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.

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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

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URINARY SYSTEM

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

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

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THE KIDNEYS

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

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

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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

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THE FILTRATION MEMBRANE

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

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

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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.

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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

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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.

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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

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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

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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

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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

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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

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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

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

Microbe Invasion

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Microbe

Invasion

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

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CYSTITIS AND URINARY TRACT

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

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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

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CYSTITIS AND URINARY TRACT

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

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CYSTITIS AND URINARY TRACT

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

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CYSTITIS AND URINARY TRACT

INFECTION

Other UTIs

• Persistent or recurrent UTI (can be

due to underlying causes/ disorders)

• Asymptomatic bacteriuria

• Catheter related bacteriuria

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LOIN PAIN

Renal causes

• Renal stones

• Renal tumour

• Acute pyelonephritis

• Obstruction of the renal pelvis

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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

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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

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Kidney stones

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

0Calculi.png

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KIDNEY STONES

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

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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.

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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

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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

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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)

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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

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HAEMATURIA

May be visible (frank) or invisible (microscopic)

o Causes

• Tumour

• Stones

• Infection

• Trauma

• Vascular – malformation, infarct

• Glomerular disease

• Clotting disorders

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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

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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)

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HYPERTENSION

oCommon feature of renal

parenchymal and vascular

disease

oEarly feature of glomerular

disorders

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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

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Renal

Artery

Stenosis

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

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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

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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

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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

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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

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CHRONIC RENAL FAILURE

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

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CHRONIC RENAL FAILURE

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

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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.

© Endeavour College of Natural Health endeavour.edu.au 46

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