Urinary System

Crystals in a urine sample:

these are microscopic solids composed of a small number of different ions and molecules. These are common in the urine and if they remain small, are not pathologic.

The location of the internal sphincter is under the urogenital diaphragm. True False

False The internal sphincter is located in the bladder rather than the urogenital diaphragm.

Involuntary loss of urine caused by dementia or immobility is known as: Urge incontinence. Functional incontinence. Stress incontinence. Neurogenic incontinence.

Functional incontinence.

Uncomplicated UTI

Occurs in the normal urinary tract Simple cystitis in non-pregnant women without any urologic abnormalities Responds well to a short course of antibiotic therapy

A sphincter malfunction that prevents urine from flowing out of the bladder would most likely result in: Urge incontinence. Functional incontinence. Overflow incontinence Stress incontinence.

Overflow incontinence Overflow incontinence is due bladder distention caused by sphincter malformation that prevents urine from flowing out of the bladder.

The relay station in the brain that plays a major role in regulating micturition is: The frontal lobe. Pontine micturition center. The cerebellum. Hypothalamic relay center.

Pontine micturition center. The pontine micturition center (PMC) located in the brainstem, performs a major role in regulating micturition.

Which of the following is a risk factor for the development of a urinary tract infection (UTI)? Marathon running Frequent showering Perimenopause Pregnancy

Pregnancy Pregnancy is a risk factor the development of a UTI.

Complicated UTI Labs:

Protein: + or - Leukocyte Esterase: + Nitrites: + or - RBCs: + WBCs: + >100,000/hhpf Casts: +

Uncomplicated UTI Labs:

Protein: + or - Leukocyte Esterase: + Nitrites: + or - RBCs: + or - WBCs: + >5000/hhpf Casts: None

J.S. is an 80 -year-old patient who resides in a local nursing home. He recently became confused and then fell while ambulating to the bathroom three days ago. Because of his confusion and fall, he was transferred to the acute care facility for evaluation and treatment. Lab work revealed that the patient was very dehydrated with hypernatremia identified and appropriate intravenous fluids started. Cystitis was also identified from the urinalysis. He was also noted to have red and excoriated skin between the buttocks and inner thighs due to urinary frequency and dribbling. To help with skin healing and to prevent further urine leakage, an indwelling catheter was inserted. Two days after the catheter was placed, the patient spiked a fever of 102 degrees Fahrenheit associated with shaking chills. An intense, foul odor was noted in the urine. On examination of the flank area, the patient yelled out when touched. A urine culture was obtained and came back positive for nitrites and RBCs. Urine microscopy revealed >100,000 WBC/hpf and casts. Based on the information provided in the case, the patient can most likely be diagnosed with: Urinary obstruction Pyelonephritis Glomerulonephritis Simple UTI

Pyelonephritis

The action of a 5-Alpha-reductase inhibitor causes: Shrinkage of the prostate gland. Reduction of the size of the nodule that is causing obstruction. Relaxation of the external sphincter. Relaxation of the smooth muscle of the bladder neck.

Shrinkage of the prostate gland. 5-alpha-reductase inhibitors shrink the size of the prostate by inhibiting the conversion of testosterone to dihydrotestosterone.

Men who have BPH are prone to developing a UTI because: The prostate is not a sterile environment. Ingested fluids do not adequately flush the kidneys. Stagnated urine in the bladder promotes bacterial growth. They have a low WBC count due to an infected prostate.

Stagnated urine in the bladder promotes bacterial growth. Stagnation of urine in the bladder promotes bacterial growth which can lead to a UTI.

A common organism that causes a urinary tract infection include: Syncytial virus. Staphylococcus saprophyticus. Streptococcus pneumonia. Methicillin Resistant Staphylococcus Aureus (MRSA).

Staphylococcus saprophyticus.

The type of stone that forms due to a urinary tract infection is: Struvite stone. Cysteine stone. Calcium Stone. Uric acid stone.

Struvite stone. Struvite stones commonly result from a UTI.

The NP would know that the patient most likely has an uncomplicated UTI because: The UTI responds well to a short course of antibiotic therapy. The bacteria are contained within the bladder. Flank pain is present but minimal. There is low-grade fever.

The UTI responds well to a short course of antibiotic therapy. An uncomplicated UTI responds to a short course of antibiotic therapy. The other choices are not typical of an uncomplicated UTI.

The purpose of straining in BPH is to overcome the obstruction encountered during urination. True False

True The individual strains to overcome the obstruction in order to release the urine.

The prostate specific antigen (PSA) helps to liquefy semen post-ejaculation. True False

True The luminal cells produce PSA which helps to liquefy semen post-ejaculation.

The underlying cause of BPH is that normal prostate cells respond to increases in dihydrotestosterone that causes them to live longer and multiply. True False

True This statement is true. The underlying cause of BPH is that normal prostate cells respond to increases in dihydrotestosterone that causes them to live longer and multiply.

When the bladder is empty, the detrusor muscle relaxes, and the internal and external sphincters constrict. True False

True When the bladder is empty, there is detrusor muscle relaxation and internal and external sphincter constriction.

Women are at a higher risk for the development of a UTI because of having a shorter urethra. True False

True Women have a shorter urethra that puts them at higher risk for developing a UTI.

RBCs (red blood cells) in a urine sample:

greater than 3 RBCs/hpf is considered abnormal. Abnormal morphology of the RBC strongly suggests glomerular disease. RBCs are often present with a UTI (hematuria).

WBC's in a urine sample:

greater than 5 WBCs/hpf is considered abnormal. These will be present in a UTI. Bacteria: will be present

Complicated UTI

A UTI that extends beyond the bladder Caused by structural or functional urinary tract abnormalities or untreated UTI Infants and older adults affected Associated with: indwelling catheters, renal calculi, Diabetes, Pregnancy

On a digital rectal exam to assess the quality of the prostate, the NP would be concerned with which of the following findings? A rubber-like quality of the prostate. A lack of pain on palpation. A soft-smooth prostate. A hard nodule.

A hard nodule A hard nodule can indicate prostate cancer.

Which of the following actions will relax the detrusor muscle of the bladder? Inhibition of the Beta-2 receptors by the sympathetic nervous system. Activation of Beta-2 receptors by the sympathetic nervous system. Activation of the muscarinic (M3) receptors by the parasympathetic nervous system. Activation of the muscarinic (M3) receptors by the sympathetic nervous system.

Activation of Beta-2 receptors by the sympathetic nervous system. When Beta-2 receptors are activated by the sympathetic nervous system, the detrusor muscle will relax.

A 45-year-old male presents to the primary care office with right flank pain that he describes as unremitting; he also reports nausea and vomiting. The NP performs an exam and observes him writhing in pain on the exam table with the inability to find a comfortable position. He is afebrile, BP 156/88 mmHg and HR 106/min. Right flank is mildly tender on palpation. Abdominal exam is negative for any abnormality. A urinalysis was performed and revealed 1+ blood. Urine microscopy also revealed 10-20 RBCs per high-power field (hpf). A kidney stone is suspected. The patient reports no prior history of a kidney stone. After providing the patient an analgesic, where the patient reported mild relief, the NP had the patient transferred to the emergency room for intravenous fluids, pain management and further work-up for the kidney stone. Upon follow-up in the office a week later, the patient reported that he was diagnosed with a kidney stone, but he was not aware of the type of stone or the cause for it. He was very concerned about why he had the associated severe flank pain and asked the NP why the pain was so severe and how could he avoid another stone in the future. Since this is the patient's first episode of having a kidney stone, it is most likely a calcium stone. It is the most common stone with the cause unknown. If there was an opportunity for the patient to pass the stone, it could be analyzed to determine the type. The NP discusses the cause of the pain and tells the patient that stones travel down the ureter to produce renal colic. The pain intensifies if the stone lodges in the ureter that creates almost unbearable pain. The NP also addresses prevention measures with the patient. Identify below which measures the NP should recommend. A high-sodium diet Adequate hydration A balanced diet Calcium restriction

Adequate hydration A balanced diet The NP should encourage him to maintain adequate hydration. If possible, the patient can be encouraged to drink at least 2 liters of water/day to prevent calcium precipitation. A high-protein diet promotes stone formation in some patients. Therefore, the NP encourages the patient to maintain a balanced diet. In addition, a high-sodium diet should be avoided because it predisposes to calcium excretion and increases the saturation of monosodium urate, which promotes calcium stone formation. Calcium restriction is not recommended because it can increase oxalate absorption and decrease urinary excretion of calcium.

The most common type of stone is: Uric acid stone. Calcium stone. Struvite stone. Cysteine stone.

Calcium stone. Calcium stones are the most commonly formed stones.

Which of the following is true regarding a complicated urinary tract infection? It is usually asymptomatic Bacteria is located mostly in the lower urinary tract Can be caused by a structural urinary tract disorder Is associated with young adults

Can be caused by a structural urinary tract disorder A complicated UTI can be caused by a structural issue in the urinary tract.

Overflow Incontinence:

Clinical Manifestation: Leakage of urine is associated with urgency, frequency, dribbling and hesitancy Leakage is due to retained urine in the bladder that leads to overdistention

Stress Incontinence:

Clinical Manifestation: Leakage of urine with activity Patho: Increased intraabdominal pressure causes leaking because there is no resistance to counteract the intraabdominal pressure

Urge Incontinence:

Clinical Manifestation: Leakage of urine with sensation of need to urinate Patho: Detrusor muscle hyperactivity leads to urine leakage

Neurogenic Incontinence:

Clinical Manifestation: Unimpeded urine leakage Patho: Neurological lesions alter nervous system impulses that innervate the detrusor muscle. The result is decreased bladder compliance and decreased sphincter tone

A 25 year- old female presents to the primary care office with urinary burning and frequency for the last 3 days. She denies any fever, chills, back pain. Her gynecological history is negative and reports no vaginal discharge. The only new information reported is that she recently had sexual intercourse with a new male partner. The NP obtains a urinalysis and determines that the urine contains leukocytes, RBCs, nitrites, and WBCs. No casts are identified. Based on symptom presentation and UA results, the patient can be diagnosed with: Upper UTI Cystitis Pyelonephritis Complicated UTI

Cystitis The patient presents with a simple cystitis and treated appropriately. In addition, although the patient has a new sexual partner with risk for a STI, the patient reports no itching and/or vaginal discharge with odor. The NP would determine if a pelvic exam is indicated at that visit to rule out an STI.

An individual can experience some transient causes of UI that subside once the issue is managed:

Delirium: the individual may be unaware of the need to urinate. Normal urination will return after the delirium is reversed. Urinary Tract Infections (UTI): A UTI can result in frequency and urgency. After treatment, UI symptoms will subside. Atrophic vaginitis: this is atrophy of the vaginal walls, bladder and urethra that occurs in estrogen-deficient post-menopausal women. With estrogen replacement, UI symptoms may subside. Drugs: many drugs can cause UI: anticholinergics prevent relaxation of the bladder; other drugs include, Anti-Parkinson drugs, alpha-agonist, and antagonist drugs (remember that alpha receptors are found in the internal sphincter). An alpha-agonist will cause bladder over-contraction of the bladder leading to overflow incontinence; an alpha-antagonist will prevent the bladder from contracting that will lead to stress incontinence. Diuretics and ACE inhibitors increase the amount and frequency of urination that results in urge incontinence, Calcium channel blockers can prevent the internal and external sphincters from contracting and sedatives and hypnotics may inhibit the individual's need to urinate. Psychological issues: depression may impede the individual's ability to control urination. Excessive fluid intake or excessive urination in the case of polydipsia experienced by the diabetic patient. Restricted mobility: the individual has the urge to urinate but is unable to ambulate to the bathroom (functional incontinence). Stool impaction: severe constipation can compress the bladder and lead to urination.

There is a significant risk for men with benign prostatic hyperplasia (BPH) to develop cellular mutations that lead to prostate cancer. True False

False

Lithotripsy is an invasive procedure used to break up the stone True False

False Lithotripsy, is a non-invasive procedure and will be performed if the stone lodges on the way out.

Renal calculi are typically confined to the bladder. True False

False Renal calculi can be found in the ureter or bladder.

The gold standard for diagnosing a renal stone is a urinalysis. True False

False The gold standard for diagnosing a renal stone is CT scan.

The location of the characteristic hyperplastic nodules of BPH is: In the periurethral zone. In the zone immediately inside the rectum. In the posterior prostate. In the anterior prostate zone.

In the periurethral zone. Prostate nodules are usually located in the periurethral zone.

Which of the following can help to prevent a UTI? Douching to prevent the growth of bacteria Increase water consumption Taking more Vitamin D Use spermicides during sexual intercourse

Increase water consumption Water consumption prevents UTI as it keeps bacteria flushed out of the urinary tract.

Identify the major risk factor J.S. has that is associated with pyelonephritis: Dehydration Fever Flank pain Indwelling Foley catheter

Indwelling foley catheter The major risk factor for the development of pyelonephritis in this patient is the indwelling Foley catheter. Flank pain, dehydration and fever are symptoms rather than risk factors.

The pathophysiology of neurogenic bladder is: Detrusor muscle hyperactivity leads to urine leakage. Lesions alter nervous system impulses that innervate the detrusor muscle to decrease bladder compliance and decreased sphincter tone. Leakage is due to retained urine in the bladder that leads to overdistention. Increased intraabdominal pressure causes leaking.

Lesions alter nervous system impulses that innervate the detrusor muscle to decrease bladder compliance and decreased sphincter tone. Neurogenic bladder involves lesions that alter the nervous system impulses that innervate the detrusor muscle to decrease bladder compliance and decreased sphincter tone.

Upon examination of a urinalysis, the NP can highly suspect that the causative bacteria are gram negative because of the presence of: RBCs. Nitrites. WBCs. Casts.

Nitrites The presence of nitrites indicates that the causative bacteria is gram-negative.

The patient most often develops symptoms of BPH when: The patient's PSA becomes elevated. The prostatic urethra becomes obstructed. A nodule forms on the prostate. The bladder becomes obstructed.

The prostatic urethra becomes obstructed. The cause of symptoms of BPH relates to the constriction of the prostatic urethra obstruction that affects that passage of urine.

Hematuria can be seen with kidney stones because: The stone creates its own blood supply around it. As WBCs increase, the RBCs also increase. The stone injures the urinary structures as it passes through them. The patient becomes anemic when stones form.

The stone injures the urinary structures as it passes through them. The passing of the stone through the renal structures become damaged and results in hematuria.

Cystine stone:

This is a rare type of kidney stone that is found mostly in children. It is caused by a genetic renal tubule defect that prevents the amino acid, cystine, from being reabsorbed that leads to the formation of a cystine stone. This stone can also from Staghorn shaped stones.

Calcium Stone:

This is the most common type of stone. It forms from the joining of calcium and oxalate or from the joining of calcium and phosphate. In some cases, individuals can form both types of calcium stone. Calcium stones are radio dense which indicates that they can be seen on x-ray. The cause of calcium stones is mostly idiopathic or unknown. Regardless of the cause, the individual becomes either hypercalcemic or presents with excess calcium in the urine (hypercalciuria). This causes the solutes to increase and form a stone. Treatment involves prescribing a thiazide diuretic to excrete urinary calcium.

Uric acid stone

This is the type of stone that is found in a patient with gout. There is an increase in uric acid. Individuals who are at risk for getting gout include those with leukemia and myeloproliferative disorder; those undergoing chemotherapy. Chemotherapy destroys the cancer cells. DNA cells contain purine. When broken down, purine will increase uric acid levels that can lead to uric acid stone formation. Uric acid increases the acidity of the urine with resultant decrease in urine pH. Uric acid stones are radiolucent, meaning that the stones cannot be seen on x-ray. Treatment includes hydration and increasing the alkaline of the urine by giving potassium bicarbonate. Individuals will also be prescribed allopurinol, an anti-gout medication.

Struvite stone:

This type of stone occurs due to a urinary tract infection, most often by proteus, klebsiella and serratia and enterobacter species. Ammonium, magnesium, and phosphate form to create the stone. The bacteria contribute to the stone formation through the production of the enzyme, urease. Urea, in the presence of urease converts to ammonia and a byproduct of CO2. This makes the urine alkaline which favors stone formation. Another name for this stone is the Staghorn stone. It obstructs the renal calyx. The location of the Staghorn stone is shown in the diagram below. The stone is given its name because of it contains irregular, horn-like structures.

The urinalysis of a patient with a complicated UTI will show WBCs and casts. True False

True

The peripheral zone of the prostate is the largest zone. True False

True Anatomically, the peripheral zone is the largest one.

At least half of individuals with renal stones will have a reoccurrence within 10 years of the prior stone. True False

True At least half of individuals with renal stones will have a reoccurrence within 10 years of the prior stone.

A 21-year-old patient reports to the primary care clinic complaining of urinary urgency, frequency and burning. She also reports a small amount of vaginal discharge that contains an odor. It is likely that the NP will perform a vaginal exam at this visit. True False

True Because of the vaginal discharge that contains an odor, the NP will most likely perform a vaginal exam to rule out an STD.

The major cause of stress incontinence in women is hypermobility of the external sphincter. True False

True Hypermobility of the external sphincter is the most common cause of stress.

The levator ani muscle plays a major role in constriction of the external sphincter. True False

True Plays a major role in constriction of the external sphincter when the abdomen contracts, especially when abdominal pressure is exerted on the bladder.

Renal colic is caused by the passing of the stone through the ureter. True False

True Renal colic is caused by the passing of the stone through the ureter with obstruction and spasm.

Renal stones are formed when calcium and oxalate in the urine combine. True False

True Stones form when calcium and oxalate in the urine combine.

A symptom of a lower urinary tract infection includes: Decreased Urination Fever Flank pain Urgency

Urgency Urgency is a symptom of lower tract UTI.

The most common stone found in the patient with gout is: Cystine stone. Struvite stone. Calcium stone. Uric acid stone.

Uric acid stone. The most common stone found in the patient with gout is uric acid stone.

Which of the following is considered be a transient cause of urinary incontinence? Structural malformation of the external sphincter. Epithelial damage to the bladder wall. Chronic renal failure. Urinary tract infection.

Urinary tract infection. A UTI is a transient cause of urinary incontinence because the symptoms subside once the issue is managed.

Casts in a urine sample:

are long cylindrical structures formed in the renal tubules due to the precipitation of Tamm-Horsfall mucoprotein. It is the most abundant protein excreted by the urine. Casts form in concentrated and/or acidic urine. The most common casts are hyaline casts that only consist of Tamm-Horsfall protein without other constituents. They are non-specific and may be seen in dehydration. Muddy brown casts suggest acute tubular necrosis. Waxy casts are suggestive of acute and chronic renal failure. Fatty casts are suggestive of nephrotic syndrome; RBC casts suggest glomerulonephritis and WBC casts suggest interstitial inflammation.