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UROLOGY. Dr.Ishara maduka. THE RENAL SYSTEM. STRUCTURES: KIDNEYS RETROPERITONEAL RENAL ARTERY & VEIN NEPHRON URETER URINARY BLADDER URETHRA. NORMAL ADULT KIDNEY –
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UROLOGY Dr.Ishara maduka
THE RENAL SYSTEM • STRUCTURES: • KIDNEYS • RETROPERITONEAL • RENAL ARTERY & VEIN • NEPHRON • URETER • URINARY BLADDER • URETHRA
NORMAL ADULT KIDNEY – The capsule has been removed and a pattern of fetal lobulations still persists, as it sometimes does. The hilum at the mid left contains some adipose tissue. At the lower right is a smooth-surfaced, small, clear fluid-filled simple renal cyst. Such cysts occur either singly or scattered around the renal parenchyma and are not uncommon in adults.
In cross section, this normal adult kidney demonstrates the lighter outer cortex and the darker medulla, with the renal pyramids into which the collecting ducts coalesce and drain into the calyces and central pelvis.
THE RENAL SYSTEM • 4 MAIN FUNCTIONS OF THE KIDNEYS: • EXCRETION OF WASTE PRODUCTS • FILTRATION • TUBULAR REABSORPTION • TUBULAR SECRETION • REGULATION OF FLUID & ELECTROLYTES • BLOOD PRESSURE REGULATION • ERYTHROPOEITIN SECRETION
THE RENAL SYSTEM PHYSIOLOGY: • RENIN-ANGIOTENSIN • ERYTHROPOEITIN • PROSTAGLANDIN RELEASED BY CELLS NEAR THE GLOMERULUS WHEN GFR IS LOW OR WHEN SYMPA-NS IS STIMULATED • RELEASED IN RESPONSE TO HYPOXEMIA • IS RELEASED BY RENAL MEDULLA; VASODILATOR; • REGULATE RENAL BLOOD FLOW
THE RENAL SYSTEM PHYSIOLOGY: • METABOLISM OF VIT D – FOR CALCIUM METABOLISM • DEGRADATION OF INSULIN • URGE TO VOID : 200-300 ml OF URINE • BLADDER DISTENTION: 400 ml • PARASYMPA-NS : DESIRE TO VOID • SYMPA-NS: MUSCLE RELAXATION & ELIMINATION
RENAL DISORDERS • RENAL FAILURE • GLOMERULONEPHRITIS • NEPHROTIC SYNDROME • NEPHROSCLEROSIS • HYDRONEPHROSIS • INFECTIONS • NEUROGENIC DISORDERS • BENIGN PROSTATIC HYPERTROPHY
RENAL FAILURE (R. F.) INABILITY OF THE KIDNEY TO FUNCTION NORMALLY & EFFECTIVELY • ACUTE RENAL FAILRE • CHRONIC RENAL FAILURE
ACUTE RENAL FAILURE SUDDEN DETERIORATION OF KIDNEY FUNCTION 3 PHASES: • OLIGURIC • ANURIC • POLYURIC / RECOVERY + WASTING OF Na, K, & base HCO3
ACUTE RENAL FAILURE CAUSES: • PRERENAL • SHOCK • MISMATCHED BT • RENAL • NEPHRITIS • NEPHROTOXIC INFECTION • POST RENAL • RENAL CALCULI
CAUSES: PRERENAL GOUT DM SUBACUTE BACTERIAL ENDOCARDITIS RENAL SLE GLOMEROLU-NEPHRITIS POSTRENAL PROSTATIC OBSTRUCTION CHRONIC RENAL FAILURE
UO ALTERATIONS WEAK INCREASINGLY DROWSY RESTLESSNES INSOMIA DRY SKIN & MUCOUS MEMBRANES NAUSEA/ VOMITING CNS IRRITABILITY ANXIETY HALLUCINATION MUSCLE TWITCHING CONVULSIONS COMA HPN ANEMIA EDEMATOUS BRUISE EASILY R. F. - SIGNS & SYMPTOMS
R. F. - MANAGEMENT MODALTIES: • CONSERVATIVE TREATMENT 2. AGGRESSIVE TREATMENT
CONSERVATIVE TREATMENT • DIET • K+, & Na+ RESTRICTED • TREATMENT OF INFECTION • ANTIBIOTICS • TREATMENT OF ALTERATIONS OF BODY CHEMISTRY
ALTERATIONS IN BODY CHEMISTRY I. SUBSTANCES FROM PROTEIN METABOLISM: • UREA • CREATININE • URIC ACID MGT: • PROTEIN RESTRICTION • PREVENTION OF INFECTION • ANABOLIC HORMONES – CAUSE TISSUE BUILD UP & REVERSE BREAKDOWN
ALTERATIONS IN BODY CHEMISTRY • ELECTROLYTES: • HYPERKALEMIA • HYPOKALEMIA • HYPERNATREMIA • HYPONATREMIA • HYPOCALCEMIA, HYPERPHOSPHATEMIA, & BONE DSE • ACIDOSIS
AGGRESSIVE TREATMENT • HEMOFILTRATION • PERITONEAL DIALYSIS • HEMODIALYSIS
HEMOFILTRATION • CONTINUOUS ARTERIOVENOUS HEMOFILTRATION (CAVH) INDICATION: • FLUID OVERLOAD FROM OLIGURIA • RENAL FAILURE A-V SHUNT ULTRAFILTRATION
HEMOFILTRATION ADVANTAGE: • DOES NOT REQUIRE DIALYSIS MACHINE OR DIALYSIS PERSONNEL DISADVANTAGE: • 36-48 HRS
DIALYSIS INDICATION: • GFR FALLS BELOW 3ml/min PURPOSE: • REMOVING WASTE PRODUCTS FROM THE BODY TYPES: • PERITONEAL DIALYSIS • HEMODIALYSIS
RENAL TRANSPLANTATION • AUTOGRAFT • ALLOGRAFT/ HOMOGRAFT • XENOGRAFT
HYDRONEPHROSIS OBSTRUCTION OF URINARY FLOW DISTENTION OF PELVIS & CALYCES THINNING OF RENAL PARENCHYMA GRADUAL DESTRUCTION OF THE KIDNEY COMPENSATORY HYPERTROPHY OF THE CONTRALATERAL KIDNEY IMPAIRMENT OF RENAL FUNCTION
HYDRONEPHROSIS CLIN MANIFESTATIONS: • Asymptomatic • Flank & back pain • Hematuria
HYDRONEPHROSIS MANAGEMENT • Urinary diversion: Nephrostomy • Antimicrobials
INFECTIONS OF THE URINARY TRACT PREDISPOSING FACTORS: • FEMALE : PROXIMITY OF THE URETHRA TO THE VAGINAL-RECTAL ORIFICES • INFANTS AFFECTED MORE OFTEN THAN OLDER CHILDREN • ELDERLY
INFECTIONS OF THE URINARY TRACT CAUSE: • ORGANISMS FROM THE BOWEL • E. coli • Pseudominas • Enterococci
INFECTIONS OF THE URINARY TRACT • Ascending infection & Vesico - Ureteral reflux • Sexual activity • Instrumentation
- KIDNEY- URETER URETERO-VESICAL JUNCTION BLADDER VESICO- URETERAL REFLUX
U.T.I. S/SX CYSTITIS: • FREQUENCY • URGENCY • DYSURIA • BLADDER SPASM • WALLS MAY BLEED WITH SEVERE INFLAMMATION
This is an opened urinary bladder. The mucosa shows many petechial hemorrhages and is swollen and congested. This is hemorrhagic cystitis. It is frequently seen with lower urinary tract infections and is particularly common in the presence of an indwelling urinary catheter.
U.T.I. S/SX PYELONEPHRITIS • PRIMARY LOWER UTI • FLANK PAIN • MUSCLE SPASM • CHILLS • FEVER • DYSURIA
This is another section of a kidney with acute suppurative pyelonephritis. Notice the parenchyma is congested and swollen. There is a calculus in the calyx.
U.T.I. TREATMENT: • ANTIBIOTICS • INCREASE FLUIDS – 3-4L /DAY • EARLY TREATMENT TO PREVENT COMPLICATIONS
U.T.I. COMPLICATIONS: • SEPTICEMIA • RENAL FAILURE
NEUROGENIC DISORDERS • PARASYMPATHETIC NERVOUS SYSTEM – SACRAL CORD 2,3,4 • PERCEPTION TO URINATE: 300-500 ML OF URINE • MAXIMUM BLADDER CAPACITY: 1L OF URINE
NEUROGENIC DISORDERS TYPES: • LESION ABOVE THE SACRAL MICTURITION CENTER (SMC) • SPASTIC, NEUROPATHIC BLADDER • LESION BELOW THE SMC • FLACCID, NEUROPATHIC BLADDER
SPASTIC BLADDER • REDUCED CAPACITY • INVOLUNTARY DETRURSOR CONTRACTIONS • HYPERTROPHY OF THE BLADDER • SPASTICITY OF PELVIC MUSCLES • AUTONOMIC DYSREFLEXIA S/SX: • INVOLUNTARY URINATION • VOIDING CAN BE TRIGGERED BY STIMULATION OF GENETALIA OR ABDOMEN, WITH SPASM OF EXTREMITIES
FLACCID (ATONIC) BLADDER TYPES: • SENSORY • MOTOR • LARGE CAPACITY • LACK OF VOLUNTARY DETRURSOR MUSCLES • MILD WALL HYPERTROPHY (TRABECULATIONS) • DECREASED TONE OF EXTERNAL SPHINCTER
FLACCID (ATONIC) BLADDER • LOSS OF SENSORY / MOTOR SUPPLY TO THE BLADDER • SHOCK PHASE OF SCI • BLADDER : • FLACCID & DISTENDED • RETENTION WITH OVERFLOW INCONTENENCE • SMOOTH MUSCLE STILL ACTIVE + WEAK STRIATED SPHINCTER MUSCLES = TRABECULATIONS • GENITAL PROBLEMS : LOSS OF ERECTION
NEUROGENIC BLADDER DIAGNOSIS: • HISTORY • NEUROLOGICAL EXAM & STUDIES (EMG) • RADIOLOGIC EXAM (VOIDING CYSTOURETHROGRAM) • UROLOGIC STUDIES (UTZ)
NEUROGENIC BLADDER INTERVENTIONS: • INTERMITTENT CATHETER DRAINAGE • CREDE’S METHOD • ALCOHOL, TEA & COFFEE AS DIURETICS • ELECTRONIC STIMULATION OF THE BLADDER
UROLITHIASIS CAUSE: • URINARY STASIS • UREA- SPLITTING ORGANISMS • E. coli • Proteus • Staph, Strep
UROLITHIASIS Types of Stones: • ACID STONES • URIC ACID • CYSTINE • ALKALINE STONES • PHOSPHATE • CALCIUM OXALATE
Alkaline Stone formation UREA-SPLITTING ORGANISMS IN THE URINE URINE BECOMES ALKALINE CALCIUM PHOSPHATE BECOMES INSOLUBE UROLITHIASIS
There was a large renal calculus (stone) that obstructed the calyces of the lower pole of this kidney, leading to a focal hydronephrosis (dilation of the collecting system). The stasis from the obstruction and dilation led to infection. The infection with inflammation is characterized by the pale yellowish-tan areas next to the dilated calyces with hyperemic mucosal surfaces. The upper pole is normal and shows good corticomedullary demarcations.
Sometimes a very large calculus nearly fills the calyceal system, with extensions into calyces that give the appearance of a stag's (deer) horns. Hence, the name "staghorn calculus". Seen here is a horn-like stone extending into a dilated calyx, with nearly unrecognizable overlying renal cortex from severe hydronephrosis and pyelonephritis. Nephrectomy may be performed because the kidney is non-functional and serves only as a source for infection.
UROLITHIASIS S/SX: • CVA PAIN • COLICKY & EXCRUCIATING • RADIATES TO THE LABIA OR SCROTUM • ASHEN FACE • DIAPHORESIS • FREQUENCY • HEMATURIA • FEVER - INFECTION
UROLITHIASIS MEDICAL TREATMENT: • ACID STONES - ALKALINE ASH DIET: • FRUITS • VEGETABLES • MILK • ALKALINE STONES - ACID ASH DIET : • MEAT • FISH • EGGS • CEREALS