Chapter 27: Disorders of the Bladder and Lower Urinary tract
What are the different ways a person ends up with a UTI?
Obstruction and reflux, (when urine backs back up into the bladder instead of washing out) Catheter induced infection
What type of incontinence results from the overfilling of the bladder with escape of urine?
Overflow incontinence
What type of calculi has dull, aching flank PAIN?
Renal calculi
What calculi causes an acute, severe, intermittent pain of flank and upper at outer abdomen on affected side?
Renal colic
Describe the third stage of CRF...
Renal failure GFR is <20 %. SHARP INCREASES IN BUN/CR; OLIGURIA, UREMIA, METABOLIC ACIDOSIS
Describe second stage CRF...
Renal insufficiency (25-50 % of functional renal tissue is destroyed) MAY HAVE OLIGURIA, POLYURIA, HTN, AND AZOTEMIA OR NO S/S
Which Neurogenic Bladder dysfunction do Parkinson patients experience?
Spastic bladder dysfunction
What are the surgical treatments for Neurogenic bladder dysfunction?
Sphincterectomy, reconstruction of sphincter and nerve resection of sacral reflex nerves
What type of reflex do stretch receptors cause?
Spinal Reflux
What are some common causes of Spastic bladder dysfunction?
Spinal cord injuries, Herniated disk, vascular lesions, tumors and Myelitis
What causes a spastic bladder?
Spinal cord injury, herniated disk, tumor, stroke, and MS (inflammation of spinal cord), detrusor sphincter dyssynergia can all cause a spastic bladder
Is urine in the kidneys and bladder sterile or nonsterile?
Sterile
What is the function of the bladder?
Storing and emptying urine
____ is the involuntary loss of urine during coughing, laughing, sneezing, or lifting that increases intra-abdominal pressure.
Stress incontinence
When do UTIs occur?
They follow respiratory infections and are predominant in patients with E. coli exposure. Entry via the blood stream or ascends via lower urinary tract.
What is an overactive bladder with or without urge incontinence?
This includes urgent and frequent urination with dysuria and nocturia. Urination is often painful and burns.
How is bacteria in the lower (distal) portion of the urethera normaly controlled?
Through the "Washout phenomena"
WHat are the causes of chronic glomerulonephritis?
UNKNOWN Lupus nephritis diabetic neruopathy rapid progressive glomerulonephritis
What are the lower UTIs?
Urethritis Prestatitis Cystitis
What is the importance of "frequency" when talking about compensation?
Waiting a few minutes allows voiding to be initiated again
When may decompensation of the urinary system occur?
When mechanisms fail
What does the PNS do for bladder fxn?
stimulates the detrusor muscle for micturition and relaxes internal sphincter to eliminate urine with contraction
The parasympathetic lower motor neurons from the detrusor muscle of the bladder are located in the ____ segments of the spinal cord; their axons travel to the bladder by the way of the ____.
sacral, pelvic nerve
T or F? UTIs are usually caused by a virus
False. Bacteria is the most common cause. Entrance through the urethra or in the bloodstream is most common
T or F: the sympathetic NS increases urine elimination
False. It decreases urine elimination!
What are risk factors for UTI?
Female Geriatric clients Strictures Impaired bladder innervation Chronic disease such as diabetes Prostatic hypertrophy Prostatitis Impaired immune response
What is the failure to empty when talking about the neurogenic bladder?
Flaccid bladder dysfunction
Which Neurogenic Bladder dysfunction do Stroke patients experience?
Flaccid bladder dysfunction
What are S/S of polycystic kidney disease?
Flank pain Hematuria Proteinuria Polyuria Nocturia UTI and Calculi are common HTN (develops as cysts obstruct renal blood flow and renin released)
What might occur with hematuria?
Frequency Urgency Dysuria
What is the primary cause of polycystic kidney disease?
Genetics
Describe nephrotic syndrone...
Glomerular membrane derangement causes increase permeability to plasma proteins Decreased plasma protein, decreased colloidal pressure (edema) MASSIVE LOSS OF PLASMA PROTEIN
What is defined as an inflammation of capillry loops of the glomeruli?
Glomerulonephritis
What is the 2nd leading cause of kidney failure worldwide and the 3rd cause of chronic kidney disease in the US and Canada?
Glomerulonephritis
What does the parasympathetic nervous system do during urination?
Produces contraction of smooth muscle of the bladder wall and relaxation of the internal sphincter.
What is the decompensatory stage of urinary obstruction?
Pronounced symptoms because of an overstretched bladder. 1-3L are being stored so there is overflow incontinence
What is the inflammation of the prostate?
Prostatitis
What is the upper UTI?
Pyelonephritis
What might UTIs lead to in children?
Pylonephritis
What is excess mucous and WBCs in urine?
Pyuria (foul odor of urine or cloudy appearance)
What does the parasympathetic lower motor neurons do?
Receives message from motor cortex and sends signal to the external sphincter
What does the sympathetic nervous system do during urination?
Relaxes smooth muscle of the bladder wall and contraction of the internal sphincter
What is urine stasis?
Retention of urine
Pudendal nerve on bladder fxn
S1-S3 somatic from external sphincter
Pelvic N on bladder fxn
S1-S3, parasympathetic from bladder
What are the risk factors for urinary obstruction?
STDs, bladder tumors, pregnancy, rectocecle, cystocele, constipation and fecal impaction
What are the effects of acquired obstruction and stasis?
STI's may cause uretheral strictures
What area of the spine is the reflex center ?
Sacral - S1 through S4, the parasympathetic lower motor neurons
What is the etiology of bladder carcinoma?
Significant correlation with smoking, chronic cystitis and bladder stones
Describe polycystic kidney disease...
Slow, progressive disease that destroys the kidney. Cysts may develop elsewhere in the body : liver, spleen, and pancreas
What is the detrusor muscle?
Smooth muscle wall of the bladder. It contracts to void and relaxes to fill
What is a failure to store urine when talking about the neurogenic bladder?
Spastic bladder dysfunction
What is the decreased ability of the vesicourethral sphincter to prevent the escape of urine during activities (coughing, lifting, exercise)?
Stress incontinence
What kind of incontinence is it when you sneeze, cough or laugh?
Stress incontinence
What are the 3 types of incontinence?
Stress incontinence Urge incontinence Overflow incontinence
What are the types of Urinary Incontinence?
Stress, overactive/urgency and overflow
What types of receptors are in the bladder?
Stretch Receptors
What is voluntary control of urination controlled by?
Striated muscles in the external sphincter and pelvic floor
What neural control center controls the detrusor muscle contractile muscle?
Subcortical center
What is the treatment for Bladder cancer?
Surgical resection, if tumor is invasive cystectomy with resection of nodes, rerouting urine flow (ileostomy , ileal conduit) external radiation and/or chemotherapy
Relaxation and storage of bladder is controlled by what?
Sympathetic nervous system
What promotes bladder filling?
Sympathetic nervous system
How do you diagnosis Incontinence?
Symptoms, health history, physical exam, blood tests, urinalysis and voiding record
Hypogastric nerve on bladder fxn
T11-L2 sympathetic from internal sphincter
What are the symptoms of kidney caner?
TRIAD OF SYMPTOMS: GROSS HEMATURIA FLANK PAIN AND PALPABLE ABDOMINAL MASS FEVER FATIGUE WEIGHT LOSS ANEMIA OR POLYCYTHEMIA MAY BE PRESENT
What is the trigone?
The bladder floor where the ureters and urethra meet. Where a bladder infection occurs
Describe the structural layers of the bladder.
The bladder is composed of four layers. The first is an outer serosal layer, which covers the upper surface and is continuous with the peritoneum; the second is a network of smooth muscle fibers called the detrusor muscle; the third is a submucosal layer of loose connective tissue; and the fourth is an inner mucosal lining of transitional epithelium.The bladder is composed of four layers. The first is an outer serosal layer, which covers the upper surface and is continuous with the peritoneum; the second is a network of smooth muscle fibers called the detrusor muscle; the third is a submucosal layer of loose connective tissue; and the fourth is an inner mucosal lining of transitional epithelium.
What occurs with progressive decompensation of the bladder that causes it to become severely overstretched with a residual urine volume of 1000-3000 mL?
The bladder loses its power of contraction and overflow incontinence
What is a urethrovesical reflux?
There is reflux from the urethra to bladder that can happen due to coughing, sneezing or halted urine flow. It occurs more in females due to increased intrabdominal pressure
What are S/S of Renal calculi?
These vary with their location and size Renal calculi Bladder calculi Renal colic
Why are women more at risk for a UTI?
They are 40x more likely in women than men because of the shortened urethra. Sexual activity can be a factor as well
What connects the kidneys and the bladder?
Ureters
What is the inflammation of the urethera?
Urethritis
What is stress incontinence with increased intrabdominal pressure?
Urinary incontinence that occurs with the pressure in vesicles is greater than the pressure in the urethra. The pelvic floor muscles are weakened and there is a loss of PVU angle. In women this occurs with aging and childbirth but with men a prostectomy. There is peripheral nerve involvement
Bladder structure changes can cause what?
Urinary obstruction Urinary incontinence-overflow incontinence
What is the NL bladder function?
Urine storage, micturition (reflex at 150-250mL)
WHat are stones in the urinary tract?
Urolithiasis
What are the types of urinary calculi?
Urolithiasis Nephrolithiasis
Define incontinence
Use of artificial kidney to filter blood
What factors are part of urination?
detrusor muscle contracts to push urine out because of stimulation from the parasympathetic. The internal sphincter relaxes, external sphincter relaxes because of voluntary relaxation by somatic motor output and abdominal muscles are recruited.
The tonicity and composition of the urine often is quite different from that of the blood, and the _____ of the bladder passage of water and other urine elements between the bladder and the blood.
epithelial lining
The ____ operates as a reserve mechanism to stop micturition when it is occurring and to maintain continence in the face of unusually high bladder pressure.
external sphincter
What is areflexia?
failure of the detrusor muscle to void urine
What are the most uncomplicated lower UTIs caused by?
Escherichia coli
What does the external sphincter do during urination?
Relaxes
What does the internal sphincter do during urination?
Relaxes
Describe the early stage of CRF...
Decreased renal reserve (COMPENSATION working). Normal BUN/Creatinine, no S/S
What is a vesicoureteral reflux?
A retrograde flow of urine into ureters that puts patients at a high risk for UTIs and predisposes them to pyelonephritis. Normally the ureter would be compressed with micturition but an obstruction can cause an increase in bladder volume and pressure. In children, congenital defects or a short ureter can cause it
What are the UTI pathophysiologies?
Descending Ascending
What UTI pathophysiology is hemaogenously from blood (glomerulus)? (It is rare and associated with previous damage or scarring of urinary tract)
Descending UTI
What is the functional unit of the urinary system?
Nephron
What are the 2 mechanisms involved with development of overactive bladder disorder?
Neurogenic and myogenic so it is either generated by the brain or by muscles
What causes a flaccid neurogenic bladder?
Neuropathy at sacral cord or roots or in the periphery. These neuropathies control detrusor muscle contraction and bladder emptying. There are no afferent stimuli of fullness so the detrusor muscle becomes overstretched and you can't urinate voluntarily. Trauma, tumor and spina bifida
What are the glomerular injury pathogenesis?
Immunologic Nonimmunologic Hereditary
The involuntary loss of urine is known as what?
Incontinence
Why does incontinence increase with age?
Muscular contraction strength decreases with age causing nocturia and decreased vesicular volume. Voiding becomes impaired due to the weakened detrusor muscles. Mobility decreases and meds increase which cause more problems.
What is the etiology of urinary obstruction?
congenital narrowing of external meatus, spina bifida, males: benign prostate hyperplasia is most common,
What does the somatic NS do for bladder fxn?
controls the external sphincter but it is under voluntary control. Increased stimulation causes contraction to control urine storage
What are the manifestations of a lower UTI?
cystitis of the bladder and urethra, usually female, frequent and urgent urination, dysuria with pain or burning sensation, back and suprapubic pain, USUALLY NO FEVER, urine may be cloudy and foul-smelling
During compensation, what type of stimuli causes hypersensitivity?
Afferent stimuli (stretch receptors)
What is acute pyelonephritis?
Bacterial infection of the kidney
What structures are involved with obstruction and urinary stasis?
Bladder neck Urethera External urethral meatus
What two mechanisms develop a neurogenic bladder?
A spastic bladder and flaccid bladder dysfunction
Define Kegel exercises
Decreased urine production
When does continence in children occur?
0-3 years. Involuntary spinal cord reflexive filling and emptying. They have conscious control about 2-4 years old. Girls first because it takes longer for myelination to occur in males
Explain malignancy of the urinary bladder
More common in men than in women. about 95% originate from the transitional epithelium. Metastasis is rare
What natural defense do we have to prevent UTIs?
Most bacteria is washed out with urination which provides natural bacteriocidal protection. We have a protective mucus and local IgA and normal bacteria flora.
Define Nicotinic
Most common cause of postrenal failure
What are stones formed in the kidney?
Nephrolithiasis
What is the term "washout" ?
Normal voiding, urination and clearing out of microbes
What is defined as an inflammatory disorder affecting the renal pelvis and functional portion of kidney tissue?
Pyelonephritis
What is inflammation of the kidney and renal pelvis?
Pyelonephritis
Describe male urethra...
16.5-18.5 cm long Passes through prostate
Define kidney cancer...
A tumor of the kidney
Define Nocturia
Accumulation of nitrogenous wastes in the blood
The activation of ____ produces contraction of the intramural ureteral musculature, bladder neck, and internal sphincter.
Alpha-receptors
What neural control center has conscious control of urination?
Cortical center
What is the 2nd layer of the bladder?
Detrusor Muscle
What muscle contracts during urination to push out urine?
Detrusor muscle Abdominal muscles may also be used
What does a flaccid bladder occur second to?
Diabetes mellitus that leads to a large residual volume and increased risk for infections. UTIs and renal complications often occur. Usually a loss of sensation happens first
What is painful or difficult urination?
Dysuria
What are S/S of UTI?
Dysuria Urinary frequency and urgency Nocturia Pyuria Hematuria Elderly may present w/ behavior change or confusion
DESCRIBE THE FOURTH STAGE OF CRF...
END STAGE RENAL DISEASE (ESRD) GFR IS < THAN 5%. EXTREME UREMIA, DIALYSIS OR TRANSPLANT REQUIRED
Define Antimuscarinic drugs
Impaired tubular reabsorption of sodium
A 53-year-old woman with multiple sclerosis presents at the clinic with urinary frequency and bladder spasms. A urinalysis is negative for infection. A complete history is taken and a physical examination is performed by the primary care physician. The woman asks the nurse why she is having bladder spasms and urinary frequency if she does not have a bladder infection. What would be the nurse's response?
In people who have multiple sclerosis, the demyelination of the nerves can cause an interruption in the messages from the brain and the spinal cord in reaching the bladder. This causes a condition known as neurogenic bladder.
What are the 3 phases of the S/S of ARF?
Initiation phase (onset of event causing tubular necrosis. few or no S/S) Maintenance phase (lasts about 2 weeks characterized by persistent reduction in GFR and tubular necrosis) (OLIGURIA, AZOTEMIA, FLUID RETENTION, ELECTROLYTE IMBALANCE, METABOLIC ACIDOSIS, EDEMA, R/T CHF, IMPAIRED RENAL ELIMINATION LEAD TO HYPERKALEMIA, HYPOCALCEMIA, UREMIA) (THE END OF MAINTENANCE PHASE IS CHARAZTERIZED BY DIURESIS) Recovery phase (GFR and tubular function have recovered and no further elevation in BUN/Creatinine
Describe renal colic...
Pain my radiate 2 suprapubic region, groin, and the external genetalia May be associated with vomiting, pallor, and cooled/clammy skin
Why do women develop incontinence following childbirth?
The angle between the bladder and the posterior proximal urethra normally is 90 to 100 degrees, with at least one-third of the bladder base contributing to the angle when not voiding. During the first stage of voiding this angle is lost as the bladder descends. In women, diminution of muscle tone associated with childbirth can causes weakness of the pelvic floor muscles and result in stress incontinence by obliterating the critical posterior urethrovesical angle. In these women, loss of the posterior urethrovesical angle, descent and funneling of the bladder neck, and backward and downward rotation of the bladder occur, so that the bladder and urethra are already in an anatomic position for the first stage of voiding. Any activity that causes downward pressure on the bladder is sufficient to allow the urine to escape involuntarily.
What is the transitional epithelium?
The barrier of the bladder that allows stretching
Explain the process of how the micturition center allows conscious control
The bladder fills with urine stimulating stretch receptors and the micturition in the pons. This stimulation causes the external sphincter to relax, detrusor muscle to contract and the internal sphincter to relax and pull open
Describe the process with parasympathetic nerves in urination?
The bladder fills with urine stimulating stretch receptors and then spinal reflexes. The parasympathetic neurons are then stimulated to cause the detrusor muscle contract and the internal sphincter to relax and pull open
What are the factors associated with age that contribute to incontinence in the elderly?
The overall capacity of the bladder is reduced, as is the urethral closing pressure. Detrusor muscle function also tends to decline with aging; thus, there is a trend toward a reduction in the strength of bladder contraction and impairment in emptying that leads to a larger postvoid residual volumes.
What type of incontinence is described as hyperactive bladder contraction?
Urge incontinence (overactive bladder)
What is defined as "masses of crystals composed of minerals" in the urinary system?
Urinary calculi
What is sudden, compelling need to urinate?
Urinary frequency and urgency
Relaxation of the pelvic support structures, such as cystocele and rectocele may occur in who?
Women
Does pregnancy increase UTI risk?
Yes
What are the four main types of urinary incontinence?
stress incontinence, overactive bladder, overflow incontinence and mixed stress/urge incontinence
A mild form of reflex neurogenic bladder can develop after a ____.
stroke
What is the etiology of UTIs in the pediatric population?
systemic disease, NICU, urinary hypoplasia, family history of UTIs or anomalies, congenital abnormalities like a shortened ureter can all cause pediatric UTIs
What is cystitis?
the most common UTI that is a trigone. It can be mild and only cause inflammation or moderate to severe which can be hemorrhagic and/or pus forming.
What does the cerebal cortex control in bladder fxn?
the precentral gyrus of the frontal lobe, motor cortex and corticospinal tract allows for conscious voluntary control
Approximately 90% of bladder cancers are derived from the ____ epithelial cells that line the bladder.
transitional
What are urinary calculi risk factors?
Dehydration (loop diuretics*) Males White people Young-middle adult Personal/family history Calcium containing antacids Co-morbid disease Frequent cola ingestion
What calculi may cause a dull suprapubic pain?
Bladder calculi
What is defined as a tumor of bladder; arises from epithelial tissue and mosts common site is urinary bladder?
Bladder cancer
How do you treat urinary obstruction?
Bladder catheterization, remove the obstruction!
What is the prevalence of UTIs in pediatrics?
Boys experience it more during the first 12 months especially if they are not circumcised. Girls have a peak during toilet training.
How are UTIs classified?
By region and primary site affected
Define Muscarinic
By-product of muscle metabolism
What is a spastic bladder?
A hyperreflexic detrusor muscle that leads to uncontrolled voiding and the inability to store urine because of the spasms. Bladder emptying becomes reflexive and lesions appear superior to the sacral spinal cord. Spinal cord control becomes segmental due to absent higher CNS control
How do you treat a UTI?
A large increase in fluids will help
What is the male urethra like?
16.5-18.5 cm long that passes through prostate
Describe female urethra...
2.5-3.5 cm long Allows urine to pass more freely Increased risk of UTI
What is the female urethra like?
2.5-3.5 cm long and allows urine to pass more freely
What are functional blocks?
A neurogenic bladder, infrequent voiding, detrusor instability and constipation can all cause UTIs because of the functions that they impact
How many layers is the bladder?
4 layers
In women, stress incontinence is a common problem. The loss of the angle between the urethrovesical junction and the bladder contributes to stress incontinence. What is the normal angle between the bladder and the urethrovesical junction?
90 to 100 degrees. In women, the angle between the bladder and the posterior proximal urethra (i.e. urethrovesical junction) is important to continence. This angle normally is 90 to 100 degrees.
What occurs after there is hypersensitivity to the afferent stimuli (stretch receptors)?
Ability to suppress urination is diminished Bladder contraction can become so strong that it produces bladder spasm URGENCY, sometimes incontinence
One of the many tests done during urodynamic studies is the sphincter electromyograph (EMG). What does this test study?
Activity of the voluntary muscles of the perineal area. Sphincter electromyograph allows the activity of the striated (voluntary) muscles of the perineal area to be studied. Cystometry measures the ability of the bladder to store urine as well as the pressure of the bladder during filling and emptying. Uroflowmetry measures the flow rate during urination.
What are the classification of pyelonephritis?
Acute Chronic
What are the classifications of glomerulonephritis?
Acute Rapidly progressive Chronic
What is defined as a rapid decrease in renal function?
Acute renal faliure
What is a rare, progressive loss of renal function and can be transmitted to future generations when talking about glomerular injury?
Alport Syndrome (Hereditary pathogenesis)
What is flaccid bladder dysfunction?
An areflexic detrusor muscle that causes failure to void urine because the bladder is flaccid and can't function properly
What are some medications to treat neurogenic bladder dysfunction?
Antimuscarnic, cholinergic, muscle relaxants and synthetic ADH (DDAVP) used to decrease the outflow resistance of internal sphincter , stimulate parasympathetic receptors, relax muscles or decrease night time frequency
Describe the activities of the pontine micturition center and cortical brain centers.
As bladder filling occurs, ascending spinal afferents relay this information to the micturition center, which also receives important descending information from the forebrain concerning behavioral cues for bladder emptying and urine storage. Descending pathways from the pontine micturition center produce coordinated inhibition or relaxation of the external sphincter. Cortical brain centers enable inhibition of the micturition center in the pons and conscious control of urination. Neural influences from the subcortical centers in the basal ganglia modulate the contractile response. They modify and delay the detrusor contractile response during filling and then modulate the expulsive activity of the bladder to facilitate complete emptying.
What UTI pathophysiology is from perineal area to lower urinary tract? (associated with females and E. coli)
Ascending UTI
What are the causes of pyelonephritis?
Ascending bladder infection Blood-borne infections Frequent calculi Other obstructions
Describe the patho of pyelonephritis,,,
Ascending infection spreads and kidney becomes edematous with localized abscesses, scar tissue replaces infected/inflamed areas. S/S ONSET IS RAPID WITH CHILLS AND FEVER, MALAISE, AND VOMITING, FLANK PAIN, COSTOVERTEGRAL TENDERNESS, URINARY FREQUENCY, AND DYSURIA
What is chronic pyelonephritis?
Associated with nonbacterial infections that may be METABOLIC, CHEMICAL, OR IMMUNOLOGICAL
_____ of the detrusor muscle and loss of the perception of bladder fullness permit the overstretching of the detrusor muscle that contributes to weak and ineffective bladder contractions seen in detrusor muscle areflexia.
Atony
One of the treatments for bladder cancer in situ is the intervesicular administration of what drug?
Bacillus Calmette-Guerin vaccine. The intervesicular administration of bacillus Calmette-Guerin (BCG) vaccine, made from a strain of Mycobacterium bovis that formerly was used to protect against tuberculosis, causes a significant reduction in the rate of relapse and prolongs relapse-free interval in persons with cancer in situ.
What are most upper and lower UTIs caused by?
Bacteria that enter via the urethera
What are the treatment for UTI?
Based on pathogen, (E-coli antibiotics), fluids, cranberry and blueberry (prevents microbial sticking to epithelial lining)
What are the treatments for Incontinence?
Behavioral modifications, kegels exercises, medications, surgical interventions and indwelling catheter
What does the sympathetic NS when you're not urinating?
Beta 2 adrenergic receptors cause the detrusor muscle to relax and increase bladder volume. The alpha 1 adrenergic receptors in the bladder neck and internal sphincter cause sphincter contraction and no voiding
The ____ receptors are found in the detrusor muscle; they produce relaxation of the detrusor muscle, increasing the bladder volume at which the micturition reflex is triggered.
Beta-adrenergic
What stores urine in the body?
Bladder
What do UTIs infect?
Bladder Urethera Prostate Ureters *Kidneys
Which of the following does not stimulate urination? A. parasympathetic nervous system neurons B. micturition center C. sympathetic nervous center D. spinal reflex
C. Sympathetic nervous center. The SNS decreases activity in both excretory and digestive systems to relax. The micturition center is in the pons and the spinal reflex responds to stretch receptors in the bladder to stimulate urination. The PNS neurons are stimulated by spinal reflex to cause urination
What are the causes of bladder cancer?
CIGARETTE SMOKE EXPOSURE TO CHEMICALS AND DYES CHRONIC USE OF PHENACETIN-CONTAINING ANALGESIC AGENTS S/S PAINLESS HEMATURIA, SYMPTOMS OF UTI, AND COLICKY PAIN.
What are urinary calculi composed mostly of?
Calcium
Describe glomerular function...
Capillary network supported by basement membrane Glomerular membrane is selectively permeable Glomerulonephritis (inflammatory process)
What are the high risk factors for renal cell cancer?
Carcinogens excreted in the urine and stored in the bladder Heavy smoking (30-50% of all bladder cancers associated) Chronic infections Some toxins from manufacture of rubber, textiles, paint, chemicals, and proteoleum
What might bladder tumors do?
Cause obstruction
What are the risk factors for Bladder cancer?
Chronic UTIs and bladder stones
What is the end stage of glomerular disorders?
Chronic glomerulonephritis
What is defined as a progressive inability (over months to years) of kidneys to respond to changes in body fluids and electrolyte composition?
Chronic renal failure (inability to produce sufficient urine) (GRF< 20 % of normal) (Serum creatinine > 5 mg/dl)
What is hypertrophy to help overcome obstruction?
Compensation
Incontinence can be transient. What are the causes of transient urinary incontinence?
Confusional states, stool impaction, recurrent urinary tract infections. Among the transient causes of urinary incontinence are recurrent urinary tract infections, medications that alter bladder function or perception of bladder filling and the need to urinate, diuretics, and conditions that increase bladder filling, stool impaction, restricted mobility, and confusional states.
What are the two ways obstruction and stasis can be obtained?
Congenital Acquired
What is the Neural control?
Coordination between sensory and motor components
Treatments for Neurogenic Bladder Dysfunction?
Depends on where lesions are located) Catheterization, bladder retraining, Medications and surgeries
What might cause hesitancy, need to strain, weak, small stream, and incomplete emptying?
Decompensation
_____ brain centers enable inhibition of the micturition center in the pons and conscious control of urination.
Cortical
What is inflammation of the urinary bladder?
Cystitis
What is the most common form of UTI?
Cystitis
How to diagnose Bladder cancer?
Cytologic studies, Cystoscopy, Biopsy, US, CT and MRI
The micturition center is located in the A. Renal medulla B. midbrain C. medulla oblongata D. Pons
D. pons
Describe nephritis syndrome...
DECREASED GLOMERULAR PERMEABILITY decreased GFR *fluid retention and nitrogenous waste accumulation
What are the nonimmunologic glomerular injuries?
DM HTN Toxic (drugs, chemicals)
May cause urinary retention
Decreased central nervous system activity
Describe the effects of prolonged urinary tract obstruction disorders in the bladder.
During the early stage of obstruction, the bladder begins to hypertrophy and becomes hypersensitive to afferent stimuli arising from stretch receptors in the bladder wall. The ability to suppress urination is diminished, and bladder contraction can become so strong that it virtually produces bladder spasm. There is further hypertrophy of the bladder muscle, the thickness of the bladder wall may double, and the pressure generated by detrusor contraction will increase to overcome the resistance from the obstruction. As the force needed to expel urine from the bladder increases, compensatory mechanisms may become ineffective, causing muscle fatigue before complete emptying can be accomplished. The inner smooth surface of the bladder is replaced with coarsely woven structures called trabeculae. Small pockets of mucosal tissue commonly develop between the trabecular ridges. These pockets form diverticula, making the patient more susceptible to secondary infections. Along with hypertrophy of the bladder wall, there is hypertrophy of the trigone area and the interureteric ridge, which is located between the two ureters. This causes backpressure on the ureters, the development of hydroureters, and eventually, kidney damage.
What are the stages of renal failure?
Early Second Third Fourth
Who often have the most problems with incontinence?
Elderly
What is detrusor-sphincter dyssynergia?
External sphincter contraction during micturition. The sphincter fails to relax so you can't void urine. Usually happens with spinal cord trauma
What is a common cause of spastic bladder dysfunction?
External sphincter spasticity. The most common causes of spastic bladder dysfunction are spinal cord lesions such as spinal cord injury, herniated intervertebral disk, vascular lesions, tumors, and myelitis.
What is a flaccid bladder dysfunction?
Failure to empty the bladder, retaining urine, Neural lesions at the sacral micturition level (S1 to S4)
What are the 2 ways neurogenic bladder may be manifested?
Failure to store urine Failure to empty
What is a Spastic bladder dysfunction?
Failure to store urine, constant releases urine , Neural lesions are above level of sacral micturition level (above S1)
What are co-morbid diseases?
Gout Hyperparathyroidism Urinary stasis Repeated infections
What are the S/S of glomerulonephritis?
HEMATURIA PROTEINURIA SALT & H2O RETENTION htn AZOTEMIA fatigue anorexia n/v and headache May have flu like symptoms, oliguria, abdominal or flank pain. Chronic develops insidiously and is often unreconized until renal failure is evident
Urinary incontinence can be a problem with the elderly. One method of treatment is habit training, or bladder training. When using this treatment with an elderly person how frequently should they be voiding?
Habit training with regularly scheduled toileting - usually every 2 to 4 hours - often is effective.
What is the origin of acute pyelonephritis?
Hematogenous or ascending infection via bladder urine reflux
What is the most common sign of bladder cancer (it may be painless)?
Hematuria
What is bloody urine?
Hematuria (usually from bleeding or inflamed bladder wall)
What are the manifestations of bladder carcinoma?
Hematuria without pain. Dysuria, frequent and urgent urination. Prognosis is often good with early detection but it is important what stage it is at at the time of diagnosis
Why does pregnancy increase risk for UTIs?
Hormones, bladder positional change and obstruction all increase the risk for UTIs. It can be asymptomatic with a risk of pyelonephritis and can cause permanent kidney damage.
What are the causes of rapidly progressive glomerulonephritis?
IDIOPATHIC (unknown) SECONDARY TO AN ACUTE INFECTION (vasculitis, SLE, or acute glomerulonephritis)
What is the most common cause of glomerular injury?
Immunologic
What can one do after intercourse to help combat UTIs?
Increase fluid intake and void soon after intercourse
Define Beta-adrenergic receptors
Increased bone resorption
What is Bladder cancer?
Influenced by carcinogens that are excreted in urine and stored in the bladder , dye industry, rubber, textiles, chemicals, paint, petroleum and smoking
What does the sympathetic NS do for bladder fxn?
Inhibits the detrusor muscle to inhibit contraction so the bladder can fill and stimulates the internal sphincter
What type of acute renal failure causes damage to structures within the kidney?
Intrinsic
What controls bladder function?
Involuntary and Voluntary control
What is incontinence?
Involuntary loss of urine
What is Overflow incontinence?
Involuntary loss of urine because of bladder distention in the absence of detrusor activity, small amount of urine excreted, especially at night time
Describe overall urinary incontinence
Involuntary loss of urine with or without knowing. Increased in older age and women are 2 times more likely to have this. It often comes and goes with medications, diuretics, stool impaction and immobility.
What is stress incontinence?
Involuntary loss of urine, absence of detrusor muscle action, intra-vesicle pressure exceeds the maximum urethral closure pressure, intra abdominal pressure increases
What is Overactive bladder/urgency incontinence?
Involuntary loss or leakage of urine due to a strong urge to void
WHat is the primary cause of ARF leading to ATN?
Ischemia
Where is urine produced in the body?
Kidneys
Describe kidney cancer...
May be primary or metastasis from a lung or breast cancer, melanoma, or malignant lymphoma.
What are the effects of congenital obstruction and stasis?
Meatal stenosis Spinal nerve damage (spinal bifida)
Is Bladder cancer more common is men or women?
Men
Who has a longer urethra men or women?
Men
What coordinates the bladder?
Micturition
What occurs when the bladder contains 150-250 Ml of urine?
Micturition Reflex
Describe the stretch receptors in the bladder...
Micturition center in pons is stimulated Stretch receptors Bladder fills w/ urine Stretch receptors Spinal reflex stimulated
What happens when decompensation occurs in the urinary system due to mechanisms failing?
Muscle fatigue may cause one to not be able to overcome obstruction and leaves residual urine in the bladder HESITANCY, need to strain, weak, small stream, and incomplete emptying
What does continence in children depend on?
NL bladder growth, afferent fiber myelination and how long it takes, conscious stimulation of external sphincter, if they are motivated. At about 5 years old 90-95% are dry by day
Acute overdistention of the bladder can occur in anyone with a neurogenic bladder that does not empty. How much urine would the nurse empty out of the bladder at one time?
No more than 1000 mL of urine at one time. With acute overdistention of the bladder, usually no more than 1,000 mL of urine is removed from the bladder at one time.
What is 2 or more awakenings at night to urinate?
Nocturia
What are the manifestations of urinary obstruction?
Nocturia, bladder distension and hesitancy, straining with initiation of urination, small weak stream, feeling of incomplete bladder emptying, overflow incontinence
What causes increased risk of UTI?
Obstruction and reflux Neruogenic disorders with impaired emptying Women who are sexually active Postmenopausal women, prostate disease, elderly, Foleys
What are acute postinfectious glomerulonephritis S/S?
Oliguria (1st symptom) Cola colored Urine (from RBC degeneration in urine) PROTEINURIA and hematuria occur as the glomerular permeability increases Edema due to sodium and water retention
Where might the bladder pouch in diverticuli?
Outward
What are the s/s of Bladder cancer?
Painless hematuria (intermittent)m frequency, urgency and dysuria
What nervous system controls the emptying of the bladder?
Parasympathetic nervous system
What promotes bladder emptying?
Parasympathetic nervous system
Where is the motor control that causes bladder emptying?
Parasympathetic nervous system
Define micturition
Presence of excessive amounts of urea in the blood
What are common causes of Flaccid bladder?
Peripheral neuropathies (interruption in afferent and efferent communication, bladder and spinal cord) and conditions that prevent external sphincter relaxation
What is defined as a HEREDITARY DISEASE or genetic predisposition characterized by CYST FORMATION and massive kidney enlargement?
Polycystic kidney disease
Define Detrusor-sphincter dyssynergia
Polyuria with urine that is almost isotonic with plasma
Where is the micturition center located?
Pons
What area of the brain controls urination?
Pontine micturition center
What causes acute glomerulonephritis?
Post streptococcal glomerulonephritis is most common form. SLE and staphylococcal or viral infections may cause
What type of acute renal failure causes obstruction of urine outflow from the kidney?
Postrenal
What are pyelonephritis risk factors?
Pregnancy Urinary tract obstruction Congenital malformation Urinary tract trauma Scarring, calculi, other kidney disorders Vericoureteral reflux (urine moves back towards kidney) Diabetes
What type of acute renal failure causes are marked decrease in renal blood flow?
Prerenal
What are the 3 stages of acute renal failure?
Prerenal (hypovolemia, CV failure, altered vascular resistance) Intrarenal (vascular disease, glomerulonephritis, nephritis, and ATN (tubular necrosis) Postrenal (extrarenal obstruction; interrenal obstruction)
Describe the actions that take place in the bladder during micturition.
The detrusor muscle of the bladder fundus and bladder neck contract down on the urine; the ureteral orifices are forced shut; the bladder neck is widened and shortened as it is pulled up by the globular muscles in the bladder fundus; the resistance of the internal sphincter in the bladder neck is decreased; and the external sphincter relaxes as urine moves out of the bladder.
What is incontinence?
The involuntary loss of urine
What is Urinary incontinence?
The involuntary loss or leakage or urine
What does the pontine micturition center do?
The middle man between the nucleus and pons that allows for coordination of urination
What does the Parasympathetic ANS do for micturition?
The muscarinic cholinergic receptors like M3 cause detrusor muscle contraction
What are the necessary factors that every child must possess in order to attain conscious control of bladder function?
The necessary factors that every child must possess in order to attain conscious control of bladder function are: (1) Normal bladder growth (2) Myelination of the ascending afferents that signal awareness of bladder filling (3) Development of cortical control and descending communication with the sacral micturition center (4) Ability to consciously tighten the external sphincter to prevent incontinence (5) Motivation of the child to stay dry.
Describe how chronic neurologic disorders can contribute to overactive bladder.
The neurogenic theory for overactive bladder postulates that the central nervous system functions as an on-off switching circuit for voluntary control of bladder function. Therefore, damage to the central nervous system inhibitory pathways may trigger bladder overactivity owing to uncontrolled voiding reflexes. Neurogenic causes of overactive bladder include stroke, Parkinson disease, and multiple sclerosis.
A 53-year-old woman with multiple sclerosis presents at the clinic with urinary frequency and bladder spasms. A urinalysis is negative for infection. A complete history is taken and a physical examination is performed by the primary care physician. The woman asks the nurse why she is having bladder spasms and urinary frequency if she does not have a bladder infection. What would the nurse expect the doctor to do for this woman to treat her bladder spasms?
The nurse would expect the client to be given an antimuscarinic drug, such as oxybutynin, tolterodine, or propantheline, to decrease detrusor muscle tone and increase bladder capcity.
List the name and function of the major nerves that regulate bladder function.
The pelvic nerve carries sensory fibers from the stretch receptors in the bladder wall; the pudendal nerve carries sensory fibers from the external sphincter and pelvic muscles; and the hypogastric nerve carries sensory fibers from the trigone area.
What is the internal sphincter?
The smooth muscle under ANS control in the bladder
Urinary obstruction in the lower urinary tract triggers changes to the urinary system to compensate for the obstruction. What is an early change the system makes in its effort to cope with an obstruction?
The stretch receptors in the bladder wall become hypersensitive. During the early stage of obstruction, the bladder begins to hypertrophy and becomes hypersensitive to afferent stimuli arising from stretch receptors in the bladder wall. The ability to suppress urination is diminished, and bladder contraction can become so strong that it virtually produces bladder spasm. There is urgency, sometimes to the point of incontinence, and frequency during the day and at night.
What is the external sphincter?
The striated skeletal muscle urethral sphincter under somatic NS control
What does the treatment or management of incontinence depend on?
The type of incontinence
What is a major factor that contributed to incontinence in the elderly?
The use of multiple medications
What is rugae?
The wrinkles lining the bladder that smooth out as the bladder fills. When the bladder empties, the folds come back
What is the neurogenic mechanism of an overactive bladder?
There is a lack of CNS inhibition that leads to an increased sensitization and activity of nerves for bladder voiding. It is often seen with a stroke, parkinson's disease and MS
What is the myogenic mechanism of an overactive bladder?
There is bladder hypertrophy and increased sensitivity due to an obstruction in the outlet. The detrusor muscle becomes over excited and urination becomes frequent and urgent. This usually occurs with residual urine, aging and DM. Over the counter meds make this worse because they stimulate this mechanism
What are the renal and urinary health problems?
UTI Urinary calcui Polycystic kidney disease Pyelonephritis Glomerulonephritis Acute renal failure Chronic renal failure Bladder cancer Kidney cancer
Children usually achieve bladder control by age 5. Girls generally achieve bladder control before boys do. What is the general rule for bladder capacity in a child?
Up to the age of 12 to 14, the capacity of the bladder is the child's age in years plus 2 . As the child grows, the bladder gradually enlarges, with the increase in capacity, in ounces, that approximates the age of the child plus 2.
Is an upper UTI or lower UTI more serious?
Upper because it can infect the kidneys
Does sexual intercourse increase risk of UTI?
Yes
You are caring for a 16-year-old male patient, newly diagnosed with a spinal cord injury. He asks you why he can no longer control his bladder. What would you explain to him?
Your spinal cord injury has disrupted the control your brain has over your bladder. You will have to learn how to in- and -out catheterize yourself. You have a condition known as detrusor-sphincter dyssynergia. Disruption of pontine control of micturition, as in spinal cord injury, results in uninhibited spinal reflex-controlled contraction of the bladder without relaxation of the external sphincter, a condition known as detrusor-sphincter dyssynergia.
What are the s/s of acute pyelonephritis due to infection?
abrupt onset, shaking, chills, fever, back pain, pain with palpation over costovertebral angle, nausea, vomiting. dysuria in lower UTI
The ____ stores urine and controls its elimination in the body.
bladder
How do you diagnose a urinary obstruction?
bladder fxn tests, pelvic/rectal exam, imaging studies, postvoid residual volume
What is the compensatory stage of urinary obstruction?
bladder hypertrophy, hypersensitivy to afferent stimuli, bladder spasms, urgency and frequency, thickening of the bladder wall, muscle fatigue, incomplete voiding cycles increasing frequency, deformity of inner bladder lining leads to pooling of urine in non-muscular folds
Explain neural control of bladder fxn
can be interrupted at any level, the peripheral nerve does not go to the spinal cord. The ascending and descending spinal tracts, pontine micturition center and cerebral cortex are all controlled by the neurological control
Describe the path of acute glomerulonephritis...
circulating antigen antibody immune complexes are formed in trapped glomerular membrane. INFLAMMATORY PROCESS occurs allowing leakage of plasma proteins and blood cells escape into urine. The RAA system is disrupted which could lead to HTN.
What are the s/s of UTI (urinary tract infection)?
frequency,. lower abdominal or back pain, burning or painful urination, cloudy and foul smelling urine (adults usually do not have a fever, children may have fever)
The most common sign of bladder cancer is painless _____.
hematuria
How do you treat a flaccid bladder?
increase abdominal or suprapubic pressure; push on it to contract the muscle on your own
What impacts our natural defenses to prevent UTIs?
increased glucose in diabetes, increased urine pH and blocked outflow can increase risk for infection and impact our natural defense
Spastic bladder is caused by conditions that produce partial or extensive neural damage above the _____ center in the sacral cord.
micturition reflex
Two mechanisms are thought to contribute to its symptomatology of overactive bladder; CNS and neural control of bladder sensation and emptying, ____ and those involving the smooth muscle of the bladder itself, _____.
neurogenic, myogenic
Alterations in bladder function include urinary ____ with retention or stasis or urine or urinary _____ with involuntary loss of urine.
obstruction, incontinence
What are the clinical manifestations of an upper UTI?
occurs in the kidney or pelvis. There is a closer proximity to blood vessels. Neutrophils elicit an inflammatory response causing shaking chills, and a moderate to high fever, lower back pain and sometimes confusion. Confusion is BAD
The motor component of the neural reflex that causes bladder emptying is controlled by the _____ nervous system, while the relaxation and storage function of the bladder is controlled by the ____ nervous system.
parasympathetic, sympathetic
What does the spinal cord do for bladder fxn?
pelvic nerve (s1-s3) controls parasympathetic and detrusor muscle. Pudendal nerve (s1-s3) controls somatic to external sphincter. The hypogastric is sympathetic is T11-L2 controls alpha 1 adrenergic receptors for the bladder, neck and trigone. There is a relaxation of the bladder and contraction at urinary sphincter
What peripheral neuropathies affect a flaccid bladder?
pelvic, pudendal and hypogastric nerves use parasympathetic, somatic and sympathetic innervation to send sensory info, motor info or both
The immediate coordination of the normal micturition reflex occurs in the micturition center in the ____, facilitated by descending input from the forebrain and ascending input from the reflex centers in the spinal cord.
pons
In the male, the _____ gland surrounds the neck of the bladder where it empties into the urethra.
prostate
The most important cause of urinary obstruction in males is external compression of the urethra caused by the enlargement of the _____.
prostate gland
What is an anatomic block?
prostatic hyperplasia and pregnancy can cause UTIs because of the anatomical placement
What is overflow incontinence?
renal impaction, BPH and bladder distension cause the intravesicular pressure to become more than the urethral pressure and strength of the bladder. This happens most often in little boys
What does urinary obstruction result in?
retention or stasis and incontinence that are classified by location, cause, degree and duration. Untreated blockage will lead to vesicouretral reflux and eventually hydronephrosis
The bladder is freely movable organ located ____ on the pelvic floor, just posterior to the public _____.
retroperitoneally, symphysis
What are risk factors for UTI?
sexually active women, obstruction can cause bacterial growth, neurogenic bladder, DM, prostate disease causes decreased levels of antimicrobial secretions, postmenopausal women and elderly because of decreased mucin produced by epithelial cells and if you have a catheter because it is an irritant on the source of entry
Neurogenic disorders of bladder function commonly are manifested in one of two ways: failure to _____ urine or failure to _____.
store, empty
Urine passes from the kidneys to the bladder through the ____.
ureters
What is a rectocele?
urinary obstruction that causes blockage and pushes on the urethra
What is a cystocele?
urinary obstruction that falls on pelvic floor and bulges into the urethra
What is nocturia?
using the restroom at night and being awakened at least 2-3 times per night
What are some clinical manifestations of a lower UTI in the elderly?
vague abdominal pain and confusion