Transcript Introduction to Urology

Introduction to Urology
Richard E. Freeman MD MPH
Curtis M. Grenoble, MS, PA-C
Lock Haven University, PA Program
Summer 2013
Urology
 The branch of medicine that focuses on the
urinary tracts of BOTH females and males,
and the reproductive systems of males.
Anatomy of Kidney
 Renal cortex: outer
1 cm
 Renal medulla:
renal columns,
pyramids - papilla
 Lobe of kidney:
pyramid and it’s
overlying cortex
 Collecting system
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Calyces
Pelvis
Ureter
Lobe of Kidney
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:
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metanephric blastema.
 Renal Function can be divided into THREE
Components
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Filtration
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Excretion
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Secretion
RENAL FUNCTION
 FILTRATION
 EXCRETION
 SECRETION:hormonal- Renin-angiotensin
Nephron – Physiology
 Glomerulus Filters fluid from blood into Bowman’s 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
GLOMERULUS
Nephron - Physiology
 Distal Convoluted tubule –
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Reabsorbs Na+, Cl-, water, urea
Secretes H+, K+
Responds (has receptors for) to aldosterone
 Collecting Tubule –
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Reabsorption of water under influence of ADH
Secretes H+ & K
Renal Vasculature
 20-25% of cardiac output passes through the
kidney
 Afferent arterioles
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Branches of the interlobular arteries to transport
blood into glomerulus
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Each supplies a single glomerulus
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(renal corpuscle)
 Efferent arterioles
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Exit the glomeruli
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Divide to form an intricate peritubular
microcirculation
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).
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:
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Blood flow in (afferent arterioles)
HEALTH OF THE GLOMERULUS
Blood flow out (efferent arterioles)
Juxtaglomerular Apparatus
←
←
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 Bowman’s
capsule
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
ureteral obstruction
edema of kidney inside a tight capsule
Factors Affecting GFR
 Decrease in concentration of plasma proteins
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Oncotic pressure
 Decrease in total area of glomerular capillary
bed
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Diseases that destroy glomeruli without
destroying tubules
Partial nephrectomy
Factors Affecting GFR
 Opposite effects that decrease GFR
 Increased permeability of glomerular filtrate…
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DM
Membranous nephropathy
Evaluation of renal function/
Blood tests
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CBC
Electrolytes
Glucose
BUN
Creatinine
CREATININE CLEARANCE TEST
Liver function
Ca, PO4
albumin
cholesterol
Evaluation of Kidney function
URINE TESTS
 Urinalysis – STAY TUNED
 Creatinine Clearance Test
 24 Urine Protein
 A lot of specialized tests to access
metabolic/dynamic function of the kidneysNEPHROLOGY
Ureter
 Tube between kidney and bladder
 Enters bladder at the
 ureterovesicular junction
 Peristalsis
 ‘THREE areas of narrowing
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Renal pelvoureterojunction
Passage over iliac vessels and pelvic brim
Uretervesicular junction’ – oblique angle
UV junction
Urinary Bladder
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Holds approximately 500 cc of urine
Lined with Transitional cells
Body of bladder – primarily detrusor muscle
Neck of bladder –
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includes the posterior urethral sphincter
AKA internal sphincter
 Innervation
 Sympathetic to body – L2
 Parasympathetics to body and neck - S2 & S3
Urinary Bladder and Urethra - Female
Female
Urethra
 3 to 4 cm long
 External urethral orifice
 between vaginal orifice
and clitoris
 Internal urethral
sphincter
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detrusor muscle
thickened, smooth
muscle, involuntary
control
 External urethral
sphincter
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skeletal muscle,
voluntary control
Male Bladder and Urethra
 Urethra: ~18 cm long
 Internal urethral sphincter
 External urethral sphincter
•3 regions
1) prostatic urethra during
orgasm receives semen
2) membranous urethra passes through pelvic
cavity
3) spongy (penile) urethra
Male Reproductive System
Male Duct System: posterior view
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
Male Inguinal & Scrotal Region
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
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near bulb of penis
empty into penile
urethra
lubricating fluid
Anatomy of the Penis
Penis
 Internal root and visible shaft and glans
 external portion is ~4 in. long when flaccid
 skin over shaft is loosely attached allowing expansion
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extends over glans as prepuce or foreskin
 Consists of 3 cylindrical bodies of erectile tissue
 single corpus spongiosum along ventral side of penis
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encloses penile urethra
ends as a dilated bulb ensheathed
by bulbospongiosus muscle
paired corpora cavernosa
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diverge like arms of a Y
each crus attaches to pubic arch & is
covered with ischiocavernosus muscle
SECTION 2
UROLOGICAL DIAGNOSTIC
STUDIES
Diagnostic Studies--URINE
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Urinalysis
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Dipstick& microscopic
 Debate regarding Microscopic
effectiveness
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Cultures
24 Hour specimens
 Creatinine Clearance
 Quantitate Protein
 Uric Acid/other metabolites
 Special Studies
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Bence Jones Protein
Urine Protein electrophoresis
24 hour urine protein
VMA/Metanephrines/cortisol
Electrolytes
and its cost
Diagnostic Studies
 ULTRASOUND
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(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
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
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Allergic Reactions
Presents significant burden on Kidney - check
BUN/Creatinine before test
Great test for evaluating the “plumbing”
IVP
IVP with
contrast dye in
bladder
Diagnostic Studies
 Renal Scans (nuclear study)
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Great to detect blood flow (dynamic study)
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Mass evaluation
Kidney function
Evaluation for Renal Artery Stenosis
 Cystoscopy
 Retrograde cytourethrogram
SECTION 3
UROLOGICAL H & P
CC/HPI FOR THE UROLOGY
PATIENT
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Urologic PAIN
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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
CC/HPI FOR THE UROLOGY
PATIENT
 UROLOGY TERMINOLOGY
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Dysuria
 Painful or uncomfortable urination
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Hematuria-RBC’s in urine
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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 – WBC’s in urine
 Upper versus lower tract
 Will discuss in UTI Lecture
CC/HPI FOR THE UROLOGY
PATIENT
 TIMING AND VOLUME
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Oliguria- decreased output < 500 ml day
Anuria – no urine being made
 (versus anuresis which is the inability to pass urine)
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Polyuria- Large Quantities of urine- > 2.5 liters per day
Frequency- more than the norm
 no relationship to volume
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Incontinence - involuntary loss of urine
 (Stress, Urgency Incontinence, Overflow incontinence)
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Nocturia - Nocturnal frequency
Enuresis - Urinary incontinence at night
Hesitancy- difficulty initiating a stream- straining to go
DribblingDecrease force of Strain
CC/HPI FOR THE UROLOGY
PATIENT
 Miscellaneous Urological terminology
 Urologic
 Erectile Dysfunction
 Loss of Libido/Anorgasmia
 Hematospermia
 Gravel/Stones in urine
 Pneumaturia; urinating air:Fistula
 Urethral Discharge clear, purulent, bloody
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Penile/scrotal Lesions
 Ulcerative, painful/non-painful
 Raised, flat
 Color/texture
Past Medical History
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Diabetes
Hypertension
Prostate Disease
UTI’s
Cancer
Previous hx of calculi
Psychological disorders-Depression
TB: urogenital TB
Peripheral Vascular Disease
Multiple Sclerosis/strokes
Sickle Cell Disease
Previous Surgery
Past Medical History:
Medications
 Classes of medications and effects on urologic system:
 Decreased libido –
antihypertensives (HCTZ)
 Erectile dysfunction –
propranolol, psychotropics
 Ejaculatory dysfunction –
α-adrenergic antagonists,
psychotropics
 Priapism –
antipsychotics,
antidepressants,
antihypertensives
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Nitric oxide (viagra)
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Decreased Spermatogenesis – chemo, drugs of abuse
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Incontinence –
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Acute renal failure –
NSAIDs, contrast dye,
antibiotics,
chemo
Urinary retention or obstructive voiding symptoms –
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smooth muscle relaxants,
diuretics
anticholinergics, muscle relaxants, CCB, antiparkinsonian drugs,
α-adrenergic antagonists, antihistamines
Family History
 Genetic Disease
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Polycystic Kidney Disease
Tuberous Sclerosis
Von Hippel Lindau Disease
Renal tubular Acidosis
Prostate Cancer
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
 Rectummasses, tenderness, blood
 Prostate Size, texture, nodularity, tenderness
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Dr. Freeman’s 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
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EXAM
maturation
Skin
Inguinal masses, nodes, hernias
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Scrotum-Contents
 Testicles, epididymis, spermatic cord
 Abnormalities: masses, cysts, tenderness
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Penis
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circumcision status
size shape tenderness
Lesions
discharge