Renal physiology and anatomy

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Renal physiology and anatomy

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Adrenal gland

• The adrenal, or suprarenal glands, pair
  yellow-orange, solid endocrine organs
• Lie within the perirenal (Gerota's) fascia
• Normal weight 5 gm, measure 3-5 cm in greater
  diameter
• The right adrenal lie more superiorly
• in the retroperitoneum than
• the left adrenal

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Composition cortex, medulla

• Cortex 3 layers
• Zona Glomerulaza ?????????? produce aldosterone
• Zona Fasciculata produce Glucocorticoid, sex
  steroid
• Zona Reticularis produce Glucocorticoid, sex
  steroid
• Medulla consists of chromaffin cells derived
  from the neural crest, related to the sympathetic
  nervous system, produce Neuroactive
  catecholamines
• (epinephrine, norepinephrin)

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• Artery multiple small arteries
• Superior Inferior phrenic artery(main)
• Middle Aorta
• Inferior Renal artery
• Vein Lt adrenal vein drain to Lt renal vein
• Rt adrenal vein drain to IVC
• Adrenal cortex no innervation
• Adrenal medulla rich sympathetic innervation

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THE KIDNEYS AND URETERS

• pair, reddish-brown,
• solid organs that lie within the retroperitoneum

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• Function
• urinary excretion, a central role in fluid,
  electrolyte, and acid-base balance
• endocrine functions, vitamin D metabolism,product,
  renin and erythropoietin
• Highly vascular organs, receiving 1/5 of the
  total cardiac output
• The normal kidney 135-150 gm, 10-12 cm in
  vertical dimension

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Renal parenchyma is divided into cortex and
medulla
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Anatomic Relations

• The right kidney lies 1 to 2 cm lower in
• than the left kidney from liver
• Position of kidney T12-L3
• Perirenal fascia Gerotas fascia
• (contain perinephric fluid collection, abscess,
  hematoma, urinoma)

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• Renal artery End artery, L2 level
• 1.Anterior segment -apical segmental artery
• -upper segmental artery
• -middle segmental artery
• -lower segmental artery
• 2.Posterior segment (first branch)
• Renal vein the renal parenchymal vein
  anastomosis freely
• Renal lymphatic abundant, follow the blood
  vessels

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Anatomic relations of the kidneys
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Normal rotational axes of the kidney
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The Ureters

• Adult 22-30 cm in total length
• Inner layer of longitudinal muscle
• Outer layer of circular and oblique muscle
• Urine drain by peritalsis active of the ureter
  muscle from renal pelvis to bladder

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• Blood supply from multiple feeding arterial
  branches along the ureter
• renal artery, gonaldal artery, abdominal aorta,
  commoniliac artery, vesical and uterine artery
• The venous and lymphatic drainage of the ureter
  parallels the arterial supply

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Anatomic relations

• The ureter is related posteriorly to the psoas
  muscle throughout its retroperitoneal course,
  crossing the iliac vessels to enter the pelvis at
  approximately the bifurcation of the common iliac
  into internal and external iliac arteries.
• Within the female pelvis, the ureters are closely
  related to the uterine cervix and are crossed
  anteriorly by the uterine arteries, and thus are
  at risk during hysterectomy.

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Normal Variations in Ureteral Caliber

• Site of narrowings of ureter
• 1.UPJ
• 2.Iliac vessels
• 3.UVJ

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Ureteral Segmentation and Nomenclature

• The abdominal ureter extends from renal pelvis to
  the iliac vessels
• The pelvic ureter extends from the iliac vessels
  to the bladder
• X-RAY
• upper ureter from the renal pelvis to the upper
  border
• of the sacrum
• middle ureter then extends to the lower border of
  
• the sacrum, corresponds with the iliac
  vessels
• lower (or distal or pelvic ) from the sacrum to
• the bladder

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Bladder

• Capacity 500 ml, an ovoid shape
• The internal surface of the bladder is lined with
  transitional epithelium.
• Muscle inner longitudinal, middle circular,
• and outer longitudinal layers

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Ureterovesical Junction and the Trigone
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Prostate

• The chestnut-shaped, attach to the bladder neck
  and pubic symphysis
• The apex of the prostate is continuous with the
  striated urethral sphincter
• Weighs 18-25 gm
• Structure 30 fibromuscular stroma, 70
  glandular elements

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Urethra

• Male urethra anterior and posterior part
• Anterior Meatus, Penile, Bulbous part
• Posterior Membranous (striated sphrincter)
  Prostatic urethra
• Female urethra 4 cm

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Evaluation of the urologic pt.

• History
• Three major components
• The chief complaint
• The present illness
• Past medical history, and Family history

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Chief Complaint and Present Illness

• The chief complaint is a constant reminder to the
  urologist as to why the patient initially sought
  care.
• In obtaining the history of the present illness,
  the duration, severity, chronicity, periodicity,
  and degree of disability are important
  considerations.

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Pain

• Pain from the GU tract may be quite severe
• usually associated with either urinary tract
  obstruction or inflammation
• Tumors in the GU tract usually do not cause pain
  unless they produce obstruction or extend beyond
  the primary organ to involve adjacent nerves.

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• Inflammation of the GU tract is most severe when
  it involves the parenchyma of a GU organ
• Due to edema and distention of the capsule
  surrounding the organ
• Pyelonephritis, prostatitis, and epididymitis are
  typically quite painful.
• Inflammation of the mucosa of a hollow viscus
  such as the bladder or urethra usually produces
  discomfort, but the pain is not nearly as severe.

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Renal Pain

• Located in the ipsilateral costovertebral angle
• By acute distention of the renal capsule,
  generally from inflammation or obstruction
• Pain due to inflammation is usually steady,
  whereas pain due to obstruction fluctuates in
  intensity.

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• Pain produced by ureteral obstruction is
  typically colicky in nature and intensifies with
  ureteral peristalsis
• Pain of renal origin may be associated with
  gastrointestinal symptoms because of reflex
  stimulation of the celiac ganglion

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Ureteral Pain

• Results from acute distention of the ureter and
  by hyperperistalsis and spasm of the smooth
  muscle of the ureter as it attempts to relieve
  the obstruction(stone or blood clot)
• The pain may be referred to the scrotum in the
  male or the labium in the female.

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• Lower ureteral obstruction frequently produces
  symptoms of vesical irritability, including
  frequency, urgency, and suprapubic discomfort
  that may radiate along the urethra in men to the
  tip of the penis.

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Vesical Pain

• By overdistention of the bladder as a result of
  acute urinary retention or inflammation
• Inflammatory conditions of the bladder
  intermittent suprapubic discomfort. (bacterial
  cystitis or interstitial cystitis) is usually
  most severe when the bladder is full and is
  relieved at least partially by voiding.

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Prostatic Pain

• Secondary to inflammation with secondary edema
  and distention of the prostatic capsule

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Penile Pain

• Secondary to inflammation in the bladder or
  urethra
• Paraphimosis, Peyronie's disease or Priapism

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Testicular Pain

• Primary or Referred pain
• Primary pain arises from within the scrotum,
  usually secondary to acute epididymitis or
  torsion of the testicle or testicular appendices
• Chronic scrotal pain related to noninflammatory
• a hydrocele, a varicocele,
• pain as a dull, heavy sensation that does not
  radiate.

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Hematuria

• Microscopic hematuria gt 3RBC/HPF
• Gross hematuria the sudden onset of blood in the
  urine
• Hematuria of any degree should never be ignored
  and, in adults, should be regarded as a symptom
  of urologic malignancy until proved otherwise.

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In evaluating hematuria

• Is the hematuria gross or microscopic?
• At what time during urination does the hematuria
  occur (beginning or end of stream or during
  entire stream)?
• Is the hematuria associated with pain?
• Is the patient passing clots?
• If the patient is passing clots, do the clots
  have a specific shape?

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Gross versus Microscopic Hematuria

• The chances of identifying significant pathology
  increase with the degree of hematuria

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Timing of Hematuria indicates the site of origin

• Initial hematuria usually arises from the urethra
• Total hematuria is most common and indicates that
  the bleeding is most likely coming from the
  bladder or upper urinary tracts.
• Terminal hematuria occurs at the end of
  micturition and is usually secondary to
  inflammation in the area of the bladder neck or
  prostatic urethra.

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Association with Pain

• Painful associate with inflammation
• or obstruction

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Presence of Clots

• The presence of clots usually indicates a more
  significant degree of hematuria

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Shape of Clots

• The amorphous clots bladder or prostatic
  urethral origin
• The vermiform (wormlike) clots, particularly if
  associated with flank pain, identifies the
  hematuria as coming from the upper urinary tract
  (formation of vermiform clots within the ureter)

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• All patients with hematuria, except perhaps young
  women with acute bacterial hemorrhagic cystitis,
  should undergo urologic evaluation
• The most common cause of gross hematuria in a
  patient older than age 50 years is bladder cancer

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Lower Urinary Tract Symptoms

• Storage Symptoms (Irritative Symptoms)
• Voiding Symptoms (Obstructive Symptoms)

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Storage Symptoms (Irritative Symptoms)

• Frequency
• Nocturia
• Urgency
• Urge incontinence
• Dysuria?

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Frequency

• Normal adult voids 5-6 times/day, volume 300 mL
  with each void
• 1.Increased urinary output (polyuria) DM, DI,
  or excessive fluid ingestion
• 2.Decreased bladder capacity decreased bladder
  compliance, increased residual urine, decreased
  functional capacity due to irritation neurogenic
  bladder with increased sensitivity and decreased
  compliance pressure from extrinsic sources or
  anxiety

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Nocturia

• gt1 time at night to void
• Most common presenting symptom of BPH
• Frequency during the day without nocturia is
  usually of psychogenic origin (anxiety)

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Urgency

• Difficult to postpone urination

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Urge incontinence

• The precipitous loss of urine preceded by a
  strong urge to void

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Voiding Symptoms (Obstructive Symptoms)

• Decreased force of urination (Poor stream)
  secondary to bladder outlet obstruction
• Urinary hesitancy delay in the start of
  micturition, delay for relaxing the urinary
  sphincter
• Intermittency involuntary start-stopping of the
  urinary stream
• Straining use of abdominal musculature to
  urinate

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• Postvoid dribbling Normal, it is secondary to a
  small amount of residual urine in either the
  bulbar or the prostatic urethra that is normally
  "milked-back" into the bladder at the end of
  micturition. In men with bladder outlet
  obstruction, this urine escapes into the bulbar
  urethra and leaks out at the end of micturition.
• Sense of incomplete emptying
• Urinary retention

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• The International Prostate Symptom Score (I-PSS)
  includes these seven questions.
• The total symptom score ranges from 0 to 35 0-7
  mild, 8-19 moderate, 20-35 severe LUTS

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Incontinence

• The involuntary loss of urine
• Continuous incontinence
• Stress incontinence
• Urgency incontinence
• Overflow urinary incontinence

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Continuous incontinence

• The involuntary loss of urine at all times and in
  all positions
• Most commonly due to a urinary tract fistula that
  bypasses the urethral sphincter
• vesicovaginal fistula (common)
• ureterovaginal fistulae
• an ectopic ureter that enters either the urethra
• or the female genital tract

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Stress incontinence

• The sudden leakage of urine with coughing,
  sneezing, exercise, or other activities that
  increase intra-abdominal pressure.
• Most common in women following childbearing or
  menopause and is related to a loss of anterior
  vaginal support and weakening of pelvic tissues.

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Urgency incontinence

• The precipitous loss of urine preceded
• by a strong urge to void.
• Cystitis
• Neurogenic bladder
• Advanced bladder oulet obstruction with secondary
  loss of bladder compliance

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Overflow urinary incontinence

• Secondary to advanced urinary retention and high
  residual urine volumes
• Paradoxical incontinence

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• Enuresis urinary incontinence that occurs during
  sleep, normal in children up to 3 years of age
• Sexual Dysfunction Loss of libido, Erectile
  dysfunction
• Loss of Libido indicate androgen deficiency,
  depression or a variety of medical illnesses
• Erectile dysfunction the inability to achieve
  and maintain an erection sufficient for
  intercourse, primarily psychogenic or organic

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• Common cause of abnormal urine color

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Thank you for your attention