ANATOMY AND PHYSIOLOGY The Urinary System The urinary tract is composed of four structures

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Kidney Ureters Bladder Urethra

The kidneys balance the urinary excretion of substances against the accumulation within the body through ingestion or production. Consequently, they are a major controller of fluid and electrolytes homeostasis. The kidneys also have several no excretory metabolic and endocrine functions, including blood pressure regulations, erythropoietin regulation and vitamin D metabolism. Filtration at the renal glumerulus is the first steps in urine formation. Normally, a volume equal to plasma volume is filtered every 24 minutes and a volume equal to total body water is filtered every 6 hours. This glomerular filtrate is similar to plasma, but it lack cells and large-molecular-weight proteins. The glomerular filtrate is modified by active transport, diffusion and osmosis as it passes through the renal tubules. Reabsorption of filtrate components enhances elimination of organic acids and bases (and some drugs). The remnants of the glomerular filtrate exit the kidney through the uterus. The ureters conduct urine from the kidney to the bladder by peristaltic contraction. The bladder is distensible chamber that stores urine until it is excreted. The urethra is the exit passageway from the bladder that carries urine for elimination from the body.

Structures of the Urinary System The kidneys are located retro peritoneal, in the posterior aspects of the abdomen, on either side of the vertebral column. They lie between the 12th thoracic and the third lumbar vertebrae. The left kidney is usually positioned slightly higher than the right. Adult kidney average approximately 11 cm in length, 5 to 7.5 cm in width and 2.5 cm in thickness. Affixing the kidneys in position behind the parietal peritoneum is a mass of perirenal fat (adipose capsule) and connective tissue called Gerota's (subserosa) fascia. A fibrous capsule (renal capsule) forms the external covering of the kidney except for the hilum. The kidney is further protected by layers of muscles of the back. Flank abdomen as well as by layer of fat, subcutaneous tissues and the skin. The kidney has a characteristics curve shape, with a convex distal edge and a concave medial boundary. In the innermost part of the concave section is hilus, through which pass the renal artery, renal vein, lymphatic, nerves and renal pelvis (the natural upper extension of the ureter). A fibrous capsule surrounds each kidney and adheres the renal parenchyma. Each kidney is divided in to three major areas: (1) cortex, (2) medulla and (3) pelvis. The cortex of the kidney lies just under the fibrous capsule, and portions of the extend down into the medulla layer to form the renal columns (columns of Bertin) or cortical tissue that separates the pyramids. The medulla is divided into eight to 18 cone shaped masses of collecting ducts called the renal pyramids. The bases of the pyramids are positioned on the corticomedullary boundary. Their apices extend toward the renal pelvis, forming papillae. The papillae have 10-25 openings each on the surface, through which the urine empties into the renal pelvis. Eight or more groups of papillae are present in each pyramid; each empties into a minor calix and several minor calices join to form a major calix. The two or three major calices are outpouching of the renal pelvis (inner area of the kidney). They channel urine from the pyramids to the renal pelvis. The renal pelvis is a cavity lined with transitional epithelium. The combined volume of the pelvis and calices is approximately 8 ml. Volumes in excess of this amount damage the renal parenchyma tissue. The renal pelvis narrows and reaches the hilus and becomes the proximal end of the ureter.

Within the cortex lies the nephron, the functional unit of the kidney, consisting both vascular and tubular elements. Filtration begins at the glumerulus. The glomerular tuft (glumerulus) contains capillaries and the beginning of the tubule system, Bowman's capsule. Filtrate from the glumerulus enters the Bowman's capsule and the passes through a series of tubule segments that modify the filtrate as it passes through the renal cortex and medulla and finally, flows into the renal calices. A second capillary bed, the peritubular capillaries, carries the reabsorbed water and solutes back towards the vena cava. Renal Blood Flow, Glomerular Filtration The kidneys receive 20% to 25% of the cardiac output under resting conditions, averaging more that 1 L of the arterial blood per minute. The renal arteries branch from the abdominal aorta at the level of the second lumbar of vertebra, enter the kidney, and progressively branch into lobar arteries, inner lobar arteries, accurate arteries and interlobular arteries. Blood flows from the inerlobular arteries through the afferent arteriole and the peritubular capillaries carry a small amount of blood (5% of renal blood flow) to the renal medulla in the vasa recta (long, straight blood vessels) before entering the venous drainage. The blood leaves the kidney in a venous system closely corresponding to the arterial system: interlobular veins, accurate veins, interlobular veins, and the renal vein. The renal circulation then empties the inferior vena cava.

Ureters The ureters from the medial tapering of the renal pelvis at the hilus of the kidney. Usually 25-35 cm long in the adult, the ureters lie in the extraperitoneal connective tissue and descend vertically along the psoas muscle towards the pelvic cavity. After dipping into the pelvic cavity, the ureters course anteriorly to join the bladder in its posterolateral aspect. At each ureterovesical junction, the ureter runs obliquely through the bladder wall for about 1.5 to 2 cm before opening into the lumen of the bladder.

Each ureter has elastic characteristics and is made of three tissues layers; (1) an inner mucosa (transitional epithelial membrane) lining the lumen, (2) a muscular layer and (3) a fibrous outer layer. The musculature is generally designed as inner longitudinal and outer circular. Along most of the ureter, however, the muscle fiber actually run obliquely and blends with one another to form a mesh-like tissue. The muscle arrangement allows urine to propel down by the ureter by peristaltic action. Peristalsis is regulated by a myogenic pacemaker located near the renal calices. Blood is supplied to ureters by one or more vessels that run longitudinal along the tube. The number and assortment of articles anastomosing with the ureteric vessels vary with each individual. Because the ureters travel through several anatomic areas, the urethral vessels are fed several of the following arteries: (1) renal (frequently), (2) testicular or ovarian, (3) aorta and common iliac, (4) internal iliac (frequently), (5) vesical, (6) umbilical and (7) uterine. Bladder The urinary bladder is a hallow organ located in the anterior half of the pelvis behind the symphisis pubis. The space between the bladder and symphisis pubis is filled with a loose connective tissue that allows the bladder to stretch cranially as it fills. The peritoneum covers the top border of the bladder, and the base is held loosely in place by the true ligaments. The bladder is also enveloped by a loose fascia. Urethra The urethra is a tube that extends from the base of the bladder to the surface of the body. The urethra differs greatly in females and males. Male Urethra In males, the urethra is a common outlet for the reproductive system and urinary elimination. The prostate gland, although not a direct part of the urinary system, is a major cause of urinary dysfunction in men. Located below the bladder neck, the prostate completely enlarges, it constrict the urethra and obstruct the outflow of urine.

The male urethra is about 20 cm long and is divided into three main sections. The prostatic urethra extends about 3 cm below the bladder neck, the ejaculatory ducts of the membranous urethra is about 1 to 2 cm in length and ends where the muscle layer forms the external sphincter. The distal portion is the cavernous (penile) urethra. Approximately 15 cm long, it travels through the penis to the urethra orifice at the tip of the penis; it is also lined with epithelial cells.

THE PATIENT’S ILLNESS (Book-Based) A. Synthesis of the Disease 1. Definition of the Disease A urinary tract infection (UTI) is a bacterial infection that affects any part of the urinary tract. The main causative agent is Escherichia coli. Although urine contains a variety of fluids, salts, and waste products, it usually does not have bacteria in it. When bacteria get into the bladder or kidney and multiply in the urine, they cause a UTI. The most common type of UTI is a bladder infection which is also often called cystitis. Another kind of UTI is a kidney infection, known as pyelonephritis, and is much more serious. Although they cause discomfort, urinary tract infections can usually be quickly and easily treated with a short course of antibiotics. Since bacteria can enter the urinary tract through the urethra (an ascending infection), poor toilet habits (such as wiping back to front for women) can predispose to infection, but other factors (pregnancy in women, prostate enlargement in men) are also important and in many cases the initiating event is unclear. While ascending infections are generally the rule for lower urinary tract infections and cystitis, the same may not necessarily be true for upper urinary tract infections like pyelonephritis which may be hematogenous in origin.

2. Predisposing/Precipitating Factors A. MODIFIABLE FACTORS 1. Toilet Habits Women who wipe back to front can predispose them to infection. Avoiding the urge to void is also a factor because urinary stasis leads to infection. 2. Socio-Economic Status The lack of access to a toilet affects the person’s toilet habits. 3. Fluid Intake Inadequate fluid intake makes the urine concentrated which increases the person’s susceptibility to infections due to the high amount of waste products.

B. NON MODIFIABLE 1. Age UTI is a prevalent disease among children and elderly. 2. Sex UTI has a higher incidence rate with the female gender.

Signs and Symptoms With Rationale • • • • • • • • • • Frequent urination along with the feeling of having to urinate even though there may be very little urine to pass. Nocturia: Need to urinate during the night. Urethritis: Discomfort, irritation or pain at the urethral meatus or a burning sensation throughout the urethra with urination (dysuria). Pain in the midline suprapubic region. Pyuria: Pus in the urine or discharge from the urethra. Hematuria: Blood in urine (not always seen to the naked eye, but often revealed during urine tests). Pyrexia: Mild fever Cloudy and foul-smelling urine Urinary incontinence: Involuntary leakage of urine Increased confusion and associated falls are common presentations to Emergency Departments for elderly patients with UTI. * Some urinary tract infections are asymptomatic.

Health Promotion and Preventive Aspects of the Disease The following are measures that studies suggest may reduce the incidence of urinary tract infections. These may be appropriate for people, especially women, with recurrent infections: • • Do not delay urination when it is necessary. Cleaning the urethral meatus (the opening of the urethra) after intercourse has been shown to be of some benefit; however, whether this is done with an antiseptic or a placebo ointment (an ointment containing no active ingredient) does not appear to matter. • It has been advocated that cranberry juice can decrease the incidence of UTI (some of these opinions are referenced in External Links section). A specific type of tannin, called A Type Proanthocyanidin, found only in cranberries and blueberries prevents the adherence of certain pathogens (eg. E. coli) to the epithelium of the urinary bladder. However the tannins that are found in green tea drunk in a daily dose of around 600mls will provide an excellent and cost effective alternative to cranberry juice in the prevention and prevelance of chronic infection. • • • For post-menopausal women, a randomized controlled trial has shown that intravaginal application of topical estrogen cream can prevent recurrent cystitis. Often long courses of low-dose antibiotics are taken at night to help prevent otherwise unexplained cases of recurring cystitis. Acupuncture has been shown to be effective in preventing new infections in recurrent cases. One study showed that urinary tract infection occurrence was reduced by 50% for six months. However, this study has been criticized for several reasons. All of the studies are done by one research team without independent reproduction of results. • • Studies have shown that breastfeeding can reduce the risk of UTIs in infants. Keeping the Foley Catheter from clogging with biofilm will prevent stasis of urine in the bladder, which serves as a culture medium for bacterial growth.

THE PATIENT’S ILLNESS (Patient-Based) MODIFIABLE FACTORS 1. Toilet Habits Avoiding the urge to void is a factor because urinary stasis leads to infection. 2. Fluid Intake Inadequate fluid intake makes the urine concentrated which increases the person’s susceptibility to infections due to the high amount of waste products.

NON MODIFIABLE 1. Age UTI is a prevalent disease among children and elderly. The patient is years old.

Signs and Symptoms The patient manifested the following: • • • Increased WBC as the body’s response to foreign bodies Cloudy urine due to pus cells Fever

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