Patho Exam 3

Advantages of ultrasound imaging of urinary tract

Noninvasive and painless

• demonstrates gross real anatomy and true kidney depth

• identifies structural abnormailitesnand perineal masses

Primary Functions of the Renal System

• Fluid and Electrolyte balance

• Water elimination

• Acid Base Balance

• Endocrine functions

Pyelonephritis

A type of UTI that affects one of both kidneys

Pyelonephritis Clinical manifestations

• Fever and chills

• Flank pain (CVA)

• Nausea and Vomiting

• Malaise

• Anorexia

Lower Urinary Tract Symptoms (LUTS) of Pyelonephritis

• Dysuria (painful urination)

• Urgency

• Frequency

Lab findings of Pyelonephritis

• Pyuria (WBCs in urine)

• Bacteriuria

• Varying degrees of hematuria

Renal Calculi

Kidney Stones

• Flank pain

• Renal colic (spasmodic, intermittent sharp pain when stones move to ureteropelvic junction)

• Nausea, vomiting, diaphoresis, tachycardia and tachypnea

• Pain reduction when stones reach the bladder

Lab values associated with Kidneys

1. Serum Creatine

2. Blood Urea Nitrogen (BUN)

3. Glomerular Filtration Rate (GFR)

Blood Urea Nitrogen (BUN)

An indirect and rough measurement of renal (kidney) function

• Increased = kidney is holding onto waste

• Creatine associated w BUN

• Norm: 10 - 20 mg/dl

Creatinine

Measure of creatinine in the blood; is produced by the muscles and excreted by the kidneys

• Increased = usually w increased BUN, not getting rid of waste/creatinine

• Norm: 0.7-1.75 mg/dl (slightly higher in men due to larger muscle mass)

Glomerular Filtration Rate

Checks if the body is getting rid of waste

• Reduction in GFR results in elevated BUN, electrolyte imbalance, and metabolic acidosis

Acute Kidney Injury / Acute Renal Failure

• Interruption in blood flow to the kidney (can’t process waste)

• Period of a few hours to a few days

• Normally results from medical procedure or multiorgan system failure

3 Phases of Acute Kidney Injury/Acute Renal Failure

1. Prodromal Phase

2. Oliguric Phase

3. Postoliguric phase

Prodromal Phase of Acute Renal Failure

• Normal or declining urine output, varies in duration

• More intake and less output

Oliguric Phase of Acute Renal Failure

• Urine output of 50-500 mL/day (very little amount)

• Retention of nitrogenous waste and electrolytes

• Fluid volume buildup

Postoliguric phase

• Diuresis occurs, tubular function remains impaired, and azotemia continues

• Decline in urine output

• Fluid volume deficit is characteristic until the kidney gradually recovers (acute issue is fixed and kidneys recover)

Prerenal Kidney Injury

Develops because of diminished perfusion of kidney

• GFR is integral in efficient removal of waste from the kidney and is dependent on pressure gradient levels and blood flow from the glomerulus to the Bowman’s capsule

Causes of Prerenal Kidney Injury

1. Hypovolemia

2. Heart Failure

3. Myocardial Infraction

4. Sepsis

5. Shock

6. Drugs such as NSAIDS

Intrarenal Kidney Injury

Within Kidney structures

• Result of direct damage to the kidneys that causes sudden loss in kidney function

• Damage is typically due to prolonged ischemia, exposure to nephrotoxins

• Classified as where in the kidney (vascular, interstitial, glomerular, tubular)

• DO NOT USE CONTRAST DYE because it is a nephrotoxin (check for elevated creatinine & BUN first)

Postrenal Kidney Injury

Result of obstruction of urinary flow and can involve mechanical obstruction of the renal pelvis, ureters, bladder, or urethra

Causes of Postrenal Kidney Injury

• Kidney stones

• Prostate cancer

• Bladder tumor

• Neurogenic bladder

• Bladder not signaling to empty (spinal cord injury)

Chronic Kidney Disease (CKD)

• Slow, progressive, irreversible loss of kidney function and glomerular filtration

• Occurs in stages, w end-stage renal disease (ESRD) as the final stage of chronic kidney disease resulting in uremia

Medical Predisposing factors of CKD

• CAD

• Heart Failure

• Obesity

• Prior kidney disease or injury

Lifestyle Predisposing factors of CKD

• High fat, high sugar, high sodium diet

• Smoking

• Sedentary lifestyle

• Recreational drug use/abuse

Stages of Chronic Kidney Disease (CKD)

GFR determines the stage (lower # = higher stage)

1. Reduced Renal Reserve

2. Mild CKD

3. Moderate CKD

4. Severe CKD

5. End Stage Renal Failure (ESRF)

CKD Stage 1: Reduced Renal Failure

Unaffected nephrons overwork to compensate for diseased nephrons

• no symptoms

• GFR >90 mL/min

CKD Stage 2: Mild CKD

GFR is reduced between 60-89 mL/min

• Polyuria and nocturia

CKD Stage 3: Moderate CKD

GFR continues to decrease (30-59 mL/min)

• Nephron damage continues w decreased nephrons

• Restriction of fluids, proteins and other electrolytes, including phosphorus, may be needed

CKD Stage 4: Severe CKD

GFR is between 15-29 mL/min

CKD Stage 5: End Stage Renal Failure (ESRF)

GFR less than 15 mL/min

• Oliguria occurs

• BUN & Creatinine build up in the blood

• Uremia (urea in blood) is the end result and is fatal; uremia is a classic marker of ESRD

Complications of CKD

• Hypertension and cardiovascular disease

• Uremic syndrome

• Metabolic acidosis

• Electrolyte imbalances

• Mineral and bone disorders

• Malnutrition

• Anemia

• Pain (back pain)

• Depression (pts have to dedicate a lot of time for dialysis schedule)

Populations at risk of bladder cancer

• Males

• Older Adults

• Smokers

• White people

• Ppl w occupational exposures (aniline textile dyes, hair dyes, paint, leather, rubber, cement workers)

• Family history

• Low fluid intake

• Prior cancer treatment

Populations at risk of Kidney Cancer (Renal Cell Carcinoma)

• Males

• Older Adults

• Smokers and obese individuals

• 1st degree relatives of those w renal cell cancer

• Hypertension

• Chemical exposures

Benign Prostatic Hypertrophy (BPH)

Prostate gland enlarges and encroaches on the urethra as it passes through the prostate (prostatic urethra)

• Compresses urethra, leads to urinary outflow obstruction

• Hyperplasia is related to an imbalance between estrogen and testosterone that results from hormonal changes in men associated w aging

• Mostly seen in older men over 65

Clinical Manifestations of Benign Prostatic Hypertrophy (BPH)

• Gradual onset

• Nocturia

• Urinary hesitancy, urgency, frequency

• Bladder pain

• Urinary incontinence

• Decreased force of urinary stream

• Difficulty initiating a stream or experiencing intermittent passage of urine

• Urinary retention

Pathology of Wilm’s tumor

• There are defects in tumor-suppressor genes on chromosome 11

• May occur in conjunction w some other congenital disorders such as absence of the iris of the eye

• It is usually a unilateral, large abdominal mass

Clinical Manifestations of Wilm’s Tumor

• Toddler presenting w a unilateral abdominal mass

• Diagnosed at ages 3-4

• Large abdominal mass becomes obvious

• Hypertension

• Hematuria

• Lung metastases may be present

Micropenis

• Congenital

• Small, normally formed penis w a stretched length more than two standard deviations below the mean

• Defects in testosterone production or deficiency that results in poor growth of organs that are a target of testosterone

• Treatment is IM injection of testosterone to stimulate penile growth

Erectile Dysfunction

• Acquired disorder

• Inability to achieve or maintain an erection sufficient for satisfactory sexual performance

• Risk factors: Hypertension, elevated cholesterol, diabetes mellitus, smoking, obesity, lack of exercise

Premature Ejaculation

• Ejaculation that always or almost always occurs before or w/in one min of vaginal penetration

• Inability to delay ejaculation upon all or almost all vaginal penetrations

• up to 30% of males

• Can be biological such as high levels of serotonin and psychosocial

Peyronie Disease

• Formation of palpable, fibrous plaque on the surface of the corpora cavernosa

• Plaque may develop in the setting of repeated microvascular trauma that leads to a series of events that include protein deposition and trapping of fibrin

• Plaque subsequently causes curvature of the penis w painful, incomplete erections

Urethral Strictures

• Areas of fibrotic narrowing of the urethra usually composed of scar tissue

• Most acquired strictures are caused by a prior infection such as gonorrhea, or trauma

• Decreased urinary stream

Priapism

• Painful persistent erection

• Lasts several hour

• Common abnormality is prob. an obstruction of venous drainage resulting in the buildup of viscous, poorly oxygenated blood in the corpora

Phimosis

Uncircumcised foreskin can’t be retracted over the glans of the penis, usually due to inflammation and infection from poor hygiene

Paraphimosis

Foreskin that has been retracted over the glans up onto the shaft of the penis can’t be replaced in its normal position

Hydrocele

Fluid collection surrounding the testicle or spermatic cord and contained w/in the tunica or processus vaginalis

• Acquired disorder

Spermatocele

Painless cystic masses containing sperm

• Acquired disorder

Hypogonadism

Androgen deficiency in the aging male (ADAM)

• Andropause

• Most common etiology: primary testicular failure

• Acquired disorder

Varicocele

Abdominal dilation of venous structures in the scrotum that drain the testes

• Engagement of the veins w/in the scrotum

• Dilation of these veins leads to blood pooling

• Can cause infertility in men

• Acquired disorder

Testicular Torsion

Twisting of the spermatic cord w subsequent compromise of the testicular vascular supply and testicular ischemia followed by infraction

• severe pain in one testicle

• Swelling of the scrotom

• Lower abdominal pain w nausea/vomiting

• Medical emergency

• Management of tension involves an operation to open the scrotum, untwist the testis, and secure it to the scrotal wall

Epididymitis

Inflammation of the testis

• Result of trauma or the reflux of sterile urine up the vas deferens

• Secondary to a bacterial cause, w both sexually transmitted organisms (gonorrhoeae and chlamydia) and non-sexually transmitted organisms involved

• Scrotum swollen and red

• Urethral discharge

• Infectious disorder

Fournier gangrene

Severe but rare condition involving gangrenous necrosis of the scrotum

• Underlying disease such as diabetes, alcoholism, or another general debility predisposes the pt to such an aggressive infection

• Sepsis

• Fever

• Pain and swelling of scrotum

• Diagnosed w CT, MRI, and ultrasound

Prostatitis

Inflammation of the prostate

• Characterized by low back pain, urinary frequency, urgency, and dysuria

• fever and chills may be present

• May also occur in the absence of infection

• From STIs, urinary catheter, UTIs, BPH

• Causes: E. Coli, Pseudomonas proteus

Categories of Prostatitis

1. Acute bacterial prostatitis

2. Chronic bacterial prostatitis

3. Chronic abacterial prostatitis

4. Asymptomatic inflammatory prostatitis

Amenorrhea

Absence or suppression of menstruation in a female age 16 years or older

• Occurs if a woman misses 4 or more consecutive periods

• Primary or Secondary

• From abnormal pattern of hormonal functioning that interrupts the normal sequence of events in which the endometrial tissue lining the uterus proliferates and then is sloughed

Dysmenorrhea

Menstruation painful enough to limit normal limit normal activity or to cause a woman to seek health care

• Symptoms tend to decrease w age

• Classified as primary or secondary

Primary vs Secondary Dysmenorrhea

• Primary: Not related to an identifiable pathologic condition

• Secondary: Related to an underlying pathologic condition

Abnormal Uterine Bleeding

Irregular bleeding patterns that may occur at any time throughout a woman’s life

Intermenstrual Bleeding

Abnormal uterine bleeding between menstrual cycles

Deficient Menstrual Flow

Hypomenorrhea (extremely light or scanty menstrual blood flow that lasts for a short duration, typically two days or less)

Infrequent menstrual bleeding

Oligomenorrhea (infrequent menstrual periods defined as having menstrual cycles that occur at intervals if greater than 35 days or having fewer than 6-9 period a year)

Frequent Menstrual Bleeding

May be associated w ovulation and may be caused by endocrine or systemic factors

Heavy menstrual bleeding

Menorrhagia (very heavy menstrual bleeding)

Uterine Prolapse

Alteration in uterine position and pelvic support that may result in severe symptoms requiring surgical correction

• Sinking of the uterus from its normal position

• Classified in 3 degrees

• Feeling of bearing down and discomfort in the vagina

• Discomfort while walking or sitting

• Difficulty urinating

• Treatment: Hysterectomy (removal of uterus)

Retrodisplacement of the Uterus

Alteration in uterine position that may result in severe symptoms requiring surgical correction

• The body of the uterus is displaced from its usual location overlying the bladder to a position in the posterior of the pelvis

• 5 positions

• If no symptoms then no treatment

• Surgical treatment for women w symptomatic

5 Positions of retrodisplacement of the uterus

1. Anteverted

2. Mild-position

3. Anteflexed

4. Retroflexed

5. Retroverted

Cystocele

Protrusion of a portion of the urinary bladder into the anterior of the vagina at a weakened part of the vaginal musculature

• Usually caused by injury during childbirth or surgery

• Risk factors include: obesity and lifting heavy objects

• Dysuria, incontinence, back pain

Rectocele

Protrusion of the anterior rectal wall into the posterior of the vagina at a weakened part of the vaginal musculature

• Aging, multiparity, obesity, postmenopausal status

• Difficulty in bowel evacuation, chronic constipation, painful sexual intercourse

Pelvic Inflammatory Disease (PID)

Principle inflammatory and infectious processes of the cervix, uterus, oviducts, and ovaries, and may have far-reaching effects

• may follow the insertion of an intrauterine device, pelvic surgery, abortion procedures, and infection during or after pregnancy

• Abdominal tenderness and pain of cervix

• Treatment is antibiotics

Vulvovaginitis

Inflammation of the vulva (vulvitis) and vagina (vaginitis) caused by a Candida albicans infection

• Thick, white discharge and red, edematous mucous membranes

• Treatment: Antifungal

Bartholinitis

Inflammation of the Bartholin glands

• Tenderness and swelling at the site

Uterine Leiomyomas

Benign growths of the female reproductive tract w widespread nature and potentially serious consequences

• Most common uterine growths

• Treatment: possible surgical removal

• Also called myomas or fibroids

Ovarian cysts

Sacs on an ovary that contain fluid or semisolid material

• Develop any time between puberty and menopause

• Irregular periods

Polycystic Ovarian Syndrome

Caused by an imbalance of reproductive hormones and common cause of development of ovarian cysts and infertility

Endometriosis

Presence of endometrial tissue outside the lining of the uterine cavity

• Dysmenorrhea w pain 5-7 days before menses

• Dyspareunia

• Pain w defecation

• Treatment: Pain relief, surgery in some cases