clin phys exam 3

upper urinary tract

kidneys and ureters

kidneys

endocrine organ and target organ of endocrine system(mineral and water balance)

main function of kidneys

filter waste and remove excess fluid from blood

impact of age on kindeys

blood flow decreases, decrease in nephrons so they get less efficient at removing waist from blood and volume of urine slightly increases

what type of cancer makes up 90% of all kidney cancers

renal cell carcinoma

risk factors of renal cell carcinoma

male, peaks at 60-70y/o, tobacco smoking, obesity, hypertension, exposure to toxic substances, and acquired kidney diesase associated with end stage renal disease

how have scientists been able to locate specific genetic abnormalities

because RCC is seen in a few hereditary diseases

classic symptoms of renal cell carcinoma

flank pain, hematuria(most common symptom), palpable abdominal mass

What percentage of clients have metastatic disease at the time of diagnosis

25-30%, this is a major reason to not ignore symptoms

path of metastasis on RCC

lungs then regional lymph nodes then bone and liver

medical management of RCC

removal of kidney mass if present via surgery(most common), use percutaneous thermal ablation using radiofrequency heat ablation or cryoablation

Renal calculi

kidney stones, third most common urinary tract disorder(5% of adults)

renal calculi risk factor

men > women, men are most commonly effected in ages 30-60, and women 20-30

once a stone is moved out of the kindey, what is it called

ureteral stone

cause of renal calculi

disorders that lead to hypersecretion/saturation of calcium or oxalates, low quantities of citrate, acidic urine pH. chronic dehydration, excess intake of supplemental calcium, sodium, sucrose, and animal protein, lack of sufficient calcium and potassium

classic symptoms of renal calculi

acute “colicky” flank pain radiating to the groin or perineal areas with hematuria, pain is severe, consistent with UTI(urinary urgency and frequency, dysuria)

medical management of renal calculi

adequate fluid intake, decreased protein consumption. eat more fruits and veggies

stones under 5mm

pass spontaneously

stones less than 1cm

treated with shock wave lithotripsy to break it into fragments

stones greater than 1cm

uretoscopy

chronic kidney disease

alteration of kidney function/structure over 3 or more months

three most common chronic kidney dieases

diabetes(44%) hypertension(27%), and glomerulonephritis(8%)

end stage renal failure

final stage of chronic kidney disease with loss of function accompanied by symptoms requiring dialysis or kidney transplant

hallmark sign of ESRD

proteinuria

what accelerates progression to stage 5 ESRD when kidneys fail

hypertension

analgesic nephropathy

increased risk of renal damage and ESRD associated with excessive over the counter analgesic drug use

early signs of ESRD

hypertension and anemia, abnormal lab results (increased blood urea nitrogen and creatine or protein in urine)

ESRD cluster of symptoms

uremia, nausea, vomiting, anorexia, lethargy, itching, sensory or motor neuropathy, pericarditis, heart issues, asterixis of upper limb, seizures

cardiovascular implications of CKD

often occurs in people with and are the leading cause of death in people with ESRD, symptoms like chest pain, nausea, SOB, and sweating

musculoskeletal implications of CKD

renal osteodytrophy may cause fractures and or bone pain(esp in spine, hips, knees, or lower extremities), bone demineralization, classification of vessels and soft tissues

most common calcification in ESRD

lungs coronary arteries, skin, peripheral arteries, joints, cornea

Neurological dysfunction with ESRD

early CNS changes like sleep disturbances and personality changes, uremic encephalopathy is manifested by recent memory loss, inability to concentrate, perceptual errors, confusion, decreased alertness, peripheral neurologic changes are typically symmetrical

medical management of CKD

prevention of hypertension and coronary heart disease, increasing physical activity, reducing/eliminating tobacco-related behaviors, lifestyle changes like weight loss, eliminate smoking, diet change, strictly control blood pressure, renal replacement therapy

treatment of choice for ESRD

renal replacement therapy(dialysis or transplantation)

considerations for rehab with CKD

• CNS deficits interfere with motor planning, exercises, body mechanics, etc

• Fatigue and general weakness may dictate that the therapist provide rest periods 

• Improvements are possible, just take time (slow)

Impact of exercise on ESRD

improves autonomic cardiac function, Autonomic dysfunction can cause max-HR to decrease by 20-40 BPM, so use RPE to gauge intensity, Low-Moderate intensity exercise can increase exercise capacity, autonomic cardiac function and maybe improve BP, When exercise is performed after dialysis, blood chemistry levels are at their best

Normal bladder function

400-600mL, fills at constant rate, continence, 5-7 voids per 24 hours

risk factors of bladder cancer

SMOKING, age(over 55), race(caucasian), gender (men> women)

common signs of bladder cancer

painless hematuria(blood in urine), too much blood=clots may form and cause urethral blockage with resultant bladder enlargement and painful spasm, the intermittent pattern of bleeding can result in delayed diagnosis, other signs are voiding dysfunction like changes in frequency, urgency, and dysuria

medical management of bladder cancer

surgery is the most common treatment

types of bladder sugery

transurethral resection, cystectomy, ileal conduit procedure

transurethral resection

done for early and superficial tumor

cytectomy

removal of bladder and replacement, is preformed for invasive cancer

ileal conduit procedure

surgery that uses a short piece of small or large intestine to create a pouch from the ureters outside the body, creating a neobladder(lacks detrusor muscle to they need to “push” to void)

normal structures involved in micturition include

brain, spinal cord, nerves to bladder

what is the type of void dysfunction dependent on

underlying cause and which nerves are affected(failure to store vs failure to void)

common disorders that can result in neurogenic bladder dysfunction

Cerebrovascular accident, dementia, Parkinson's disease, multiple sclerosis, brain tumors, spinal cord injury/tumors, herniated disc, myelitis

impact of bladder function depends on

location of lesion

primary goals of medical management of neurogenic bladder disorders

preventing incontinence, bladder oversitention, UTIs, and renal damage

treatment modalities for neurogenic bladder disorders

catheterization, pharmacological agents, bladder training, surgery

how is bladder over distention avoided

clean intermittent catheterization

how to determine cause, treatment, and category of neurogenic bladder disorders

urodynamic testing

common complication for neurogenic bladder disorders

UTIs, kidney stones, deterioration in renal function

urinary incontinence

occurs most often when bladder pressure exceeds the sphincter resistance, inside pressure > closure pressure of urethra

functional urinary incontinence

secondary to factors other than abnormal urinary tract function. May be due to weakness, poor mobility/dexterity, cognitive problems, various medications, or environmental impediments 

urge urinary incontinence

abrupt urgency, frequency and nocturia, most common

stress urinary incontinence

Loss of small amounts of urine with physical activity (coughing, sneezing, laughing, walking stairs/lifting. Due to increase in intra-abdominal pressure on bladder that is not over distended and is not a result of detrusor contractions. 2nd MOST COMMON

mixed urinary incontinence

combination of urge and stress

overflow urinary incontinence

Occurs when bladder is distended from urine retention. Symptoms include weak stream, hesitancy, intermittency, dysuria, nocturia, frequency, incomplete voiding (feel like not emptying all the way), frequent/constant dribbling

UI prevalence in community dwelling

10-35%

UI prevalence in nursing home adults

50-60%

what percentage of all admission to skilled nursing are direct results of UI

50%

contributing factors to UI

medications, caffeine intake, constipation

management of UI

depends on the type, age, and general health, behavioral, pharmacological, surgical

behavioral management of UI

first line of treatment, includes lifestyle and diet changes, prescription exercises including pelvic floor, pelvic floor e-stim

pharmacologic management of UI

Anticholinergics or muscarinic antagonists→inhibits involuntary detrusor contractions, First line in terms of drug therapy, Used in conjunction with behavioral modifications

surgical management of UI

several options, last time of treatment

urinary tract infection

occurs when pathogens are able to adhere to the urinary tract mucosa, colonize and cause infection; most common route of entry via urethra, can involve urethra (urethritis) and/or bladder (cystitis)

Upper UTI

aka pyelonephritis, bacteria spreads to upper portion of urinary tract and involve kidneys 

UTIs are more common in ——— than ——

females, males

risk factors of UTIs

young sexually active women, history of UTIs, frequent/recent sexual activity, use of spermicidal agent, pregnant women older women, people with diabetes, catheterization (increases risk of introducing bacteria)

classic symptoms of UTI

• Frequency, urgency, dysuria, nocturia

• Enuresis in children

• Fever, chills, and malaise may be present

• Cloudy, bloody, or foul-smelling urine

• Burning/painful sensation during urination or intercourse

how are UTIs diagnosised

urinalysis and history

treatment of UTI

In health, nonpregnant clients typically treated with antibiotics, Increased fluid intake may help relieve symptoms and signs (no concrete evidence proving this though)

changes that occur that impact male sexual dysfunction

testes smaller, thickening of seminiferous tubules which impedes sperm production, sclerotic changed in local blood vessels, prostate gland enlarged

prostatitis

multiple disorders that cause pelvic pain and discomfort ranging from acute bacterial infection to complex conditions

Category 1 of prostatitis

acute bacterial prostatitis

category 2 Prostatitis

chronic bacterial prostatitis

category 3 prostatitis

chronic prostatitis/CPPS, can be inflammatory(A) or non-inflammatory(B)

category 4 prostatitis

asymptomatic inflammation prostatitis, typically dont know they have it

medical management of prostatitis

Urinalysis, digital rectal exam used to diagnose, Differentiated from benign prostate hyperplasia (BPH) and prostate cancer by the presence of pain (rarely present in BPH or cancer) and AGE (over half of those with prostatitis are under 45 years old)

Benign prostate hyperplasia

age-related enlargement of prostate gland, usually asymptomatic

clinical presentation of benign prostate hyperplasia

Decreased caliber and force of urine stream and difficulty initiating or continuing urine stream so that only small amounts of urine are released, Residual urine in bladder→increase urinary frequency, typically at night (nocturia)

medical management of benign prostate hyperplasia

if mild, just monitor, if having symptoms treatment includes pharmacological and surgical intervention

symptoms suggesting advanced benign prostate hyperplasia

urine retention, incontinence, hematuria, and chronic UTIs

pharmacological management of benign prostate hyperplasia

drugs that shrink the gland (5-alpha-reductase inhibitors) and relaxing smooth muscle tissue of prostate, bladder neck, and urethra

surgical treatment of benign prostate hyperplasia

Transurethral resection of prostate (TURP)=gold standard treatment, Thermotherapy via transurethral microwave therapy (TUMT), laser therapy

most common male cancer(1 in 5 men) and most common cause of male death from cancer

prostate cancer

medical management treatments of prostate cancer

radiation, hormonal therapy, radical prostatectomy

mortality rate of prostate cancer had decreased because

detection in early stages with fewer cases of metastases at diagnosis

surgery for prostate cancer

radical prostatectomy involves removal of entire prostate, seminal vesicles, and portion of bladder neck and regional lymph nodes

radiation for prostate cancer

may be used to treat localized prostatic lesions after radical prostatectomy, Can also be used for palliative effects in presence of widespread disease

most men will survive prostate cancer but may live with what

urinary incontinence and sexual dysfunction

risk factors of erectile dysfunction

• Age-related testosterone deficiency

• Medications

• CAD (coronary artery disease)

• Neurologic conditions

• DM (diabetes mellitus)

• Alcohol use, smoking

• Mental or emotional problems

for 70% of men younger than 35 what is the cause of ED

psychogenic(stress, mental health)

in 85% of men over 50 what causes ED

organic(blood flow or nerve issue)

treatment of erectile dysfunction

pelvic floor PT has shown to be effective in restoring function in some men, maintaining healthy weight and improving cardiovascular function

primary functions of female genital system

preparing woman for conception, gestation (pregnancy) and gestation itself; sexual function

obstructive disease

increased compliance of lungs(overstretched) causing airflow limitation during exhalation, large lung fields, collection of diseases

decreased airflow to the lungs in an obstructive disease

results in increased lung volumes(residual/air trapping)