Lesson 4

Urinary Pathology
 Recall the key anatomy
Components of the urinary
system:

• Kidney
• Ureter
• Bladder
• Urethra

• This is often called the

“KUBU” system
 Inside the Kidney
• Each kidney has about 1
million nephrons in it
• If there are no nephrons
working, there is no
kidney working either!!
• The nephrons are
where urine is created
 Glomerulus
• Recall the glomerulus is
a large network of
capillaries in the kidney
• Blood enters here and
gets filtered prior to
going into the nephron
 Bowman’s Capsule
• The glomerulus sits in a
pocketed structure
called the Bowman’s
Capsule
 The nephron: names of parts
1) Proximal convoluted
tubule
2) Descending loop of
Henle
3) Ascending loop of
Henle
4) Distal convoluted
tubule
Cross sectional view
 Kidney pathology
• If the kidney doesn’t
work as a good filter
any more, then we may
lose good stuff in the
urine and retain bad
stuff in the body
• e.g. acid & wastes
retained while protein
and blood are lost!
 Urine Composition
Things that should be there Things that shouldn’t be there
• Urea • Bacteria
• Acid • Blood
• Bicarbonate • Proteins
• Bilirubin • Glucose
 Kidney disease and Edema
• Edema can be defined as palpable swelling
produced by expansion of the interstitial fluid
volume
• The most common site of plasma protein loss
is the kidney
• Plasma proteins exert the osmotic force
needed to pull fluid back into the capillary
from the tissue space
 Kidney disease & Edema
• If plasma proteins are lost in the urine due to
kidney disease, the “sucking” force the
proteins exert in the blood is lost
• This allows water to escape from blood vessels
into the interstitial fluid, resulting in palpable
swelling
 Ureter blockage
• If the ureter is blocked,
anything before the
blockage cannot get
released and we get
buildup of urine and
swelling
• This can do kidney
damage as urine is
toxic!!
 What can block the ureter?
• Tumours
• Infections
• Stones
• Foreign bodies

• A swollen kidney is
called hydronephrosis
 What is stasis?
• Ureter blockage
prevents urine from
exiting, so it sits there
and accumulates (stasis)
• Anything that stands
still is a breeding
ground for infection!
 Pain patterns
• Kidney pain can often
refer pain to the lower
back, flank area or
genital area
• Often are made worse
by straining, coughing
and by drinking fluids
 Renal Pain
– Obstruction of the renal pelvis or upper ureter
causes pain and tenderness over the flank area
– With lower levels of obstruction, the pain may
radiate to the testes in the male or the labia in the
female
– With partial obstruction, particularly of the
ureteropelvic junction, pain may occur during
periods of high fluid intake when a high rate of
urine flow causes an acute distention or the renal
pelvis
 Renal developmental issues
• Horseshoe kidney: both
kidneys fused into one –
still works normally
• Renal agenesis: one
does not develop at all
 Renal Hypoplasia
• means that part of a
kidney does not fully
develop in the womb
• The kidney may be only
slightly smaller than
usual or it may be tiny
• Because of its size, it
may not work as well as
a normal-sized kidney
 Renal Hypoplasia Causes
• It is not always possible to
know why renal hypoplasia
happens
• In the majority of cases, it
is not caused by anything
that the mother does
during her pregnancy
• It is unlikely that a future
pregnancy will result in
renal hypoplasia or other
problems with the kidneys
 Altered position
• An ectopic kidney is a
birth defect in which a
kidney is located below,
above, or on the
opposite side of its
usual position
• Often it functions
completely normally
 Causes of ectopic kidney
• No real answer
• Thought to be genetic
or if the mother took a
drug that resulted in
congenital anomaly
during pregnancy
 Kidney Infections
• Urinary tract infections
(UTI) can occur in the
upper or lower regions
• Most common
causative bug is E. Coli
bacteria
 Route of entry
• E. Coli enters through
the urethra
• Women more at risk
because vagina can
be easily
contaminated with
fecal flora
• Also, women have
no prostatic fluid
present to fight
infection
 Risk factors for UTI
Risk factors:
• Catheterization
• Sexual activity
• Prostate disease
• Impaired bladder
emptying
• Elderly (immobility)
 Catheter Induced Infection
• Urinary catheters – are a source of urethral
irritation and provide a means for entry of
microorganisms into the urinary tract
• Catheter-associated bacteriuria remains the
most frequent cause of gram-negative
septicemia in hospitalized patients
Upper Vs. Lower UTI
Upper vs. Lower UTI by name
• Upper:
Ureteritis: ureter infection
Pyelonephritis: kidney infection

• Lower:
Cystitis: bladder infection
Urethritis: urethra infection
 Prolonged obstruction
• This can cause backflow
of acidic urine which
can damage the kidney
if not released
• Upper UTI are worse
than lower due to the
close proximity of the
renal artery and chance
of sepsis
 Reflux
• Reflux occurs when the urine from the urethra
moves into the bladder (urethrovesical reflux)
or from the bladder into the ureters
(vesicoureteral reflux)
• Because the urethral orifice frequently is
contaminated with bacteria, the reflux
mechanism may cause bacteria to be drawn
back into the bladder
 UTI symptoms
• Fever (especially in kids)
• Dysuria (painful pee)
• Cloudy urine
• Increased frequency
and urgency for
urination
• Nausea and lower back
pain
 Defenses against UTI
1) The washout
phenomenon, in which
bacteria are removed
form the bladder and
urethra during voiding
2) The protective mucin
layer that lines the
bladder and protects
against bacterial
invasion
3) Local immune
response
 UTIs and kids
• UTIs in children frequently involve the upper
urinary tract (pyelonephritis)
• Unlike adults, children frequently do not
present with the typical signs of a UTI
• Fever is the most common sign of UTIs in children
and the possibility of UTI should be considered in
children with unexplained fever
 UTIs and kids
– Toddlers often present
with abdominal pain,
vomiting, diarrhea,
abnormal voiding patterns,
foul-smelling urine, fever,
and poor growth
– In older children with
lower UTIs, the classic
features – enuresis,
frequency, dysuria, and
suprapubic discomfort are
more common
 Pyelonephritis
• infection of one of both
kidneys usually due to
urinary tract infection
• refers to an
inflammation of the
kidney parenchyma
and renal pelvis

Manifestations: fever with

chills, vomiting, abdominal or
back pain
 Acute Pyelonephritis
• Factors that contribute to the development of
acute pyelonephritis are catheterization and
urinary instrumentation, vesicoureteral reflux,
pregnancy, and neurogenic bladder
• The onset of acute pyelonephritis typically is
abrupt, with chills, fever, headache, back pain,
tenderness over the costovertebral angle, and
general malaise
– It usually is accompanied by symptoms of bladder
irritation, such as dysuria, frequency, and urgency
 Chronic Pyelonephritis
• Chronic pyelonephritis may cause many of the
same symptoms as acute pyelonephritis, or its
onset may be insidious

– Severe hypertension often is a contributing factor

in the progress of the disease
– Chronic pyelonephritis is a significant cause renal
failure
 Glomerulonephritis
– inflammation of
glomeruli within the
kidney
– Occurs due to
infection by
Streptococcus
bacteria
Manifestations: decreased
urine output, proteinuria,
anemia and back pain.
 Glomerulonephritis
– It is the leading
cause of chronic
renal failure in the
US
– Accounts for one
half of persons
with end-stage
renal disease
 Glomerulonephritis
– The disease may occur
as a primary condition in
which the glomerular
abnormality is the only
disease present
– It may also occur as a
secondary conditions in
which the glomerular
abnormality results from
another disease, such as
diabetes mellitus or SLE
 Drug-related Nephropathies
• Drug-related nephropathies involve functional or
structural changes in the kidneys that occur after
exposure to a drug
– The kidneys are exposed to a high rate of delivery of any
substance in the blood because of their large blood flow
and high filtration pressure
• Drugs and toxic substances can damage the
kidneys by causing a decrease in renal blood
flow; obstructing urine flow; directly damaging
tubulointerstitial structures; or producing
hypersensitivity reactions
 Nephrotic syndrome
Occurs due to damage
to glomeruli due to
many causes such as
heavy metals
Manifestations: loss of
protein (albumin) in the
urine
- General edema
- proteinuria
 Renal Calculi (Kidney Stones)
• AKA nephrolithiasis

–Kidney stones typically

leave the body by
passage in the urine
stream, and many
stones are formed and
passed without
causing symptoms
 Renal Calculi (Kidney Stones)
• If stones grow to
sufficient size before
passage (usually at
least 2-3 millimeters),
they can cause
obstruction of the
ureter
 Renal Calculi (Kidney Stones)
There are several types
of kidney stones based
on the type of crystals
of which they consist
– The majority are
calcium oxalate
stones, followed by
calcium phosphate
stones.
 Renal Calculi (Kidney Stones)

There can be blood in

the urine, visible with
the naked eye or
under the microscope
(macroscopic or
microscopic
hematuria) due to
damage to the lining
of the urinary tract
 Renal Calculi (Kidney Stones)

The resulting obstruction

causes dilation or
stretching of the upper
ureter and renal pelvis
This leads to pain, most
commonly felt in the
flank, lower abdomen
and groin (a condition
called renal colic)
 Colic vs. non colic
Classic ureter colic is manifested by acute, intermittent,
and excruciating pain in the flank and upper outer
quadrant of the abdomen on the affected side
• Pain may radiate to the lower abdominal quadrant,
bladder area, perineum, or scrotum in the male
Noncolicky pain is caused by stones that produce
distention of the renal calices or renal pelvis
• Pain is usually is a dull, deep ache in flank or back that
can vary in intensity from mild to severe
• The pain is often exaggerated by drinking large
amounts of fluid
 Kidney Cancer
• Kidney cancer is
largely a silent
disorder during its
early stages, and
symptoms usually
denote advanced
disease
 Kidney Cancer
• In approximately
one thirds of cases,
metastases are
present at the time
of diagnosis
 Renal cell carcinoma
• Adults kidney cancer accounts for 2% to 3% of
all new cancers
• Renal cell carcinoma originates in
the renal cortex and accounts for
approximately 80% to 85% of
kidney tumours
 Kidney Cancer Risk Factors
• The cause of renal
cell carcinoma
remains unclear
– Some of these
tumours may occur
as a result of chronic
irritation associated
with kidney stones
 Kidney Cancer Risk Factors
– Epidemiologic
evidence suggests a
correlation between
smoking and kidney
cancer
– Obesity also is a risk
factor, particularly
in women
 Diabetes and Kidney Disease
• Diabetic
nephropathy, or
kidney disease, is a
major complication
of diabetes mellitus
• The glomerulus is
the most
commonly affected
structure in
diabetic
nephropathy
 Hypertension
• Hypertension can
be viewed as both
a cause and an
effect of kidney
disease
 Self Test Questions
• What does hydronephrosis mean?
• What does pyelonephritis mean?
• What are kidney stones most commonly made of?
• What common endocrine condition is associated with
kidney disease?
• What is worse: upper urinary tract infection or lower?
Why?
• What is an ectopic kidney?
• Most common bug for UTI is?
• What does urinary stasis mean? Why is this bad?
 Self Test Questions
• Name 3 potential risk factors for kidney cancer
• Where is the pain in renal colic?
• What structure in the kidney receives blood to
be filtered?
• What protein is present in the urine with
nephrotic syndrome?
• What is blood in the urine called?
• What is pain with urination called?