Urinary Notes PDF

Urinary Notes Thursday, January 9, 2025 11:45 AM Pathologies of the urinary system - Kidney pathologies - Lower urinary tract pathologies - Neoplasms of t...

Urinary Notes Thursday, January 9, 2025 11:45 AM Pathologies of the urinary system - Kidney pathologies - Lower urinary tract pathologies - Neoplasms of the urinary system Kidney pathologies - Pyelonephritis - Renal calculi - Glomerulonephritis Nephrotic Nephritic Acute glomerulonephritis Chronic glomerulonephritis - Polycystic kidney disease Pathologies of the lower urinary tract - Urinary tract infection Cystitis Urethritis Neoplasms of the urinary tract - Bladder cancer - Renal cell carcinoma - Malignancies of renal and ureters - Urethral cancer Pathologies of the kidneys - Pyelonephritis - Renal calculi - Glomerulonephritis Nephrotic Nephritic Acute glomerulonephritis Chronic glomerulonephritis - Polycystic kidney disease Pyelonephritis Overview - Kidney infection - m/c cause = ascending bacterial UTI - SSx Fever ○ Differentiating feature Back and flank pain ○ Referral ○ Low back pain that goes up to the sides Nausea/ vomiting Urgency Frequency - Diagnosis Urinalysis Blood analysis Imagine ○ MRI ○ CT ○ U/S Etiology - MC cause = ascending UTI Escherichia coli bacteria - Urinary tract blockage can also cause pyelonephritis Pregnancy Renal calculi (kidney stones) Benign prostatic hyperplasia Instrumentation ○ Ex. Catheter Symptoms - Sudden onset of fever - Nausea/ vomiting - Flank or mid-low back pain - Painful, enlarged kidneys with costovertebral tenderness Murphy's punch sign ○ Punched in kidneys and it hurts - Polyuria, frequency urination, hematuria - Possible ureter spasm D/t irritation from infection or kidney stone Renal colic may occur with ureter spasm ○ Renal colic - pain from distention of tubes - Children experience subtle sx that can be difficult to recognize - Elderly May have no systems of urinary tract problem Delirium is common symptom of infection in elderly May be no symptom until sepsis occurs - Can be acute ot chronic Chronic pyelonephritis presents with vague symptoms and intermittent fevers Diagnosis - Urinalysis Check for urine for presence of WBCs and other changes Urine culture (petri dish) ○ To identify the causative organism for more precise, better treatment ○ To figure out exact bacteria - CBC Complete blood cell count To check for elevated WBC or bacteria in blood - Ultrasound/ UT 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, PO (per os) antibiotics are usually successful if No nausea/ vomiting or dehydration No signs of severe infection ○ Low BP ○ Confusion - If any of the above exist, pt is hospitalized for treatment IV antibiotics for 2 days, then given PO Complications - Pus accumulation of kidneys Pyonephrosis - Sepsis The worst complication If you catch it early, you can treat it - Kidney failure - Because of the above, kidney infections require prompt medical attention Massage - CI - Medical attention is needed - Massage tx postponed until resolved Renal Calculi Definition - 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 - Can be composed of made of Calcium ○ Calcium oxalate stones ○ 80% are composed of calcium oxalate Uric acid Struvite Cystine - Vary in shape nad size and therefore vary in systemic symptoms - Formation may be prevented with dietary changes Etiology - Diets high in: proteins Vitamin C Calcium - Genetics Family history - Hyperparathyroidism - Gout - UTIs Struvite stones ("infection stones") Signs and symptoms - Stones may cause no symptoms until urinary blockage occurs Usually in the ureters - Severe and intermittent back and flank pain, renal colic - Urine related Hematuria, frequency, urgency, dysuria, urinary retention - Nausea/ vomiting, sweating, chills, fever If infection is present - Bladder stones Lower abdominal pain Possible interruption of urine flow LUTS ○ Lower urinary tract symptoms - Asymptomatic during formation Begin to cause problems when they are big enough Diagnosis - Suspected based on pain pattern - Urinalysis RBC, WBC< crystals - Imaging is done to visualize size and location of stone US CT Treatment - Small stones pass without intervention Increasing fluids may help massage Alpha-adrenergic blockers ○ Tamsulosin ○ Dilates urethra Analgesics - Stones too large to pass on their own may require shockwave lithotripsy or an endoscopic technique Compressed air providing punches that break down the stone Prevention - Depends on composition of stone - Increased fluid may help prevent all types - Calcium stones Diet low in sodium, high in potassium Calcium intake should remain normal ○ 1000-1500mg/ day - Uric acid stones Diet low in protein/ purines - Oxalate stones Diet low in rhubarb, spinach, cocoa, nuts, pepper, tea Massage - CI - Medical attention is needed - Massage is postponed until resolved - Once resolved, there is no CI Glomerulonephritis Overview - Glomerulonephritis Disorder of glomeruli (clusters of vessels in the kidney that filter blood) causing damage and affecting filtration - Can show nephritic syndrome or nephrotic syndrome (or combo of both) - May be acute or chronic Etiology - Most causes of acute glomerulonephritis are due to strep infections Poststreptococcal glomerulonephritis Type 3 HS reaction ○ Ag-Ab complexes get stuck in glomerulus - Chronic acute glomeulitis may be caused by infection or systemic AI disease Bacterial infection ○ Streptococcal Viral infection ○ Hep A,C, HIV Systemic disease ○ Diabetes ○ HT ○ SLE Common signs and - Full picture depends on degree of nephrotic or nephritic syndrome present symptoms - Common signs and symptoms include Edema Headache Visual disturbances Seizures 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: (PALE) Massive Proteinuria, Hypoalbuminemia Hyperlipidemia Edema - Without 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 (PHAROAH) Mild proteinuria Hematuria Azotemia ○ Nitrogen related RBC cases in urine ○ Cylinder of RBCs being peed out Oliguria ○ Decreased peeing Hypertension Acute - Acute inflammation of the glomerulus Glomerulonephritis Usually presents as nephritic syndrome (blood in pee) (AGN) - m/c cause is infection due to bacterial streptococcus infection of throat or skin Poststreptococcal glomerulophritis (PSGN) ○ PSGN is more common in children aged 2-10 - Infection with staph or pneumococcus bacteria, chicken pox virus, parasitic malaria can also cause AGN AGN Signs and - About half of pt have no SSx Symptoms - Common SSx Edema Oligura Pink or cola coloured urine that foams - Progressive HTN But rare or mild at first - When rapidly progressing, symptoms also include Weakness Fever Fatigue - Also common Nausea/ vomiting Loss of appetite Abdominal pain Chronic - Chronic inflammation that causes slow, cumulative damage and scarring of Glomerulonephritis glomerulus More likely to result in nephrotic syndrome than AGN ○ No blood in pee Can be a result of prolonged inflammation of AGN Occasionally due to hereditary nephritis Cause is often unknown CGN Signs and - SSx are mild and subtle, often undetected for a long period of time Symptoms - Facial and extremity edema may occur - HTN is possible Increased fluids and HTN can eventually lead to ○ headache ○ Visual disturbances ○ Coma - Protein in urine Diagnosis of Acute and - Blood tests and urinalysis are formed in those with suspicious symptoms Chronic GN Increased suspicion in those with recent strep throat or infection - Urinalysis shows proteins and/or blood cells in urine Normal function ○ No blood ○ No protein in urine Rapid progression disease = RBC cast - Lab tests show increase waste products (urea and creatinine) in blood, increased WBC, anemia - Kidney biopsy is confirmative and done to determine prognosis Done under US or CT guidance Invasive yet safe Treatment of AGN and - Low sodium and low protein diet while kidney recovers CGN Reduces strain on kidneys - Diuretics to excrete excess sodium and water Furosemide is the drug of choice Loop diuretic ○ (reduces Na+ and Cl- reabsorption in the ascending limb of Henle) - HTN medications PRN Beta-blockers ACE inhibitors - Corticosteroids given IV for rapidly progressive disease After one week, followed by PO tx - Antibiotics are given if infection is still present - Tx should start 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 - CI - AGN requires medical attention - Massage treatment is postponed until resolved - Chronic GN Both minimal abdominal and CVA pressure should be applied Polycystic Kidney Disease Definition - Genetic disorder of the kidneys that cause fluid-filled cysts to form on kidneys bilaterally Recessive ○ Severe illness in childhood Dominant ○ Adult onset with more mild symptoms - Kidney enlarge But have less functional tissue Scarring and reduction in blood flow causes loss of function Signs and symptoms - Symptoms range from none to severe flank pain, frequent infection, kidney stones - Recessive PKD: Childhood onset Abdominal distention Kidney failure may develop in utero and lead to early death Cystic liver resulting in portal HTN and eventual liver failure - Dominant PKD: slow, adult onset May be subclinical ○ Subclinical: asymptomatic HTN Flank pain Hematuria Frequent urination Kidney stones and renal colic More severe cases ○ Fatigue ○ Nausea ○ Kidney failure Diagnosis - Blood work Kidney function tests ○ BUN § Blood urea nitrogen ○ CR § Urea creatinine ○ GFR § Filtration rate Imaging ○ US ○ CT Treatment - Treat sequelae (helps to slow kidney destruction) Antibiotics for UTI Antihypertensives for HTN Lithotripsy for kidney stones - Dialysis or transplantation for kidney failure Massage - Abdominal massage and massage over the CVA is CI CVA - costovertebral angle Don’t treat low back - A note Lymphatic drainage has limited evidence of benefits for patient with PKD It may provide relief of edema ○ Also increases stress on the kidney by increasing fluid return This should be discussed with patients medical team Kidney - Diagnosis is beyond scope of practice, but awareness and recognition of kidney Pathologies disorder is crucial to patients well-being and safety overview Mistaking kidney inflammation for a muscular strain can result in inappropriate therapy - Kidney inflammation is often mistaken for tense or strained back mm Important to r/o kidney due to 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 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 related to 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 if LUT (lower urinary tract) - Urinary tract infection Cystitis Urethritis Urinary Tract Infections Overview - UTI is an infection that can occur anywhere along the urinary tract Kidneys Ureters Bladder Urethra - m/c in bladder and urethra - UTI's are classified as upper or lower Upper ○ Kidneys (pyelonephritis) Lower ○ Bladder § Cystitis ○ Urethra § Urethritis - In bilateral organs Can occur in one or both Cystitis (UTI) Etiology - Routes of infection - Causative agents - Routes of infection Two routes of infection 1. Pathogen enters through the urethral opening § Most common § Ascends urethra to bladder § Possibly to ureters and kidney 2. Pathogens spreads from the blood stream § Infection in blood spreads to kidneys - Causative agents Bacterial UTI's are very common ○ Sexually active women at higher risk ○ Hospitalized persons with catheter at higher risk Escherichia coli is m/c ○ Cause of lower UTI § 75-95% of cases - 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 Mc is candida albicans Usually in immunocompromised persons Others ○ Blastomycosis (blastomyces) ○ Coccidiodomycosis (coccidiodes) - Parasites A number of parasites Including certain types of worms Risk factors for - Obstruction (ex. Stones) anywhere in the urinary tract ascending infection - Sexual intercourse - Abnormal bladder function that prevents proper emptying Neurologic diseases like MS, Nerve damage from CES/ vaginal 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 female - In persons ages 20-50, UTI is 50x more common in females than males Cystitis specifically - 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 sexual intercourse Pregnancy ○ Increased pressure makes emptying bladder more difficult Some women have recurring episodes ○ Decreased emptying of bladder ○ Decreased acidity of urethra ○ Weakened immune system ○ Low estrogens Cystitis in males - Less common in males - Infection starts in urethra, moves to prostate, then bladder - Mc cause of recurring cystitis: prostatitis Antibiotics quickly clear bacteria from urine in the bladder May need longer course of treatment to clear prostate Signs and 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) urine sample may be taken, followed by urine culture ○ Dipstick chemical test are used to test foreign substances in urine Two positives indicative of infection (don’t need to know specifics) ○ Nitrates § Metabolic end products of bacteria ○ Leukocyte esterase § Enzyme found in WBC § Indicates WBC presence in urine Culture helps determine causative agent more specific treatment Treatment - Antibiotics Broad spectrum antibiotics started ASAP ○ Choice of drug and dosage may be modified based on urine culture Complicating factors, conditions making elimination difficult, may require stronger, longer course of antibiotics ○ Diabetes ○ Being immunocompromised ○ Stones ○ Strictures ○ Prostate enlargement Prevention - Drink plenty of fluids Fluids flush bacteria - Wipe front to back - Post-coital voiding - Avoid tight, non-porous underwear - Void often Urethritis (UTI) Inflammation of the urethra Etiology - Bacteria Flora overgrowth Gonorrhea Chlamydia - Fungi - Viruses HSV - M/c cause in female Bacteria of the lower intestine (E. xoli) Infections in women often result in cystitis - m/c cause in makes STI ○ Usually gonorrhea or chlamydia In men, urethritis that is not caused by gonorrhea is called NGU (non- gonococcal urethritis) Cystitis less likely - Chemical irritation From spermicides or soaps Signs and symptoms - LUTS Frequency, painful urination with sensation of urgency - Less commonly Painful ejaculation Urethral discharge ○ If due to gonorrhea or chlamydia, green or yellow (don’t need to know specifics) ○ Other organisms cause discharge § May present like cystitis or vaginitis ○ Discharge less common in women Itching Complications - Untreated/ inadequately treated infection can cause stricture of the urethra Leads to increased risk of bladder and kidney infection Stricture: ○ Creates scar tissue and can adhere the urethra shut ○ Cannot occur in bladder bc its too big - Can also progress to the kidney Which is a much more severe disease Diagnosis - Based on symptoms and exam - If discharge present, a swab sample is taken to identify the invading organism - Urinalysis is not useful for urethritis Prevention and - Safe sex/ condom for prevention of STIs Treatment - Treatment depends on cause of infection Cultures may take days to grow MD can begin broad spectrum Ab before results for confirmed Massage - Should be postponed until pt is fever free for 24 hours - If fever free There is no Cis Be careful with pressure applied to lower abdomen Neoplasms of the urinary tract - Bladder cancer - Renal cell carcinoma - Malignancies of renal pelvis and ureters - Urethral cancer Introduction - Occurrence: males > females General urinary tract neoplasms - Most are malignancy - Primary tumours are more common Bladder Cancer Overview - Most common malignancy in urinary system Notes say GU system - 3x more common in males - Smoking Single greatest risk factor - Other factors Second-hand smoke Chronic or recurrent cystitis - Most occur >50 yo - MC type: transitional cell cancer Signs and - Mc early symptoms symptoms Painless hematuria ○ Biggest s&s of bladder cancer ○ Can lead to anemia with fatigue and pallor - About 1/3 of pt can have irritative voiding symptoms such as Pain Burning during urination Urgency 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 Route microscopic exam of urinalysis Urine may be visible red - Suspected when SSx linked to cystitis do not resolve with treatment for infection - m/c diagnosis tool Cystoscopy - Urinalysis will be negative with bladder cancer bc no inflammation - Accidental diagnosis during CT or US - DDX May mimic symptoms of cystitis, prostatis Rule out UTI or infection Prognosis - Slow growing tumours and superficial tumours of inner lining have 95% 5 year survival rate - Deeper tumours of mm later have 45-60% 5 year survival rate - Metastatic bladder cancer has much poor prognosis Treatment - Superficial tumours may be removed completely during cystoscopy - Deeper tumours require partial or total cystectomy Radiation and/or chemotherapy may be necessary Massage - No CI Renal Cell Carcinoma - m/c type of renal cancer (RCC) Involved renal cortex The 2nd mc type is transitional cell carcinomas of the renal pelvis - 2x more common in males - 2x more likely in smokers - Other risk factors Age 50-70 Exposure to toxic substances ○ Cadmium ○ Asbestos Obesity Signs and 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 Paraneoplastic syndrome ○ Due to increased EPO release Pruritis, headache, fatigue, dizziness, visual disturbances - Potential anemia Fatigue dizziness Pallor Cold extremities Diagnosis - Advanced imagine: CT or MRI Often incidental finding - If dx confirmed, further studies are requires to rule out metastasis CXR, CT of head and/or chest, bone scan Prognosis - Dependent on many factors - If contained in the kidney, 5 year survival rate is 85% - Local spread to renal vein or IVC only, 5 year survival is 35-60% - Distant metastasis has 5 year survival rate of 10% May be limited to palliative care 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 CI Malignancies of Renal - Mc type of malignancy affecting renal pelvis and ureters is transitional cell Pelvis and Ureters cancer - ~17% of patients with transitional cell cancer 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 Signs and symptoms - Mc first systemic symptoms Hematuria 70-80% of pt present at diagnosis - Other SSx 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 DDx neoplasms from stone 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 Urethra Cancer (looks similar to urethritis) Overview - Rare - May be related to certain strains of HPV and frequent UTIs - Most commonly affects Caucasian females - Usually age 50+ Signs and symptoms - Mc 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 CIs