPD (continuous ambulatory peritoneal dialysis)

Peritoneal membrane serves as semipermeable membrane

Catheter w/ entry and exit points implanted
Dialyzing fluid instilled in catheter into cavity
Remains there
Allows exchange of wastes and electrolytes to occur
Dialysate drained from by gravity from cavity into container

Requires more time than hemo

b/c continuous exchange, prevents sudden changes in fluid and
electrolyte levels
Complications
Infection in peritoneal cavity

Peritoneal Dialysis

Disorders of the Urinary System:

Urinary Tract Infections (UTI)
Very common
Urine is excellent medium for
microorganismal growth
Escherichia coli

Most are ascending

Perineal cavity mucosa bladder
ureters kidneys

UTIEtiology
Females more anatomically vulnerable
Short urethra
Proximity to anus
Frequent irritation to tissues
Tampons, bubble bath, sexual activity

Older males with prostatic hypertrophy

and retention of urine prone to UTI

UTIEtiology

Incontinence
Bladder retention of urine
Obstruction of urine flow
Congenital abnormality
Pregnancy, scar tissue, kidney stones,
vesicourethral reflex
Urine does not flow freely

Decreased host resistance (immunosuppression)

Impaired blood supply to bladder (aging)
Diabetes mellitus

UTI: CystitisPathophysiology
Bladder wall and urethra inflamed, red, swollen
Decreased bladder capacity

UTI: CystitisSigns and

Symptoms
Pain in lower abdomen
Dysuria, frequency, urgency
Inflammation of bladder wall irritated by urine

Systemic signs of infection

Cloudy urine with unusual odor
Urinalysis indicates bacteria
(+100,000/mL), pyuria, microscopic
hematuria

UTI: Pyelonephritis
Pathophysiology
1 or both kidneys involved
Infection from ureter renal pelvis medullary
tissue (tubules and interstitial)
Purulent exudate fills kidney pelvis and calyces
Abscess and necrosis seen in medulla
May extend thru cortex to capsule
Severe may compress renal artery and vein and
obstruct urine flow to ureter
Bilateral obstruction results in acute renal failure

Recurrent chronic infection

Can lead to fibrous tissue over calyx
Loss of tubule function

UTI: PyelonephritisSigns and

Symptoms
Signs of cystitis
Pain
Dull aching in lower back
Results from renal capsule
stretching

Urinalysis
Similar to cystitis
Except urinary cast
Leukocytes or renal
epithelial cells present
Involvement of renal
tubules

UTITreatment
Antibiotics (Bactrim)
Increase fluid intake
Especially cranberry juice
Tannin decreases ability of E. coli to adhere to
bladder mucosa

Infection reoccurs unless predisposing

factors removed

Disorders of the Urinary System:

Inflammatory Disorders
Glomerulonephritis
Many forms
Acute Poststreptococcal Glomerulonephritis
(APSGN)
Follows streptococcal infection
Originates as upper resp infection, middle ear
infection, strep throat
Primarily affects kids 3-7 (especially boys)

develops 2 weeks after previous infection

Inflammatory Diseases:
Glomerulonephritis
Pathophysiology

Antistreptococcal antibodies create antigen-antibody

complex
Type III hypersensitivity rxn
Lodge in glomerular capillaries
Cause inflammation in both kidneys
Increase cap perm and cell proliferation
Leakage of proteins and erythrocytes into filtrate

Severe inflammation
Congestion and proliferation interfere w/ filtration in kidney
Decrease GFR and retention of fluid and wastes

If blood flow impaired, acute renal failure

Low blood flow increase renin increase bp and edema

Scar tissue on kidney

GlomerulonephritisSigns and
Symptoms
Back pain
Stretching renal capsule

Dark, cloudy urine

Oliguria
Facial edema, then generalized
Low osmotic pressure of blood
Salt, water retention

Generalized signs of inflammation

Increased bp

GlomerulonephritisDiagnostic
Tests
Blood tests
High serum urea and creatinine and
decreasing GFR
Streptococcal antibodies, ASO, ASK
Metabolic acidosis
Low serum bicarbonate, low pH

Urinalysis
Confirms presence of proteinuria, erythrocyte
casts

GlomerulonephritisTreatment

Sodium restriction
Glucocorticoids
Antibiotics
Recovery w/ minimal damage
Imp to prevent further exposure to streptococcal
infection and recurrent inflam
Adults more difficult
Acute renal failure in 2%
Chronic glomerulonephritis in 10%
Gradually destroys kidneys

Postrecovery testing should be done

Urinary Tract Obstructions:

Urolithiasis
Also called:
Calculi
Kidney stones

Frequently reoccur if
not treated

CalculiPathophysiology
Can develop anywhere in UT; lg or small
Once any solid material or debris forms
Tend to form when:
excessive amts of relatively insoluble salts are in filtrate
Insufficient fluid intake creates highly concentrated filtrate

75% composed of calcium salts

Remainder: uric acid, struvite, oxalate

Usually cause manifestations only when obstruct flow of

urine
Infection if stasis of urine

Kidney StonesPathophysiology:
Types of Stones
Calcium stones
Form when calcium levels high in urine
Hypercalcemia

Mixed inorganic salts

Infection
Debris from infection begin deposition of crystals

Urine pH alkaline

Uric acid stones

Develop w/ hyperuricemia
Due to gout, cancer chemo

Calcium oxalate
Certain vegetarian diets
High levels of oxalate in urine

Kidney Stones

CalculiSigns and Symptoms

Stones in kidney/bladder frequently
asymptomatic
Obstruction of ureter causes attack
renal colic
Consists of intense spasms in back and groin
Pain caused by vigorous contractions of ureter
Effort to pass the stone

CalculiTreatment
Small stones eventually passed out
Larger stones
Extracorporeal shock-wave lithotripsy (ESWL)
Decreases need for invasive surgery

Some drugs can partially dissolve

Need to prevent recurrences

ESWL

Urinary Tract Obstructions: Tumors

Renal Cell Carcinoma
Primary, silent tumor
Arises from tubule epithelium
Asymptomatic in early stage
Often metastize to liver, lungs, bones, CNS at time of diagnosis

Common after 50
More freq in males and smokers

Initial sign is painless hematuria

Other manifestations
Dull aching flank pain, palpable mass, anemia

Treatment is kidney removal

5 yr survival rate 50%

Renal Failure: Acute Renal Failure

Pathophysiology

May fail suddenly for different reasons

Failure reversible if primary problem successfully treated
Dialysis required
Develops rapidly
Either:
Directly decreases blood flow to kidney
Inflammation and necrosis of tubules cause obstruction and
back pressure
Greatly decreases GFR and oliguria

Blood tests show high N (kidneys not removing wastes)

If cause not promptly treated, chronic

Acute Renal FailureEtiology

Acute bilateral kidney disease
Glomerulonephritis
Low GFR

Severe prolonged circulatory shock or heart failure

Results in tissue necrosis
Burns: Hb accum in tubules = obstruction

Nephrotoxins
Drugs, chemicals, toxins
Aspirin, NSAIDs, penicillin

Cause tubule necrosis and obstruction of blood flow

Mechanical obstruction
Calculi, blood clots, tumors
Block urine from leaving kidney

Acute Renal FailureTreatment

Important to reverse primary problem
quickly
Dialysis
Recovery evidenced by increased urine
output
May take couple months before renal tubules
fully recover

Chronic Renal Failure

Pathophysiology
Gradual, irreversible destruction of kidney nephrons
May result from:
Chronic kidney disease
Bilateral pyelonephritis

Systemic disorders
Hypertension
Diabetes

Long term exposure to nephrotoxins

Asymptomatic until well advanced

Due to reserve function of nephrons
Cant be stopped once in advanced
Scar tissue and loss of functional organization
Further degenerative changes

Chronic Renal Failure

Pathophysiology: Stages
Decreased reserve
60% nephron loss
Low GFR, high creatinine levels
Both still in normal range

Normal urea levels

No apparent clinical signs
Remaining nephrons adapt
Increase capacity for filtration

Stages
Renal Insufficiency

75% nephron loss

Changes in blood chemistry and manifestations
GFR decrease to 20% of normal
Significant retention of N wastes in blood
Decrease tubule function
Failure to concentrate urine and control secretion for
exchange of acids and electrolytes

Excretion of lg vol of dilute urine

High bp
Cardiovascular system compensates

Stages
Uremia (End-stage renal failure)
+90% nephron loss
negligible GFR
Fluid, electrolytes, wastes retained in body
All systems affected

Oliguria or anuria
Regular dialysis or transplant needed to
sustain life

Chronic Renal FailureSigns and

Symptoms

Early signs
Increase urine output (polyuria)
General signs
Increase wastes and altered blood chemistry
Bone marrow depression, impaired cell function

Increase bp

Uremic signs

Oliguria
Dry, hyperpigmented skin
Peripheral neuropathy (abnorm sensations in lower limbs)
Males impotence, decrease libido; females irreg menstrual cycle
Encephalopathy (lethargy, memory lapses, seizures, tremors)
CHF, arrhythmias
Failure of kidneys to activate vitamin D
Leads to hypocalcemia, osteodystrophy, osteoporosis, tetany

Uremic frost on skin, urine-like breath

Systemic infection
pneumonia

Chronic Renal FailureDiagnostic

Tests
Metabolic acidosis becomes decompensated
Serum pH below 7.35
Low GFR
Tubule function lost

Azotemia
Presence of N wastes in blood

Severe anemia
Varying electrolyte levels
Depends on amt water retained

Chronic Renal Failure

Affects all body systems
Difficult to maintain control of blood chemistry
and body fluid levels
Drugs to treat:
Hypertension, arrhythmias, heart failure
Dosages adjusted b/c decreased ability to excrete
them

Subject to many complications

Affect uremia
Infection increases wastes in body; compromises all
body systems