Question | Answer |
Obstructive uropathy can occur from ____ to ____ | Renal calyces
Distal urethral meatus |
Obstructive Uropathy
Common Causes | Pregnancy
BPH
Calculi
Congential anomalies
Inflammation |
Obstructive Uropathy
Common Sequelae | Stagnation of urine with
-↑ risk of infxn
-↑ risk of calculi
Loss of renal fxn from hydronephrosis |
Obstructive lesions of the urinary tract can be
____ Vs ____ | Sudden Vs. Insidious
Partial Vs. Complete
Intrinsic Vs. Extrinsic
Mechanical Vs. Functional |
Hydronephrosis | Dilation of the renal pelvis and calyces associated with atrophy of the kidney
Caused by obstruction of outflow of urine |
Obstructive Uropathy
Clinical considerations | Pain: renal colic
Altered U/O: stream, amount, etc
Unilateral obstruction may be asymptomatic |
Obstructive Uropathy
Clinical considerations
Bilateral Partial | From chronic tubulointerstial nephritis
Presents with polyuria, nocturia from inability to concentrate urine |
Obstructive Uropathy
Clinical considerations
Bilateral complete | Presents with oliguria or anuria
Urine output must be restored for survival |
Urolithiasis
General | Calculi can form at any level
Most arise in the kidney
~80% are unilateral |
Urolithiasis
Clinical | 5-10% US population, M>F
Familial/hereditary tendencies
Smaller stones→ureters→renal colic pain obstruction and hematuria
Larger stones→hematuria, hydronephrosis |
Urolithiasis
Etiology | 4 main types
1.Calcium (oxalate/phosphate) ~70%
2.Struvite (triple stone): Mg, NH4, phosphate
3.Uric Acid 4.Cystine |
Urolithiasis
Etiology/Pathology | Urinary supersatutation
-Low urine volume
-Metabolic abnormalities, altered pH
Loss of natural inhibitors
Infection |
Calculi
Calcium | Radiopaque
~70% of all stones
Hypercalcemic states
-Hyperparathyroidism, diffuse bone disease, sarcoidosis
Hypercalciuria w/o hypercalcemia |
Calculi
Magnesium ammonium phosphate | ~20% of all stones
Bacterial infections
-Urea→ammonia (↑ urine pH)
+↑precipitation of Mg, NH4, phos
Large stones (Staghorn caculi) |
Caculi
Uric acid | Radiolucent
~10% of stones
Hyperuricemia (gout)
Tendency to excrete urine with pH < 5.5 |
Caculi
Cystine | <1%
Genetic efects in renal reabsorption of amino acids
Stoned form at low urine pH |
Urinary bladder
Anatomy | Superior surface: dome
Anteriosuperior: apex
Posterior surface: base
Trigone: triangular region located at base of bladder
Bladder neck: most distal |
Urinary bladder
Layers of visceral organ | Mucosa: urothelium
Lamina propria: slips of smooth muscle
Muscularis propria: thick bundles of smooth muscle
Adventitia (conn tiss) |
Urinary bladder disorders/diseases
Non-neoplastic
(congenital or developmental) | Diverticula
Exstrophy
Urachal cysts
VRR (most common)
Inflammation
Metaplastic changes |
Urinary bladder disorders/diseases
Neoplastic | Urothelial (TCC)
Squamous cell carcinoma
Adenocarcinoma
Mixed carcinoma
Small cell carcinoma |
Diverticula | True:out-pouching of visceral organ consisting of all wall layers
Acquired:increased intraluminal pressure
Congenital:defect in wall muscle |
Exstrophy | ~33/1,000,000 live births
Anterior bladder wall and abdominal wall are absent
Exposes bladder mucosa to external environment
↑ risk of cystitis and carcinoma |
Urachus | Vestigial remnant of the connection of bladder apex to the allantois
Prone to neoplastic transformation→adenocarcinoma
<0.5% bladder cancers |
Patent urachus | Communicating duct between umbilicus and urinary bladder→infection
May close spontaneously
Typically requires surgical closure |
Urachal cysts | **Most common urachal anomaly**
Suprapubic palpable mass
Columnar lining secrets watery secretions |
Cystitis | Can be acute or chronic
Systemic signs are uncommon in uncomplicated cystitis |
Infectious Cystitis | Bacterial: E.coli
Fungal: Candida
Parasitic: Schistosomiasis
-Middle East, northern Africa
Viruses: Chlamydia |
Chemical or Physical Agent Cystitis | Drugs and other chemicals:
-Cytotoxic chemotherapy (cyclophosphamide) hemorrhagic cystitis
Radiation
Cacluli (mechanical) |
Interstitial Cystitis | Chronic pelvic pain syndrome
Etiology uncertain
F>>M
Recurrent, severe, intermittent suprapubic pain
Hematuria, Urinary urgency |
Interstitial Cystitis
(cont) | May result in transmural fibrosis with dysfunctional bladder
*May mimic in situ urothelial carcinoma* |
Malacoplakia | Macroscopic: soft, tan/yellow slightly elevated mucosal plaques
**Micro: large foamy macrophages mixed with multinucleated giant cells
-Michaelis-Gutmann bodies** |
Malcoplakia
(cont) | Chronic bacterial infections
-E.coli
-immunosuppressed transplant pts |
Metaplasia | Alteration of the epthelium from its typical mature form to a different type of epithelium
Mostly transitional to columnar
Metaplastic epi offers beneficial protective features |
Neoplasms of the Urinary Bladder | ~95% are epithelial |
Urothelial
(Transitional cell) | Benign: urothelial papilloma
Premalignant:
Papillary- PUNLMP
Flat- urothelial carcinoma in situ (CIS) |
**Urothelial Carcinoma In Situ
(CIS)** | Multifocal
Greater tendency to progress to more aggressive malignant neoplasm
Multifocal- pagetoid spread of tumor cells |
Cancers of Transitional Epithelium | Papillary urothelial carcinoma (TCC):
Tend to recur, maybe multifocal
Not all are invasive
"Flat" (ass. with CIS):
Multifocal, invasive, high-grade |
Staging of Urinary Bladder Cancers | Ta: noninvasive papillary
Tis: carcinoma in situ
T#: invasive
Higher #, more invasion |
Squamous cell carcinoma | ~3-7% of bladder cancers
More common in areas with schistosomiasis
Most common ass. with Sch. (70%)
Ass. Chronic irritation/infxn |
Bladder Cancer
Epidemiology | M>F
More common in developed countries
Urban>rural
Generally no familial association |
Bladder Cancer
Pathogenesis | Modifiable risk factors
*Tobacco
*Artlamine chemicals (aromatic hydrocarbons)
Long-term analgesic use
Radiation exposure |
Urinary Bladder Cancer
Clinical Features | Classic: painless hematuria
Risk of recurrence: tumor size, stage, grade, multifocality, presence of CIS
Prognosis: grade and stage at Dx most important (early detection) |
Urinary Bladder Cancer
Treatment
Small, localized papillary tumors | Transurethral resection of bladder tumor (TURBT)
Close follow-up surveillance |
Urinary Bladder Cancer
Treatment
CIS, high grade TCC, etc | Topical immunotherapy/chemo
Intravesical installation of bacillus Calmette-Guerin (BCG)
Local inflammation reaction destroys tumor |
Urinary Bladder Cancer
Treatment
Invasion of muscularis propria | Cystectomy
Possibly systemic chemotherapt |