Renal & Urological Systems PDF

Structure & Function of the Renal and Urological Systems Chapter 29 Learning Objectives Discuss the pathophysiology related to various diseases of the urinary system Identify risk factors in the development of renal disease Describe the pathophysiology, causative factors...

Structure & Function of the Renal and Urological Systems Chapter 29 Learning Objectives Discuss the pathophysiology related to various diseases of the urinary system Identify risk factors in the development of renal disease Describe the pathophysiology, causative factors, clinical manifestations, and complications of infectious, obstructive, and inflammatory renal disorders Differentiate between acute and chronic renal failure Discuss the use of dialysis in the treatment of renal failure Discuss the effects of renal failure on the body systems Structure of the Kidney  The Nephron There are 1.2 million nephrons per kidney! - They are the functional unit of the kidney - What would be the functional unit of the lung?? - Bowman's Capsule; where the Glomerulus resides - Blood flows through the glomerulus & filters out wastes and water into the tubule  The Nephron Tubular reabsorption and secretion - Forms a filtrate of protein-free fluid - Regulates the filtrate to maintain fluid volume, electrolytes, and pH Renal Blood Flow Glomerular Filtration Rate (GFR) - The rate at which the glomeruli filter blood - Normal GFR is 87-139 mL/minute Creatinine Clearance - The most accurate measure of glomerular filtration, as creatinine is filtered by the glomeruli but not reabsorbed by the tubules - The volume of blood (mL) that the kidney can clear of creatinine in 1 minute - Creatinine is a waste product of skeletal muscles The higher the blood creatinine level, the lower the estimated GFR Urinary Structures Ureters: bring urine from kidneys to bladder Bladder: muscular container for urine, holds 300-500 mL (urge to urinate at 250-300 mL) Urethra: a narrow passageway from the bladder to the outside of the body, it has internal and external sphincters; 3-4 cm in females, 18-20 cm in males Urine Composition Urine is normally clear yellow of amber in colour Cloudiness may indicate presence of bacteria, cells, or high solute concentration pH ranges from 4.6 - 8.0, but is normally acidic providing protection against bacteria Normal urine does not contain glucose of blood cells, and only occasionally contains trace protein; usually in association with rigorous exercise A healthy human should create 0.5 - 1 cc of urine/ kg per hour (average 30 cc/hr) Functions of the Kidneys Maintaining fluid & electrolyte concentration ○ Hormones such as ADH & Aldosterone Maintaining acid-base balance ○ Secreting H+ ions (if in a state of alkalosis) or reabsorbing HCO3 ions (if in a state of acidosis) Detoxifying the blood and eliminating wastes Regulating blood pressure (RAAS system) Aiding RBC production (erythropoiesis) Regulating vitamin D and calcium formation Hormones and Renal Function Antidiuretic hormone (ADH): produced by your pituitary gland; alters the tubules’ permeability to water ○ ↑ADH means increased permeability to water (reabsorbed) resulting in a concentrated low volume of urine ○ ↓ or no ADH means there is less permeability to water, causing more water to be excreted creating a larger volume of less concentrated urine Aldosterone: produced by the adrenal cortex; regulates water and sodium reabsorption ○ ↑Aldosterone increases H2O & Na reabsorption ○ ↓Aldosterone promotes H2O & Na reabsorption Renin: secreted in response to decreased extracellular volume; step one of the renin-angiotensin-aldosterone system Vitamin D: the kidneys help vitamin D convert into its active form! Necessary for the absorption of calcium and phosphate Erythropoietin: released when decreased oxygen to the kidney; stimulates RBC production Renin-Angiotensin-Aldosterone System https://www.youtube.com/watch?v=tiirLoa5jK0 For review of RAAS Tests of Renal and Bladder Function Renal Function Tests Blood Studies ○ Blood Urea Nitrogen (BUN) → urea is a cellular waste product removed from the blood ○ Creatinine → waste product of skeletal muscles ○ Electrolytes (K+, Na+) Glomerular filtration rate (GFR) ○ If your GFR < 60 this indicates renal injury! Urinalysis ○ Appearance: Colour, turbidity (cloudiness), pH, specific gravity (density of water), blood ○ Microscopic Urine: bacteria, RBC, WBC, crystals, fat, casts ○ Urinary Chemistry: bilirubin, ketones, glucose, sodium, potassium, protein Bladder Function Tests Cystometry: measures bladder pressure by using a pressure-measuring catheter Uroflowmetry: measures the time it takes to empty a full bladder (faster with urge incontinence or slower with prostatic obstruction) Post Void Residual (PVR): measures residual urine in the bladder after voiding (usually with US--bladder scanner). >200ml is abnormal! Direct visualization tests ○ Cystoscopy: camera inserted through the urethra and visualizes inside of the bladder ○ Ureteroscopy: camera inserted through the urethra and bladder directly into ureter to visualise upper urinary tract Age-Related Renal Function Pediatric Geriatric Decreased ability to remove excess water and Decrease in renal blood flow and GFR solutes Altered sodium and water balance Decreased concentrating ability Number of nephrons decrease due to renal Narrow margin for fluid and electrolyte vascular and perfusion changes balance Response to acid–base changes delayed Increased risk of medication toxicity Increased risk for medication toxicity Alterations in thirst and water intake  Alterations of Renal and Urinary Tract Function Chapter 30 Urinary Tract Obstruction Urinary tract obstruction is an interference with the flow of urine at any site along the urinary tract Obstruction can be caused by an anatomical change (obstructive uropathy) or functional defect Severity based on: - Location - Completeness - Involvement of ureters and kidneys - Duration - Cause Urinary Tract Obstruction Sites Upper: common causes include stricture, compression of a calyx (calculi, tumor, inflammation or scarring), or ureteral blockage Lower: common causes include storage of urine (overactive bladder) or emptying of urine (urethral stenosis, prostate hypertrophy)... neurogenic or anatomical Upper Urinary Tract Obstruction Hydroureter: kinking and dilation of the ureter Hydronephrosis: enlargement of the renal pelvis and calyces Ureterohydronephrosis: dilation of both the ureter and the renal pelvis & calyces →dilation is an early response to obstruction; increased pressure decreases filtration Response to Relief of Obstruction: diuresis (post-obstructive), restoration of fluid balance and correction of electrolyte imbalance (lose K+ with diuresis) Kidney Stones- Upper Urinary Tract Obstruction Renal calculi or urinary stones are masses of crystals, protein or other substances that form within and may obstruct the urinary tract The stones are usually made from calcium oxalate, calcium phosphate, struvite (magnesium-ammonium-phosphate) or uric acid Risk Factors - Gender (male), age, race (Caucasian), geographical location & seasonal factors - Geographical location & season; what is their influence on fluid intake & dietary patterns? - Decreased fluid intake - Infection (inflamed or scarred tissue provide a site for calculus development) - Obstruction (allows collection of substances that create a stone) - Diet (increased intake of calcium of oxalate-rich food) Kidney Stones- Upper Urinary Tract Obstruction Pathophysiology Supersaturation of one of more salts in the urine Precipitation of salts from liquid to solid (temperature & pH) ○ Acidic urine 90 mL/min) ○ Mild (GFR 60 to 89 mL/min) ○ Moderate (GFR 30 to 59 mL/min) ○ Severe (GFR 15 to 29 mL/min) ○ End stage (GFR 90%, although higher risk for HF, kidney failure, and HTN in the long-term Childhood Incontinence (Enuresis) Involuntary passage of urine by a child who is Theories: beyond the age (~5 years old) when voluntary - Organic causes (UTIs, congenital defects) bladder control should have been acquired - Factors that increase urine production (diabetes, sickle cell disease - Primary Enuresis: the child has never - Maturational lag (developmental delay) been continent - Genetic factors - Secondary Enuresis: the child has been - Sleep patterns (obstructive sleep apnea) - Psychosocial theories (ADHD, stress (new continent for at least 6 months before sibling)) incontinence recurs - Daytime or Nighttime Diagnosis: history, urinalysis, physical exam Treatment: therapeutic management; education, implementation of timed voiding, fluid management, UTIs Medications are also available for overactive bladders  Structure and Function of the Reproductive System Chapter 32 Learning Objectives Discuss factors related to altered puberty Identify common uterine disorders in women Describe benign and malignant uterine growths Identify causative factors related to male and female sexual dysfunction Discuss the pathophysiology of male and female reproductive disorders Describe structural male reproductive disorders Discuss the prevalence, treatment, and complication of STIs Describe medical treatment for male and female disorders Identify male and female breast disorders Identify risk factors related to the development of reproductive cancers in men and women Review signs, symptoms, and complications of cancer affecting the reproductive organs Development of the Reproductive System Dependant on sex hormones - Males: testosterone - Needed in utero to differentiate into external male genitalia - Production of sperm begins at puberty - Females: estrogen, progesterone, follicle-stimulating hormone (FSH) and luteinizing hormone (LH) - Production of ova occurs only during fetal life; one gamete matures per menstrual cycle Female Reproductive System External Genitalia (vulva): mons pubis, labia majora, labia minora, clitoris, perineum Internal Genitalia: vagina, cervix, uterus, fallopian tubes, ovaries Female Sex Hormones Estrogen: a generic term for 3 similar hormones derived from cholesterol; estradiol, estrone, and estriol - Maturation of reproductive organs, development of secondary sex characteristics, and maintenance of pregnancy require estrogen Androgen: produced by the adrenal cortex and ovaries; contribute to skeletal growth, pubic hair growth, and activate sebaceous glands (acne), and play a role in libido Progesterone: controls the menstrual cycle (along with estrogen); “hormone of pregnancy” as it; 1. Maintains the thickened endometrium 2. Relaxes smooth muscle to help the uterus expand 3. Thickens the myometrium which prepares it for labour 4. Promotes lactation Menstrual Cycle Menarche: first menstruation Menopause: cessation of menstrual flow for 1 year Cycle average is 28 days, with day 1 being the first day of menses Phases Menstruation (menses); shedding of the functional layer of the endometrium Follicular/Proliferative; maturation of a follicle and proliferation of the endometrium Ovulation; release of an ovum from mature follicle Luteal/Secretory; follicle turns into a corpus luteum (secretes progesterone)... the endometrium is ready for implantation ○ If fertilized, human gonadotropin (hCG) supports the corpus luteum (hCG is detectable in the urine) ○ If no conception of implantation, the corpus luteum degenerates, progesterone levels drop, and the endometrium lining is shed Follicle Development After ovulation, the follicle develops into the corpus luteum. If fertilization occurs, the corpus luteum enlarges and begins to secrete hormones that maintain and support pregnancy. If fertilization does not occur, the corpus luteum secretes these hormones for approximately 14 days and then degenerates, which triggers the maturation of another follicle. Male Reproductive System External Genitalia: scrotum, testes, epididymis, vas deferens and penis Internal Genitalia: ducts (vas deferens, ejaculatory, and urethra), and glands (seminal vesicles, prostate, cowper) Male Sex Hormones Androgens Primary androgen—testosterone Produced mainly in the Leydig cells of the testes Testosterone ○ Sexual differentiation ○ Urogenital system development ○ Nervous and skeletal tissue development ○ Libido Alterations of the Female Reproductive System Chapter 33 Dysmenorrhea- Hormonal and Menstrual Alterations Primary dysmenorrhea: Painful menstruation associated with prostaglandin release in ovulatory cycles Excessive prostaglandin F₂α ○ Increased myometrial contractions ○ Constricted endometrial blood vessels ○ Increased nerve hypersensitivity Secondary dysmenorrhea: Related to pelvic pathology & may occur any time in the menstrual cycle Diagnosis: medical history and pelvic exam Treatment: NSAIDs, hormonal contraceptives, exercise, decrease stress, application of heat, acupuncture, thiamine & vitamin E supplements Amenorrhea - Hormonal and Menstrual Alterations Amenorrhea: lack of menstruation; due to pregnancy, hypothalamic dysfunction, polycystic ovarian syndrome, hyperprolactinemia and ovarian failure Primary amenorrhea: Failure of menarche and absence of menstruation by age 13 without development of secondary sex characteristics or by age 15 regardless of presence of secondary sex characteristics Secondary amenorrhea: Absence of menses after previous menstrual periods - Common in early adolescence, pregnancy, lactation, and during perimenopause - Also associated with thyroid disorders, hyperprolactinemia, excessive stress or weight loss, and polycystic ovary syndrome (PCOS) - Pregnancy must be ruled out before any further evaluation Polycystic Ovary Syndrome (PCOS)- Hormonal and Menstrual Alterations One of the most common endocrine disturbances affecting women; leading cause of infertility in North America Diagnosis includes two of the following: - Few or anovulatory menstrual cycles - Elevated levels of androgens - Polycystic ovaries Associated with genetic predisposition and obesity - Insulin resistance, excessive insulin and androgens (messes will all the hormones) Symptoms related to anovulation and hyperandrogenism - Amenorrhea, hirsutism, acne and infertility Treated with oral contraceptives to control irregular cycles, weight loss Premenstrual Syndrome (PMS) & Premenstrual Dysphoric Disorder (PMDD) PMDD considered a severe, sometimes disabling extension of PMS Cyclic physical, psychological, or behavioural changes that impair interpersonal relationships or interfere with usual activities Occurs in luteal phase of the menstrual cycle Multiple theories to explain causes/symptoms - Hormones - Genetics - Environmental Symptomatic treatment Pelvic Inflammatory Disease (PID)- Infection & Inflammation Acute inflammatory process caused by infection; may involve any organ of the upper genital tract… affects the entire peritoneal cavity in severest form - Salpingitis is inflammation of the fallopian tubes Usually caused by STIs that migrate from the vagina to the upper genital tract Risk Factors: Multiple sexual partners, being sexually active at a younger age, previous PID, using douches, and having an IUD for birth control Clinical Manifestations: varies from no pain to sudden, severe abdominal pain with fever; dysuria and irregular bleeding Diagnosis: history, abdominal tenderness, cervical motion tenderness, mucopurulent discharge, STI testing Rapid broad spectrum antibiotic treatment to prevent complications Pelvic Inflammatory Disease (PID)- Infection & Inflammation Vaginitis- Infection & Inflammation Irritation/inflammation usually caused by an infection of the vagina Causes: sexually transmitted pathogens, overgrowth of normal flora, and Candida albicans Acidic nature of the vagina provides some protection - Maintained by cervical secretions and normal flora - Altered by douching, soaps, spermicides, feminine hygiene sprays, deodorized pads or tampons, pregnancy, and diabetes Treatment to develop and maintain acidic environment; administration of antimicrobials or antifungals; symptom relief (pruritus and irritation) Pelvic Organ Prolapse Uterine prolapse: Descent of the cervix or entire uterus into the vaginal canal or completely through the vagina - Grade 1: Not treated unless it causes discomfort - Grades 2 and 3: Cause feelings of fullness, heaviness, and collapse through the vagina Treatment: Pessary (removable mechanical device that holds the uterus in position) Kegel exercises Estrogen therapy Surgery is treatment of last resort Endometriosis Presence of functioning endometrial tissue or implants outside the uterus; responds to hormone fluctuations of the menstrual cycle Pathophysiology is still poorly understood Highly associated with infertility Dyschezia (pain on defecation) is hallmark symptom Treatment to prevent progression, alleviate pain, and Pelvic sites of implantation in endometriosis; restore fertility endometrial cells may enter the pelvic cavity during retrograde menstruation Infertility Inability to conceive after 1 year of unprotected intercourse Female infertility results from dysfunction of the normal reproductive process ○ Menses and ovulation ○ Fallopian tube function ○ Implantation of fertilized egg Initial workup includes semen analysis, determination of ovulation, and hysterosalpingography of the fallopian tubes Treatment aimed toward correction of problems identified Alterations of the Male Reproductive System Chapter 34 Uretritis- Disorders of the Urethra Inflammation of the urethra is usually, but not always, caused by a sexually transmitted infection →Nonsexual origins can be caused by urological procedures, insertion of foreign objects, anatomical abnormalities, or trauma Clinical Manifestations: urethral tingling, itching or burning sensation, urinary frequency and urgency, purulent discharge Diagnosis: urine nucleic acid detection amplification tests for gonorrhea and chlamydia Treatment: antibiotic therapy and avoidance of future exposure or mechanical irritation Urethral Strictures- Disorders of the Urethra Fibrotic narrowing of the urethra caused by scarring →Commonly a result of trauma or untreated or severe urethral infections →Can result in hydronephrosis and kidney failure if severe and prolonged Clinical Manifestations: urinary tract infection symptoms, diminished “force & calibre”, urinary hesitancy, double stream, dribbling after voiding Diagnosis: history & physical, flow rate and cystoscopy Treatment: surgical; urethral dilation Disorders of the Penis Phimosis: inability to retract foreskin from the glans of the penis, frequently caused by poor hygiene or chronic infections → may require circumcision Paraphimosis: inability to replace or cover the glans with the foreskin → surgical emergency to prevent necrosis if severe Peyronie Disease: “bent nail syndrome”; fibrous plaque development in the erectile tissue causing a painful lateral curvature of the penis during erection Priapism: condition of a prolonged penile erection… urological emergency! Balanitis: inflammation of the glans penis; usually associated with prepuce inflammation related to accumulation of smegma Benign Prostate Hyperplasia (BPH) Enlargement of the prostate gland, leading to compression of the urethra Risks: family history, obesity Clinical Manifestations: FUNWISE - Frequency - Urgency - Nocturia - Weak stream - Intermittency (stop/start) - Straining - Emptying (do they feel empty after voiding?) Diagnosis: digital rectal examination and measurement of prostate-specific antigen (PSA), transurethral ultrasound Treatment: medications (tamsulosin), education (double void, avoid fluids before bed, reduce consumption of mild diuretics like caffeine and alcohol) Sexual Dysfunction Impairment of any of all processes of male sexual response (erection, emission & ejeculation) 1. Vascular, endocrine, and neurological disorders 2. Chronic disease, including kidney failure and diabetes mellitus 3. Penile diseases and penile trauma 4. Surgery and pharmacological therapies Treatment: medications (vasodilators; sildenafil *A/E*), cessation of smoking, penile implants, penile revascularization and correction of other anatomical defects Sexually Transmitted Infections (STIs) Reportable infections do not include some of the most prevalent sexually transmitted infections Complications: pelvic inflammatory disease (PID), infertility, ectopic pregnancy, chronic pelvic pain, neonatal morbidity and mortality, genital cancer, and epidemiological synergy with HIV transmission (coinfection, amplifies one another) Although the majority of STIs can be treated, viral-induced STIs are considered incurable Sexually Transmitted Infections (STIs) Bacterial sources - Gonococcal infections - Bacterial vaginosis - Syphilis - Lymphogranuloma - Chlamydial infections Viral sources - Genital herpes Parasitic sources - Trichomoniasis - Human papillomavirus (HPV) - Condylomata acuminata - Scabies - Pediculosis pubis