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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

  • Physiology
  • Congenital/ hereditary
  • Inflammatory disorders
  • Urinary Calculi
  • Urinary Tract Obstruction
  • Cysts and tumors
  • Renal Vein Thrombosis
  • Acute renal failure
  • Chronic renal failure
  • 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
      • 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