HOSA Urinary Diseases and Conditions

Urinary System

Prod, store, excretion of urine, stopping body from becoming toxic; cleansing of blood of waste products and metabolism and regulating water, salts, acids in body fluids ensures homeostasis; includes kidneys (manufacture urine, regulate systemic BP) and accessory structures which transport urine until excreted voluntarily by urethra

Kidneys

two of them, each composed of 1 million nephrons; nephrons filtrate, reabsorb, secrete urine; urine transported from nephron to renal pelvis, then ureters; kidney can secrete renin, a hormone that raises BP, and erythropoietin which stimulates RBC prod; can activate vitamin D

Acute Glomerulonephritis

Infla and swelling of glomeruli of kidney; can be primary to kidney or secondary to systemic disease; followed streptococcal bacterial infection of throat/skin; marked by proteinuria, edema, dec urine volume; hematuria can be insignificant to grossly bloody; urine can be dark or coffee colored; often children, adolescents; hypertension related to altered renal function and fluid retention possible; headaches, visual disturbances, malaise, anorexia, low-grade fever, flank, back pain from swelling of kidney tissue; symptoms req prompt med attention; follows infection of group A beta-hemolytic streptococcus, can be idiopathic from immune reaction causing circulating antigen-antibody complexes trapped in capillaries of glomerulus; sometimes antigen is endogenous as accompaniment of tumors; injury to glomeruli causes dec rate of filtration of blood and retention of water/salts in body; diagnosis based on clinical findings, history, urinalysis; urine has gross blood, RBC presence, WBCs, renal tubular cells, casts; proteinuria; blood tests show elevated blood urea nitrogen, hypoalbuminemia, ESR; KUB radiographs and ultrasonography reveal bilateral kidney enlargement; renal biopsy confirms diagnosis; no specialized treatment for streptococcal cause; antibiotics if infection cause; diuretics for edema, hypertension; Na intake low to stop circulatory overload or convulsions; corticosteroids for immune reaction cause; most cases resolve in 2 weeks; prevention based on condition, w/ antibiotics for streptococcus cause early can help

Chronic Glomerulonephritis

Slowly progressive, noninfectious disease irreversible renal damage, renal failure; advanced stage of many kidney disorders; infla to destruction of glomeruli, reducing glomerular filtration and retention of uremic poisons; first asymptomatic, progression hypertension, hematuria, proteinuria, oliguria, edema; later stages renal failure, severe hypertension, azotemia; urea in sweat if failure to remove urea from blood, tiny urea crystals on skin; fatigue, malaise, nausea, vomiting, pruritus, dyspnea; often already diagnosed, if hematuria appointment ASAP; immune mechanisms suspected cause; antigen-antibody complexes lodge in glomerular capsular membrane, triggering infla response and glomerular injury; primary renal disorders, multisystem diseases (lupus) possible causes; blood tests, urinalysis, radiographs, ultrasonography, renal biopsy grounds diagnosis; findings of advanced renal insufficiency, rising BUN, serum creatinine levels, abnormal urinalysis from electron microscopy, immunofluorescence valuable; comfort measures, antihypertensives, diuretics, antibiotics if UTI; protein, Na+, phosphate, fluid intake limited; ACE inhibitors to reduce proteinuria; may req dialysis or kidney transplant; prognosis varies w/ extent to destruction and response to therapy; prompt treatment of acute version prevents

Nephrosis

Disease of basement membrane of glomerulus, 2ndary to renal diseases or systemic disorders; composes group of symptoms known as “protein-losing kidneys” loss of excess protein (albumin) in urine; hypoalbuminemia, low glomerular filtration causing water, Na retained, edema, hypertension; microscopic or gross hematuria, plasma lipid levels up for not understood reason, fat bodies in urine, susceptibility to infections; lethargic depressed feeling, loss of appetite, pale look, puffy eyes, pitting edema, weight gain; symptoms req prompt assessment; inc permeability of glomerulus induces kidney damage cause, often following attack of glomerulonephritis, exposure to certain drugs/toxins, pregnancy, kidney transplants, diabetes mellitus, allergies; clinical findings of proteinuria, lipiduria in 24-hour urine specimen; renal biopsy if tumor suspected; diet protein intake adjusted to GFR, Na intake lowered for edema, diuretics, ACE inhibitors for hypertension and protein loss, corticosteroids (prednisone) to control proteinuria, urine output monitored; prognosis based on extent of destruction and therapy response; prompt treatment to glomerulonephritis req for prevention, avoiding toxins/drugs, monitoring kidney function of pregnant women

Nephrotoxic Agents

Solvents carbon tetrachloride, methanol, ethylene glycol; Heavy Metals Lead, Arsenic, Mercury; Pesticides; Antibiotics Kanamycin, Gentamicin, Polymyxin B, Amphotericin B, Colistin, Neomycin, Phenazopyridine; NSAIDs, Iodinated Radiographic Contrast Media, Antineoplastic Agents; Acetaminophen, Amphetamines, Heroin, Silicon, Cyclosporine; Poison Mushrooms

Acute Renal Failure

Sudden, severe reduction in renal function; common clinical emergency as nitrogenous waste accumulates in blood quickly causing uremic episode; initially oliguria, GI disturbances, headache, drowsiness, other alterations of consciousness level; other symptoms based on cause, impairment degree, BUN; req prompt attention; causes classified by those that diminish blood flow (shock, heart failure), involve intrarenal damage/disease (glomerulonephritis), those that result in obstruction in urine; intrarenal damage from nephrotoxic substances; sudden renal dysfunction disrupts other body systems can become fatal; certain antibiotics (gentamicin, streptomycin) can cause; blood tests and urinalysis reveal abnormal findings of oliguria and nitrogenous waste; BUN, serum creatinine, K levels high in blood; kidney scans, ultrasonography, radiographs, IV pyelograms help ground diagnosis; all body systems monitored, patient evaluated for dialysis, fluid intake and output balanced, nutrition managed to prevent metabolic acidosis; high carb low protein diet, Na/K intake controlled, antihypertensives, diuretics, antiinfective agents for infection treats; oftentimes reversible and recovery rapid, complete; prognosis varies w/ cause, response to treatment; can be fatal if untreated; stopping causes prevents

Chronic Renal Failure

Gradual, progressive loss of nephrons w/ irreversible loss of function and onset of uremia; effects soon manifest all over body; weak, tired, lethargic feeling; hypertension, edema from fluid retention; arrhythmias, muscle weakness, dyspnea, metabolic acidosis, ulceration of GI mucosa, hair/skin changes w/ progression; req prompt attention if hematuria, often already diagnosed most times; primary diseases/infections of kidney (glomerulonephritis, pyelonephritis, polycystic kidneys) causes; CRH can be end stage of chronic renal diseases, e.g. chronic obstruction of urine outflow; blood studies show high BUN, serum creatinine, K, dec hemoglobin, hematocrit; urinalysis abnormal, w/ excess protein, glucose, leukocytes, casts; 24 hour urine volume greatly dec; radiographs, KUB films, renal ultrasonograms, kidney scans, IV pyelograms, renal arteriograms grounds diagnosis; treatment of underlying cause first; evaluation for dialysis/kidney transplant if prolong life; diet, nutrition mods to control protein/Na intake to reduce kidney work; fluid in/outtake monitored; diuretics, antihypertensives, antiinfective agents, antiemetics; more carb/fat calories, lower protein in diet resolves nausea, loss of appetite symptoms; anemia fixed w/ erythropoietin, a protein forming new RBC; bone degeneration symptom fixed w/ calcitriol; prognosis variables, no total cure known; prevention depends on causative factors 

Pyelonephritis

Most common renal disease, infla of renal pelvis and connective tissue of 1+ kidneys; pus collects in renal pelvis, forming abscesses; rapid onset fever, chills, nausea, vomiting, lumbar pain; often preceded by UTI w/ urinary freq/urgency; foul odor of urine, hematuria, pyuria, tenderness to suprapubic region, abdomen becomes rigid, tender enlarged kidney may be palpated; urinalysis shows abnormal constituents (casts); symptoms req prompt attention; bacteria from lower urinary tract to kidney common cause; less commonly from hematogenous or lymphatic bacteria; obstruction, stasis of urine by renal calculi, tumors, benign prostatic hypertrophy predisposes, allowing bacteria (E. Coli) to infect; women more at risk from sex or poor perineal hygiene; catheterization w/ endoscopic (cystoscopic) exam can introduce organisms into urinary bladder, ascending infection to kidneys; clinical findings, urinalysis of clean-catch urine specimen showing inc WBCs, RBCs w/ presence of bacteria, pus, protein, casts, blood cultures and urine cultures finding causative organism; radiographs show swollen/enlarged kidneys; IV or oral antibiotics, penicillin/cephalosporin, for 7-10 days or 10-14 antibiotics of fluoroquinolones or 2nd/3rd gen cephalosporins 7-10 days; inc fluid to dilute urine, bed rest; often good response unless UTI, yielding recurrences; if recurrence, IVP and renal ultrasound to determine renal abnormality; complicated cases req surgery to correct anomaly; early detection and treatment good prognosis; untreated, recurrent can cause hypertension, bacteremia, chronic pyelonephritis, permanent kidney damage; prevention is eight glasses of water a day

Hydronephrosis

Abnormal dilation of renal pelvis from P from urine that cannot flow past an obstruction; if obstruction severe/prolonged, fibrotic changes, loss of function in nephrons; often chronic w/ destruction of kidneys w/o pain or symptoms, found incidentally during radiographs or ultrasonography; vague backache, diminished urine output maybe only symptoms identifiable; if w/ infection, fever, chills, hematuria, pyuria, kidneys palpable; req prompt med attention, often first requested when slightly feeling sick; obstruction causes; often right kidney affected, but can be both; obstruction from renal calculi, tumors, infection infla, prostatic hyperplasia, bladder tumors, congenital abnormalities, pregnancy; first indication from investigation of ab structures; follow up contrast studies of ureters done; retrograde pyelogram req, cystoscopy rules out obstruction of tumor; treatment varies w/ cause; if obstruction found early, must be removed by surgery; if not found, after two months, kidneys no function, so surgery not indicated; concurrent infections req antibiotics; nephrostomy inserted if no surgery or obstruction cannot be removed; often resolves once obstruction removed; if long duration, permanent damage; preventing kidney stones or any obstructions prevents

Renal Calculi

Kidney stones anywhere in urinary tract formed by concentration of various mineral salts; 1+, vary in size; staghorn calculus is larger in shape of renal pelvis; small stones can pass unnoticed; symptoms vary w/ degree of obstruction; if infection or blockage, severe pain in flank area (renal colic), w/ urinary urgency; nausea, vomiting, hematuria, fever, chills, ab distention, blood in urine from trauma from small stones which are gravellike, or larger stones; hydronephrosis can develop from stones; emergency if pain; often cause unknown, hereditary tendency though; form when excessive Ca, uric acid in blood; more men, 30-50s, forming when sources of crystals found in urine w/ absence of crystalline inhibitors; risk factors of prolonged dehydration, immobilization, infection, urinary stasis from obstruction, long-term ingestion of certain meds, hyperparathyroidism, gout; family history. Clinical findings, urinalysis, radiographic KUB studies, CT, renal ultrasonogram, IV urogram; patient urged to urine, capturing stones for lab work; analgesics; location/size determines treatment; small calculi <3mm treated w/ fluid in hope of passing naturally; large calculi removed w/ several surgeries; attempts to crush stones too large to pass ureter or lodged in pelvis of kidney or trapped in proximal portion of ureter by extracorporeal shock wave lithotripsy, making stones smaller to pass naturally; surgery w/ ureteroscope to capture stone in basket and remove it for stones trapped in distal aspect of ureter; if attempt to capture stones unsuccessful, electrohydraulic lithotripsy or laser lithotripsy breaks stone into smaller particles, often under anesthetic/fluoroscopy; after removal of calculus, ureter visualized w/ ureteroscope, and pelvis of kidney inspected for damages; stent from bladder to pelvis of kidney to prevent edema and spasms of ureter, removed after 2-5 days; stones often pass spontaneously, but if not, removal done during cystoscopy; if previous measures no work, surgical percutaneous nephrolithotomy indicated to remove before permanent damage; small incision into kidney, shattering of stone w/ ultrasound or EHL; based on chem composition, can be dissolved or prevented from forming w/ meds; drinking 8-12 glasses of water/day, diuretics to stop urinary stasis; prognosis good after removal or passage, but more stones can form; urine/blood chem measurements provide clues to preventable measures, e.g. diet mods, inc exercise, adequate fluid intake

Infectious Cystitis / Urethritis

infla of bladder, urethritis infla of urethra; common forms of lower UTI; infla/infection cause urinary urgency, freq, possibly incontinence; P on pelvis, pain in pelvic region, low back pain, spasm of bladder, fever, chills; burning sensation during urination; color of urine from dark yellow, pink, red if blood; classic symptoms req prompt attention; bacterial invasion ascending from urinary tract cause, often E. coli, Klebsiella, Enterobacter, Proteus, Pseudomonas species; STDs can cause; viruses, fungi, parasites, chemo/radiation can cause; lesions can develop in bladder 2ndary to infla, intensifying symptoms; diagnosis from clinical findings, urinalysis of clean-catch urine specimen, urine culture, cystoscopy; urinalysis shows colored urine w/ abnormal urinary sediment, blood, pus; microscopic exam of urine shows RBCs (occult blood), inc # epithelial cells/leukocytes, bacteria; urine maybe foul odor; urine culture finds causative organism; cystoscopy shows reddened inflamed bladder wall; palpation shows tenderness in suprapubic region, pain in lower back; organism-specific antibiotics or urinary antiseptic therapy (amoxicillin, Bactrim DS, Septra DS, Cipro, Levquin); Penicillin derivatives for complicated versions, which tend to recur; treatment for 3-5 days min for uncomplicated infections, 7-10 days for recurrent infections; Pyridium, urinary analgesic, stops dysuria, painful urination; inc fluid encouraged; antiinfective drugs yield great prognosis; drinking 8 glasses water/day; history of lower UTIs advised to void freq, proper toilet tissue when wiping prevents

Diabetic Nephropathy

Renal changes from diabetes mellitus, inducing glomerulosclerosis in type I diabetes patients, inc mortality; also in type II sometimes; urinary retention, hypertension, nausea, proteinuria; UTI, pyelonephritis common; found in routine assessments of diabetics; lesions of glomeruli eventually cause dec filtration rate; insufficient control of blood glucose levels or BP can hasten deterioration of renal function; blood tests show elevated BUN level, inc cholesterol; urinalysis shows protein, pus in urine; urinary microalbumin signals presence of urinary albumin, indicator of disease; diagnosis confirmed by radiograph of kidneys, renal biopsy; treatment individualized; medical control of diabetes, BO important; ACe inhibitor for BP control, fluid in/outtake balanced; diuretics Rx; low protein low fat mods to diet recommended; dialysis or evaluation for kidney transplant for long-term management of ESRD; prognosis varied based on stage when intervention begins; early detection and treatment inc prognosis; no cure; end stage renal disease is final outcome, req dialysis or kidney transplant; close monitoring of blood glucose, BP w/ proper treatment prevents

Polycystic Kidney Disease

Slowly progressive, irreversible disorder when normal renal tissue replaced w/ multiple grapelike cysts; bilateral, w/ cysts forming from dilated nephrons and collecting ducts; soon kidneys enlarged w/ compression of surrounding tissue, impairing renal function, renal failure; as kidneys dilate, they are palpable on phys exam; lumbar pain, ab pain, tenderness, hematuria, systemic hypertension, more prone to infections, renal calculi; often high BP, kidney infections; symptoms req prompt attention; inherited, but may not manifest until adulthood; unclear why cysts forms; acquired version (noninherited) is a sequela of long-term kidney disease or long-term dialysis; autosomal recessive version in infants/children, progresses rapidly to end-stage renal disease/death; autosomal dominant version onset during middle age; diagnosis by clinical findings, urinalysis showing gross blood, proteinuria, pus; radiographs, ab CT scans, ab MRI, IV pyelogram shows enlarged kidneys w/ irregular outlines and spidery appearance; cannot be cured; treatment of dialysis, kidney transplantation, management of UTIs and hypertension; majority inherited, no prevention 

Neurogenic Bladder

Dysfunction of urinary bladder control, difficulty in emptying bladder, urinary incontinence; symptoms/signs vary based on cause; sensory-related problems, hesitancy, dec volume of urinary stream; urinary retention from dec stimuli to void; if from motor paralysis, sensation of full bladder but inability to initiate stream; uninhibited version not able to control voiding pattern and persistently incontinent; reflex version has normal sensation absent, w/ uncontrolled bladder contractions resulting in spontaneous voiding of spurts of urine; autonomous versions has all sensations/contraction absent, resulting in inability to void w/o applying pressure to suprapubic area; prompt assessment considered; insult to brain, spinal cord, or nerves supplying lower urinary tract, whether by trauma/disease, can result; damage by cerebrovascular accident, spinal cord trauma, tumors, neuropathies, herniated lumbar disks, poliomyelitis, spinal cord lesions, myelomeningocele causes; history of trauma/disease, clinical findings, urodynamic studies of bladder function ground diagnosis; uroflowmeter gets urine flow rate in mL/s, helps; catheterization, whether intermittent/indwelling, can help quality of life; drug therapy w/ parasympathomimetic agents can help; surgery, use of ext collection devices alternatives; complications include hydronephrosis, renal failure; often no cure, drug therapy can help (Oxybutynin, Detrol) used for urinary incontinence from muscle spasms; prevention varies w/ cause

Stress Incontinence

Uncontrollable leakage of small amounts of urine from urinary bladder during phys exertion or actions inducing stress of pelvic muscles (laughing, sneezing, lifting, stretching, running); symptom, sign, and diagnosis; inc ab pressure forces urine through bladder sphincter, leaking urine; more often women; patient unable to control leakage during phys exertion; not a n emergency, but can feel like it; weakening of pelvic floor muscles and urethral structures causes disorder, trauma to area from childbirth common cause, P from existing pregnancy can cause, hormonal changes from aging, menopause make common in older women; certain meds, obesity can precipitate; symptoms clearly indicates; endoscopy, VCUG reveal abnormal bladder position w/ leakage provoked by urodynamics; Kegel exercises, estrogen replacement (better when inserted vaginally), drug therapy, surgical repair, collagen injections treats; prognosis varies w/ cause; prevented by strengthening pelvic, perineal muscles

Urinary Incontinence

Usually, a reflex stimulates initiation of voluntary urination (micturition); sphincters of bladder and pelvic diaphragm relax, bladder muscles contract, emptying bladder; def partial/total loss of voluntary control of bladder w/ inability to retain urine; often elderly due to overactivity of bladder musculature, inducing urgency and incontinent w/ small volumes of urine; sometimes temporary after childbirth; children experience form of enuresis, bedwetting; managed by degree, type, and cause; antispasmodic agents, adult diapers, bladder training, estrogen therapy, pelvic muscle exercises; chronic indwelling catheters avoided in management due to prevalence of infection 

Overactive Bladder

Urinary urgency, strong sudden urges to urinate; sudden uncomfortable urge either day or awakening them during sleep; urge incontinence results in urinary incontinence w/ accidental leakage of small amounts of urine; can present social, occupational, psychosocial problems due to randomness of occurrence; normally, bladder muscle transmits impulses to brain when full when req to empty; here, false signals sent to brain; rehabilitation of pelvic muscles, learning behavior therapies, drug therapy treats; rehab uses biofeedback to train sphincter after some time; drug therapy faster treatment, estrogen for postmenopausal females only if no cancer risk; Detrol (LA), oxybutynin can help relax smooth muscles of bladder reducing spasms

Renal Cell Carcinoma

1+ malignant tumors in 1+ kidneys; less common is Wilm’s Tumor, a congenital renal tumor of childhood, or cancer of renal pelvis; triad of symptoms hematuria, ab mass, lumbar pain, w/ <10% having all three unless disease advanced; less common is weight loss, anemia, fever, hepatic dysfunction, hypocalcemia; often no symptoms until advanced; hematuria req prompt assessment; often sporadic, but sometimes familial forms; von Hippel-Lindau syndrome most common component, predisposing multiple bilateral renal cysts and carcinomas/tumors in other locations; risk factors are smoking, obesity, dialysis patient w/ acquired cystic kidney disease, prolonged exposure to chemicals (cadmium, asbestos); incidence varies geographically, highest in Scandinavia, NA; radiology exams can detect; ab CT, ab ultrasound, IV pyelogram can diagnose; CT of ab/chest and bone scan for metastases; biopsy of tumor not needed; TNM stages; surgical removal, partial nephrectomy for small tumors of one kidney, or radical nephrectomy treats; metastatic version often resistant to surgical removal and chemo, but can be sensitive to immunotherapy w/ high dose interleukin-2; prognosis determined mainly by pathologic stage; overall 5-year survival 60%, w/ early 79-94% and metastatic tumors <5%; ind w/ high risk should undergo periodic screening of urine cytology and ab ultrasound to prevent

Bladder Tumors

Transitional epithelium (urothelium) that lines surface of bladder has neoplasms, minority SC; urothelium lines entire urinary tract from renal pelvis to urethra; can develop in bladder and recur at any site of urothelium-lined urinary tract; gross intermittent painless hematuria; pain in flank/suprapubic area from carcinoma becomes locally advanced, metastatic; voiding symptoms of dysuria, urgency, inc freq sometimes; advanced disease shows fatigue, weight loss, anorexia; env exposures are often cause; aniline dyes, diesel exhaust, cigarette smoke, history of prior bladder cancer; schistosomiasis (infection w/ parasitic worm Schistosoma haematobium) leads to development in endemic areas (Egypt); >80% in patients over age 60; unexplained hematuria >40 denotes cancer in urinary tract unless proven otherwise; full urologic evaluation of entire urinary tract indicated, w/ cystoscopy, urinary cytology (exam of transitional cells in patient’s voided urine), IV pyelogram, CT; once diagnosis known, CT for extravesical extension and metastases; staged by TNM; tumor resection via transurethral resection of bladder tumor, where complete cystoscopic resection of any visible tumors and selected biopsies of bladder mucosa; issue w/ TURBT is 80% recur within 12 months; for noninvasive carcinoma post-TURBT, follow up of urine cytology and cystoscopy at 6-month intervals for 3-5 years, recurrently found tumors removed w/ TURBT; if high risk of recurrence, BCG administered in bladder, a mycobacterium modified to less pathologic state, inducing local immune reaction suppressing tumors; invasive carcinoma confined to bladder is treated w/ either radical cystectomy or partial cystectomy w/ adjuvant chemo; for metastatic carcinoma, multidrug chemo (methotrexate, vinblastine, doxorubicin, cisplatin, or gemcitabine, cisplatin) can shrink tumor and inc survival, rarely does it cure; stage determines prognosis; once invasion outside bladder or nodal disease detected, therapy works poorly; recurrence more common problem than progression; reducing occupational exposures and smoking can prevent