The Genito-Urinary System

• Signs and Symptoms of Urological Problems

– EDEMA
• associated with fluid retention
• Renal dysfunctions usually produce
ANASARCA
– HEMATURIA
• Painless hematuria may indicate URINARY
CANCER!
Hematuria
– DYSURIA
at
no

• Pain with urination= lower UTI

Ife
– POLYURIA
• More than 2 Liters urine per day

1 To
– OLIGURIA
me
• Less than 400 mL per day Its
– ANURIA
• Less than 50 mL per day
 Kidney function
The Nephron produces urine to eliminate Impaired urine production and azotemia
waste

Secretes Erythropoietin to increase RBC ANEMIA

Metabolism of Vitamin D Calcium and Phosphate imbalances

Produces bicarbonate and secretes acids Metabolic ACIDOSIS

Excretes excess POTASSIUM HYPERKALEMIA

 Acute renal failure
• Sudden interruption of kidney function to regulate
fluid and electrolyte balance and remove toxic
products from the body
M
• Most important manifestation: OLIGURIA
• Pathophysiology
• Pre renal CAUSE:
• Factors interfering with perfusion and resulting in
diminished blood flow and glomerular filtrate,
ischemia, and oliguria; include CHF, cardiogenic
shock, acute vasoconstriction, hemorrhage, burns,
septicemia, hypotension, anaphylaxis
• Intra renal CAUSE:
• Conditions that cause damage to the nephrons;
include acute tubular necrosis (ATN), endocarditis,
diabetes mellitus, malignant hypertension, acute
glomerulonephritis, tumors, blood transfusion
reactions, hypercalcemia, nephrotoxins .

• Post renal CAUSE:

• Mechanical obstruction anywhere from the tubules
to the urethra; includes calculi, BPH, tumors,
strictures, blood clots, trauma, and anatomic
malformation
Acute renal failure
• Three phases of acute renal failure

1. Oliguric phase (Urine output less than 400 cc/24

hours)
• Manifested by dilutional hyponatremia,
hyperkalemia, hyperphosphatemia, hypocalcemia,
hypermagnesemia, and metabolic acidosis
• Diagnostic tests: BUN and creatinine elevated
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2. Diuretic phase
• Diuresis may occur (output 3—5 liters/day) due to
partially regenerated tubule’s inability to
concentrate urine
• manifested by hyponatremia, hypokalemia, and
hypovolemia.
• 3. Convalescence or recovery phase
• Recovery or convalescent phase:
• Renal function stabilizes with gradual improvement
over next 3—12 months
EÉ
• Chronic Renal Failure
• Gradual, Progressive irreversible destruction of the
kidneys causing severe renal dysfunction.
cearatinene
• The result is azotemia to UREMIA N2
IT Eason
• Predisposing factors:
Diabetingm
–DM= worldwide leading cause
–Recurrent infections & U.T. obstruction
– Nephritis & Hypertension
• Diagnostic tests of CRF:
• a. 24 hour creatinine clearance urinalysis
• b. Protein, sodium, BUN, Crea and WBC
elevated
urea 614 5
• c. Specific gravity, platelets, and calcium
decreased
• D. CBC= anemia
urea crew blood
• Assess every hour for signs of uremia (fatigue,
loss of appetite, decreased urine output, apathy,
confusion, elevated blood pressure, edema of face
and feet, itchy skin, restlessness, seizures
• PATHOPHYSIOLOGY of chronic renal failure
• As renal functions decline

• Retention of end-products of metabolism

• Three stages of CRF
• STAGE 1= reduced renal reserve, 40-75% loss of
nephron function flomelwar fltration rate Normala
• STAGE 2= renal insufficiency, 75-90% loss of
nephron function
• STAGE 3= end-stage renal disease, more than
90% loss.
• DIALYSIS IS THE TREATMENT!
• DIALYSIS
• A procedure that is used to remove fluid and uremic
wastes from the body when the kidneys cannot
function
• Two methods

• 1. Hemodialysis

• 2. Peritoneal dialysis
• Acute nephritic syndrome:
same
• Resulting from (acute glomerular inflammation)
• Acute glomerulonephritis;
• Characterized by
• Hematuria.
• Hypertension
• Azotemia
• Oliguria
• Edema
• Almost always caused by acute autoimmune
glomerular disease
• The pathologic lesion consists of
• 1. Acute glomerular inflammation
• 2. Reactive hyperplasia (proliferation) of glomerular
cells, which impair blood flow through the
glomerular and reduce renal function
• 3. Hypertension is caused by increased renin output
because not enough blood is getting through the
glomerulus.
• 4. Hematuria from damaged glomeruli
• 5. Oliguria from diminished glomerular blood flow
• An example of acute nephritic syndrome is
• Acute glomerulonephritis that occurs after
streptococcal sore throats or skin infections
• Nephrotic Syndrome: (in children called nephrosis)
• Evolves from various glomerular diseases and is
characterized by marked proteinuria
more than 3.5 gm/day
•The most common
cause is systemic hypoalbuminemia
autoimmune disease
•SLE
•DM
M Generalized edema
•Hypertension (loss of proteins)

Hyperlipidemia & lipiduria

Low plasma albumin
 bores Hi It

hypotension on 8 41
348,02in
• Glomerular Disease
• Most common cause is an autoimmune reaction
• Most common clinical presentation are
• 1. acute nephritic syndrome
• 2. nephrotic syndrome
• The autoimmune reaction of primary glomerular
disease are usually one of two types N

•Direct antibody attack (type II •Deposition in the glomerulus of

t circulating antigen—antibody
hypersensitivity reaction)
on glomerular basement complexes formed elsewhere
membrane by antiglomerular (type III hypersensitivity reaction)
basement membrane antibody See next slide
See next slide
Autoimmune Reactions

i
• Acute Tubular Necrosis (ATN):
m
• Is extensive necrosis of tubular epithelial cells and is
the most common cause of acute renal failure.
• Ischemic acute tubular necrosis is usually a
consequence of vascular collapse which is
commonly caused by severe hemorrhage.
• Nephrotoxic acute tubular necrosis is caused by a
variety of chemicals that include antibiotics,
mercury, and other heavy metals, and by
intravenous use of diagnostic x-ray contrast media
i
 I
• Pyelonephritis and Urinary Tract Infection:
• Infections are important cause of urinary tract
disease.
• Women are more often infected than men are
• Ascending infection
• 1. urethra is shorter
• 2. pregnancy
• Pyelonephritis:
• is bacterial infection of the kidney and is one of the
most important diseases of the kidney.
• Gram-negative fecal bacteria are the usual cause;
Escherichia coli accounts for 80% of cases
• Most infections occur in women and ascend to the
kidney from an infected bladder.
• Acute pyelonephritis is associated with clinical signs
and symptoms of acute infection.
• The clinical presentation of chronic pyelonephritis
is usually associated with chronic urinary reflux or
obstruction.
• The clinical presentation of chronic pyelonephritis
is variable: it may be
• 1) silent and present for many years, ultimately
presenting as chronic renal failure,
• or 2) it may be symptomatic: flare-ups of acute
pyelonephritis inter-spersed with relatively quiet
intervals.
• Acute pyelonephritis
• is almost always secondary to lower urinary tract
infection.
• Obstruction and reflex are less common causes of
infection in acute pyelonephritis than in chronic
pyelonephritis.
• Microscopically, an acute (neutrophilic)
inflammatory exudate spreads throughout the
kidney.
• Uncomplicated acute pyelonephritis presents as
flank pain associated with fever, high peripheral
white blood cell count.
• The urine is usually packed with white blood cells
(pyuria), and bacteria usually can be cultured and
seen on microscopic examination of urine sediment.
• Chronic pyelonephritis
• is chronic bacterial infection of the kidney.
• It is usually associated with chronic urinary reflux or
obstruction and frequently appears clinically as
recurrent episodes of acute pyelonephritis with
fever, flank pain, dysuria, and pyuria; however,
some patients with low-grade infection and reflux or
obstruction may be asymptomatic, especially early
in the course of disease.
• Renal Stones:
• Stones, (calculi, nephrolithiasis)
• Stones are fairly common, affecting about 5% of the
population. Most occur in young adults in their
twenties or thirties; and men are affected more often
than women are.
44,641
• Hereditary predisposition is a strong factor, and
patients with some genetic metabolic diseases-gout
or aminoaciduria, for example-excrete in urine very
large amounts of metabolic products that may
crystallize into stones.
• Three categories of stones are recognized
• Calcium stones:
• About 75% of stones are composed mainly of
calcium. Typically these stones are hard and dark.
• Most patients have increased levels of urinary
calcium, but blood calcium levels are usually
normal. Calcieton em
• Other patients with hyper parathyroidism have
increased levels of urine calcium secondary to high
blood calcium levels.
• Infection stones:
• Bacterial infection changes urine pH from acidic to
alkaline, which causes the formation of stones that
are mainly composed of magnesium.
• About 15% of stones are magnesium stones, which
are softer and more breakable (friable) than calcium
stones are.
• Uric acid stones:
• About 5% of stones are composed mainly of uric
07
acid. About 25% of patients with gout develop uric
acid stones; however, most patients with uric acid
stones do not have gout or high levels of blood uric
acid
• Often the first symptom of a renal stone is
hematuria. In other cases, stones are asymptomatic;
many are found incidentally by x-ray or routine
urinalysis that detects occult hematuria.
• As a stone or fragment passes down the ureter, it
causes a distinctive and very painful syndrome of
cramping and flank pain known as renal colic.
• A renal stone too large to pass will remain in the
renal pelvis, where it may grow very large and mold
it-self into the shape of the calyces-called a staghorn
calculus, which is always associated with
hydronephrosis and chronic infection.
• Renal Tumors
• Most occur in mature or older adults; men are
affected more often than women are.
• Renal cell carcinoma (clear cell carcinoma)
• is a malignancy of renal tubular epithelium and
accounts for 90% of renal malignancies.
• Most occur in older adults; cigarette smokers have
twice the risk of nonsmokers-about one third of
renal cell carcinomas are linked to tobacco use.
• Usually hematuria is the presenting symptom, but
some tumors may be large enough to find by
palpating the flank of a patient presenting with flank
pain
• Renal cell carcinomas display a variety of
paraneoplastic syndromes including fever of
unknown origin, polycythemia, hypertension,
Cushing syndrome, and hypercalcemia.
• Renal cell carcinoma is especially prone to invade
renal veins (inferior vena cava).
• Metastases to lung and bone are common and may
be the first sign of the presence of a renal cell
carcinoma.
• Five-year survival is about 75% in patients without
metastasis, about 50% in those with metastasis, and
about 15% in those with renal vein invasion.
Surgical excision of the kidney (nephrectomy) is the
preferred treatment.