Urinary System Disorders 1 · Urinary System Disorders 1 Lecture 16 Pathology and Clinical Science...

Urinary System Disorders 1

Lecture 16

Pathology and Clinical

Science 1 (BIOC211)

Department of BioscienceText Reference:

Grossman, S.C. & Porth, C.M. (2014). Porth’s Pathophysiology: concepts of

altered health states, (9th ed.). Philadelphia, U.S.A. Walters Kluwer Health -

Lippincott, Williams & Wilkins.

© endeavour.edu.au

© Endeavour College of Natural Health endeavour.edu.au 2

Session Learning Objectives

This session aims to:

o Understand the use of various diagnostic tests and

procedures for the disorders related to the urinary system.

o Comprehend how and why the symptoms and signs of

urinary disorder appears

o Discuss the causes and management of acute and chronic

renal failure


URINARY SYSTEM

From Principles of Anatomy and Physiology (12th ed.,p. 1019), by

G. Tortora & B. Derrickson. 2009. Hoboken, NJ. John Wiley & Sons.


THE KIDNEYS

From Principles of Anatomy and Physiology (12th ed.,p. 1023), by G.

Tortora & B. Derrickson. 2009. Hoboken, NJ. John Wiley & Sons.


TYPES OF NEPHRON CELLSo The Glomerulus is made up of four types of cells

• Endothelial cells

– Fenestrated with 500-1000 pores

• Visceral epithelial cells (podocytes)

– Support the delicate glomerular basement membrane

• Parietal epithelial cells

– Cover the bowman’s capsule

• Mesangial cells

– modified smooth muscle cells of RE system

o Juxtaglomerular cells

• Macula densa cells in the thick ascending limb of the loop

of Henle


THE FILTRATION MEMBRANE

From Principles of Anatomy and Physiology (12th ed.,p. 1031), by G.

Tortora & B. Derrickson. 2009. Hoboken, NJ. John Wiley & Sons.


FLOW OF URINE THROUGH THE

NEPHRON

From Principles of Anatomy and Physiology (12th ed.,p. 1025), by G. Tortora & B. Derrickson.

2009. Hoboken, NJ. John Wiley & Sons.

Path of urine drainage:

o Urine produced in the

Nephron collecting duct

papillary duct minor calyx

(one for each

pyramid)major calyx (2-3 )

renal pelvis (single large

cavity) Ureter urinary

bladder urethra.


FILTRATION

From Principles of Anatomy and Physiology (12th ed.,p. 1029), by G. Tortora & B. Derrickson.

2009. Hoboken, NJ. John Wiley & Sons.

o Glomerular filtration

o Tubular reabsorption

o Tubular secretion


GLOMERULAR PRESSURES

o Glomerular blood

hydrostatic pressure (GBHP)

= 55mmHg

o Capsular hydrostatic

pressure (CHP) = 15mmHg

o Blood Colloid

Osmotic pressure (BCOP) =

30mmHg

o Net filtration pressure (NFP)

• = GBHP - CHP - BCOP

• = 55 - 15 - 30 = 10mmHg

`

`

From Principles of Anatomy and Physiology (12th ed), by G. Tortora & B. Derrickson. 2009.

Hoboken, NJ. John Wiley & Sons.


CLINICAL EXAMINATION

Clinical presentation may include:

o Hands – brown line pigmentation

o Skin – complexion, bruising, pruritus

o BP - often elevated

o Fundoscopy – hypertensive changes in eyes

o Heart and lungs – auscultation of heart sounds,

breath sounds

o Abdomen – enlarged kidney, tenderness

o Sacral and ankle oedema


INVESTIGATION OF RENAL AND

URINARY TRACT DISEASE

http://www.mortonmedical.co.uk/images/Medi_Test_Combi_8_Urine_Test_S

trips___Tube_of_100.jpg

http://bladder-health.net/images/hematuria.jpg

http://www.gregorygordonmd.com/images/urine-culture.jpg

E-coli

Tests of function

• Blood urea, serum creatinine

• GFR

• Urinalysis


INVESTIGATION OF RENAL AND

URINARY TRACT DISEASEo Imaging

• Plain X ray abdomen

• Ultrasound

• Intravenous urography (IVU)

• Pyelography

• Renal angiography and venography

• CT

• MRI

o Other tests

• Radionuclide studies

• Renal biopsy / Cystoscopy


CLINICAL PRESENTATIONS OF

RENAL & URINARY TRACT DISEASE

o Cystitis and UTIs o Haematuria

o Loin pain/ renal colic o Oedema

o Excessive micturition

o Hypertension

o Reduced micturition o Acute renal failure

o Erectile dysfunction o Chronic renal failure

o Proteinuria


Pain associated with Urinary

System Disorders

http://fitsweb.uchc.edu/student/selectives/mavoznesensky/case1_4_clip_image002.jpg

Possible Pain Presentation

○ Back radiating

to flank

○ Flank/loin

radiating to groin


CYSTITIS AND URINARY TRACT

INFECTION

o Most common bacterial infection in general practice

o Up to 50% of women have a UTI at sometime,

uncommon in males

o Incidence increases with age

Causes

• 75% of infections by Escherichia coli derived from

fecal reservoir

• other organisms are Proteus, Pseudomonas,

Streptococci & Staphylococci

• most are ascending infections


Gould B. Pathophysiology for the Health Professions. 2nd edition 2002. W B Saunders Company

Microbe Invasion


Microbe

Invasion




INFECTION

Predisposing factors

o Female - short urethra

o Minor urethral trauma - sexual intercourse

o Inadequate perineal hygiene

o Instrumentation of bladder

o Residual urine left after voiding

- Obstruction below bladder – benign prostatic hyperplasia (BPH)

- Gynecological abnormalities

- Vesico-ureteric reflux

- Neurological problems


Vesico-

ureteric

Reflux

http://www.urologyhealth.org/urology/articles/images/anatomy_Vesicoureteral_reflux.jpg

http://4.bp.blogspot.com/_ZqtoZ58XLq0/Sq0AlksudLI/AAA

AAAAAAL4/wa4KiJMotZw/s400/vur.jpg



INFECTIONClinical features

o Frequency of micturition

o Scalding pain in urethra during micturition

(dysuria)

o Suprapubic pain in cystitis (during and after

voiding)

o Urgency

o Cloudy urine with unpleasant smell

o Haematuria



INFECTIONo Investigation

• Microscopic examination and culture of urine

• Urine dipstick tests

• Full blood count

• Blood tests

• Pelvic and rectal exam

• Ultrasound or CT

• Intravenous Urogram (IVU)

o Management

• Antibiotics

• Adequate fluid intake



INFECTION

Other UTIs

• Persistent or recurrent UTI (can be

due to underlying causes/ disorders)

• Asymptomatic bacteriuria

• Catheter related bacteriuria


LOIN PAIN

Renal causes

• Renal stones

• Renal tumour

• Acute pyelonephritis

• Obstruction of the renal pelvis


LOIN PAIN

Acute pyelonephritis

Kidneys are infected in minority of patients with lower UTI or bacteriuria

o Pathology

• Caused by ascending infection from bladder

• acutely inflamed renal pelvis with small abscesses in renal parenchyma

o Clinical features

• Loin pain, fever and tenderness over kidneys (classic triad)

o Investigation and management

• Similar to lower UTI


LOIN PAIN

Renal colic

• Acute loin pain radiating to the groin

(renal colic) together with

haematuria is typical of ureteric

obstruction most commonly due to

calculi


Kidney stones

http://faculty.ksu.edu.sa/3800/Evolution%20in%20Renal%20Stone%20Management/Bilateral%20Staghorn%2

0Calculi.png


KIDNEY STONES



STAGHORN

CALCULI

From Porth’s Pathophysiology: concepts of altered health states,

(9th ed., p. 1092) by Grossman, S.C. & Porth, C.M. (2014).

Philadelphia, U.S.A. Walters Kluwer Health - Lippincott, Williams

& Wilkins.


EXCESSIVE MICTURITIONo Polyuria > 3L/day due to

• Excess fluid intake

• Osmotic diuresis

• Diabetes insipidus

o Nocturia due to

• Consequence of polyuria

• Fluid intake or diuretic use in evening

• Chronic kidney disease

• Prostate enlargement

o Frequency due to

• Consequence of polyuria

• Diuretic use

• UTIs


EXCESSIVE MICTURITION

Urinary incontinence

• Involuntary leakage of urine

• Types

–Stress incontinence

–Urge incontinence

–Continual incontinence

–Overflow incontinence

–Post-micturition dribble

– Incontinence due to neurological disease


REDUCED MICTURITION

Oliguria

Less than 300ml/day/ anuria<50ml/day

• Reduced urine production (pre-renal

acute renal failure, rapidly progressive

GN)

• Urinary tract obstruction (urinary calculi,

prostate enlargement)


ERECTILE DYSFUNCTIONIn 50% of men with advanced chronic kidney disease or

on dialysis

o Causes

• With reduced libido

– Hypogonadism

– Depression

• With intact libido

– Psychological - anxiety

– Vascular insufficiency - atheroma

– Neuropathic – Diabetes Mellitus, alcohol excess

– Drugs – beta-blocker


HAEMATURIA

May be visible (frank) or invisible (microscopic)

o Causes

• Tumour

• Stones

• Infection

• Trauma

• Vascular – malformation, infarct

• Glomerular disease

• Clotting disorders


PROTEINURIA

More than150 mg/day indicate renal damage (renal disease/ injury)

o Usually asymptomatic, large amount may make urine frothy

o Microalbuminuria is sign of glomerular abnormality

o In nephrotic syndrome, substantial amounts of protein are lost in the urine


OEDEMA

http://www.pathology.vcu.edu/education/dental2/images/case3-3.jpg

Pitting oedema reflects

increased interstitial fluid

Renal causes

• Nephrotic syndrome (low

serum albumin)

• Renal failure (volume

expansion)


HYPERTENSION

oCommon feature of renal

parenchymal and vascular

disease

oEarly feature of glomerular

disorders


ACUTE RENAL FAILURE

Sudden and usually reversible loss of renal function which develops over a period of days or weeks and usually accompanied by reduction in urine

volume

Causes

o Prerenal

o Renal

o Postrenal


Renal

Artery

Stenosis

http://www.ajronline.org/content/189/3/528/F21.large.jpg


REVERSIBLE PRE-RENAL

ACUTE RENAL FAILURE

o Pathogenesis

• Due to fall in perfusion pressure

(hypovolaemia, shock, heart failure or

narrowing of renal arteries)

o Management

• Identify and correct the underlying

cause


ESTABLISHED ACUTE RENAL

FAILUREo May develop following severe or prolonged

under-perfusion of the kidney (pre-renal ARF) → acute tubular necrosis

o In patients without obvious cause of pre-renal ARF, renal and post-renal causes must be considered

Clinical features – depend on underlying cause

• Usually reduced urine volumes

• Disturbances in water, electrolyte and acid base balance

• Uremic symptoms


ESTABLISHED ACUTE RENAL

FAILURE

o Management

• Emergency resuscitation

• Management of underlying cause

• Fluid and electrolyte balance

• Protein and energy intake

• Infection control

• Renal replacement therapy

o Prognosis

• Depends on underlying cause


CHRONIC RENAL FAILURE

Irreversible deterioration in renal function develops over a period of years

Common causes

o Glomerular diseases ( 10-20%)

o Hypertension ( 5- 20% )

o Diabetes mellitus ( 20-40% )

o Congenital & inherited diseases (polycystic kidneys) 5%

o Renal artery stenosis 5%

o Interstitial diseases 5-15%

o Systemic inflammatory disease (SLE, vasculitis)

o Unknown



Early

o asymptomatic

o discovered on routine check-up

- proteinuria

- anemia

- hypertension

- raised blood urea and creatinine

Late

o end-stage renal failure and features of uremia

- anemia

- renal osteodystrophy

- neuropathy

- myopathy

- hypertension

- acidosis

- endocrine abnormalities

- susceptibility to infection

Clinical Features



Retarding the progression of CRF

– Control BP, diet

Limiting the complications

– Anemia

– Fluid and electrolyte balance

– Acidosis

– CVS disease and lipids

– Infection

– Bleeding

– Renal osteodystrophy

Renal replacement therapy

– Haemodialysis

– Peritoneal dialysis

– Renal transplantation

Management


Readings and ResourcesResources:

o Set Textbooks:

Colledge, N.R., Walker, B.R. & Ralston S.H. (2014). Davidson’s Principles and Practice of Medicine, (22nd ed.). Edinburgh.

Churchill Livingstone.

Grossman, S.C. & Porth, C.M. (2014). Porth’s Pathophysiology: concepts of altered health states, (9th ed.). Philadelphia,

U.S.A. Walters Kluwer Health - Lippincott, Williams & Wilkins.

o Additional textbooks:

Davies, A. & Moores, C. (2010). The respiratory system: basic science and clinical conditions, (2nd ed.). Edinburgh. Churchill,

Livingstone, Elsevier.

Field, M., Pollock, C., Harris, D. (2010). Systems of the Body: The Renal System; Basic Science and Clinical Conditions. (2nd

ed.). United Kingdom: Churchill Livingstone.

Jamison, J.R. (2006) Differential Diagnosis for Primary Care: a handbook for health care practitioners. (2nd ed.). Edinburgh.

Churchill Livingstone.

Lee, G. & Bishop, P. (2013). Microbiology and Infection Control for Health Professionals, (5th ed.). Frenchs Forest, NSW.

Pearson Education.

McCance, K.L. & Huether, S.E. (2014). Pathophysiology: the biological basis for disease in adults and children, (7th ed.). St.

Louis, MO. Elsevier.

Murphy, K. (2011). Janeway’s immunobiology, (8th ed.). New York. Garland Science.

Noble, A., Johnson, R. & Bass, P. (2010). The cardiovascular system: basic science and clinical conditions, (2nd ed.).

Edinburgh. Churchill, Livingstone, Elsevier.

Pagana, K.D. & Pagana, T.J. (2013). Mosby’s diagnostic and laboratory test reference, (11th ed.). St. Louis, MO. Elsevier.

Smith, M.E. & Morton, D.G. (2010). The digestive system: basic science and clinical conditions, (2nd ed.). Edinburgh.

Churchill, Livingstone, Elsevier.

VanMeter, K.C. & Hubert, R. (2014). Gould’s pathophysiology for health professions, (5th ed.). St. Louis, MO. Elsevier.


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Urinary System Disorders 1 · Urinary System Disorders 1 Lecture 16 Pathology and Clinical Science...

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