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Urinary System. Marilyn Rose RT, RDMS. outline. Physiology Congenital/ hereditary Inflammatory disorders Urinary Calculi Urinary Tract Obstruction Cysts and tumors Renal Vein Thrombosis Acute renal failure Chronic renal failure. physiology. Kidneys, ureters and bladder

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Urinary system

Urinary System

Marilyn Rose RT, RDMS


Outline
outline

  • Physiology

  • Congenital/ hereditary

  • Inflammatory disorders

  • Urinary Calculi

  • Urinary Tract Obstruction

  • Cysts and tumors

  • Renal Vein Thrombosis

  • Acute renal failure

  • Chronic renal failure


Physiology
physiology

  • Kidneys, ureters and bladder

  • Functional unit- nephron (each kid > 1million)

    • Filter waste from blood

    • Reabsorb water and nutrients, secrete excess as urine

    • Nephron filters 190 L of water each day- only 1-2 L excreted so 99% of water is reabsorbed into the blood.

  • Urine formation

    • Begins in glomerulus > BP into Bowman’s capsule allow filtration to occur

    • Proximal convoluted tubule- lg amt of water and all nutrients are reabsorbed- sodium & chloride depends on {} in the body

      • Influenced by hormones: antidiuretic (ADH-pituitary) and aldosterone (adrenal glands)

    • Loop of Henle- reabsorb of salt and water

    • Distal convoluted- permit excretion of concentrated urine by excreting- potassium & hydrogen ions and some drugs

    • Kidney maintains salt or electrolyte balance/ acid base balance


Physiology contd
Physiology contd.

  • Healthy metabolism

    • pH in range of 7.35- 7.45

    • < acidic- acid urine > alkaline urine

  • Urine passes:

    • collecting tubules-> calyces-> renal pelvis-> ureters

  • Peristalsis forces urine down ureters

  • Bladder is a reservoir

  • Two ureters enter posterior- trigone and anterior corner-urethral opening

  • 250 ml- stimulate autonomic nerves to void (voluntary contraction of external sphincter- possible if motor system is intact (spinal cord injury- incontinent)

  • Kidney produces RBC to control blood pressure

    • Erythropoietin- stimulates rate of production

    • Renin- produces angiotensin- decreased bloodflow in arterioles increases agniotensin to constrict peripheral arterioles in body causing blood pressure to elevate


Congenital hereditary
Congenital/ Hereditary

  • Anomalies of:

    • number/ size

      • Unilateral renal agenesis (solitary kid)

        • Rare but associated with other malformations

        • Failure of embryonic renal bud / vasculature to form

        • Ureter is also missing

        • Compensatory hypertrophy of solitary kidney results

      • Supernumerary kidney

        • A third small kidney with a separate pelvis/ ureterand blood supply

        • Can cause 2ndary infections

      • Hypoplastic kidney

        • Small replica of a normal kidney- good function

        • Can also cause compensatory hyperetrophy


Congenital anomalies
Congenital- anomalies

  • Rotation/ position/ fusion

    • Ectopic

      • Pelvic (more common )

      • intrathoracic (above diaphragm) (less common)

      • Usually functions normally but may be more easily obscured

    • Crossed ectopia

      • Ectopic kidney lies on the samee side as the normal kidney

      • Commonly fused with the other kidney

    • Horseshoe

      • MOST COMMON TYPE OF FUSION ANOMALY

      • Both kidneys are malrotated and their lower poles are joined by renal parenchyma (isthmus) across midline

      • Ureters airseantereiorly and lower pole calyces pint medially

      • UPJ obstruction is common

    • Complete fusion

      • An irregular mass with no resemblance to renal structure “reneform shape”


Congenital anomalies1
Congenital- anomalies

  • Renal pelvis/ ureter

    • Duplication

      • Simple bifid pelvis

      • double pelvis (collecting system)

        • Complicated by obstruction or VUR

        • Obstruction usually affects the upper pole

  • Ureterocele

    • Cystic dilation of distal ureter near insertion into the bladder

    • Stenosis leads to prolapse of distal ureter into the bladder

    • Ectopic ureteroceles are found exclusively in infants and accompanied by ureteral duplication (upper pole obstruction and lower pole VUR)

    • Radiographic- oval density with a thin halo on US it appears as a cystlike structure within the bladder

  • Posterior urethral valves

    • Thin transveerse membranes found in males that cause bladder outlet obstruction and severe hydronephrosis/ hydroureter/ renal damage


Inflammatory disorders
Inflammatory Disorders

  • Glomereulonephritis

    • Inflammatory process of glomeruli

    • Antigen-antibody rxn

    • occurs several weeks post acute respiratory /middle ear infection (hemolytic strep)

    • More often chronic autoimmune disorder

    • Leaking into the urine:

      • albumin (proteinuria)

      • red blood cells (hematuria)

      • <glomerular filtration rate = oliguria- < amt of urine

  • Pyeleonephritis

    • Inflammation of the kidney and renal pelvis caused by pyogenicbactereia

    • Affects interstitual tissue between the tubules

    • Patchy distribution and involves one kidney

    • Often occurs in women and children

      • From obstruction- enlarged prostate, kid stone, cong defect)

      • Catheterization of the ureter

      • Blunting, round or clubbed calyces

      • CT and US can also show an abscess, hydronephrosis

      • Chronic- loss of parenchyma

  • Emphysematous pyelonephritis

    • Severe form of acute parenchymal and peerirenal infection with gas-forming bacteria

    • Occurs in diabetic men

    • Causes acute necrosis of entire kidney


Inflammatory contd
Inflammatory contd.

  • TB

    • Hematogenous spread of TB

    • Small granulomas in cortex of kids

    • 2ary infection- 5-10 years post primary

    • Radiographic- ulcerative destruction of papillae and enlargement of calyces- flecks of ca++

  • Papillary necrosis

    • Destructive process of medullary papillae

    • Diabetes, pyelonephritis, UTI, sickle cell, phenacetin (acetaminophen)

    • Radiographic- sloughing of papillae, ca++

    • Echogenicnonshadowing structures in collecting system

  • Cystitis

    • Inflammation of urinary bladder

    • More common in women (short urethra)- bacteria

    • Catheterization- most common nosocomial infection in the hospital

    • Radiographic- chronic- decreased bladder size, thick wall

    • Emphysematous in diabetic


Urinary calculi
Urinary calculi

  • Most commonly form in the kidney

  • Asymptomatic until lodge in ureter- partial obstruction

  • Metabolic abnormality- hypercalcemia (hyperparathyroid)

    • Also urinary stasis and infection

  • Radiographic- 80% have enough ca++ to see on xray

    • Noncon CT demonstrates stone (type), hydroureter or hydronephrosis

    • US- echogenic, acoustic shadow, hydroureter and hydronephrosis

    • Staghorn calculi- completely fill pelvis- block urine flow

    • Nephrocalcinosis- ca++ in parenchyma- hyperparathyroid, sarcoidosis, hyperbvitamin D, ren tub acidosis

    • Ureter calculi- from downward movement of stone- lodge of UVJ

    • Bladder stone- elderly men- blad outlet obstrcution, urethral stricture, neuroblad, bladdivertic


Urinary tract obstruction

UPJ obstruction

Urinary tract obstruction

  • Adults- urinary calculi, pelvic tumor, urethral stricture, enlarged prostate

  • Children- congenital malformations- UPJ narrow, uretereocele, retrocaval ureter, PUV

  • Blockage above bladder- unilateral hydroureter and hydronephrosis

  • Below bladder- bilateral hydroureter and hydronephrosis

  • Radiographic

    • CT- mass effects, stone- acute obstruction- kidney swollen

    • US- detect hydronephrosis

    • Physiologic hydronephrosis occurs during pregnancy


Renal cysts
Renal Cysts

  • Renal cyst

    • Simple renal cysts

      • most common unifocal masses of the kidney

      • Fluid filled- unilocular (septa occassionally)

      • Vary in size- single or multiple on one or both kidneys

      • Some (3%) have a thin calcified wall- not usually in benign

      • Radiographic- protruding portion elevates the edges of the cortex

      • US best for distinguishing fluid filled simple cysts (enhancement) from solid lesions

      • CT also accurate in simple cysts-

      • Needs to be followed since abscess, necrotic tumors or hemorrhagic cyst can mimic simple cysts


Polycystic kidney disease
Polycystic kidney disease

  • Polycystic kidney disease

    • Inherited disorder (ADPKD)

      • Multiple cysts of varying size

      • Lobulated enlargement of kids and progressive renal impairment

      • Cystic compression of nephrons-

        • intrarenal obstruction/ HTN

      • 1/3 -cysts on liver (does not interfere with hepatic function)

      • 10% -berry aneurysms- cerebral arteries

      • Asymptomatic during first 3 decades

      • Radiographic- enlarged kidneys, with multiple varying sized cysts

        • Renal parenchyma hyperechoic

        • small cyst that -not fluid filled- wall interface makes them echogeneic

        • Demonstration of hepatic cysts can make the diagnosis

        • Screen other family members

      • Fatal form- (ARPKD)-

        • bilateral- diffusely enlarged kidneys,

        • renal failure

        • maldevelopment of intrahepatic bile ducts

        • Individual cysts too small to see, distorted kidneys

        • No cure- renal transplant is necessary

        • usually bilateral nephrectomy necessary to stabilize cardiac/ lung function with the patient on dialysis until transplant.


Renal tumors
Renal Tumors

  • Renal carcinoma- RCC

    • Hypernephroma- most common renal neoplasm

    • >40 with painless hematuria

    • 10% involve ca++ and tumor necrosis

    • 90% malignancy in masses with ca++ (nonperipheral)

    • Triad= hematuria, flank pain, palpable abdominal mass

    • Radiographic

      • Bulging or generalized renal enlargement

      • Infiltration can lead to distortion- obliteration of collecting system or tumor invasion into the vein

      • US- solid mass, internal echoes and no enhancement

      • CT- solid neoplasm homogeneous / post injection increased density

        • Best modality for spread to ipsilateral side/ vein or lymph nodes


Wilm s tumor pediatrics
Wilm’s tumor- pediatrics

  • Nephroblastoma

    • Most common abdominal neoplasm of infancy/ childhood

    • Arise from embryonic renal tissue

    • May be bilateral

    • Highly malignant

    • Must be differentiated from neuroblastoma

      • Adrenal -2nd common

    • US distinguish Wilm’s from hydro

      • solid appearance

      • Distortion of renal structure

      • Demonstrated intrarenal location of mass (neuro- extrarenal)

      • CT for tumor invasion into renal veins/ IVC or recurrence


Bladder carcinoma
Bladder carcinoma

  • Originates in the epithelium

  • Urothelial carcinoma- (previous TCC)

  • Men > 50- 4th most common cancer in men

    • Cigarette smoke, parasitic infection in Egypt

  • Radiographic

    • Finger-like projections into lumen

    • Polypoid defect arising from bladder wall or focal bladder wall thickening

    • CT with a full bladder can demonstrate estravesical extension in pelvis- lymph nodes


Renal vein thrombosis
Renal vein thrombosis

  • Most frequently in children severely dehydrated

  • Adult- complication of another renal disease

    • Glomerulonephritis/ Amyloidosis/ pyelonephritis

    • trauma

    • Extension of thrombus from IVC

    • Direct invasion

    • Extrinsic pressure from renal tumor

      • Radiogrpahic

      • Unilateral/ bilateral

      • Sudden- causes striking kidney enlargement

        • Longstanding will become small, atrophic nonfunctioning kidney

        • Partial or with collaterals- kidney enlarges- collecting system is stretched

        • US first modality- enlarged kidney with decreased echogenicity from edema- doppler can show the extent of the clot (CT does not) (also no iodine which is hard on the kidneys)


Acute renal failure
Acute renal failure

  • Rapid deterioration in kidney function

  • Accumulation of nitrogen waste in the blood “fishy”

  • Pre-renal failure-

    • <blood flow to kidneys from low blood volume- hemorrhage, dehydration, surgical shock, cardiac failure or renal artery obstruction

  • Post-renal failure-

    • Obstruction of urine outflow from both kidneys (oliguria)

    • Prostatic disease, obstruction of bladder neck

  • Acute renal failure can be from:

    • Kid disease-glomneph, acute pyelo, severe HTN

    • Nephrotoxic agents- antibiotics, radiographic contrast, anesthetic agents, heavy metal, organic solvents, hemolysis, >myoglobin

  • US useful for dilated ureters, renal size, focal lesions, cystic disease- useful so that contrast does not have to further damage the kidney


Chronic renal failure
Chronic renal failure

  • Reflection of prerenal, postrenal or intrinsic kid disease

    • Bilatren art stenosis, bilatureteral obstruction, glomneph, pyelo and familial cystic diseases.

  • Uremia- failure to clear nitrogen waste, accum of urea and creatinine

    • Toxic effects: nausea, vomiting, diarrhea, drowsiness, dim vision, <mental ability, convulsions, coma

    • Failure to synthesize erythropoietin- leads to anemia

    • Pruritus- itching of skin, sallow (yellow) pigment

    • >water retention due to >sodium- edema and CHF

    • <serum ca++ - muscle twitching > ca++ from bones- kid stones

    • Radiographic

      • US best to eval = small echogenic kidneys

      • Hydro, renal size, focal lesions, cysts


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