Pathophysiology of Urinary Disorders

Urinary incontinence

loss of urinary control

Enuresis

• involuntary urination by a child after 4-5 years of age

• causes may be psychological and structural, but usually resolves with or without treatment

• nocturnal enuresis = bed wetting

Stress incontinence

loss of urine from intra-abdominal pressure exerted on the bladder by coughing, sneezing, laughing, exercising, or lifting something heavy; occurs when the sphincter muscle of the bladder is weakened

Contributing factors to stress incontinence

• pregnancy

• childbirth

• menopause

• cystocele

• prostate removal

• obesity

• chronic coughing

Overactive bladder (urge incontinence)

sudden, intense urge to urinate, followed by an involuntary loss of urine

Causes of overactive bladder

• UTIs

• bladder irritants

• bowel conditions

• smoking

• Parkinson’s disease

• Alzheimer’s disease

• stroke

• injury

• nervous system damage

Reflex incontinence

urinary incontinence caused by trauma or damage to the nervous system; involuntary loss of a moderate amount of urine without warning due to hyperreflexia of a muscle due to spinal cord dysfunction; urgency is generally absent

Detrusor hyperreflexia

increased detrusor muscle contractility that occurs even though there is no sensation to void

Mixed incontinence

occurs when symptoms of more than one type of urinary incontinence are experienced

Overflow incontinence

inability to empty the bladder, or retention; dribbling urine and a weak urine stream; distended and palpable bladder

Causes of overflow incontinence

• bladder damage

• urethral blockage

• nerve damage

• prostate conditions

Chronic overdistension (overflow incontinence)

occurs because of a perceived inability to interrupt work to void that results in detrusor muscle areflexia and overflow incontinence

Functional incontinence

occurs in many older adults who have a physical or mental impairment that prevents toileting in time

Transient incontinence

urinary incontinence resulting from a temporary condition; urinary infection, restrictive mobility, etc.

Causes of transient incontinence

• delirium

• infection

• atrophic vaginitis

• use of certain medications (EX: diuretics and sedatives)

• psychological factors

• high urine output

• restricted mobility

• fecal impaction

• alcohol

• caffeine

Gross total incontinence

a continuous leaking of urine, day and night, or the periodic uncontrollable leakage of large volumes of urine; the bladder has no storage capacity

Causes of gross total incontinence

• anatomical defects

• spinal cord or urine system injuries

• fistulas (abnormal opening) between the bladder and an adjacent structure (EX: vagina)

Risk factors for incontinence

• female gender

• advancing age

• being overweight

• smoking

• renal disease

Complications of incontinence

• skin breakdown

• recurrent urinary tract infections

• negative psychological consequences

• interruption of usual activities

Neurogenic bladder

bladder dysfunction caused by an interruption of normal bladder nerve innervation; either flaccid or spastic

Causes of neurogenic bladder

• brain or spinal cord injury OR infections

• nervous system tumors

• dementia

• Parkinson’s disease

• spina bifida

• diabeties mellitus

• stroke

• medications

• vaginal childbirth

• multiple sclerosis

• chronic alcoholism

• systemic lupus erythematosus

• heavy metal poisoning

• herpes zoster

Manifestations of neurogenic bladder

symptoms of overactive and underactive bladder

Interstitial cystitis/bladder pain syndrome

chronic bladder condition that causes pain and pressure in the suprapubic, pelvic, and abdominal area; exact cause is unknown; noninfectious but inflammatory

Interstitial cystitis/bladder pain syndrome is common in

women and aging individuals

Progression of Interstitial cystitis/bladder pain syndrome

• 5% experience symptoms for 2+ years

• 5% develop end-stage disease where bladder hardens, capacity is low, and pain worsens

Manifestations of interstitial cystitis/bladder pain syndrome

• pain in urinary tract (often worse with pressure)

• frequency

• nocturia

• urgency (often constant, worsened by stress)

• sexual dysfunction

Types of interstitial cystitis/bladder pain syndrome

• nonulcerative = 90%; pinpoint hemorrhages in bladder wall

• ulcerative

★Urinary tract infection (UTI)★

among the most common bacterial infections encountered in clinical practice; any infection that spreads to the urinary tract; most commonly an ascending infection; can be acute, recurrent, or chronic; very common for UTI to ascend and become systemic

Risk factors for UTIs

• female genitalia

• sexually active (multiple partners increases risk)

• use of diaphragm with spermicide

• history of diabetes

• recent instrumentation (catheters)

• structural abnormalities

• improper personal hygiene

• immobility

Upper urinary tract UTIs

• pyelonephritis (kidney infection)

  • acute

  • chronic

Lower urinary tract UTIs

• cystitis

• urethritis = infections in urethra

UTIs: Cystitis

infections in the bladder; bladder and urethra will become red and swollen; bacteria ascend to the bladder via the urethra and possible further up to the kidneys

Causes of cystitis

infection and irritants, EX:

• tampon use

• bubble baths

• restrictive garments

• non-cotton underwear

Most common UTI bacteria

E. coli; accounts for 75-95% of UTIs

★Typical symptoms of lower urinary tract UTI★

• burning on urination

• urgency

• dysuria

• frequency

• low back pain

• foul smelling urine

• cloudy urine (pyuria)

• hematuria

• fever (occasionally

★Typical symptoms of upper urinary tract UTI★

• flank pain

• fever

• nausea

• vomiting

• increased BP

• may have symptoms of cystitis

Elderly patients with UTIs

ALWAYS ASK AN ELDERLY PERSON WITH NO ONSET CONFUSION; screen for UTI; hypothermia for granted (take core/rectal temp)

UTI: Pyelonephritis

acute or chronic infection that has reached one or both kidneys; kidneys become grossly edematous (swollen) and fill with exudate (pus/junk), compressing renal artery and potentially developing abscesses or necrosis

Complications of pyelonephritis

• renal failure

• recurrent UTIs

• sepsis

Manifestations of pyelonephritis

• severe UTI symptoms

• flank pain

• increased BP

• fever may be present

• patient is usually sicker (age dependent)

Renal and urinary calculi (kidney stones)

presence of renal calculi, hard crystals composed of minerals that the kidneys normally excrete, in renal pelvis, ureters, or bladder; any type of blockage that prevents outflow can cause damage; size of calculi causes problems (can we pass it?)

Renal and urinary calculi are most common in

men and Caucasians

Most frequent type of calculi contain

calcium, in combination with either oxalate or phosphate

Other types of calculi stones

• struvite/infection stones

• uric acid stones

• cystine stones

• aggregation of particles can turn into stones

Risk factors for renal and urinary calculi

• pH changes

• excessive concentration of insoluble salts in the urine

• urinary stasis/reflux = urine backs up and causes infections

• family history

• obesity

• hypertension

• diet

Calcium oxalate calculi

most common (70%); hypercalciuria and family hx

Calcium phosphate calculi

alkaline urine, hyperparathyroidism

Struvite calculi

UTIs, proteus organisms

Uric acid calculi

gout

Cystine calculi

highly acidic urine

Manifestations of renal and urinary calculi

• colicky pain in the flank area that radiates to the lower abdomen and groin (pain = stone is moving)

• bloody, cloudy, or foul-smelling urine

• dysuria

• frequency

• genital discharge

• nausea, vomiting, fever, and chills

People more prone to calculi

• bone disease

• gout

• renal disease

• dietary abnormalities

• urinary stasis

• immobility/bed bound

Nephrolithiasis

stone formed in kidney

Hydronephrosis

abnormal dilation of the renal pelvis and the calyces of one or both kidneys

Unilateral hydronephrosis

obstruction in one of the ureters

Bilateral hydronephrosis

obstruction in the urethra

Causes of hydronephrosis

• urolithiasis

• tumors

• benign prostatic hyperplasia

• strictures

• stenosis

• congenital urologic defects

Complications of hydronephrosis

• atrophy

• necrosis

• glomerular filtration cessation

Manifestations of hydronephrosis

• colicky flank pain or pressure

• bloody, cloudy, foul-smelling urine

• dysuria

• decreased urine output

• frequency

• urgency

• nausea

• vomiting

• abdominal distension

• UTIs

Renal cell carcinoma

most frequently occurring kidney cancer in adults; benign tumors are rarely in the urinary system

Risk factors for renal cell carcinoma

• male

• smoking

• obesity

• hypertension

• other kidney disease

Renal cell carcinoma can metastasize to

common in

• liver

• lungs

• bone

• nervous system

Manifestations of renal cell carcinoma

asymptomatic in early stages

• painless hematuria

• abnormal urine color

• dull and achy flank pain

• urinary retention

• palpable mass over the affected kidney

• unexplained weight loss

• anemia

• polycythemia

• hypertension

• paraneoplastic syndromes (pain)

• fever

Renal cell carcinoma can cause

• urine flow obstruction

• impaired function

Bladder cancer

any cancer that forms in the tissue of the bladder, 90% are urolithelial; recurrence in about 40% of cases

Bladder cancer can metastasize to

common in

• pelvic lymph nodes

• liver

• bone

Risk factors of bladder cancer

• advancing age

• men

• Caucasians

• working with chemicals

• smoking

• excessive use of analgesics

• experiencing recurrent UTIs

• long-term catheter placement

• chemotherapy

• radiation

Manifestations of bladder cancer

• painless hematuria - usually notice first

• abnormal urine color

• frequency

• dysuria

• UTIs

• back or abdominal pain

★Benign prostatic hyperplasia★

a common, nonmalignant enlargement of the prostate gland that occurs as men age; the exact cause is unknown, but it may result in urinary stasis and UTIs; as the prostate expands, it presses against the urethra and obstructs urine flow, bladder becomes thick, irritated, and overfilled; lose ability to empty compleely

Potential causes of benign prostatic hyperplasia

• declining testosterone and increasing estrogen levels are through to cause prostatic stromal cell proliferation, enlarging the prostate

• or stem cells in the prostate do not mature and die as programmed, enlarging the prostate

Manifestations of benign prostatic hyperplasia

does NOT increase risk of prostate cancer, manifestations are similar

• frequency

• urgency

• retention

• difficulty initiating urination

• weak urinary stream

• dribbling urine

• nocturia

• bladder distension

• overflow incontinence

• erectile dysfunction

Polycystic kidney disease (PKD)

inherited disorder characterized by numerous grape-like clusters of fluid-filled cysts in both kidneys; cysts enlarge the kidneys while compressing and eventually replacing the functional kidney tissue; exact cause is unknown, maybe genetic mutations; prognosis and progression vary on the type

Manifestations of PKD

• hematuria

• nocturia

• drowsiness

Manifestations of PKD in neonates

• potter facies

• large, symmetrical masses on flank

• respiratory distress (masive fluid accumulation)

Manifestations of PKD in adults

• hypertension

• abdominal girth, swelling, and tenderness/lumbar pain

• grossly enlarged, palpable kidneys

Complications of PKD

• pyelonephritis

• cyst rupture

• retroperitoneal bleeding

• renal failure

• anemia

• hypertension

• renal calculi

Glomerulonephritis

acute or chronic bilateral inflammatory disorder of the glomeruli that typically follows a streptococcal infection, which is the leading cause of kidney failure; can affect any layer or structure of the glomerulus; inflammaatory changes impair the kidney’s ability to excrete waste and excess fluid

Glomerulonephritis affects

men more than women

Nephrotic syndrome

results from antibody-antigen complexes lodging in the glomerular membrane (affects), triggering activation of the complement system; glomeruli do NOT properly filter the protein albumin

Causes of nephrotic syndrome

• systemic diseases (lupus)

• gold therapy

• hepatitis B

• idiopathic 

Nephrotic syndrome results in

increased glomerular capillary permeability, leading to marked proteinuria, lipiduria, hypoalbuminemia, and anasarca

Manifestations of nephrotic syndrome

• hypoalbuminemia

• hyperlipidemia

• dark and cloudy urine

• immunoglobulins in the urine

• edema (peripheral)

• heavy proteinuria

• hypercholesterolemia

Complications of nephrotic syndrome

risk for infection and atherosclerosis

Nephritic syndrome

inflammatory injury to the glomeruli that can occur because of antibodies interacting with normally occurring antigens in the glomeruli; glomeruli do NOT properly filter RBCs; can be acute or chronic; immune complexes become trapped in glomerular membrane

Causes of nephritic syndrome

• diseases that initiate the inflammatory response

• primary secondary cause = connective tissue diseases

• acute infections (group B streptococcus, viral)

Manifestations of nephritic syndrome

• gross hematuria - main feature

• urinary casts and leukocytes

• low GFR

• azotemia (increased BUN & Cr; high levels of waste products in urine)

• oliguria = low urine output

• high BP

• hypertension

• proteinuria

• RBC breakdown

• cola-colored urine

Complications of nephritic syndrome

impaired renal function

Acute kidney injury

sudden loss of renal function, often critically ill hospital patients, generally reversible

Prerenal conditions

extremely low BP or blood volume; cardiac dysfunction/CHF; volume depletion, heart failure, cardiogenic shock, anaphylaxis, decompensated liver disease; above kidneys

Intrarenal conditions

reduced blood supply in kidneys, hemolytic uremic syndrome, renal inflammation, toxic injury; direct damage to kidney from lack of oxygen

Postrenal conditions

ureter obstruction, bladder obstruction/dysfunction; kidney stones or anything that obstructs the urine; below the kidneys (ureters, bladder)

Risk factors for acute kidney injury

• advancing age

• autoimmune disorders

• liver disease

Phases of acute kidney injury

• asymptomatic

• oliguric - daily urine output <400 mL, electrolyte disturbances, fluid volume excess, azotemia, metabolic acidosis

• diuretic - daily urine output >5 L, electorlyte disturbances, dehydration, and hypotension

• recovery phase - glomerular function gradually returns to normal

Chronic kidney damage

gradual loss of renal function that is IRREVERSIBLE; long standing, progressive deterioration of kidney function; can progress to end stage renal failure

Causes of chronic kidney damage

• diabetes mellitus

• hypertension

• urine obstructions

• renal disease

• renal artery stenosis

• ongoing exposure to toxins and nephrotoxic medications

• sickle cell disease

• systemic lupus erythematosus

• smoking

• advancing age

Stages of chronic kidney disease

• stage 1 = kidney damage present but GFR is >90

• stage 2 = kidney damage worsens as the GFR falls to 60-89

• stage 3 = kidney function is significantly impaired as GFR is between 30-59

• stage 4 = kidney function is barely present with GFR dropping between 15-29

• stage 5 = kidney failure as the GFR drops to less than 15 or the patient begins dialysis

Glomerular filtration rate (GHF)

a measure of how well your kidneys filter blood and determines your stage of kidney disease, normal is between 60-120; as kidney loses function,

Manifestations of chronic kidney disease

remember: if I can’t pee/my kidneys don’t work, everything I need to get rid of is now in my system

• hypertension

• polyuria with pale urine (early)

• oliguria or anuria with dark colored urine (late)

• anemia

• bruising and bleeding tendencies

• muscle twitches and cramps

• electrolyte imbalance

• pericarditis, pericardial effusion, pleuritis, and pleural effusion

• congestion heart failure

• respiratory distress and abnormal breath sounds

• sudden weight change

• edema of the feet and ankles

• azotemia

• peripheral neuropathy, restless leg syndrome, seizures

• nausea and vomiting

• anorezia

• malasie

• fatigue and weakness

• headaches that seem unrelated to any other cause

• sleep disturbances

• decreased mental alertness

• flank pain

• jaundice

• persistent pruritus

• recurrent infections

Azotemia

elevated levels of nitrogenous waste products in the blood, such as urea snd creatinine

Early manifestation of chronic kidney disease

ability to concentrate urine is most common early manifestation