Urinary System Notes PDF

Notes – Urinary 2025-01-08 5:36 PM Pathologies of the Kidney: 1. Pyelonephritis 2. Renal Calculi 3. Glomerulonephritis 4. Po...

Notes – Urinary 2025-01-08 5:36 PM Pathologies of the Kidney: 1. Pyelonephritis 2. Renal Calculi 3. Glomerulonephritis 4. Polycystic Kidney Disease Pyelonephritis: Kidney Infection Most common cause – Ascending bacterial urinary tract infection Etiology m/c cause is ascending UTI – Escherichia coli bacteria (for women) Women 10x more likely to develop Urinary tract blockage can also cause pyelonephritis Pregnancy Renal calculi Benign prostatic hyperplasia Instrumentation (eg. Catheter) Symptoms Sudden onset of fever, nausea, vomiting, and flank or mid-low back pain Painful, enlarged kidneys w/ costovertebral tenderness Murphy's punch sign (punch them in the kidneys) Polyuria (volume), frequent urination, hematuria Possible ureter spasm d/t irritation from infection or kidney stone Renal colic may occur with ureter spams (renal distension) Children Experience subtle symptoms that can be difficult to recognize Elderly May have no symptoms of UTI Delirium is common symptom of infection in elderly May have no symptoms until sepsis occurs Can be acute or chronic Chronic pyelonephritis presents w/ vague symptoms and intermittent fever Diagnosis Urinalysis Check the urine for presence of WBCs and other changes Urine culture (petri dish) - to identify the causative organism for more precise, better treatment CBC to check for elevated WBC or bacteria in blood (complete blood cell count) Ultrasound of CT used to check for kidney stones, structural abnormalities, obstruction Treatment Antibiotics Broad spectrum antibiotics started ASAP - Choice of drug and dosage may be modified based on urine culture Outpatient, by mouth antibiotics are usually successful if: - no N/V or dehydration - no signs of severe infection (low BP, condusion) If any of the above exist, pt is hospitalized for treatment - IV antibiotics for two days, then given PO Complications Pus accumulation of kidney (pyonephrosis) Sepsis Kidney failure Because of the above, kidney infections require prompt medical attention Massage CONTRAINDICATION Medical attention is needed, massage treatment is postponed until resolved Renal Calculi: Aka kidney stones Hard masses that form anywhere in the urinary tract Epidemiology Occurs in 1/1000 people yearly Most common in middle-aged men What are Kidney Stones made of? Can be composed of: Calcium (calcium oxalate stones) - 80% are composed of calcium oxalate Uric acid Struvite Cystine Vary in shape and size and therefore vary in symptoms Formation may be prevented with dietary changes Etiology Diets high in protein, vitamin C, calcium Diets low in water, calcium Genetics (family Hx) Hyperparathyroidism Gout UTIs - struvite stones aka "infection stones" Signs & Symptoms Stones may cause no symptoms until urinary blockage occurs, usually in the ureters Severe and intermittent back and flank pain, renal colic Hematuria, freqency, urgency, dysuria, urinary retention Nausea, vomitting, sweating, chills, fever – if infection present Bladder stones: lower abdominal pain, possible interruption of urine flow, lower urinary tract symptoms Diagnosis Suspected based on pain pattern Urinalysis RBC, WBC, and crystals Imaging is done to visualize size and location of stone US, CT Treatment Small Stones: Pass w/out intervention Increasing fluids may help passage Alpha-adrenergic blockers (tamsulosin, dilates urethra) Analgesics Large Stones: May require shockwave lithotripsy or and endoscopic technique Applying sound waves – can break the stones down Prevention Depends on composition of stone Increased fluids may help prevent all types Calcium stones Diet low in sodium, high in potassium Calcium intake should remain normal Uric acid stones Diet low in protein/purines Oxalate stones Diet low in rhubarb, spinach, cocoa, nuts, pepper, tea Massage CONTRAINDICATION Medical attention is needed, massage treatment is postponed until resolved Once resolved, there are no contraindications Glomerulonephritis: Disorder of the glomeruli (clusters of vessels in the kidney that filter blood) causing damage and affecting filtration Can show up as nephritis syndrome or nephrotic syndrome (or a combo of both) May be acute or chronic Etiology Most causes of acute glomerulonephritis are due to strep infections Poststreptococcal glomerulonephritis Type III hypersensitivity reaction – AG + AB complexes get stuck in glomerulus Chronic acute glomerulitis may be caused by infection or systemic autoimmune diseases Bacterial infection – Streptococcal Viral infection – Hep B, Hep C, HIV Systemic diseases – Diabetes mellitus, Hypertension, SLE Common Signs & Symptoms Full picture depends on degree of nephrotic or nephritic syndrome present Common signs and symptoms include Edema H/A Visual disturbances Seizures Types: Nephrotic Syndrome Inflammation of the glomerulus causing damage to the membrane Pores created in glomerulus are large enough to allow proteins to cross, but not large enough for RBC to cross the membrane Characterized by massive proteinuria, hypoalbuminemia, hyperlipidemia, edema – "PALE" W/out albumin protein in blood, edema occurs With less antithrombin protein, clotting can occur Hyperlipidemia occurs as liver tries to synthesize protein to compensate for loss Nephritic Syndrome Inflammation of the glomerulus Larger pores created vs nephrotic syndrome Significant destruction of glomerulus results in RBC crossing the membrane Characterized by mild proteinuria, hematuria, axotemia, RBC casts in urine, oliguria, antistreptolyin O titers, hypertension – "PHAROAH" Acute Glomerulonephritis (AGN) Acute inflammation of the glomerulus Usually presents as nephritic syndrome m/c cause is infection due to bacterial streptococcus infection of throat or skin – Poststreptococcal glomerulonephritis, 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 Signs & Symptoms About ½ of patients have no signs or symptoms (especially early on) Common: edema, oliguria, and pink or cola coloured urine that is foamy "PHAROAH" Progressive hypertension, but rare or mild at first When rapidly progressing, symptoms also include weakness, fever, and fatigue N/V, loss of appetite, and abdominal pain are also common Chronic Glomerulonephritis Chronic inflammation that causes slow, cumulative damage and scarring of glomerulus More likely to result in nephrotic syndrome than AGN Can be a result of prolonged inflammation of AGN Occasionally d/t hereditary nephritis Cause is often unknown Signs & Symptoms Signs & symptoms are mild and subtle, often undetected for a long period of time Facial and extremity edema may occur Hypertension is possible Increase fluids and hypertension can eventually lead to H/A, visual disturbances, seizures, and/or coma Protein in urine Diagnosis Blood tests and urinalysis are performed in those w/ suspicious symptoms Increased suspicion in those w/ recent strep throat or infection Urinalysis shows protein and/or blood cells in urine Normal function = no blood, no protein in urine Rapid progression dz = RBC cast Lab tests show increased waste products (urea and creatinine) in blood, increase WBC, and anemia Kidney biopsy is confirmative and done to determine prognosis Done under US or CT guidance Invasive yet safe Treatment Low sodium and low protein diet while kidney recovers – reduces strain on kidneys Diuretics to excrete excess sodium and water HTN medication PRN – as needed Beta-blockers ACE inhibitors Corticosteroids given IV for rapidly progressive dz After one week, followed by PO tx Antibiotics are given if infection is still present Treatment should be started immediately to reduce likelihood of kidney failure and/or dialysis Transplantation is considered if CRF develops Rapidly progressive GN may recur even post-transplant Massage CONTRAINDICATION AGN requires medical attention, massage treatment is postponed until resolved Chronic GN, both minimal abdominal and CVA pressure should be applied Polycystic Kidney Disease: Genetic disorder of the kidneys that cause fluid-filled cysts to form on kidneys bilaterally Can be a dominant or recessive trait Recessive: severe illness in childhood Dominant: adult onset with more mild symptoms Kidneys enlarge, but have less functional tissue Scarring and reduction in blood flow causes loss of function Signs & Symptoms Symptoms range from non to severe flank pain, frequent infections, and kidney stones Recessive PKD: Childhood Onset Abdominal distension Kidney failure may develop in utero and lead to early death Cystic liver resulting in portal hypertension and eventual liver failure Dominant PKD: Slow, Adult Onset May be subclinical – asymptomatic Hypertension Flank pain Hematuria Frequent urination Kidney stones and renal colic More severe cases: fatigue, nausea, kidney failure Diagnosis Blood work – kidney function test (BUN/Cr, GFR) Imaging – US or CT Treatment Treat sequelae – helps slow kidney destruction Antibiotics for UTI Anti-hypertensives for hypertension Lithotripsy for kidney stones Dialysis or transplantation for kidney failure Massage Abdominal massage and massage over the CVA is CONTRAINDICATION for PKD A note: Lymphatic drainage has limited evidence of benefit for patients w/ PKD It may provide relief of edema, but also increases stress on the kidneys by increasing fluid return This should be discussed with patients medical team Kidney Pathologies Overview: 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 r/o kidney d/o for pts who present with lower thoracic and upper lumbar pain Practitioners should never assume back pain is due to a muscular imbalance and should have a screening process to rule out kidney inflammation in place Taking the extra time during a client intake with 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, as it would push more fluid through an already overburdened system Post-acute pts can benefit from massage to release guarded back/core muscles and decrease SNS Pathologies of the Lower Urinary Tract: 1. Urinary Tract Infections (UTI) Cystitis Urethritis Urinary Tract Infections (UTI): Cystitis UTI is an infection that can occur anywhere along the urinary tract – kidneys, ureter, bladder or urethra m/c in bladder and urethra UTIs are classified as upper or lower Upper: kidneys (pyelonephritis) Lower: bladder (cystitis) and urethra (urethritis) In bilateral organs, can occur in one or both Etiology: Route of Infection Two routes of infection 1. Pathogen enters through the urethral opening Most common Ascends urethra to bladder, possibly to ureters and kidneys 2. Pathogen spreads from the blood stream Infection in blood spreads to kidneys Causative Agents Bacterial UTIs are very common Sexually active women are at higher risk Hospitalized persons with catheter at high risk Escherichia coli – most common cause of lower UTI (75-95% of cases) Kidney stones can harbour proteus enterobacteria that can cause UTI Other Causative Agents Viral HSV-2 is a viral cause of UTI, usually in the urethra Causes painful urination, difficulty emptying bladder Fungi can cause UTI, referred to as yeast infection m/c is Candida Albicans Usually in immunocompromised persons Others: blastomycosis (blastomyces), coccidioidomycosis (coccidioides) Parasites Number of parasites, including certain types of worms, can infect the urinary tract Risk Factors Obstruction (eg. Stones) anywhere in the urinary tract Sexual intercourse Abnormal bladder function that prevents proper emptying Neurologic diseases like MS, nerve damage from CES/vag delivery/cord injury, diabetes, prostate enlargement Backflow from bladder into ureter, possibly reaching kidney More likely in children (less oblique orientation or ureters) Urinary catheter Cystitis in Females In persons ages 20-50, UTI is 50x more common in females than males In persons 50+, females and males have similar risk of occurrence Risk factors: Shorter urethra Proximity of urethra to bacteria of vagina and anus Motion of secual intercourse Pregnancy – increased pressure makes emptying bladder more difficult Some women have recurring episodes Decreased emptying of bladder, decreased acidity of urethra, weakend immune system, low estrogen Cystitis in Males Less common in males Infection starts in urethra, moves to prostate, then bladder m/c cause of recurring cystitis – prostatitis Antibiotics quickly clear bacteria from urine in the bladder May need longer course of treatment to clear prostate Signs & Symptoms Lower Urinary Tract Symptoms (LUTS) Urgency and frequency Urgency can cause loss of bladder control (urge incontinence), especially in elderly Dysuria Possible suprapubic pain – rarely, low back pain Fever does not usually happen with cystitis – may be low grade If fever present, more likely to be pyelonephritis Urine can be cloudy or contain blood Blood (hematuria) is visible in ~30% Diagnosis Diagnosis based primarily on symptoms Urinalysis: midstream clean catch (uncontaminated) The middle part of the urine stream is what they want for the sample Dipstick chemical tests Treatment Antibiotics Broad spectrum antibiotics started ASAP - choice of drug and dosage may be modified based on urine culture Complicating factors (diabetes, being immunocompromised) or conditions making elimination difficult (stones, strictures, prostate enlargement) may require stronger, longer course of antibiotics Prevention Drink plenty of fluids Fluids flush bacteria Wipe front to back Post-coital voiding Avoid tight, non-porous underwear Urinary Tract Infection (UTI): Urethritis Urethritis – inflammation of the urethra Etiology Bacteria (flora overgrowth, gonorrhoea, chlamydia), fungi, or viruses (HSV) M/C cause in females is bacteria of the lower intestine (E. Coli) Infection in a women often results in cystitis M/C cause in males is an STI, usually gonorrhoea or chlamydia In med, urethritis that is NOT caused by gonorrhoea is called NGU (non gonococcal urethritis) Cystitis less likely Chemical irritation (from spermicides or soaps) Signs and Symptoms Lower urinary tract symptoms (LUTS) Frequent, painful urination with sensation of urgency Less commonly Painful ejaculation Urethral discharge (discharge less common in women) Itching Complications Untreated/inadequately treated infections can cause stricture of the urethra Stricture = scar tissue forming and close the urethral opening Leads to increased risk of bladder and kidney infection Can also progress to the kidney, which is a much more severe disease Diagnosis Based on symptoms and exam If d/c present, a swab sample is taken to identify the invading organism Urinalysis is not useful for urethritis Prevention & Treatment Safe sex/condom for prevention of STI's Treatment depends on cause of infection Cultures may take days to grow MD can begin with broad spectrum antibiotics before results are confimed Massage Massage should be postponed until the client is fever free for 24 hours If fever free, there is no contraindication Be careful with pressure applied to lower abdomen Neoplasms of the Urinary System: 1. Bladder Cancer 2. Renal Cell Carcinoma (RCC) 3. Malignancies of Renal Pelvis & Ureters 4. Urethral Cancer Introduction Occurrence: Males > Females (general urinary tract neoplasms) Most are malignant Primary tumors are more common Bladder Cancer: 12,300 new cases each year in Canada The m/c malignancy involving the urinary system 3x more common in males Smoking: single greatest risk factor Other risk factors – second-hand smoke, chronic or recurrent cystitis Most occur >50 years old Signs and Symptoms M/C early symptom: PAINLESS hematuria Can lead to anemia w/ fatigue and pallor About 1/3 of patients can have irritative voiding symptoms such as pain and burning during urination, urgency or frequency If there is pain, usually related to local advanced or metastatic tumours: Back pain Suprapubic pain Abdominal pain Diagnosis Suspected when there is blood in urine Routine microscopic exam of urinalysis Urine may be visibly red Suspected when symptoms linked to cystitis do not resolve with treatment for infection M/C diagnostic tool: cystoscopy Accidental diagnosis during CT or US DDX May mimic symptoms of cystitis, prostatitis R/o UTI or infection Prognosis Slow growing tumour and superficial tumours of the inner lining have 95% 5 year survival rate Deeper tumours of the muscle layer have 45-60% 5 year survival rate Metastatic bladder cancer has a much poor prognosis Treatment Superficial tumours may be removed completely during cystoscopy Deeper tumours require partial or total cystectomy Radiation and/or chemo may be necessary Massage No contraindications Renal Cell Carcinoma (RCC): RCC is the most common type (80-85%) of renal cancer – involves renal cortex 2x more common in males 2x more likely in smokers Other risk factors: Age 50 – 70 Exposure to toxic substances – cadmium, asbestos Obesity Signs & Symptoms Hematuria, flank pain, fever, weight loss M/C first symptom: blood in urine May be microscopic Abdominal exam may reveal palpable lump or enlarged kidney Potential Polycythemia – too many RBC Paraneoplastic syndrome d/t increase EPO release Pruritis, H/A, fatigue, dizziness, visual disturbances Potential anemia Fatigue, dizziness, pallor, cold extremities Diagnosis Advanced imaging: CT or MRI Often incidental finding If diagnosis is confirmed, further studies are required to r/o metastasis CXR, CT or head and/or chest, and bone scan Prognosis Dependent on many factors As metastasis happens – survival rate diminishes Treatment Surgical removal may be curative when there is no metastasis or only local metastasis to vasculature Total kidney Tumour and locally adjacent tissue only Early spread, especially to lungs, is common Chemo/radiation Palliative care Massage No contraindications Malignancies of Renal Pelvis & Ureters: The M/C type of malignancy affecting renal PELVIS and the URETERS is Transitional Cell Cancer ~17% of patients with transitional cell CA of renal pelvis or ureters will have concurrent bladder cancer at presentation Renal pelvis and ureters much less common than cancer of the rest of the kidney and bladder Fewer than 6,000 people/year US Signs & Symptoms M/C first symptom: Hematuria (70-80% of patients present at diagnosis) Other symptoms: crampy flank pain, lower abdominal pain, obstruction of urine flow Diagnosis Urinalysis and microscopic exam may reveal cancer cells Ureteroscope may be used for both diagnosis and treatment Confirmative diagnosis: CT scan Can differential diagnose neoplasms from stones and/or blood clots Prognosis Local, non-metastatic tumours are often cured by surgical resection If metastasis occurs, outlook is poor Treatment Nephroureterectomy and partial bladder removal for cases where there is no evidence of metastasis If pt only has one functioning kidney, it is usually not removed - avoid dialysis dependence Certain cancers may be treated with laser therapy or minimally invasive resections Non-cancerous portion of ureter and bladder remain Metastatic cancer requires chemo and/or radiation Massage No contraindications Urethral Cancer: Rare May be related to certain strains of HPV and frequent UTIs Most commonly affects caucasian females Signs & Symptoms M/C first sign: Blood in urine Microscopic or visual Weak, interrupted flow of urine ("stop and go") Frequent urge to urinate/feeling of incomplete emptying Discharge from urethra Enlarged lymph nodes in the groin Friable tissue surrounding urethral meatus Diagnosis Cystoscopy Urinalysis Confirmed with biopsy Prognosis Dependent on precise location and staging Treatment Surgical resection Chemo and/or radiation Massage No contraindications