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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.
© endeavour.edu.au
© Endeavour College of Natural Health endeavour.edu.au 2
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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