Introduction to Urology

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Introduction to Urology

• Richard E. Freeman MD MPH
• Curtis M. Grenoble, MS, PA-C
• Lock Haven University, PA Program
• Summer 2013

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Urology

• The branch of medicine that focuses on the
  urinary tracts of BOTH females and males, and the
  reproductive systems of males.

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Anatomy of Kidney

• Renal cortex outer 1 cm
• Renal medulla renal columns, pyramids - papilla
• Lobe of kidney pyramid and its overlying cortex
• Collecting system
• Calyces
• Pelvis
• Ureter

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Lobe of Kidney
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Nephron

• Functional unit of the kidney
• Each human kidney contains about 1 million
  nephrons
• A nephron consists of the glomerulus or renal
  corpuscle, the proximal tubule, the thin loops of
  Henle, and the distal tubule, all of which
  originate from the
• metanephric blastema.
• Renal Function can be divided into THREE
  Components
• Filtration
• Excretion
• Secretion

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RENAL FUNCTION

• FILTRATION
• EXCRETION
• SECRETIONhormonal- Renin-angiotensin

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Nephron Physiology

• Glomerulus-
• Filters fluid from blood into Bowmans capsule
• Prevents passage of bloods and proteins
• Proximal convoluted tubule
• Reabsorbs 2/3 of water electrolytes
• and all filtered bicarbonate, glucose, amino
  acids and vitamins
• Descending Loop of Henle
• Reabsorbs water
• Delivers concentrated filtrate to ascending loop
• Ascending Loop of Henle
• Reabsorbs Na, Cl, K,
• Produces a hypo-osmotic filtrate and high
  interstitial osmolality

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GLOMERULUS
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Nephron - Physiology

• Distal Convoluted tubule
• Reabsorbs Na, Cl-, water, urea
• Secretes H, K
• Responds (has receptors for) to aldosterone
• Collecting Tubule
• Reabsorption of water under influence of ADH
• Secretes H K

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Renal Vasculature

• 20-25 of cardiac output passes through the
  kidney
• Afferent arterioles
• Branches of the interlobular arteries to
  transport blood into glomerulus
• Each supplies a single glomerulus
• (renal corpuscle)
• Efferent arterioles
• Exit the glomeruli
• Divide to form an intricate peritubular
  microcirculation

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Renal Function

• In a 70-kg person, renal blood flow (RBF) amounts
  to one fourth to one fifth of the resting cardiac
  output, or 1.2 liters per minute
• With one kidney removed, blood flow to the
  remaining kidney will nearly double within a few
  weeks (reserve capacity).

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Glomerular filtration rate

• Glomerular filtration rate (GFR) is the volume of
  fluid filtered from therenal (kidney) glomerular
  capillaries into the
• Bowman's capsule per unit time.
• BASED ON THREE FACTORS
• Blood flow in (afferent arterioles)
• HEALTH OF THE GLOMERULUS
• Blood flow out (efferent arterioles)

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Juxtaglomerular Apparatus
?
?
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Factors Affecting GFR

• Decrease in RBF
• Decrease in glomerular hydrostatic pressure
• Decrease in systemic BP
• Afferent arteriolar constriction
• Efferent arteriolar dilation
• Increase in hydrostatic pressure in Bowmans
  capsule
• ureteral obstruction
• edema of kidney inside a tight capsule

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Factors Affecting GFR

• Decrease in concentration of plasma proteins
• Oncotic pressure
• Decrease in total area of glomerular capillary
  bed
• Diseases that destroy glomeruli without
  destroying tubules
• Partial nephrectomy

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Factors Affecting GFR

• Opposite effects that decrease GFR
• Increased permeability of glomerular filtrate
• DM
• Membranous nephropathy

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Evaluation of renal function/Blood tests

• CBC
• Electrolytes
• Glucose
• BUN
• Creatinine
• CREATININE CLEARANCE TEST
• Liver function
• Ca, PO4
• albumin
• cholesterol

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Evaluation of Kidney functionURINE TESTS

• Urinalysis STAY TUNED
• Creatinine Clearance Test
• 24 Urine Protein
• A lot of specialized tests to access
  metabolic/dynamic function of the kidneys-
  NEPHROLOGY

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Ureter

• Tube between kidney and bladder
• Enters bladder at the
• ureterovesicular junction
• Peristalsis
• THREE areas of narrowing
• Renal pelvoureterojunction
• Passage over iliac vessels and pelvic brim
• Uretervesicular junction oblique angle

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UV junction
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Urinary Bladder

• Holds approximately 500 cc of urine
• Lined with Transitional cells
• Body of bladder primarily detrusor muscle
• Neck of bladder
• includes the posterior urethral sphincter
• AKA internal sphincter
• Innervation
• Sympathetic to body L2
• Parasympathetics to body and neck - S2 S3

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Urinary Bladder and Urethra - Female
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Female Urethra

• 3 to 4 cm long
• External urethral orifice
• between vaginal orifice and clitoris
• Internal urethral sphincter
• detrusor muscle thickened, smooth muscle,
  involuntary control
• External urethral sphincter
• skeletal muscle, voluntary control

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Male Bladder and Urethra

• Urethra 18 cm long
• Internal urethral sphincter
• External urethral sphincter

• 3 regions
• prostatic urethra during orgasm receives semen
• membranous urethra - passes through pelvic
  cavity
• spongy (penile) urethra

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Male Reproductive System
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Male Duct System posterior view
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Testis and Associated Structures

• Oval organ, 4 cm long x 2.5 cm in diameter
• Tunica albuginea white fibrous capsule
• Tunica vaginalis derived from the peritoneum
• Testicular veins drain to the inferior vena cava
  arteries come from abd aorta
• Seminiferous tubules drain into network called
  rete testis

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Male Inguinal Scrotal Region
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Accessory Glands

• Seminal vesicles
• posterior to bladder
• empty into ejaculatory duct
• Prostate gland
• below bladder, surrounds urethra and ejaculatory
  duct
• 2 x 4 x 3 cm
• Bulbourethral glands
• near bulb of penis
• empty into penile urethra
• lubricating fluid

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Anatomy of the Penis
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Penis

• Internal root and visible shaft and glans
• external portion is 4 in. long when flaccid
• skin over shaft is loosely attached allowing
  expansion
• extends over glans as prepuce or foreskin
• Consists of 3 cylindrical bodies of erectile
  tissue
• single corpus spongiosum along ventral side of
  penis
• encloses penile urethra
• ends as a dilated bulb ensheathed by
  bulbospongiosus muscle
• paired corpora cavernosa
• diverge like arms of a Y
• each crus attaches to pubic arch is covered
  with ischiocavernosus muscle

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UROLOGICAL DIAGNOSTIC STUDIES

• SECTION 2

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Diagnostic Studies--URINE

• Urinalysis
• Dipstick microscopic
• Debate regarding Microscopic
  and its cost effectiveness
• Cultures
• 24 Hour specimens
• Creatinine Clearance
• Quantitate Protein
• Uric Acid/other metabolites
• Special Studies
• Bence Jones Protein
• Urine Protein electrophoresis
• 24 hour urine protein
• VMA/Metanephrines/cortisol
• Electrolytes

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Diagnostic Studies

• ULTRASOUND (trans-abd vs. trans rectal)
• Relatively non-invasive
• Good for sizing Prostate
• Good for estimating post void
  bladder residual
• Good for looking at renal or
• prostate mass density
• Good for assessing kidney size, shape, stones,
  hydronephrosis, solid and cystic masses
• Can be used to help guide biopsy
• Doppler may be able to evaluate renal arteries

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IVP- intravenous pyelogram

• IV contrast injected into blood and is
  concentrated in the renal collecting system
• Multiple Xray pictures taken good assessment of
  function/obstruction
• Invasive
• Contrast may cause
• Allergic Reactions
• Presents significant burden on Kidney - check
  BUN/Creatinine before test
• Great test for evaluating the plumbing

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IVP
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IVP with contrast dye in bladder
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Diagnostic Studies

• Renal Scans (nuclear study)
• Great to detect blood flow (dynamic study)
• Mass evaluation
• Kidney function
• Evaluation for Renal Artery Stenosis

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• Cystoscopy
• Retrograde cytourethrogram

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Urological H P

• SECTION 3

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CC/HPI FOR THE UROLOGY PATIENT

• Urologic PAIN
• Pain (LOSCRATES)
• Most commonly from either obstruction or
  irritation (inflammation)
• Careful hx can often determine site of
  obstruction
• Small stones causing obstruction very painful
• Large non-obstructing stones no pain
• CVA pain and tenderness
• Prostate
• suprapubic, perineal, low back
• Testicular-
• epididymitis, torsion testicle/testicular
  appendices, hernia, radiating pain from kidney
• Penile-
• priapism, Peyronies, phimosis, paraphimosis
• Other locations? RADIATION IMPORTANT

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CC/HPI FOR THE UROLOGY PATIENT

• UROLOGY TERMINOLOGY
• Dysuria
• Painful or uncomfortable urination
• Hematuria-RBCs in urine
• Gross vs microscopic
• Upper or lower tract (casts vs rbcs?)
• True vs pseudo- things that color urine
• WholeCells vs Free Hemoglobin
• Myoglobin muscle cells
• Rhabdomyolysis
• Pyuria WBCs in urine
• Upper versus lower tract
• Will discuss in UTI Lecture

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CC/HPI FOR THE UROLOGY PATIENT

• TIMING AND VOLUME
• Oliguria- decreased output lt 500 ml day
• Anuria no urine being made
• (versus anuresis which is the inability to pass
  urine)
• Polyuria- Large Quantities of urine- gt 2.5 liters
  per day
• Frequency- more than the norm
• no relationship to volume
• Incontinence - involuntary loss of urine
• (Stress, Urgency Incontinence, Overflow
  incontinence)
• Nocturia - Nocturnal frequency
• Enuresis - Urinary incontinence at night
• Hesitancy- difficulty initiating a stream-
  straining to go
• Dribbling-
• Decrease force of Strain

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CC/HPI FOR THE UROLOGY PATIENT

• Miscellaneous Urological terminology
• Urologic
• Erectile Dysfunction
• Loss of Libido/Anorgasmia
• Hematospermia
• Gravel/Stones in urine
• Pneumaturia urinating airFistula
• Urethral Discharge-
• clear, purulent, bloody
• Penile/scrotal Lesions
• Ulcerative, painful/non-painful
• Raised, flat
• Color/texture

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Past Medical History

• Diabetes
• Hypertension
• Prostate Disease
• UTIs
• Cancer
• Previous hx of calculi
• Psychological disorders-Depression
• TB urogenital TB
• Peripheral Vascular Disease
• Multiple Sclerosis/strokes
• Sickle Cell Disease
• Previous Surgery

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Past Medical HistoryMedications

• Classes of medications and effects on urologic
  system
• Decreased libido antihypertensives (HCTZ)
• Erectile dysfunction propranolol,
  psychotropics
• Ejaculatory dysfunction a-adrenergic
  antagonists, psychotropics
• Priapism antipsychotics, antidepressants
  , antihypertensives
• 
  Nitric oxide (viagra)
• Decreased Spermatogenesis chemo, drugs of abuse
• Incontinence smooth muscle relaxants,
  diuretics
• Acute renal failure NSAIDs, contrast dye,
  antibiotics, chemo
• Urinary retention or obstructive voiding symptoms
  
• anticholinergics, muscle relaxants, CCB,
  antiparkinsonian drugs, a-adrenergic antagonists,
  antihistamines

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Family History

• Genetic Disease
• Polycystic Kidney Disease
• Tuberous Sclerosis
• Von Hippel Lindau Disease
• Renal tubular Acidosis
• Prostate Cancer

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Physical Examination of the Urogenital Tract

• MUST include
• Kidneys Attempt to trap, CVA tenderness
• Abdominal Exam
• Inspect for distension- bladder
• Percuss bladder for distension
• Palpate for masses, tenderness
• Rectal/Prostate on all Male
• Rectum-
• masses, tenderness, blood
• Prostate-
• Size, texture, nodularity, tenderness
• Dr. Freemans 5th commandment
• If thou hath a finger and thy patient has an
  anus- a rectal exam shalt thou do
• Pelvic on Females
• Neurologic Exam
• Sensory Reflexes -sphincter and muscle tone

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Physical Examination of the Urogenital Tract

• GENITAL EXAM
• maturation
• Skin
• Inguinal-
• masses, nodes, hernias
• Scrotum-Contents
• Testicles, epididymis, spermatic cord
• Abnormalities masses, cysts, tenderness
• Penis-
• circumcision status
• size shape tenderness
• Lesions
• discharge

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