PathoPhysiology Chapter 29
Transcript of PathoPhysiology Chapter 29
LOWER URINARY TRACT• Role is to transport urine formed by the
kidneys and allow removal from the body• Urine movement due to the effect of gravity
and facilitated by peristaltic movement of the ureters• Released through the urethra; requires
integrity of ureters and bladder, competent urethral sphincters, functioning nervous system
LOWER URINARY TRACT (CONT.)
Diagnostic Tests• Urinalysis: for diagnosis of infection• Ultrasonography: visualization of the
urinary system• Fluoroscopic voiding cystourethrography or
radionuclide voiding cystography: used to identify reflux or urethral abnormalities• Urodynamic testing: used for diagnosing
voiding dysfunctions
LOWER URINARY TRACT (CONT.)
Mechanics of Micturition• Bladder innervation is supplied by the
sympathetic nerves that exit the spinal cord at L1 and L2 and allow relaxation and filling• Stimulation of parasympathetic nerves from
S1-S4 results in bladder contraction and relaxation of the internal sphincter
LOWER URINARY TRACT (CONT.)
Mechanics of Micturition • The somatic pudendal nerve innervates the
external bladder sphincter• The sympathetic system innervates blood
vessels via the hypogastric plexus• Micturition requires central, autonomic, and
peripheral nervous system functioning • It is a result of parasympathetic and
voluntary motor control
VOIDING DYSFUNCTION• May be secondary to:• Disorders of the lower urinary tract • Pathologies affecting the central, autonomic, and
peripheral nervous systems • A wide variety of factors affecting control of
micturition, including medication and access to toileting facilities
VOIDING DYSFUNCTION (CONT.)
Incontinence• Urge incontinence: may be idiopathic, due
to bladder infection, radiation therapy, tumors or stones, or CNS damage• Stress incontinence: due to weakening of
pelvic muscles or intrinsic urethral sphincter deficiency• Mixed incontinence: due to a combination
of stress and urge incontinence
VOIDING DYSFUNCTION (CONT.)• Neurogenic bladder: broad classification of
voiding dysfunction in which the specific cause is a pathology that produces a disruption of nervous communication governing micturition• Treatment options for voiding dysfunction
are behavioral, pharmaceutical, and surgical
VOIDING DYSFUNCTION (CONT.)Enuresis• Inappropriate wetting of clothing or bedding• Typically refers to incontinence in children,
particularly at night• Primary cause is maturational delay• Treatment: behavioral modification with or
without pharmaceutical intervention
CONGENITAL DISORDERSVesicoureteral Reflux• Reflux of urine from the bladder to the
ureter and renal pelvis• Due to incompetence of the valvular
mechanism at the ureter-bladder junction• Classified as primary or secondary etiology• Clinical manifestations may include
recurrent UTI, voiding dysfunction, renal insufficiency, or hypertension in children
CONGENITAL DISORDERS• Include misimplantation of ureters,
strictures, an extra ureter, and ureterocele• Cause problems by obstructing normal
urine flow and predisposing to the retrograde flow of urine, urine stasis, and secondary infection• Usually treated with surgical interventions
CONGENITAL DISORDERS (CONT.)
Obstruction of the Ureteropelvic Junction• Blockage in urinary flow (partial or
complete) from the renal pelvis at the entry point of one or both ureters• Typically presents with hydronephrosis• May be managed conservatively or require
surgical intervention
CONGENITAL DISORDERS (CONT.)
Ureteral Ectopy• Ectopic ureter is a single ureter implanted
in an abnormal location or a duplicate ureter• Can increase risk of infection and reduction
in renal function• Typically found with other genitourinary
pathologies• Surgical interventions usually required
CONGENITAL DISORDERS (CONT.)
Ureterocele• Cystic dilation of the distal end of the ureter• Obstruction in the collecting system results
in ureteral and renal calyx dilation; reflux and infection• Clinical manifestations include
hydronephrosis, UTIs, voiding dysfunction, hematuria, urosepsis, or failure to thrive• Surgical intervention is necessary
NEOPLASMSBladder Cancer• Fourth most common cancer in males
eighth most common in females• Risk increases with age; predisposing
factors include smoking and exposure to carcinogenic chemicals• Most tumors originate from the transitional
epithelium (urothelium) lining the urinary tract
NEOPLASMS (CONT.)Bladder Cancer• Primarily manifested as hematuria;
frequency and urgency may be present• Cystoscopy used for diagnosis with tissue
biopsy and washings• Treatment protocols based on type, grade
and stage of bladder cancer; primary options are surgery, radiation therapy, chemotherapy, and immunotherapy
INFLAMMATION AND INFECTIONUrethritis• Inflammation of the urethra• Caused by infection from the bladder, STD-
related or from external factors• STDs confined to the urethra; infection of
other etiologies may ascend to the bladder before symptoms present• Treatment depends on the cause
INFLAMMATION AND INFECTION (CONT.)
Cystitis• Inflammation of the bladder lining• From infection, chemical irritants, stones,
trauma• Most cases have an infectious etiology and
result from infection originating in the urethra• Predisposing factors include female gender,
increased age, catheterization, DM, bladder dysfunction, poor hygiene, and urinary stasis
INFLAMMATION AND INFECTION (CONT.)
Cystitis• Manifestations: frequency, urgency,
dysuria, suprapubic pain, and cloudy urine• Symptoms in older adults may include
lethargy, anorexia, confusion, and anxiety• Most female patients treated based on
symptoms; males and children or more complicated cases may require urine culture and/or further assessment
INFLAMMATION AND INFECTIONInterstitial Cystitis/Painful BladderSyndrome• Chronic condition consisting of bladder
pain, urgency, frequency, and nocturia• Diagnosed based on symptoms• Treatment: identifying contributory lifestyle
factors, such as some foods and beverages; avoidance is primary intervention; medications may be helpful in relieving symptoms
OBSTRUCTIONLower Urinary Tract Urolithiasis• Most often caused by stones traveling to
the ureters, bladder, or urethra from the kidney• Manifestations include ureteral colic,
hematuria, tachycardia, tachypnea, diaphoresis, and N/V
OBSTRUCTION (CONT.)Lower Urinary Tract Urolithiasis• Bladder urolithiasis due to stones traveling
from ureters, but may form in bladder because of urinary stasis• Bladder stone symptoms include frequency
and dysuria; hematuria possible• If infection: antimicrobial therapy based on
culture and sensitivity• Stones that don’t pass spontaneously may
require endoscopic lithotripsy