HLSC 301 Exam 3 - Renal System

Urinary Tract Obstruction

• Impedance in flow of urine
• Dilates the urinary system
• Increased risk for infection
• Compromises renal
function

Anatomic Urinary Tract Obstruction

Obstructive uropathy

Functional Urinary Tract Obstruction

Neurogenic bladder

Causes of Urinary Tract Obstruction

• Stricture
• Congenital compression
• Tumor
• Inflammation & scarring
• Calculi (stones)*

Complications of Urinary Tract Obstruction

• Ureter, renal pelvis, calyces, & renal parenchyma
• Hydroureter
• Hydronephrosis
• Ureterohydronephrosis
• May lead to fibrosis if not corrected
• Loss of renal function and ultimate thinning of the renal cortex
• Begins within hours irreversible damage with 4 weeks
• Lose ability to concentrate urine, reabsorb bicarbonate,
excrete ammonia, or regulate metabolic acid-base balance
• If one-sided can undergo compensatory hypertrophy or hyperfunction
• May develop post-obstructive diuresis
• Generally mild but can be severe and lead to dehydration

Nephrolithiasis

• Kidney stones or calculi
• May be in the kidneys, ureters, or urinary bladder
• Mass of crystals, proteins, minerals normally excreted

Risk Factors for Kidney Stones

Males, whites, geographic location, season, fluid intake, diet, occupation age

Most frequent type of calculi

Calcium oxalate or phosphate (80%)

Pathophysiology of Nephrolithiasis

• Supersaturation of salt in the urine
• More salt in the fluid than the volume can dissolve
• Precipitation of the salt from liquid to solid state
• Growth through crystallization
• Presence/absence of stone inhibitors

Calcium Phosphate Stones

Alkaline pH in bladder

Uric Acid, cystine, xanathine stones

Acidic pH in bladder

Risk factors for Kidney Stones

Diet (excess calcium or purines), pH changes,
excessive concentration of insoluble
salts in the urine, urinary stasis, urinary
infection (struvite stones), family history,
obesity, hypertension, and hyperparathyroidism

Manifestations of Kidney Stones

Renal colic (pain in the flank area that radiates
to the lower abdomen and groin); bloody,
cloudy, or foul-smelling urine; dysuria;
frequency; genital discharge; nausea;
vomiting; fever; and chills

Diagnosis of Kidney Stones

H&P, urine examination, kidney-ureter-
bladder (KUB)X-ray, CT abdomen/pelvis,
ultrasound, intravenous pyelogram (IVP),
calculi analysis, and serum studies

Treatment of Kidney Stones

strain all urine, increase fluids,
extracorporeal shock wave lithotripsy,
percutaneous nephrolithotomy,
ureteroscopy, surgery, pain management,
dietary changes, and physical activity

Lower Urinary Tract Obstruction

Generally related to storage of urine in the bladder or emptying of urine through the bladder outlet

Causes of Anatomic Lower Urinary Tract Obstruction

Prostate enlargement, urethral stricture, pelvic organ prolapse

Causes of Lower Urinary Tract Obstruction

• Neurogenic
• Anatomic
• Prostate enlargement, urethral stricture, pelvic organ prolapse
• Combination

Complications of Lower Urinary Tract Obstruction

• Incontinence
• Frequent daytime voiding, nocturia, poor force of stream,
intermittency of stream, urinary urgency with hesitancy, feeling of incomplete voiding
• Overtime decreased compliance of the bladder

Neurogenic bladder

• Bladder dysfunction related to neurologic disorder

dyssynergia (loss of coordinated neuromuscular contraction)

Upper motor Neuron lesions

cauda equina syndrome

Lower motor neuron lesions

• Detrusor areflexia: noncontractile detrusor, atonic bladder with retention of urine & distention.
• Full bladder is sensed, results in stress or overflow incontinence

Urge incontinence

Urgency with involuntary detrusor contraction when bladder is filling

Overflow incontinence

Detrusor becomes weak and unable to fully empty

Manifestations of Overactive Bladder Syndrome

Social isolation, cause depression, risk for falls & UTI’s in elderly

Diagnosis of Overactive Bladder Syndrome

H&P, u/a, urodynamic evaluation

Treatment of Overactive Bladder Syndrome

Antimuscarinics, surgery

Urinary Incontinence

Loss of urinary control

Enuresis

– Involuntary urination by a child after 4–5 years of age
– Nocturnal enuresis – bed-wetting
– Causes may be psychological and structural
– Usually resolves with or without treatment

Transient incontinence

– Urinary incontinence resulting from a temporary condition

Causes of Transient Incontinence

– delirium, infection, atrophic vaginitis, medications, psychologic factors, high urine output, restricted mobility, fecal impaction, alcohol, and caffeine.

Stress incontinence

• Loss of urine after pressure exerted on the bladder by coughing, sneezing,
laughing, exercising, or lifting something heavy

• Occurs when the sphincter muscle of the bladder is weakened

Causes of Stress Incontinence

• Pregnancy, childbirth, menopause, cystocele,
prostate removal, obesity, and chronic coughing

Urge incontinence

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

Causes of Urge incontinence

• UTI’s, bladder irritants, bowel conditions, smoking, Parkinson’s disease, Alzheimer’s disease, stroke, injury, and nervous system
damage

Reflex incontinence

• Urinary incontinence caused by trauma or
damage to the nervous system

• Urgency is generally
absent

Detrusor hyperreflexia 

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

Overflow incontinence

• Inability to empty the bladder,
or retention
• Dribbling urine and a weak
urine stream

Causes of Overflow Incontinence

• bladder damage, urethral
blockage, nerve damage, and
prostate conditions

Chronic overdistension

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

Mixed incontinence

• Occurs when symptoms of more than one type of urinary incontinence are experienced

Functional incontinence

• Occurs in many older adults, especially people in nursing home, who have a physical or mental impairment prevents toileting in time

Gross total incontinence

• A continuous leaking of urine, day and night, or the periodic uncontrollable leaking of large volumes of urine
• The bladder has no storage capacity

Causes of Gross Total Incontinence 

• anatomic defects, spinal cord or urinary system injuries, and fistulas between the bladder and an adjacent structure, such as the vagina

Risk Factors of Incontinence

• Being female
• Advancing age
• Being overweight
• Smoking
• Other diseases

Diagnosis of Incontinence 

• H&P, bladder diary, U/A,
urine cultures, cystourethrogram,
cystoscopy, pelvic ultrasound, postvoid
residual measurement, and urodynamic testing

Complications of Incontinence

• Skin problems
• Recurrent urinary tract
infections
• Negative psychological
consequences
• Interruption of usual
activities

Treatment of urinary Incontinence

• Bladder training
• Scheduled toileting
• Fluid and diet management
• Pelvic floor muscle exercises
• Electric stimulation
• Medications
• Urethral inserts
• Pessary
• Artificial urinary sphincter
• Sling procedures
• Bladder neck suspension
• Absorbent pads and protective
garments
• Urinary catheter
• Radiofrequency therapy
• Botulinum toxin type A injections
into the bladder muscle
• Bulking material injections into
tissue surrounding the urethra
• Sacral nerve stimulator
• Skin barrier creams
• Safety measures
• Acupuncture
• Hypnotherapy
• Herbal remedies
• Coping strategies and support
• Increased perineal hygiene

Causes of Prostate Enlargement

• Acute inflammation
• Benign prostatic hyperplasia
• Prostate cancer

Benign Prostatic Hyperplasia (BPH)

• A common, nonmalignant enlargement of the prostate gland that occurs as males age

Cause of Benign Prostatic Hyperplasia

• The exact cause is unknown
• Declining testosterone and increasing estrogen levels are thought 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

Complications of Benign Prostatic Hyperplasia

Urinary stasis and UTIs

Manifestations of Benign Prostatic Hyperplasia

• Frequency, urgency, retention, difficulty initiating urination, weak urinary stream, dribbling urine, nocturia, bladder distension, overflow incontinence, and erectile dysfunction

Diagnosis of Benign Prostatic Hyperplasia

• H&P (digital rectal exam- DRE), urine flow measures, U/A, post-void residual volume, prostate-specific antigen, rectal ultrasound, biopsy, and cystoscopy

Stricture

• Narrowing of the lumen of the urethra
• Male>female

Causes of Stricture

• Scar tissue due to infection injury or surgical manipulation

Symptoms of Stricture

• Of Lower Urinary Blockage
• Severity depends on location of obstruction, length of obstruction, and diameter of the lumen

Diagnosis of Stricture

H&P, u/a, cultures, measuring post-void residual volume

Treatment of Stricture

Catheterization, surgery if severe

Pelvic Organ Prolapse

• Almost entirely in females
• Rarely in males – bladder will prolapse into the scrotum

Rectocele

Rectum into the vagina

Cystocele

Bladder into the vagina

Manifestations of Pelvic Organ Prolapse

Urinary obstruction, pressure in the vagina, infection

Diagnosis of Pelvic Organ Prolapse

H&P, urodynamic testing, cultures

Treatment of Pelvic Organ Prolapse

Pessary, surgery

Urinary Tract Infections

• Extremely common
• Lower tract most frequent site
• Bladder
• Urethra, prostate, ureter, kidney
• Escherichia coli most common culprit

Risk factors for Urinary Tract Infections

female, BPH, congenital urinary tract abnormalities, immobility, urinary or bowel incontinence, renal calculi, decreased cognition, pregnancy, impaired immune response, urinary catheterization, and improper personal hygiene

Why females are more likely to get UTIs

Short urethra, Proximity of anus & opening of urethra

Manifestations of Urinary Tract Infections

may be asymptomatic, urgency, dysuria, frequency, hematuria, cloudy and foul-smelling urine, and symptoms of infection

Diagnosis of Urinary Tract Infections

H&P, U/A, urine culture & susceptibility, cystoscopy, and CBC

Treatment of Urinary Tract Infections

antibiotics (3-7days), increasing hydration, avoiding irritants, performing proper perineal hygiene, wearing cotton underwear, not delaying urination, adequately emptying the bladder, and providing appropriate catheter care

Cystitis

• Inflammation of the bladder
• Most common UTI

• The bladder and urethra walls to become red
and swollen

Causes of Cystitis

infection and irritants

Manifestations of Cystitis

Asymptomatic, UTI symptoms, suprapubic & LBP,
and pelvic pressure

Painful Bladder Syndrome

Nonbacterial, noninfectious cystitis, and Interstitial
Cystitis (idiopathic)
• Symptoms of cystitis without known etiology

Manifestations of Painful Bladder Syndrome

Bladder fullness, frequency, nocturia, small urine volume, chronic pelvic pain

Diagnosis of Painful Bladder Syndrome

H&P, exclusion of other causes

Treatment of Painful Bladder Syndrome

Bladder training, behavioral modification, PT, analgesics, antihistamines, TCA, benzodiazepines

Pyelonephritis

• Infection that has reached one or both kidneys
• Originating from lower urinary tract or bloodstream
• E. coli is the most common culprit
• Kidneys become grossly edematous and filled with exudate
• Often compressing the renal artery
• Abscesses and necrosis can develop, impairing renal
function and causing permanent damage

Complications of Pyelonephritis

renal failure, recurrent UTIs, and sepsis

Manifestations of Pyelonephritis

evere UTI symptoms (or no lower UTI symptoms), flank pain, fever, chills, nausea, vomiting, and increased blood pressure

Diagnosis of Pyelonephritis

H&P, U/A, urine and blood cultures, CBC, cystoscopy, intravenous pyelogram, CT scan, renal ultrasound, biopsy, and cystourethrogram

Treatment of Pyelonephritis 

usual UTI treatments, but long-term antibiotics up to 4–6 weeks are required

Chronic pyelonephritis

• Persistent or recurrent infection in the kidney(s)
• Leads to scarring of the kidney
• More likely when pyelonephritis caused by obstruction
• Nephrolithiasis, vesicoureteral reflux
• Other sources of chronic inflammation
• Aspirin, acetaminophen, radiation, immune complex diseases, ischemia
• May lead to chronic kidney failure if diffuse scarring and impaired
urine-concentrating ability

Manifestations of Chronic Pyelonephritis

Hypertension, flank pain, frequency, dysuria

Diagnosis of Chronic Pyelonephritis

H&P, u/a, IVP, u/s, CT scan

Treatment of Chronic Pyelonephritis

Underlying cause, antibiotics if bacterial infection

Glomerulonephritis

Inflammation of the glomerulus

Primary Glomerulonephritis

Immune response, ischemia, vascular disorders, drugs, infection

Secondary Glomerulonephritis

Systemic disease (DM***, SLE, CHF, HIV)

Manifestations of Glomerulonephritis

• Insidious or rapid, severe oliguria, hypertension, renal failure, electrolyte imbalances, metabolic acidosis
• If focal lesions less severe: edema (from salt & water reabsorption), fluid volume excess, hypertension
• If severe: hematuria with RBC casts, proteinuria >3-5g/day

Treatment of Glomerulonephritis

Underlying cause, correct edema, hypertension,
hyperlipidemia, antibiotics (if needed), steroids, immune regulators, anticoagulants (if fibrin crescent formation

Nephrotic Syndrome

Results from antibody-antigen complexes lodging in the glomerular membrane, triggering the complement system

Primary Nephrotic Syndrome

Minimal change disease, membranous glomerulonephritis, focal segmental glomerulosclerosis

Secondary Nephrotic Syndrome

systemic diseases, drugs, infections, vascular disorders and idiopathic

Treatment of Nephrotic syndrome

Normal-protein, Low-fat, low-salt diet, diuretics,
heparin, steroids, immunosuppressive agents

Nephritic syndrome

Related to immune injury

Causes of Nephritic syndrome

diseases that initiate the inflammatory response
• Post-infectious glomerulonephritis, diabetic nephropathy, lupus nephritis, IgA nephropathy

Manifestations of Nephritic syndrome

gross hematuria*, urinary casts and leukocytes, low GFR, azotemia, oliguria, and HTN

Diagnosis & Treatment: of Nephritic syndrome

Similar to nephrotic syndrome