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Introduction to Urology

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Title: Introduction to Urology Author: Curtis M. Grenoble Last modified by: Richard Freeman Created Date: 7/21/2004 2:55:42 AM Document presentation format – PowerPoint PPT presentation

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Title: Introduction to Urology


1
Introduction to Urology
  • Richard E. Freeman MD MPH
  • Curtis M. Grenoble, MS, PA-C
  • Lock Haven University, PA Program
  • Summer 2013

2
Urology
  • The branch of medicine that focuses on the
    urinary tracts of BOTH females and males, and the
    reproductive systems of males.

3
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4
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

5
Lobe of Kidney
6
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

7
RENAL FUNCTION
  • FILTRATION
  • EXCRETION
  • SECRETIONhormonal- Renin-angiotensin

8
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9
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

10
GLOMERULUS
11
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12
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

13
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14
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

15
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).

16
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)

17
Juxtaglomerular Apparatus
?
?
18
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

19
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

20
Factors Affecting GFR
  • Opposite effects that decrease GFR
  • Increased permeability of glomerular filtrate
  • DM
  • Membranous nephropathy

21
Evaluation of renal function/Blood tests
  • CBC
  • Electrolytes
  • Glucose
  • BUN
  • Creatinine
  • CREATININE CLEARANCE TEST
  • Liver function
  • Ca, PO4
  • albumin
  • cholesterol

22
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

23
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

24
UV junction
25
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

26
Urinary Bladder and Urethra - Female
27
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

28
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

29
Male Reproductive System
30
Male Duct System posterior view
31
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

32
Male Inguinal Scrotal Region
33
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34
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

35
Anatomy of the Penis
36
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

37
UROLOGICAL DIAGNOSTIC STUDIES
  • SECTION 2

38
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

39
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

40
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

41
IVP
42
IVP with contrast dye in bladder
43
Diagnostic Studies
  • Renal Scans (nuclear study)
  • Great to detect blood flow (dynamic study)
  • Mass evaluation
  • Kidney function
  • Evaluation for Renal Artery Stenosis

44
  • Cystoscopy
  • Retrograde cytourethrogram

45
Urological H P
  • SECTION 3

46
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

47
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

48
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

49
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

50
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

51
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

52
Family History
  • Genetic Disease
  • Polycystic Kidney Disease
  • Tuberous Sclerosis
  • Von Hippel Lindau Disease
  • Renal tubular Acidosis
  • Prostate Cancer

53
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

54
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

55
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