Urinary System

• •Regulates:
• –Fluid volume
• –Blood pressure
• –Metabolic waste and drug excretion
• –Vitamin D conversion
• –Acid-base balance
• –Hormone synthesis

•Includes: kidneys, ureters, bladder, and urethra

• •Located on either side of the vertebrae in retroperitoneal
• space

•Renal capsule – connective tissue surrounding the kidney

• •Renal cortex – area immediately beneath the capsule, which
• contains the nephrons

•Renal artery – supplies each kidney with blood

• •Renal hilum – opening in the kidney
• that renal artery and nerves enter and renal vein and ureter exit

•Renal sinus - cavity that forms the renal pelvis

•Calyces – tubes urine drains into the renal pelvis

•Voluntary activity

• •As urine volume in the bladder increases, the urine exerts
• pressure on the two bladder sphincters (internal and external) and stretch receptors in the bladder

• •A pressure of 200 to 300 mL on the sphincters and receptors sends nerve impulses to the
• brain, triggering the urge to urinate

• •The bladder contracts and the external sphincter relaxes,
• forcing urine out through the urethra

• •Each kidney contains 1-2 million nephrons
• -Each nephron contains multiple
• sections responsible for filtering specific substances

•Bowman’s capsule – double membrane that surrounds the glomerulus

•Glomerulus – cluster of capillaries

• •Glomerular filtration rate – rate of blood flow through
• the glomerulus
• –Best indicator renal function
• –Normal 125 mL/min

•Antidiuretic hormone

•Aldosterone

Renin-angiotensin-aldosterone

•Ammonia

•Urea

•Uric Acid

•Converts vitamin D to its active form

•Secretes bicarbonate

•Excretes or retains hydrogen

•Synthesizes atrial natriuretic peptide, erythropoietin, and renin

•System functions less efficiently

•Exacerbated by the presence of chronic conditions

• •Increased risk for waste accumulation and loss of homeostatic
• regulation

•Other renal-related complications include anemia, hypertension, and osteoporosis

•Increased risk for drug toxicity

•Loss of urinary control

• •Enuresis
• –Involuntary urination by a child after 4–5 years of age
• –Nocturnal enuresis – bed-wetting
• –Causes may be psychological and structural
• –Usually resolves with or without treatment

• •Transient incontinence
• –Urinary incontinence resulting from a temporary condition

• –Causes: delirium, infection, atrophic vaginitis, medications, psychologic factors, high urine output, restricted mobility, fecal impaction,
• alcohol, and caffeine.

• •Stress incontinence
• –Loss of urine from pressure exerted on the bladder by coughing, sneezing, laughing, exercising, or lifting something heavy

–Occurs when the sphincter muscle of the bladder is weakened

–Contributing factors: pregnancy, childbirth, menopause, cystocele, prostate removal, obesity, and chronic coughing

• •Urge incontinence
• ―Sudden, intense urge to urinate, followed by an
• involuntary loss of urine

• ―Causes: urinary tract infections, bladder
• irritants, bowel conditions, smoking, Parkinson’s disease, Alzheimer’s disease, stroke, injury, and nervous system damage

• ―Overactive bladder - urge incontinence with no
• known cause

• ―Urinary incontinence caused by trauma or damage to
• the nervous system

―Detrusor hyperreflexia - increased detrusor muscle contractility that occurs even though there is no sensation to void

―Urgency is generally absent

• •Overflow incontinence
• ―Inability to empty the bladder (retention)
• ―Other indications: dribbling urine and a weak urine
• stream

• ―Causes: bladder damage, urethral blockage, nerve
• damage, and prostate conditions

• ―Chronic overdistension occurs
• because of perceived inability to interrupt work to void that results in detrusor muscle areflexia and overflow
• incontinence

•Skin problems

•Recurrent urinary tract infections

•Negative psychological consequences

•Interruption of usual activities

•Bladder dysfunction caused by an interruption of normal bladder nerve innervation

•Causes: brain or spinal cord injury, nervous system tumors, brain or spinal cord infections, dementia, Parkinson’s disease, spina bifida, diabetes mellitus, stroke, medications, vaginal childbirth, multiple sclerosis, chronic alcoholism, systemic lupus erythematosus, heavy metal poisoning, and herpes zoster

•Often occur with a reproductive abnormality

•Kidney development begins about the 5th week of gestation

•Urine is the main component of amniotic fluid

• •Decreased amniotic fluid can result in serious fetal
• abnormalities

• •Inherited disorder characterized by numerous, grape-like
• clusters of fluid-filled cysts in both kidneys

•Cysts enlarge the kidneys while compressing and eventually replacing the functional kidney tissue

•The exact trigger is unknown

•Prognosis and progression vary widely depending on the type

• •Autosomal dominant PKD
• –Mutation on the shortmarm of chromosome 16 and 4
• –Occurs in both children and adults, but it is much more common in adults
• –Symptoms often do not showing up until middle age

• •Autosomal recessive PKD
• –Less common and more serious
• –Appears in infancy or childhood

–Progresses rapidly, resulting in end-stage kidney failure and generally causing death in infancy or childhood

• •Also known as nephroblastoma
• -Rare cancer that primarily affects children
• -Usually occurs in one kidney, but it can affect both
• -Usually grows as a solitary mass that can become quite large

•The exact cause is unknown, but may arise in utero when the cells that normally form the kidneys fail to develop properly

•Manifestations: asymptomatic abdominal mass, high blood pressure, hematuria, urinary tract infections, abdominal pain, nausea, vomiting, anorexia, bowel pattern changes, weight loss, and fatigue

•Diagnosis: history, physical examination, renal ultrasound, and biopsy

•Staging system guides treatment

•Treatment: surgery, chemotherapy, and radiation

• •Extremely common
• -Lower tract most frequent site
• -Escherichia coli most common culprit

• •Risk factors: female, benign prostatic hypertrophy, congenital urinary tract abnormalities, immobility, urinary or bowel incontinence, renal calculi, decreased cognition, pregnancy, impaired immune response, urinary
• catheterization, and improper personal hygiene

• •Manifestations: may be asymptomatic, urgency, dysuria, frequency, hematuria, bacteriuria, cloudy and
• foul-smelling urine, and symptoms of infection

•Diagnosis: history, physical examination, urinalysis, urine culture, cystoscopy, and complete blood count

• •Treatment: antibiotics, increasing hydration, avoiding
• irritants, performing proper perineal hygiene, wearing cotton underwear, not delaying urination, adequately emptying the bladder, and providing appropriate catheter care

•Inflammation of the bladder

•The bladder and urethra walls to become red and swollen

•Causes: infection and irritants

•Manifestations: UTI symptoms, abdominal pain, and pelvic pressure

•Diagnosis and treatment follow those usually seen for UTIs

•Infection that has reached one or both kidneys

•E. coli is the most common culprit

•Kidneys become grossly edematous and fill with exudate, compressing the renal artery

•Abscesses and necrosis can develop, impairing renal function and causing permanent damage

•May be acute or chronic

•Complications: renal failure, recurrent UTIs, and sepsis

•Manifestations: severe UTI symptoms, flank pain, and increased blood pressure

•Diagnosis: history, physical examination, urinalysis, urine and blood cultures, complete blood count, cystoscopy, intravenous pyelogram, computed tomography, renal ultrasound, biopsy, and cystourethrogram

•Treatment: usual UTI treatments, but long-term antibiotics (4–6 weeks) are usually required

•Bilateral inflammatory disorder of the glomeruli that typically follows a streptococcal infection

• •Affects men more than women
• -Leading cause of renal failure

•Inflammatory changes impair the kidneys’ ability to excrete waste and excess fluid

•May be acute or chronic

• •Nephrotic and nephritic syndromes are the most
• prevalent forms

•Results from antibody-antigen complexes lodging in the glomerular membrane, triggering the complement system

•Causes: systemic diseases, gold therapy, and idiopathic

•Results in increased glomerular capillary permeability, leading to marked proteinuria, lipiduria, hypoalbuminemia, and anasarca

•Other manifestations: hypoalbuminemia, dark and cloudy urine, immunoglobulins in the urine

•Complications: risk for infection and atherosclerosis

• •Inflammatory injury to the glomeruli that can occur because of antibodies interacting with normally
• occurring antigens in the glomeruli

•Causes: diseases that initiate the inflammatory response

•Manifestations: gross hematuria, urinary casts and leukocytes, low GFR, azotemia, oliguria, and high blood pressure

•Complications: impaired renal function

•Diagnosis: history, physical examination, urinalysis, blood chemistry, serum antibody levels, computed tomography, and renal biopsy

•Treatment: antibiotic therapy, corticosteroids, blood pressure management, and temporary dialysis

•Presence of renal calculi, hard crystals composed of minerals that the kidneys normally excrete

•More common in men and Caucasians

•Calculi can form in the renal pelvis, ureters, and bladder

• •The most frequent type of calculi contains calcium in
• combination with either oxalate or phosphate

•Other types include struvite or infection stones, uric acid stones, and cystine stones

•Risk factors: pH changes, excessive concentration of insoluble salts in the urine, urinary stasis, family history, obesity, hypertension, and diet

• •Manifestations: colicky pain in the flank area that radiates to the lower abdomen and groin;
• bloody, cloudy, or foul-smelling urine; dysuria; frequency; genital discharge; nausea; vomiting; fever; and chills

•Diagnosis: history, physical examination, urine examination, kidney-ureter-bladder X-ray, computed tomagraphy , ultrasound, intravenous pyelogram, calculi analysis, and serum studies

• •Treatment: strain all urine, increase fluids, extracorporeal shock wave lithotripsy, percutaneous nephrolithotomy, ureteroscopy, surgery, pain management, dietary changes, and physical
• activity

•Abnormal dilation of the renal pelvis and the calyces of one or both kidneys

• •Causes: urolithiasis, tumors, benign
• prostatic hyperplasia, strictures, stenosis, and congenital urologic defects

•Unilateral renal involvement indicates an obstruction in one of the ureters

• •Bilateral renal involvement indicates an obstruction in the
• urethra

•Complications: atrophy, necrosis, and glomerular filtration cessation

• •Manifestations: colicky, flank pain or pressure; bloody,
• cloudy, or foul-smelling urine; dysuria; decreased urine output; frequency; urgency; nausea; vomiting;
• abdominal distension; and UTIs

Diagnosis: history, physical examination, urinalysis, renal ultrasound, computed tomography, intravenous pyelogram, and magnetic resonance imaging

•Treatment: ureteral stents, nephrostomy tubes, and antibiotics

•Most frequently occurring kidney cancer in adults

•Risk factors: being male and smoking

•Metastasis to the liver, lungs, bone, or nervous system is common

• •Manifestations: asymptomatic, painless hematuria, abnormal urine color, dull and achy flank
• pain, urinary retention, palpable mass over affected kidney, unexplained weight loss, anemia, polycythemia, hypertension, paraneoplastic syndromes, and fever

• •Diagnosis: history, physical examination, urinalysis, computed tomography, magnetic resonance imaging, positron emission tomography scan, bone
• scan, chest X-ray, intravenous pyelogram, cystoscopy, renal arteriogram, biopsy, liver function
• panel, complete blood count, and blood chemistry

•Treatment: surgery, newer chemotherapies, hormone, and immunotherapy

•Types: transitional cell carcinoma, squamous cell carcinoma, and adenocarcinoma

•Metastasis is common to the pelvic lymph nodes, liver, and bone

•Risk factors: advancing age, men, Caucasians, working with chemicals, smoking, excessive use of analgesics, experience recurrent UTIs, long-term catheter placement, chemotherapy, and radiation

•Manifestations: painless hematuria, abnormal urine color, frequency, dysuria, UTIs, and back or abdominal pain

•Diagnosis: history, physical examination, urinalysis, computed tomography, magnetic resonance imaging, positron emission tomography scan, bone scan, chest X-ray, intravenous pyelogram, cystoscopy, biopsy, and liver function panel

• •Treatment: surgical removal, radiation, chemotherapy, and
• immunologic agents

•A common, nonmalignant enlargement of the prostate that occurs with age

•The exact cause is unknown

• –Declining testosterone and increasing estrogen levels are thought to cause prostatic stromal cell proliferation,
• enlarging the prostate

–Or stem cells in the prostate do not mature and die as programmed, enlarging the prostate

•As the prostate expands, it presses against the urethra and obstructs urine flow

•Complications: urinary stasis and UTIs

• •Manifestations: frequency, urgency, retention, difficulty
• initiating urination, weak urinary stream, dribbling urine, nocturia, bladder distension, overflow incontinence,
• and erectile dysfunction

•Diagnosis: history, physical examination, urine flow measures, urinalysis, prostate-specific antigen, rectal ultrasound, biopsy, and cystoscopy

•Treatment: alpha-blockers and alpha5-reductase inhibitors, saw palmetto, partial or complete surgical removal of the prostate, and avoid alcohol

•Kidneys are unable to function adequately

•Classified as either acute or chronic

•Sudden loss of renal function

•Generally reversible

•Most common in critically ill, hospitalized patients

•Risk factors: advanced age, autoimmune disorders, and liver disease

• •Prerenal conditions
• –Extremely low blood pressure or blood volume (Shock)
• –Heart dysfunction

• •Intrarenal conditions
• –Reduced blood supply within the kidneys (GFR)
• –Hemolytic uremic syndrome
• –Renal inflammation
• –Toxic injury

• •Postrenal conditions
• –Ureter obstruction (Urithrolisias)
• –Bladder obstruction and dysfunction

1.Asymptomatic phase

• 2.Oliguric phase - daily urine output decreases to
• approximately 400 mL or less, and waste products accumulate

3.Diuretic phase - daily urine output increases to as much as 5 L


4.Recovery phase - glomerular function gradually returns to normal

• •Oliguric phase: decreasing urine output, electrolyte
• disturbances, fluid volume excess, azotemia, and metabolic acidosis

• •Diuretic phase: increased urine output, electrolyte
• disturbances, dehydration, and hypotension

•Recovery phase: symptoms begin resolving

• Diagnosis: history, physical examination,
• blood chemistry, arterial blood gases, urinalysis, complete blood count, renal ultrasound, and biopsy

• •Treatment:
• –Correct fluid and electrolyte imbalances
• –Dialysis
• –A diet high in calories and restricted in protein, sodium, potassium, and phosphates

–Hypertension management

–Anemia treatment with synthetic erythropoietin

–Infection prevention strategies

•Gradual loss of renal function that is irreversible

•Causes: diabetes mellitus, hypertension, urine obstructions, renal diseases, renal artery stenosis, ongoing exposure to toxins and nephrotoxic medications, sickle cell disease, systemic lupus erythematosus, smoking, advancing age

• 1.Renal impairment
• –60% of nephrons are lost
• –Manifestations appear slowly

• 2.Renal insufficiency
• –75% of the nephrons are lost and GFR
• reduces by 20%
• –Waste products begin to accumulate
• –Unable to concentrate the urine, maintain blood pressure control, and secrete erythropoietin

• 3.End-stage renal disease
• –90% of nephron destruction and GFRndrops to 10 mL/min
• –Unable to maintain homeostasis while waste products, fluid, and electrolytes accumulate

• •Peripheral neuropathy, restless leg syndrome, and seizures
• •Nausea and vomiting
• •Anorexia
• •Malaise
• •Fatigue and weakness

• •Headaches that seem unrelated to any other cause
• •Sleep disturbances
• •Decreased mental alertness
• •Flank pain
• •Jaundice

• •Persistent pruritus
• •Recurrent infections
• •Pericarditis, pericardial effusion, pleuritis, and pleural effusion Congestive heart failure
• •Respiratory distress and abnormal breath sounds
• •Sudden weight change
• Edema of the feet and ankles
• Azotemia

•Diagnosis: history, physical examination, urinalysis, blood chemistry, computed tomography, magnetic resonance imaging, renal ultrasound, biopsy, complete blood count, and arterial blood gases

•Treatment: manage and prevent complications and alternative medication dosing