Chapter 27 - Common Urologic Disorders

tamm horsfall protein

most abundant protein in urine, protects against pathogens that cause urinary tract infections

urinary tract infection

occurs when bacteria enter the urinary system and multiply, causing an infection.

• extremely common

• more common in women than men

• most common between 16-35 years

women than men

are more prone to infection because…

• Urethra is shorter.

• Urethra opens closer to the anus, vagina, and perineum.

• Tissues are more susceptible to trauma and irritation and may result from sexual activity, bubble baths, and use of feminine hygiene products.

predisposing factors of UTI

in both men and women include incontinence, incomplete emptying of the bladder, retention of urine in the bladder, and any obstruction to urine flow.

• improper hygiene practices (wiping back to front)

E. coli

most common organism responsible for UTIs

urethritis

infection of the urethra, inflammation of the urethra caused by infection

• caused by gonorrhea, chlamydia, and mycoplasma infections

• is a lower UTI

• symptoms - dysuria (painful or difficult urination), burning, urgency, frequency to urinate, incontinence

other organisms associated with UTIs

Klebsiella, Proteus, Enterobacter, Citrobacter, Serratia, Pseudomonas, Enterococcus, coagulase-negative Staphylococcus, Chlamydia, and Mycoplasma.

cystitis

infection of the bladder

• its a lower UTI

• symptoms - burning, urgency, frequency to urinate, incontinence

pyelonephritis

bacterial infection of the kidney (kidney tissue and renal pelvis)

• is an upper UTI

• develops when bacteria from a lower UTI trails upward to the kidneys

• symptoms - fever, flank pain, CVA tenderness

CM of UTI

• Dysuria (burning or painful urination)

• Urinary frequency and urgency

• Suprapubic pain (lower abdominal pain)

• Cloudy or bloody urine

infectious bacteria for urinary systems

E. coli - Most common cause of UTIs; normally lives in the intestines

Klebsiella - Can cause UTIs, especially in hospitalized patients

Proteus - Associated with UTIs and struvite kidney stones

Enterococcus - Can cause complicated or catheter-associated UTIs

Staphylococcus saprophyticus - Can cause UTIs, particularly in young sexually active women

pathophysiology of UTI

1. bacteria enter the urethra - usually bacteria from the GI tract

2. bacteria travels to the bladder - attach to the urinary tract lining and multiply

3. inflammation develops - causes burning, urgency, frequency, and discomfort

4. infection may spread upward - bacteria can travel through the ureters to the kidneys, causing pyelonephritis

obstructive disorders

refer to any anatomical or functional condition that impairs the flow of urine. The severity of symptoms depends on the location and duration of the obstruction and the presence of urinary stasis or infection.

•  can lead to bladder and kidney infections as well as pressure back-up and damage to the kidneys also known as hydronephrosis.

causes of obstruction disorders

tumors, inflammation, scarring, stenosis, congenital defects, and renal calculi (kidney stones)

types of obstructive disorders

1. kidney stones

2. benign prostatic hypertrophy (BPH)

3. urethral structures

kidney stones prevalence

• Kidney stones frequently recur if the underlying cause is not treated.

• 1 to 2 million people in the United States have kidney stone disease (nephrolithiasis) each year.

• Higher incidence is observed in the Southeast, Southwest and Midwest due to climate and diet.

• Kidney stone disease is more common in men than women.

• Most often, it affects people between 20-55 years old.

kidney stone etiology

• This is a combination of genetic predisposition and environmental factors.

• Dehydration leads to concentrated urine, supersaturation of certain waste products (urate, calcium oxalate), and then, crystal formation.

benign prostatic hypertrophy etiology

• Etiology is not completely understood and is not related to cancer.

• Hormonal changes associated with aging seem to be a factor.

• There is a genetic predisposition to BPH.

BPH prevalence

• BPH is a very common problem in older men.

• It is estimated that 50% of men over 65 years experience some form varying from mild to severe.

urethral structures

Fibrotic changes of urethral lumen are caused by trauma, urethritis (especially gonococcal infections), surgical interventions or repeated catheterizations, as well as congenital defects of the urethra.

cancers of urinary tract

1. bladder cancer

2. renal cell carcinoma

bladder cancer

occurs when abnormal cells grow uncontrollably in the bladder lining, the most common type is urothelial carcinoma

• arise from the transitional epithelium lining the bladder in the trigone area

• most occur in men after 50 years

bladder cancer characteristics

• More common in men: Men have a higher risk of developing bladder cancer.

• Smoking: A major risk factor because harmful chemicals from cigarettes enter the bloodstream, are filtered by the kidneys, and become concentrated in urine.

• Often asymptomatic early: Patients may not notice symptoms initially.

• Multiple tumors: Cancer may develop in several areas of the bladder.

• High recurrence rate: Bladder cancer can return even after successful treatment.

prevalence of malignant cancers

• Malignant tumors occur primarily after the age of 50 years and more in males than females, and the ratio is 3:2.

• The American Cancer Society estimates that there would be 65,150 new cases of renal cell carcinomas in 2013, resulting in 13,680 deaths.²

• It accounts for 3% of adult malignancies and 90-95% of neoplasms arising from the kidneys.

predisposing factors of malignant cancers

• smoking (major)

• obesity

• hypertension

• recurrent infection

• NSAIDs

causes of malignant tumors

• Irritants (carcinogens) from the blood stream are concentrated in the urine.

• Toxins cause cellular changes in the lining of the bladder (transitional epithelium) and kidney.

• Cells undergo process of metaplasia, carcinoma-in-situ, and overt cancer.

renal cell carcinoma (RCC)

most common type of kidney cancer in adults, develops from cells in the kidney tubules

RCC characteristics

• More common in men.

• Smoking, obesity, and hypertension are major risk factors.

• May have no symptoms in early stages.

• Can spread to other organs, including the lungs and bones

• symptoms: hematuria (blood in urine), flank pain and weight loss

adult polycystic kidney disease

is an inherited genetic disorder in which multiple fluid-filled sacs (cysts) develop inside the kidneys

• Over time, these cysts grow larger and can damage kidney tissue, reducing the kidneys' ability to filter waste from the blood.

urinary infections

invasion by bacteria tends to occur quickly and aggressively. Most infections are ascending,starting with invasion by organisms in the genital area and traveling up into the bladder, then along the ureters to the kidneys.

pathophysiology of cystitis

• Bladder wall becomes inflamed, red, and swollen.

• Bladder wall may ulcerate and bleed (causing hematuria).

• Wall becomes irritable and painful, causing frequent urination.

• Bladder capacity is usually reduced.

pathphysiology of urethritis

• Urethral wall becomes inflamed, red, swollen, and painful.

• Often significant pain with (and fear of) urination is observed.

• Urethra may bleed or have a mucous discharge.

pathophysiology of pyelonephritis

• One or both kidneys may be involved.

• Infection involves the renal pelvis, tubules, and interstitial tissue.

• Purulent exudate fills the kidney pelvis and calyces, and the medulla becomes inflamed, resulting in bleeding and pain.

• Abscesses and necrosis can occur that can extend through the cortex to the surface of the capsule.

• Severe infections can compress the renal artery and vein and obstruct urine flow to the ureter.

• Recurrent or chronic infection can lead to fibrous scar formation in the kidney, leading to loss of tubule function.

• If severe and bilateral, can lead to chronic renal failure.

result of obstructive disorders

result in an inability of the body to rid itself of urine. The urine continues to be produced despite the obstruction, leading to rising pressures within the kidneys and ureters, with marked dilation of the renal pelvis (hydronephrosis). This pressure can decrease blood flow to the kidneys and leads to renal failure (hydronephrosis).

pathophysiology of kidney stone disease

• Stones (calculi) can develop anywhere in the urinary tract.

• Stones may be small or large; small stones can pass unnoticed.

• Stones tend to form when there are excessive amounts of insoluble salts in the filtrate, or when dehydration creates a highly-concentrated filtrate.

• Once a tiny crystal forms, deposits continue to build up on this focus and eventually form a large mass.

• Stones can get stuck as they try to descend and may obstruct the flow of urine. In unilateral development of a stone, pain will be on the affected side. Urine flow will divert to the unaffected kidney. There are occasions that stones develop in both kidneys.

• These stones usually cause symptoms and bleeding when they move or obstruct the flow of urine.

pathophysiology of BPH

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

• It compresses urethra, leads to urinary outflow obstruction.

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

• No connection between BPH and prostatic carcinoma

pathophysiology of urethral structure

• Inflammation and scarring narrows the lumen of the urethra.

• Ability to open or close in response to the bladder becomes impaired.

• Commonly, urethral opening becomes impaired as a result of inflammation and/or scarring.

pathophysiology of renal cell carcinoma

• The primary tumor arises from epithelium of the tubules, especially in the renal cortex.

• In many cases, there is a structural alteration in chromosome 3, although there are both hereditary and non-hereditary forms.

• The cancer spreads to lymph nodes, lungs, liver, adrenal glands, brain, or bones.

pathophysiology of bladder cancer

• Multiple tumors develop in the lining of the bladder (urothelium).

• Transitional cell and squamous cell are the most common types.

• Tumor is invasive through the wall to adjacent structures, and it metastasizes through the blood to pelvic lymph nodes, liver, and bone.

pathophysiology of polycystic KD

• Multiple cysts develop in both kidneys and gradually enlarge.

• Kidneys become enlarged due to the cysts, compressing and destroying kidney tissue until chronic renal failure occurs.

• Cysts can occur in other organs such as the liver.

• Adult form is transmitted as an autosomal dominant gene, causes 10% of all cases of chronic renal failure.

• This can also be transmitted as an autosomal recessive trait in children, usually associated with underdeveloped kidneys and a 30% death rate.

CM of KSD

• Sudden, severe flank, back, or lower abdominal pain (depending on where the stone is lodged)

• Nausea and vomiting

• Profuse sweating

• Chills and fever

• Pacing, difficulty finding a comfortable position

• Testicular pain in men; labial pain in women; groin pain in both

• Dysuria; urinary urgency, frequency, hesitancy

CM of 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

CM of bladder and kidney cancer

early asymptomatic

• initial symptom is blood in the urine

• Fatigue

• Anorexia

• Weight loss

• Blood in the urine

• Signs of symptoms of metastases to liver, bone, lungs

• Fever

• Hypertension

• Anemia

• Microscopic and/or gross hematuria (especially in bladder cancer)

• Urinary retention and incontinence (bladder cancer)

• Palpable flank or abdominal mass (renal cell carcinoma)