Clin Med- GUT Genitourinary tract Anatomy & Radiology Flashcards
Anatomy of the KUB:
-Note location of the Kidneys, ureters and bladder
Image: slide 3
-Superior mesenteric a
Note how high the gonadal vessels are
L1= transpyloric line (body of the pancreas, duodenal curve, AND renal arteries are there!!!!)
-Pt with stenosis of the renal artery can cause HTN (renal HTN) and activate the renin angiotensin system
-note bladder and rectum
Note location of constrictions in the KUB:
first constriction=
second constriction=
third constriction=
first= Ureteropelvic junction 2nd= pelvic inlet
3rd= entrance to bladder
(notes: Narrowing and constrictions in the urinary tract and the constrictions are where stones hang out_
Ureter calculi are EXCEEDINGly painful- stones
Psoas Major: is innervated by ___
-Psoas major joins the Iliacus (___ Femoral Nerve)–> Iliopsoas
L1-L3
-L2-4 Femoral nerve**
Quadratus Lumborum is innervated by _____
T12 to L4
Psoas abscess can
occur, with pain and
____
Psoas spasm
What is the function
of the Psoas and Iliopsoas?
Combined with the iliopsoas muscle, the psoas is a major contributor of flexion of the hip joint
Notes:–Sometimes there can be abscesses in the Psoas muscle-– so if the psoas muscle contracts the hip this will pull the lesser trochanter up and anterior and there will be external rotation of the thigh and these Pts will be bent over and while supine they will resist the straightening or internal rotation of their leg (iliopsoas m)
Kidneys are swimming pool shaped organ in the _________
**retroperitoneum
Kidney:
-Supine, approximately ___ to ___ vertebrae, at the ribs ___ to _____
**approx T12 to L3 vertebrae, Ribs 11-12 to L3-4
T/F: Right kidney is lower than the left
True!
On the right, the kidney is close to the ________ (which organs)
descending duodenum,
posterior liver, hepatic flexure
of colon
On the left, the kidney is close to the ______ (which organs?)
Stomach, Spleen, Pancreas, and Splenic Flexure
Medially to the kidneys are the _____ muscles
psoas**
Kidneys are retroperitoneal and are surrounded by _____ _____
renal fascia
The kidney’s are protected from pancreatitis by ______
gerota’s fascia
Note: Renal fascia and ____ surround the kidneys, as well as _____ muscle, and the IVC and aorta
perinephric (perirenal) fat
-Psoas m
Describe the internal structure of the kidneys:
-Hilum of the kidney contains:
- renal artery
- renal vein
- renal pelvis
- ureter
Describe the fx of minor and major calyx of the kidneys
A minor calyx surrounds the renal papillae of each pyramid and collects urine from that pyramid aka “cups” urine. Several minor calyces converge to form a major calyx. From the major calyces, the urine flows into the renal pelvis; and from there, it flows into the ureter.
Level of the renal arteries=
L1-L2= Transpyloric line**
Aortic aneurysms can involve the _____
renal arteries
Note “constrictions” in the ureters. Stones tend to hangup at these levels –-> leading to _____
**hematuria
**Visceral afferents (pain fibers) return
to ___ to ___spinal cord levels. Pain is referred to cutaneous areas supplied
by __ to ___ -– posterior and lateral abdominal wall below ribs and above iliac crest into scrotum and labia majora
and proximal anterior thigh
- T12 to L2**
- T12 to L2
4 parts of the urethra in males
- Preprostatic part of urethra
- Prostatic part of urethra
- Membranous part of urethra
- Spongy part of urethra
Short Urethra is thought to predispose the female to ____
**cystitis
Bladder catheters for females are:
straight shot with a curve anteriorly
Inserting Catheters into males:
Straighten the penis out so you have a straight shot and use that catheter bend and insert into the 2nd bend of the penis so it goes into the bladder easily. IF the bend is going in the OPPOSITe direction this can damage the urethra
With filling of the bladder, the detrusor muscle is in it’s relaxed state, the control mechanism is ____.
-The internal sphincter and external sphincter are both _____
**sympathetic (B2)
contracted**
- -internal sphincter (contracted via sympathetic (alpha 1)
- -external sphincter contracted via voluntary** control
Spinal cord level ___-___ controls B2 (detrusor muscle in the relaxed state)
L1-L3**
Emptying of the bladder:
- Detrusor muscle is _____ via _____ control mechanism
- Internal sphincter is _____ via _____
-external sphincter is _____ via ______
- **contracted via parasympathetic (M)= S2-4
- relaxed via parasympathetic (M) (S2-S4)
- Relaxed via Voluntary control
External sphincter= _____ control
somatic, voluntary muscle –allows you to hold pee in
When you have to pee–>
detrusor contracts via parasympathetic control, the internal sphincter relaxes via the Parasympathetic system and external sphincter relaxes via voluntary control. => emptying of the bladder
KNOW!!
Surrounding the testis is the _____
**tunica vaginalis
Note the normal Inverted Y or lambda shape of the _____ gland
Adrenal Gland**
Benign adrenal adenoma:
-how common?
common
Pheochromocytoma=
a small vascular tumor of the adrenal medulla, causing irregular secretion of epinephrine and norepinephrine, leading to attacks of raised blood pressure, palpitations, and headache.**
Conn tumor: causes ______
**hyperaldosteronism= HTN and excrete K+ in urine
60 yo male presents with HTN and hypokalemia. Dx=
Conn tumor= hyperaldosteronism
Adrenal carcinoma:
-how common?
rare
VUR:
-does it cause renal damage?
-nt necessarily!
Primary VUR=
=genetic predisposition to short ureteral tunnel through bladder) – small chance of renal damage from VUR
Secondary VUR=
2/2: bladder and/or urethral dysfunction, ie neurogenic bladder or posterior urethral valves) – **These cases have the most problems and have increased chance of renal damage from VUR. See below
VUR:
- VUR does not predispose to UTIs if there is no stasis of urine in the GUT.
- A Hydronephrosis found on prenatal Ultrasound requires a follow-up evaluation after birth to determine etiology.
- 30-40% of children <5 yrs with UTIs have VUR
- Febrile UTIs, or VUR plus UTIs have increased chance of renal scarring
- Surgery to reimplant ureters and/or prophylactic antibiotics do not necessarily prevent urinary tract infections and/or renal damage.
- Greater grade of reflux associated with increased chance of renal damage
VUR: bottom line
VUR and UTIs require individual evaluation and treatment as these are complex entities with still evolving knowledge of their associations
____ is the MC bug for UTIs
E. coli**
VUR Grade 1-4
Grade 1, grade 3 , grade 4 (signif atrophy of renal tubules), Grade 5= atrophy of tubules and cortical loss
VUR work-up should include:
- a VCUG or Isotope Cystogram and a Radionuclide DMSA Renogram
- You are evaluating renal parenchyma and presence of reflux.
“Christmas tree” bladder or atonic bladder=
**Neurogenic bladder!!
Contraction of the bladder against a constricted ureteral sphincter= CHRISTMAS tree bladder= neurogenic bladder
Components of urinary storage and voiding:
Autonomic Nervous System (SNS and PSNS) and Somatic NS
Urinary storage and voiding:
-PSNS from pelvic nerves arising from ____, The Spinal Micturition Center, carries
motor and stretch sensory receptors
-SNS carries motor and sensory (pain, touch, and temperature) from Thoracolumbar
segments ______
-Pudendal Nerve (Striated external sphincter and UG Diaphragm) motor
and Sensory Somatic fibers from ____
-PMC =
- S2-4
- T11- L2
- S2-4
- Pontine Micturition Center
Motor Supply to bladder musculature, the involuntary sphincter, and striated
external sphincter is from _____– The Spinal Micturition Center
S2-4
Note that the Spinal Micturition Center is located at the level of the \_\_\_\_ and \_\_\_\_, vertebral bodies (Conus Medullaris)
T12 and L1
tip of conus medullaris= L1
Micturition Reflex is coordinated in the ______
Pontine Micturition Center (PMC)
Urinary Storage - Bladder Storage Reflex (describe the urine storage reflex)
During the storage of urine, distention of the bladder produces low-level vesical afferent firing. This in turn stimulates the sympathetic outflow in the hypogastric nerve to the bladder outlet (the bladder base and the urethra) and the pudendal outflow to the external urethral sphincter.
- These responses occur by spinal reflex pathways and represent guarding reflexes, which promote continence.
- Sympathetic firing also inhibits contraction of the detrusor muscle and modulates neurotransmission in bladder ganglia.
Micturition Reflex (aka voiding reflex): describe
During the elimination of urine, intense bladder-afferent firing in the pelvic nerve activates spinobulbospinal reflex pathways (shown in blue) that pass through the pontine micturition center. This stimulates the parasympathetic outflow to the bladder and to the urethral smooth muscle (shown in green) and inhibits the sympathetic and pudendal outflow to the urethral outlet (shown in red).
Neurogenic/Neuropathic Bladder:
-classification systems?
There are multiple Classification Systems given the multiple etiologies, multiple levels of injury, and multiple components to storage and micturition.
Overactive detrusor, overactive sphincter=
cant let urine out?
Overactive detrusor and normal spincter=
constantly peeing?
Normal detrusor and underactive sphincter=
?
Underactive Detrusor and overactive sphincter–>
?
Normal detrusor and overactive sphincter=
?
**Overactive detrusor and underactive sphincter=
Pt WET ALL the time**
UMN lesion:
- characteristics=
- Clinical manifestation=
- Causes=
- no inhibitions, bladder is emptied in response to stretching of bladder wall
- incontinence, frequency, urgency, **voiding is unpredictable and incomplete
- Causes: corticospinal tract lesion (from stroke, MS, brain tumor)
LMN:
- characteristics=
- Clinical manifestation=
- Causes=
- bladder acts as if there were paralysis of motor fx’s
- **fills without emptying, retention, dribbling incontinence
- Causes: lesions that involve S2-S4, lesions of pelvic nerve
Supra-pontine neurologic disorders=
Loss of tonic inhibition of the PMC. Spontaneous involuntary detrusor overactivity. Storage dysfunction.
Examples: CVA, Traumatic brain injury, Normal pressure hydrocephalus, Cerebral palsy, Parkinson’s
Pontine neurologic disorders=
Rare. Mixed findings, urinary tract retention, detrusor underactivity.
Examples: Brain tumors, cerebellar ataxia syndromes, ischemic infarcts
Supra-sacral spinal cord/upper motor neuron disorders:
**Detrusor overactivity; storage and emptying dysfunction – urinary urgency/frequency, urge incontinence, intermittent stream, hesitancy; urinary retention (spinal shock initially).
Examples: Spinal cord injury, degenerative disc disease, spina bifida.
Sacral spinal cord disorders:=
**Detrusor underactivity (acontractile detrusor), tonic contraction of smooth muscle urinary sphincter, emptying dysfunction, uroflow absent/diminished.
Examples: Cauda equina syndrome, post radical pelvic surgery
LMN/neuropathy disorders=
**Detrusor underactivity, urinary retention, impaired sensation.
Examples: Diabetes mellitus, peripheral neuropathy, Guillain-Barre
Non-neurologic lesions=
Fowler’s Syndrome: idiopathic spasm of urethral sphincter, urinary retention. Dementia, incontinence
Damage to any of the nerves involving the storage and micturition of urine can cause a ______ ______
neurogenic bladder.
(KNOW)
A lesion above the brain stem affecting micturition can result in ______
involuntary bladder contractions (detrusor hyperreflexia) with coordinated sphincter relaxation, ie urge incontinence, a sudden strong urge to urinate.
A complete lesion of the spinal cord above T12 vertebral body:
**may leave the spinal reflex center intact, an upper motor neuron lesion. These patients have detrusor hyperreflexia and an uncoordinated spastic external sphincter (detrusor-sphincter dyssynergy), residual urine with reduced bladder capacity.
**A lesion to the spinal micturition reflex center or below can lead to ______
a LMN lesion with detrusor areflexia. Both motor and sensory fibers are affected. Loss of a sense of fullness, weak and un-sustained contractions, incomplete bladder emptying with large amounts of residual urine.
Neurogenic Bladder: UMN type (summary)
-spastic bladder
-Hypertonic
-normal or small volume
-Detrusor contraction= overactivity
–urge incontinence
-Sx= urgency/frequency, nocturia
Retention= incomplete bladder voiding,
Conditions= Spinal cord damage above T12, CVAs
Neurogenic Bladder: LMN type (summary)
- flaccid bladder
- Hypotonic
- Large volume
- detrusor contraction= underactivity
- Overflow incontinence
- Sx: dribbling, ED in men
- Conditions= spinal cord damage at S2-S4, peripheral nerve injury, cauda equina damage, or conus medullaris
After injury, a shock phase may last weeks to months. The bladder can have no sensation and be _____
areflexic
Bladder dynamics in neurogenic bladders often change over time. Periodic reevaluation is required.
Complications include: ?
UTI, vesicoureteral reflux with damage, stone formation, incontinence.
Neurogenic Bladder: tx
-Hyperreflexic bladder=
Decrease residual volume with meds (alpha antagonists), surgery (TURP), clean intermittant catheterization, increase functional capacity with meds (anticholinergics), botox, enterocystoplasty.
Neurogenic Bladder: tx
-areflexic bladder=
Facilitate complete emptying, Crede, TURP, timed voiding, timed clean intermittent catheterization.
-**Try to avoid chronic indwelling catheters, due to infection.
urolithiasis=
the formation of stony concretions in the bladder or urinary tract
Flank pain and hematuria=
**renal stone
- -Causes uretocolic pain!! VERY severe pain and it comes and goes (as It travels down) classic situation= “hot day and under or over hydrated”
- if you over hydrate you can dilate renal pelvis
Ureteric calculi=
stones lying within the ureter, at any point from the ureteropelvic junction (UPJ) to the vesicoureteric junction (VUJ). T
- hey are the classic cause of renal colic-type abdominal pain.
- They are a subtype of the broader pathology of urolithiasis.
________ IS THE DIAGNOSITIC TEST OF CHOICE TO EVALUATE FOR THE STONE AND OTHER DIAGNOISTIC POSSIBILIES
**NON CONTRAST SPIRAL CT
Hydronephrosis can occur 2/2 ______
ureteral obstruction**
Renal papillary necrosis:
-causes?
- seen in Diabetic pts (Any one can get it if they have issues with vascularity – think DM OR smokers – small arterioles will narrow)
- Analgesic induced** (tylenol)
Nephrocalcinosis:
-cortical forms can be seen in:
ACUTE CORTICAL NECROSIS, CHRONIC GLOMERULONEPHRITIS, PROLONGED HYPERCALCEMIA AND HYPERCALCURIA, POISONING AND TOXICITIES.
Nephrocalcinosis:
medullary forms seen in:
HYPERPARATHYROIDISM, MEDULLARY SPONGE KIDNEY, RENAL TUBULAR ACIDOSIS, RENAL PAPILLARY NECROSIS, AND MILK-ALKALI SYNDROME, AND HYPEROXALURIA. .
Adult Polycystic kidney disease
- autosomal dominant form** (runs in families)
- many cysts in the kidney
- it’s lethal*
(on imaging: NOTE GROSSLY ENLARGED KIDNEYS ON IVP ON LEFT. NOTE LIVER AND PANCREAS CYSTS ON RIGHT
Horse shoe kidney=
when the 2 kidneys join (fuse) together at the bottom to form a U shape like a horseshoe. It is also known as renal fusion. The condition occurs when a baby is growing in the womb, as the baby’s kidneys move into place. Horseshoe kidney can occur alone or with other disorders.
Renal artery stenosis–> leads to decreased BP in kidneys–> **Activation of RAAS leads to _______
**HTN
-
for RAS, activation of RAAS creates HTN–>
This Hypertension is potentially curative: (why?)
- Atherosclerotic form treated with meds initially then with balloon angioplasty or surgical correction of the stenosis.
- Fibromuscular form treated with balloon angioplasty
2 forms of RAS:
- atherosclerotic
- Fibromuscular Dysplasia (Hyperplasia)
*-assess by checking for bruits over renal arteries- at the transpyloric line =L1
Fibromuscular Dysplasia:
- causes?
- describe
- tx?
-Can be genetic, with familial association
=Fibrous thickening of all layers of artery wall
-HTN treatable with balloon angioplasty
smoker and painless hematuria=
Carcinoma of the bladder** until proven otherwise
On Transrectal Ultrasonography:
hypoechoic areas suggest _____
**carcinoma of the prostate
Cryptorchidism=
congenital (born without testes) if no testicle– it prbly has not decended, for a year or so the vast majority will descend, BUT if it doesn’t you must look for it high chance it’s malignancy
large avascular,
hypoechoic left Testis=
**testicular torsion
Why does it happen? The testicle can rotate within the tunica and that causes the torsion . THERE IS NO BLOOD FLOW
“bell clapper deformity”=
**testicular torsion
Testicular Torsion: ddx
Epididymitis= increased blood flow to the epididymis and normal flow to the Testis
Epididymo-orchitis=> shows diffusely increased blood flow to the Testis
Testicular Malignancy:
seminoma–>
vs
mixed germ cell tumors–>
Seminomas can be treated successfully
-mixed germ cell tumors not so much
PCOD =
Enlarged ovaries with thick sclerotic capsules and an abnormally high number of follicles
Stein-Leventhal Syndrome=
amenorrhea, infertility, hirsutism and enlarged polycystic ovaries
Ovarian torsion:
-how common?
- *very common.
- -pelvic pain or lower abdominal pain- NEED to know ddx for this
Question: young woman with lower abdominal pain —> ddx: PID, ectopic pregnancy**, and ovarian torsion, ruptured ovarian cyst, Ectopic pregnancy is lethal. Criteria= beta Hcg
- gluteus medius/minimus= innervated by _____
- Inferior gluteal nerve innervates the ______ via the greater sciatic foramen
superior gluteal nerve
-gluteus maximus
**Uterine Adenomyosis=
ectopic endometrial glandular tissue in uterine muscle
**thickened myometrium on imaging
parametrial invasion of contrast seen on imaging in
this patient=
carcinoma of the cervix**
a woman has uterine bleeding post menopausally YOU NEED TO R/O:
endometrial carcinoma**
_____ gland is a very common metastatic site
**adrenal gland
Infantile Polycystic kidney disease=
-autosomal recessive form
This case is in newborn infant, often picked up in fetal US–> this is a significant problem cuz these kids kidneys are non functioning
- these children will need to be on dialysis **
- urine produces amniotic fluid (significant portion of it) if these kidneys are non functioning–> so these kids will have oligohydramnios (less amniotic fluid)
