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Anatomy and Physiology
The urinary system comprises the kidneys, ureters, bladder, and urethra. A thorough understanding of the urinary system is necessary for assessing individuals with acute or chronic urinary dysfunction and implementing appropriate nursing care.
ANATOMY OF THE UPPER AND LOWER URINARY TRACTS The urinary system—the structures of which precisely environment maintain of the the internal chemical various
excretory, regulatory, and secretory functions.
Kidneys The kidneys are a pair of brownish-red structures located retroperitoneally (behind and outside the peritoneal cavity) on the posterior wall of the abdomen from the 12th thoracic vertebra to the 3rd lumbar vertebra in the adult (Fig. 43-1). An adult kidney weighs 120 to 170 g (about 4.5 oz) and is 12 cm (about 4.5 inches) long, 6 cm wide, and 2.5 cm thick. The kidneys are well protected by the ribs, muscles, Gerota’s fascia, perirenal fat, and the renal capsule, which surround each kidney.
The hilum. Blood leaves the glomerulus through the efferent arteriole and flows back to the inferior vena cava through a network of capillaries and veins. the functional units of the kidney. proximal tubule. and the epithelium. eventually forming the afferent arteriole. distal tubule. proximal and distal tubules. The pyramids are situated with the base facing the concave surface of the kidney and the apex facing the hilum. The juxtamedullary nephrons are distinguished by their long loops of Henle and the vasa recta. such as blood cells and albumin. which is the capillary bed responsible for glomerular filtration. which empty into the minor calices. Each kidney contains approximately 8 to 18 pyramids. The glomerulus is composed of three filtering layers: the capillary endothelium. The pyramids drain into 4 to 13 minor calices that. Bowman’s capsule. which drain into three major calices that open directly into the renal pelvis. or pelvis. the basement membrane. The medulla resembles conical pyramids. drain into 2 to 3 major calices that open directly into the renal pelvis. The renal artery (arising from the abdominal aorta) divides into smaller and smaller vessels. and juxtamedullary nephrons sit adjacent to the medulla. Nephrons are structurally divided into two types: cortical and juxtamedullary. and cortical collecting ducts and their adjacent peritubular capillaries. The nephron consists of a glomerulus containing afferent and efferent arterioles. Each kidney contains about 1 million nephrons. and collecting ducts Collecting ducts converge into papillae. the renal parenchyma and the renal pelvis. in turn. long capillary loops that dip into the medulla of the kidney. Cortical nephrons are found in the cortex of the kidney. loop of Henle. The cortex contains the glomeruli. The glomerular membrane normally allows filtration of fluid and small molecules yet limits passage of larger molecules. Kidney function begins to decrease at a rate of approximately 1% each year beginning at approximately age 30. The afferent arteriole branches to form the glomerulus. or pelvis. is the concave portion of the kidney through which the renal artery enters and the renal vein exits. .The kidney consists of two distinct regions. Each kidney is capable of providing adequate renal function if the opposite kidney is damaged or becomes nonfunctional. The renal parenchyma is divided into the cortex and the medulla.
The angling of the ureterovesical junction is the primary means= of providing antegrade. As in the bladder. each 24 to 30 cm long. which is the retrograde. hollow sac located just behind the pubic bone. The outermost layer is the adventitia. flows into the ureter. The wall of the bladder comprises four layers. The movement of urine from the renal pelves through the ureters into the bladder is facilitated by peristaltic waves (occurring about one to five times per minute) from contraction of the smooth muscle in the ureter wall (Walsh. and the ureterovesical junction. the bladder is found within the abdomen. The lining of the ureters is made up of transitional cell epithelium called urothelium. the bladder assumes its position in the true pelvis. The urinary bladder is a muscular. intravesical pressure returns to its normal low baseline value. muscular tubes. Adult bladder capacity is about 300 to 600 mL of urine. or downward. up the ureter. Beneath the detrusor is a smooth muscle tunic . Immediately beneath the adventitia is a smooth muscle layer known as the detrusor. 1998). The bladder is characterized by its central. The three areas of narrowing within the ureters have a propensity toward obstruction because of renal calculi (kidney stones) or stricture. which is formed within the nephrons. Vaughan & Wein. allowing efflux of urine to resume. Retik. There are three narrowed areas of each ureter: the ureteropelvic junction. a long fibromuscular tube that connects each kidney to the bladder. In adolescence and through adulthood. and Urethra Urine. Therefore. the only time that the bladder is completely empty is in the last seconds of micturition before efflux of urine resumes. toward the kidney. hollow area called the vesicle. also referred to as efflux of urine. Bladder.Ureters. This angling prevents vesicoureteral reflux. which is made up of connective tissue. The ureters are narrow. The left ureter is slightly shorter than the right. movement of urine. In infancy. increased intravesical pressure keeps the ureterovesical junction closed and keeps urine within the ureters. or backward. During voiding (micturition). Obstruction of the ureteropelvic junction is the most serious because of its close proximity to the kidney and the risk of associated kidney dysfunction. the ureteral segment near the sacroiliac junction. movement of urine from the bladder. that originate at the lower portion of the renal pelvis and terminate in the trigone of the bladder wall. the urothelium prevents reabsorption of urine. As soon as micturition is completed. which is surrounded by the bladder neck. which has two inlets (the ureters) and one outlet (the urethrovesical junction).
PHYSIOLOGY OF THE UPPER AND LOWER URINARY TRACTS The urinary system performs various roles that are essential for normal bodily homeostasis . the urothelium. it opens just anterior to the vagina. which serves as an interface between the detrusor and the innermost layer.known as the lamina propria. 1998).These functions include urine formation. . and autoregulation of blood pressure. The portion of the sphincteric mechanism that is under voluntary control is the external urinary sphincter at the anterior urethra. which lies just below the bladder neck. The urothelium prevents the reabsorption of urine stored in the bladder. the segment most distal from the bladder (Walsh et al. In the male. transitional cell epithelium. The urothelium layer is specialized. in the female. and water excretion. The urethra arises from the base of the bladder: In the male. acid. the prostate gland. The bladder neck contains bundles of involuntary smooth muscle that form a portion of the urethral sphincter known as the internal sphincter. excretion of waste products. it passes through the penis. surrounds the urethra posteriorly and laterally.. regulation of electrolyte. containing a membrane that is impermeable to water.
Within the tubule. Glycosuria is also common in pregnancy.Urine Formation Urine is formed in the nephrons through a complex three-step process: glomerular filtration. tubular reabsorption. however. and excreted in the urine include sodium. reabsorbed by the tubules. The various substances normally filtered by the glomerulus. bicarbonate. glucose appears in the urine. In diabetes. creatinine. chloride. glucose. are completely reabsorbed in the tubule and normally do not appear in the urine. Figure 43-3 illustrates the three processes of urine formation and typical values of water and electrolytes associated with each process. Others are secreted from the blood into the filtrate as it travels down the tubule. Amino acids and glucose are usually filtered at the level of the glomerulus and reabsorbed so that neither is excreted in the urine. Glucose. some of these substances are selectively reabsorbed into the blood. Some substances. potassium. when the blood glucose level exceeds the kidneys’ reabsorption capacity. and uric acid. urea. Normally. glucose is completely reabsorbed when the blood glucose level is less than 200 mg/dL (11 mmol/L). and tubular secretion. such as glucose. appears in the urine (glycosuria) if the amount of glucose in the blood and glomerular filtrate exceeds the amount that the tubules are able to reabsorb. .
eliminating the body’s metabolic waste products. low-molecular-weight proteins (globulins and albumin) may periodically be excreted in small amounts. Excretion of Waste Products The kidney functions as the body’s main excretory organ. • Tubular reabsorption and tubular secretion: The second and third steps of urine formation occur in the renal tubules and are called tubular reabsorption and tubular secretion. including hypotension. decreased oncotic pressure in the blood.Protein molecules are also generally not found in the urine. The filtrate normally consists of water. Although most reabsorption occurs in the proximal tubule.500 mL of urine each day.200 mL/min. because water and small molecules are allowed to pass. In tubular secretion. electrolytes. The major waste product of protein . reabsorption occurs along the entire tubule. amounting to about 180 L/day of filtrate. about 20% of the blood passing through the glomeruli is filtered into the nephron. whereas larger molecules stay in the bloodstream. Transient proteinuria in amounts less than 150 mg/dL is considered normal and does not require further evaluation. Efficient filtration depends on adequate blood flow maintaining a consistent pressure through the glomerulus. resulting in 1. also known as filtrate or ultrafiltrate. filtration occurs. Filtrate becomes concentrated in the distal tubule and collecting ducts under the influence of antidiuretic hormone (ADH) and becomes urine. The filtered fluid. however. As blood flows into the glomerulus from an afferent arteriole. then enters the renal tubules. Under normal conditions. The steps of urine formation are: • Glomerular filtration: The normal blood flow through thekidneys is about 1. a substance moves from the peritubular capillaries or vasa recta into tubular filtrate. which then enters the renal pelvis. Many factors can alter this blood flow and pressure. and increased pressure in the renal tubules from an obstruction. In tubular reabsorption. Of the 180 L (45 gallons) of filtrate that the kidneys produce each day. a substance moves from the filtrate back into the peritubular capillaries or vasa recta. Persistent proteinuria usually signifies damage to the glomeruli. and other small molecules.000 to 1. 99% is reabsorbed into the bloodstream. Reabsorption and secretion in the tubule frequently involve passive and active transport and may require the use of energy.
and sulfates. of which about 25 to 30 g is produced and excreted daily.metabolism is urea. less sodium is excreted in the urine because aldosterone fosters renal reabsorption of sodium. fluid retention results. If more sodium is excreted than ingested. dehydration results. is also eliminated in the urine. or decreased sodium chloride delivery to the tubules. Release of aldosterone from the adrenal cortex is largely under the control of angiotensin II. the average American daily diet contains 6 to 8 g each of sodium chloride (salt) and potassium chloride. Angiotensin II levels are in turn controlled by renin. Activation of this system increases the retention of water and expansion of intravascular fluid volume. The regulation of sodium volume excreted depends on aldosterone. a hormone synthesized and released from the adrenal cortex. the kidneys are . All of this urea must be excreted in the urine. This complex system is activated when pressure in the renal arterioles falls below normal levels. Regulation of Electrolyte Excretion When the kidneys are functioning normally. dehydration. Electrolyte excretion includes sodium and potassium. the volume of electrolytes excreted per day is exactly equal to the amount ingested. the kidney can regulate the volume of body fluids. Nearly all of this is excreted in the urine. SODIUM More than 99% of the water and sodium filtered at the glomeruli is reabsorbed into the blood by the time the urine leaves the body. By regulating the amount of sodium (and therefore water) reabsorbed. an enzyme that is released from specialized cells in the kidneys (Fig. POTASSIUM Potassium is the most abundant intracellular ion. phosphates. For example. as occurs with shock. To maintain a normal potassium balance in the body. The kidneys serve as the primary mechanism for excreting drug metabolites. With increased aldosterone in the blood. otherwise it will accumulate in body tissues. Uric acid. Other waste products of metabolism that must be excreted are creatinine. with about 98% of the total-body potassium located intracellularly. Water from the filtrate follows the reabsorbed sodium to maintain osmotic balance. if less sodium is excreted than ingested. formed as a waste product of purine metabolism. 43-4).
in particular phosphoric and sulfuric acids. Regulation of Water Excretion Regulation of the amount of water excreted is also an important function of the kidney. the kidney is able to excrete large quantities of acid in a bound form. in contrast to aldosterone’s effects on sodium described previously.5. usually needs to be eliminated from the body than can be excreted directly as free acid in the urine. Conversely. and the flow rate of the filtrate in the distal tubule also influence the amount of potassium secreted into the urine. and in the feces. A person with normal kidney function excretes about 70 mEq of acid each day.responsible for excreting more than 90% of the total daily potassium intake. Retention of potassium is the most life-threatening effect of renal failure. without further lowering the pH of the urine. however. the amount of dietary potassium intake. Regulation of Acid Excretion The catabolism. A person normally ingests about 1 to 2 L of water per day. and ammonia is produced by the cells of the renal tubules and secreted into the tubular fluid. a large volume of dilute urine is excreted. which is 1. . Aldosterone causes the kidney to excrete potassium. More acid. or breakdown. from the lungs during breathing. The remainder is lost from the skin. When buffered with acid. Through the buffering process. With high fluid intake. phosphoric and sulfuric acids are nonvolatile and cannot be eliminated by the lungs. Phosphate is present in the glomerular filtrate. Unlike carbon dioxide (CO2). they must be excreted in the urine. Several factors influence potassium loss through the kidneys. with a low fluid intake. These excess acids are bound to chemical buffers so they can be excreted in the urine. The kidney is able to excrete some of this acid directly into the urine until the urine pH reaches 4. a small volume of concentrated urine is excreted. Acid–base balance. Two important chemical buffers are phosphate ions and ammonia (NH3).000 times more acidic than blood. of proteins results in the production of acid compounds. The normal daily diet also includes a certain amount of acid materials. Because accumulation of these acids in the blood would lower its pH (making the blood more acidic) and inhibit cell function. and normally all but 400 to 500 mL of this fluid is excreted in the urine. ammonia becomes ammonium (NH4).