Disorders of the Urinary SystemDepartemen Ilmu Penyakit DalamFakultas KedokteranUniversitas Muhammadiyah Sumatera UtaraDr. dr. Shahrul Rahman, Sp.PD, FINASIM

ORGANS THAT CONSTITUTE THE URINARY SYSTEM?????Kidneys

Ureters

Urinary bladder

Urethra

Key point:The cortex contains all the structures of the nephron

The medulla contains only the collecting ducts & the loop of Henle

Functions of the kidneyRemoves nitrogenous wastesUreaUric acidCreatinineAmmoniaMaintains homeostasisFluid balanceElectrolyte balanceAcid-base balanceExcretory OrganVia blood filtration & formation of urineRegulation of Blood PressureJuxtaglomerular apparatusRAA systemReninAngiotensinAldosteroneUrine formationFiltrationOccurs in renal corpuscleReabsorptionOccurs in proximal convoluted tubuleAlso occurs in distal convoluted tubuleIt takes things back into bloodSecretionOccurs in distal convoluted tubuleBlood gives things up to the urineConcentrationOccurs in collecting tubules

See next slide

2 key factors determine volume of urine producesGlomerular filtration rate (GFR)Determined by the unique arrangment of blood vesselsHormonal secretionDetermined by fluid & electrolyte balance

Diagnostic Tests - Urinalysis1. Physical Characteristics & Measurementsappearancecolor odorvolumespecific gravity2. Chemical MeasurementspHprotein; glucoseketonesbilirubin; urobilinogenleukocytes; nitriteblood3. Microscopiccells (wbc, rbc, sperm)castscrystalsbacteria4. Detection of Bacteriurianitrite test qualitative or screening testC & S Colony Count, if done, make this a quantitative test

NOTE: Step 4, qualitatively, is done as part of step 2

Appearance Clear = normalCloudy = ? Infection If sediment = kidney diseaseDark = ?blood, ?bilirubin, ?concentratedColorUrochrome pigment = yellowcomes from breakdown of hemoglobinConcentrationMore Concentrated = Deeper YellowChange of Color From:MedsVitamin = yellowDiseasesBlood = red-brownLiver = OrangeFoodsRhubarb = red-brownOdorNormal = ammonia-like smellfrom breakdown of ureaUnpleasant = ? infection

QuantityAverage per 24 hours = 1500 cc60 cc per hourGFR = 125 cc/minThus, 7500 cc/ hourUrine Made Per Hour = 60 ccUrine GFR Per Hour = 7500 cc KEY: 1 % of filtered urine remains urine; 99 % becomes reabsorbed back into blood

Oliguria = 100 - 400 cc per dayAnuria = less than 100 cc per dayPolyuria = diabetes, nerves, diuretics

Specific GravityDetermines ConcentrationCompares Test Liquid to H2ONormal = 1010 - 1030First AM Specimen = > 1020In many kidney diseases, one loses the ability to concentrate urine3 ways to do it:1. Reagent Strip2. Refractometer3. UrinometerpH Determines Acidity or AlkalinityNormal = 6.0Range = 4.5 - 8.0Acidity example = diabetesAlkaline example = UTI

ProteinOK to have a Trace in the urineBenign Conditions:exerciseexposure to cold protein consumptionGenerally Means Kidney DiseaseGlucose Will only be in urine if exceed Renal Threshold (160 - 180 mg/dl)Ketone (note Acetone is a Ketone)Ketones are products of Fat MetabolismIf cant breakdown Sugars for energy, the body will begin using FatSeen in: Uncontrolled DiabetesStarvationHi-Fat Diet

Bilirubin & Urobilinogen FormationWhen used-up RBCs are broken down by R-E System, a by-product is BilirubinBilirubin removed from blood by liver & excreted into intestineBacteria in intestine convert Bilirubin into UrobilinogenSome Urobilinogen reabsorbed into bloodOf this amount reabsorbed some my be normally passed in urineBilirubinNormally None in UrineFound in urine if it cant get from the liver into G-I tractFrom Obstruction of Bile DuctsFound in urine if have:Liver Disease (hepatitis)Blood Disease (hemolysis)Urobilinogen generally follows whatever happens to bilirubinmay get none in urine if on antibiotics (destruction of gut flora)usually get small amount in urineBlood None is normalBut may see some if female is menstruatingLeukocytesfrom inflammation of kidney or lower G-U tractNitritesscreening test for bacteriuriabacteria convert nitrate to nitrite

Other Diagnostic TestsBlood testsBUN / creatinineCBC ------ anemia if decreased EPO productionRenin Antistreptolysin titersUrine culture & sensitivity (C&S)Include colony countImagingIVPRetrograde pyelographyCAT/ MRISurgical proceduresCystoscopyBiopsy

Cardinal signs of Urinary System DisordersAbnormal constituents of urineProtein (Albumin), blood/ haemoglobin, cells & tissue casts, pus, glucose, ketone bodies,etc

Abnormal volume of urine

Pain and dysuria

Uraemia

Incontinence & retentionUTIsInflammatory disordersNephrotic syndromeUrinary tract obstructionStonesHydronephrosisTumors Renal cell carcinomaBladder cancerCongenital disordersPolycystic kidneysWilms tumor (nephroblastoma)Renal failureAcuteChronicDialysis Urinary Tract Disordersoverall outline

Renal Calculi (Kidney Stones)Made of crystals of calcium phosphate and uric acidGradually they get larger until they block uretersFirst sym severe painOther sym nausea and vomiting, frequency, chills, fever, hematuriaDiagnosis by symptoms, ultrasound, or x-rayRx increase fluids to flush out stone, medications, and if needed LITHOTRIPSY

LithostripsySurgical procedure to remove kidney stonesShock waves hit dense stones and break them upDone on outpatient basis

NephritisInflammation of the kidney (kidney infection)Incontinence involuntary urination

CystitisInflammation of the mucous membrane lining of the urinary bladderMost common cause E.ColiSym- DYSUIA (painful urination) and frequencyUsually in females (shorter urethra)Rx - antibiotics

HemodialysisUsed for kidney failureInvolves the passage of blood through device with semipermeable membraneDialysis serves as substitute kidneyBlood from patient flows through machine and is filteredCan be done at home or in clinicTakes 2-4 hours, 2-3 times a week.

Kidney TransplantAs a last resortInvolves donor organ from someone with a similar immune systemMain complication - rejection

Definitions

EnuresisGlycosuriaNocturiaPolyuriaBedwettingSugar in urineFrequent urination at nightLarge amounts of urine

Definitions Continues

PyuriaAnuriaHematuriaDiureticPus in urineNo urine producedBlood in urineDrug or substance to increase urine production