Urinary System

Urinary System Review

• The urinary system is composed of two kidneys and the urinary tract
• The kidneys receive 25% of the cardiac output
• The kidneys are the major excretory organs and produce urine
• Urine is a fluid containing water, ions, and small soluble substances
• The urinary tract includes the ureters, urinary bladder, and urethra
• Ureters receive urine from the kidneys and conduct it to the bladder via gravity and peristalsis
• The urinary bladder receives and stores urine, with muscle contractions driving urination
• The urethra conducts urine from the bladder to the outside of the body, also conducts semen in the penis

Major Functions of the Urinary System

• There are 8 major functions
• Regulation of blood ions such as Ca2+, Na+, K+, Cl-, and PO43- (phosphate)
• Regulation of blood pH happens by excreting H+ and conserving HCO3-
• Regulation of blood volume is achieved by excreting or conserving H2O
• Regulation of blood pressure is achieved by secreting renin, increased renin equals increased blood pressure
• The system regulates blood glucose by gluconeogenesis, which produces new glucose
• Maintenance of blood osmolarity happens by regulating the loss of H2O and solutes, maintaining 300 mOsm/L with dissolved particles per liter of solution
• Hormone production includes calcitriol and erythropoietin (EPO)
• The urinary system excretes waste such as ammonia, urea, bilirubin, creatinine, uric acid, drugs, and environmental toxins

The Nephron and Kidney Lobe

• Kidney lobe or renal lobe is a pyramid of overlying cortex and adjacent renal columns
• Each kidney contains 6-18 lobes
• The nephron is the functional unit of the kidney
• Nephrons produce urine by removing waste and excess substances from the blood
• There are approximately 1 million nephrons per kidney

Kidney Pathologies: Pyelonephritis

• Pyelonephritis is a kidney infection
• The most common cause is an ascending bacterial urinary tract infection
• Symptoms include fever, back and flank pain, nausea/vomiting, urgency, and frequency
• Diagnosis involves urinalysis, blood analysis, and imaging like MRI, CT, or ultrasound
• Treatment includes antibiotics
• Escherichia coli bacteria is the most common cause of ascending UTI causing pyelonephritis
• Blockage of the urinary tract such as pregnancy, renal calculi, benign prostatic hyperplasia, or instrumentation, can cause pyelonephritis
• Sudden onset of fever, nausea/vomiting, and flank or mid-low back pain are pyelonephritis symptoms
• Painful, enlarged kidneys with costovertebral tenderness such a Murphy's punch sign, and polyuria, frequent urination and hematuria are symptoms
• There can be ureter spasms due to irritation from infection or kidney stones, and renal colic symptoms if there is a ureter spasm
• Children experience subtle symptoms of pyelonephritis that can be difficult to recognize
• The elderly may have no symptoms of a urinary tract problem
• Delirium can be a common symptom of infection in elderly, and sepsis can occur before symptoms are realized
• Pyelonephritis can be acute or chronic
• Chronic pyelonephritis presents with vague symptoms and intermittent fever
• Urinalysis checks the urine for the presence of WBCs and other changes
• Urine culture, using a Petri dish, identifies the causative organism for more precise treatment
• A CBC checks for elevated WBCs or bacteria in the blood
• Ultrasound or CT are used to check for kidney stones and structural abnormalities
• Broad-spectrum antibiotics are started as soon as possible
• Drug and dosage choices are modified based on urine culture
• Outpatient oral antibiotics are usually successful without nausea/vomiting, dehydration or severe infection
• Hospitalization would be required if any of the preceeding symptoms are apparent, with antibiotics given intravenously for two days, then orally
• Complications can include pus accumulation of kidney or pyonephrosis
• Other complications are sepsis and kidney failure
• A kidney infection requires prompt medical attention due to the above
• Massage is contraindicated, and medical attention is needed and massage treatment is postponed until resolved

Kidney Pathologies: Renal Calculi

• Renal calculi are also known as kidney stones
• Kidney stones are hard masses that form anywhere in the urinary tract
• Renal calculi occur in 1/1000 people yearly
• Kidney stones are most common in middle-aged men
• Kidney stones can be composed of Calcium, mostly Calcium oxalate stones 80%, Uric acid 19% , Struvite or Cystine
• Stones vary in shape and size and symptoms vary accordingly
• Formation may be prevented with dietary changes
• Etiology includes diets high in protein, vitamin C, calcium, or diets low in water and calcium
• Other etiology includes Genetics, Hyperparathyroidism, Gout, and UTIs such as Struvite stones, also known as "infection stones"
• Stones may cause no symptoms until obstruction occurs, typically in the ureters
• Severe and intermittent back and flank pain, causing renal colic can be a symptom
• Other symptoms are Hematuria, frequency, urgency, dysuria, urinary retention, Nausea/ Vomiting, sweating, chills, fever, or a bladder stone
• A bladder stones symptom is include lower abdominal pain, interruptions of urine flow, and lower urinary tract symptoms (LUTS)
• The diagnosis is suspected based on pain pattern and urinalysis that detects RBC, WBC, and crystals
• Imaging is required to visualize size and location of stone using US or CT scan
• Small stones typically pass without intervention
• Fluid intake may help, and alpha-adrenergic blockers like Tamsulosin dilate the urethra, pain can be treated
• Larger stones may require shockwave lithotripsy or an endoscopic technique
• Prevention depends on the composition of the stone
• Increased fluids may help prevent all types
• Calcium stones prevention is a diet low in sodium and high in potassium, while maintaining calcium intake of 1,000-1,500mg/day
• Uric acid stone prevention is a diet low in protein and purines
• Oxalate stone prevention is a diet low in rhubarb, spinach, cocoa, nuts, pepper, and tea
• Massage is contraindicated when there are renal calculi
• Medical intervention is needed and massage is postponed until it is resolved, once resolved there are no contraindications

Kidney Pathologies: Glomerulonephritis

• Glomerulonephritis is a disorder of the glomeruli or clusters of vessels in the kidney that filter blood
• Disorders in filtration cause damage and affect filtration
• Glomerulonephritis can manifest as nephritic syndrome or nephrotic syndrome, or a combination of both
• It can be acute or chronic
• The most common causes of acute glomerulonephritis are strep infections; poststreptococcal glomerulonephritis
• This infection is a Type III hypersensitivity reaction
• Chronic acute glomerulitis may be caused by bacterial or viral infection, or systemic autoimmune diseases
• Viral infections that can cause it are Hepatitis B, hepatitis C, and HIV
• Autoimmune systemic diseases that can cause it are Hypertension, diabetes mellitus, and SLE(type 3 hypersensitivity)
• Signs and symptoms that manifest depend on the degree of nephrotic or nephritic syndrome present
• Common signs and symptoms are edema, headache, visual disturbances and seizures

Kidney Pathologies: Nephrotic and Nephritic Syndromes

• Nephrotic Syndrome symptoms include inflammation of the glomerulus causing damage to the membrane
• Nephrotic syndrome includes Pores are are large enough to allow protein to cross, but not large enough for RBCs
• Nephrotic syndrome is characterized by massive Proteinuria, Hypoalbuminemia, Hyperlipidemia and Edema
• In patients Without albumin protein in blood, edema occurs
• In patients With less antithrombin protein, clotting can occur
• Hyperlipidemia occurs as liver tries to synthesize protein to compensate for loss
• Nephritic syndrome includes inflammation of the glomerulus
• The pores in nephritic syndrome are larger vs nephrotic syndrome
• RBCs cross the membrane to cause Significant destruction of glomerulus
• Nephritic is characterized by Mild Proteinuria, Hematuria, Azotemia, RBC casts in urine,Oliguria, Antistreptolyin O titers and Hypertension

Nephritic and Nephrotic Mnemonics

• PHAROAH refers to nephritic symptoms: Proteinuria Mild, Hematuria, Azotemia, RBC casts in urine, Oliguria, Antistreptolynin O titers and Hypertension
• PALE refers to nephrotic syndrome: Proteinuria, Hypoalbuminemia, Hyperlipidemia and Edema

Acute Glomerulonephritis (AGN)

• Acute Glomerulonephritis (AGN) are a syndrome of acute inflammation of the glomerulus
• It often presents as nephritic syndrome
• The most common cause is from a bacterial streptococcus infection of throat or skin;poststreptococcal glomerulonephritis, called PSGN
• PSGN is more common in children aged 2-10
• Infections with staph or pneumococcus bacteria, chicken pox virus, and parasitic malaria can also cause AGN
• About half of patients have no clear systemic symptoms
• Common symptoms are edema, oliguria, and red/pink coloured foamy urine
• The preceeding is referred to as “PHAROАН
• Progressive HTN, but rare or mild at first
• When rapidly progressing, symptoms also include weakness, fever, and fatigue, loss of appetite and abdominal pain

Chronic Glomerulonephritis

• Chronic inflammation causes slow, cumulative damage and scarring of glomerulus
• Chronic Glomerulonephritis is More likely to result in nephrotic syndrome than AGN
• It Can be a result of prolonged inflammation of AGN
• Sometimes it is d/t hereditary nephritis, while often its Cause is unknown
• Symptoms are mild and subtle, often undetected for a long period of time
• Symptoms such as facial and extremity edema may occur
• Hypertension is possible
• Increased fluids and HTN can eventually lead to H/A, visual disturbances, seizures, and/or coma
• Protein in urine is a symptom
• Blood tests and urinalysis are performed to diagnose acute and chronic glomerulonphritis, but only in those with suspicious symptoms
• This is the case with Increased suspicition in those with recent strep throat or infection
• Urinalysis is used to look for protein and/or blood cells in urine
• Normal function has neither blood nor protein in the urine
• Rapid progression is confirmed with the presence of RBC casts
• Lab tests show increased waste products in blood, such as urea and creatinine, increased WBC, and anemia
• A kidney biopsy is done to determine prognosis
• Kidney biopsies require ultrasound or CT guidance, and are Invasive yet safe
• Low sodium and low protein diet is prescribed while kidney recovers, this reduces strain on the kidneys
• Diuretics may be needed to excrete sodium and fluid, with Furosemide a drug of choice
• Loop diuretics reduce Na+ and Cl- reabsorption in the ascending limb of Henle
• HTN medications may be prescribed Prn, such as Beta-blockers and ACE inhibitors
• Corticosteroids may be given intravenously for rapidly progressive disease
• After one week, PO tx may be prescribed
• Antibiotics will be given, if infection is still present
• Tx should be started immediately to reduce likelihood of kidney failure and/or dialysis
• If chronic renal failure develops, Transplantation is considered
• Rapidly progressive GN may recur even post-transplant
• Massage is contraindicated for glomerulonephritis
• AgN requires immediate medical attention
• Treatment and massage should be postponed until it is resolved
• With chronic GN, minimal abdominal and CVA pressure should be applied

Kidney Pathologies: Polycystic Kidney Disease

• Polycystic kidney disease is a genetic disorder that causes fluid-filled cysts on kidneys bilaterally
• It can be a dominant or recessive trait
• Recessive traits mean severe illness in childhood
• Dominant traits mean kidney disease in adults with more mild symptoms
• Kidneys enlarge, but have less functional tissue
• Scarring and reduction in blood flow causes loss of function
• Recessive polycystic kidney disease symptoms in childhood is include abdominal distension, kidney and liver failure
• Dominant/Adult polycystic kidney disease symptoms are May be subclinical, hypertension + flank pain, hematuria, and frequent urination
• Kidney stones, fatigue, nausea and kidney failure are symptoms with this phenotype
• Diagnosis includes blood work, such as kidney function tests, creatinine, or GFR, and imaging such as US of CT scans
• Treatment includes antibiotics for UTI, anti-hypertensives for HTN patients, or lithotripsy for kidney stones Dialysis, kidney transplantation, and other modes will slow down destruction and treat sequelae
• Abdominal massage and massage over the CVA is contraindicated for PKD
• Lymphatic drainage has limited evidence of benefit for patients with PKD
• It may provide relief of edema, but also increases stress on the kidneys by increasing fluid return
• This should be discussed with the patients medical team

General Considerations for Kidney Pathologies

• Diagnosis is beyond scope of practice, but awareness and recognition of kidney disorder is crucial to patient's well-being and safety
• Mistaking kidney inflammation for a muscular strain can result in inappropriate therapy
• Kidney inflammation is often mistaken for tense or strained back muscles
• Important to rule out kidney d/o who present with lower thoracic and upper lumbar pain
• Practitioners should never assume back pain is due to a muscular imbalance without ruling out kidney inflammation first Taking the extra time during a client intake will enable condition-appropriate massage and prevent symptom exacerbation
• Inflamed kidneys are more susceptible to injury from vigorous massage due to being retroperitoneal
• Edema is often a sign of malfunctioning kidneys
• Systemic circulatory massage is inappropriate for pts with edema r/t kidney d/o it as it would push more fluid through an already overburdened system
• Post-acute patients can benefit from massage to release guarded back and core muscles and decrease SNS

Lower Urinary Tract Pathologies: Urinary Tract Infections (UTI)

• A urinary tract infection is an infection that can occur anywhere along the urinary tract
• It can affect Kidneys, ureter, bladder, or urethra, but Most commonly affects bladder and urethra UTIs, are classified as an upper of lower infection
• Upper UTIs affect the kidney or pyelonephritis
• Lower UTIs affect Bladder (cystitis) and urethra (urethritis)
• In bilateral organs, can occur in one or both

Lower Urinary Tract Pathologies: Etiology of Cystitis

• Two routes of infection can cause cystitis
• Pathogen enters through the urethral opening, as in a a Most common route
• From here It Ascends urethra to bladder, possibly to ureters and kidneys
• Pathogen spreads from the blood stream Infection in blood spreads to kidneys
• Bacterial UTIs are very common Sexually active women and Hospitalized persons with catheter at higher risk Escherichia coli is the most common cause of lower UTI 75-95% of cases
• Kidney stones can cause this, and harbour Proteus enterobacteria that can cause UTI
• Viral etiologies exist, with HSV-2 being the main cause, usually in the urethra causing pain and emptying difficulties
• Fungi can cause UTI, referred to as yeast infection
• The Most Common fungus is Candida Albicans, Usually in immunocompromised persons
• Other fungi blastomyces and coccidioides also cause UTIs
• Parasites, such as several worms, can infect the urinary tract
• Obstruction is a Risk Factor for Ascending Infection
• Other RFs are Sexual intercourse and Abnormal bladder function
• Backflow from bladder into ureter can be a RF, since it reaches the kidney and is More likely in children Neurologic diseases like MS, nerve damage from CES/vaginal delivery/cord injury, diabetes, and prostate enlargement are aRFs
• Urinary catheter are also an RF for cystitis

Lower Urinary Tract Pathologies: Cystitis in Females

• In persons aged 20-50, UTI is 50x more common in females than males due to shorter urethras
• Due to proximity of urethra to bacteria in vagina and anus + Motion of sexual intercourse +Pregnancy adds Pressure makes emptying bladder more difficult
• . In persons 50+, females and males have similar risk of occurrence
• Some women have recurring episodes due to Decreased emptying of bladder + decreased acidity of urethra + weakened immune system +low estrogens

Lower Urinary Tract Pathologies: Etiology, Signs and Symptoms of Cystitis

• In Males this is less common
• If Infection starts in urethra, the same moves to prostate then bladder
• MC cause of recurring cystitis: prostatitis
• Antibiotics quickly clear bacteria from urine in the bladder, and a longer course of treatment to clear prostate may be required
• Lower urinary tract symptoms (LUTS) are a sign and symptom
• Typical signs are Urgency/frequency +Urgency, LUTS causes loss of bladder control, especially in elderly
• Dysuria is also a known symptom + Possible suprapubic pain + Low back pain
• Fever does will not usually happen with cystitis, but may be low grade, and may indicate another problem
• Urine can be cloudy or contain some blood which could indicates another problem, +30% get hematuria

Lower Urinary Tract Pathologies: Diagnosing and Treating Cystitis

• Diagnosis is based primarily on symptoms
• For further analysis, Urinalysis can tests urine a midstream technique
• For foreign substances in urine, Dipstick chemical tests are performed
• The following must be positive, indicating a UTI: Presence of Nitrates and WBC
• Culture may also be performed on urine cultures to determine causitive agent for tx
• Antibiotics will will be delivered Broad spectrum ASAP
• Complicating factors can include other conditions that make elimination difficult ,like diabetes and prostate elargement
• Other preveention techniques includes drinking plenty of fluids, wiping front to back and voidding after s ex
• Avooid wearring underwear that has tiight , non-porous fabrics+Avoid tight or Underwear can prevent

Lower Urinary Tract Pathologies: Urethritis

• Urethritis = inflammation of the urethra
• Bacterial overgrowth is also an Etiology along with gonorrhea and chlamydia), fungi, or viruses (HSV)
• Most commonly the female etiology is bacteria from the female intestinal tract, and in men that is from chlamydia or gonoreah
• Chemical irritations such spirmicide can also be the cause
• Lower urinary tract symptoms (LUTS) with Frequent, painful urination with sensation of urgency are symptoms
• Urethral discharge (d/c) + Pain during ejaculation is less common
• If from gonorrhoea or Chlamydia, men will will may release yellow green color -Otherwise Other orgs, release liquid that also may look like cytsitics + itiching
• The untreatted Infections can also lead cause structure if structure is not prevented than that increase other infections
• Diagnosis can start off from the synptoms so a practioner will need to find out if there is a dicharge
• If yes, the MD should deliver broad range of AB
• Avoid all of said complications just means make sure that there is proper protection and condoms
• Tx does depend heavily on dx and MD can give it in AB
• Be sure that you are free from disease and free from infection
• In regards to UTIs, massage should be avoided until the patient has been fever free for 24 hours
• If the patient is fever free, there are no contraindications
• Take care with pressure applied to lower abdomen

Neoplasms of the Urinary System and Kidney Pathologies

• In general males are have a higher chance of it then women of have it which is considered a higher rate then those that are malignant
• The most common are Primary tumors
• In terms of bladder cancer there are about +10000 cause every year, MC system is this
• Smoking is highest risk, other factors that make it worse its that your older when having bladder cancer
• In that hematuria is likely the first sign is PAINLESS + the patients can have voiding symptoms
• The best method for dx is with cytotospy and will include bloodwork and a
• The Differential diagnosis (DDX)May mimic symptoms of cystitis or prostatitis and r/o UTI or infection
• The prognosis depends, those that have had it inside are easier to heal then those with higher stages
• There are No Contraindications
• RCC is the most common type (80-85%) of renal cancer and inovlves the renal cortex and The 2nd MC type is transitional cell carcinomas of the renal pelvis
• RCC is 2x more common in males, and 2x more likely in smokers, age 50-70 + exposure to toxic substances and obesity are risk factors
• Hematuria, flank pain, fever, weight loss are symptoms+blood in the urine Is MC first sx
• Abdominal exam may reveal palpable lump or enlarged kidney,and potential polcythemia, paraneoplastic syndrome d/t increased EPO release, Pruritis fatigue and dizziness occur
• Advanced imaging such as CT or MRI is done but has is often incidental + if dx is confirmed, further studies are required to r/o metastasis with CXR. CT of head and/or chest or bone scan
• 5-year survival rate for RCC contained to kidney its 85%+the only local to the renal vein or IVC is about 35-60% Distant Metastass has survival rate of 10 percent with possible palliative care Treatment is through surgically removing tumor + removing locally the tumour or removing total kidney. It might be removed with chemo + radiation
• Surgical options may be curative, and spread esepcially ot lungs is common
• Massage is not contraindicated
• The most common type of malignancy affecting renal PELVIS and URETERS is transitional cell CA
• About 17 percent in pts tran cell CA it will result in some other conditions and The most common in the US + MC sign as hemura but the symptoms are cramps and pain Diagnosis is done with CY scans after the test so doctor know what to do as a team
• And be carefull for the stones it may indicate + Local treatment that gets rid the tumor which is good. If cancer metastasis occurs than the outlook is poor Treatment is removed through nephroureterecomy + Partial and it will depend on how many tumors in there. Metastitac is also treatable with laser
• If pT one pt just has kidne remove th epartial side the non cancerous

Urethral Cancer Pathologies

• This is rare form and it's due tot he HPW virus and has affects those 50+
• First sign is blood in urine ,you wont be able to urinate, some release and also enlarged the lymph nodes.
• It is diagnosed with a CY and you will have to give give what needs to be done to stop the cancer
• You will hav to go through stage and then do surgery .
• Malignancies + no contradictions