KEY wk 7 lec 2 Flashcards
superomeidal aspect of kidney has _____ gland for endocrine function
suprarenal
retroperitoneal structures for urination
superior urinary organs (kidneys and ureters), their vessels, and the suprarenal glands
____ fat surrounds the kidneys and extends to renal sinuse
perinephric
entrance to kidney
renal hilum–> renal sinus
where do renal arteries lie at
L1-L2 vertebrae
segmental arteries all come from which branch
anterior branch
Segmental arteries are distributed to the renal segments as follows
The superior (apical) segment is supplied by the superior (apical) segmental artery
The anterosuperior and antero-inferior segments are supplied by the anterosuperior segmental and antero-inferior segmental arteries
The inferior segment is supplied by the inferior segmental artery.
ALL These arteries originate from the anterior branch of the renal artery.
The posterior segmental artery, which originates from a continuation of the posterior branch of the renal artery, supplies the posterior segment of the kidney.
renal veins drain into
IVC
atomic nerves of the kidneys and ureters
-kidneys: abdominopelvic splanchnic nerves –> renal nerve plexus
ureter: from renal, abdominal aortic, and superior hypogastric plexuses
visceral afferents for pain T11-L2
ureteric pain from ipsilateral lower quadrant of anterior abdomen wall
nerves of the bladder
sympathetic from inferior thoracic and upper lumbar spinal cord to vesicle plexus via hypogastric plexus
PNS from pelvic splanchnic nerves and the inferior hypogastric plexus
PNS fibers in bladder
motor to the detrusor muscle and inhibitory to the internal urethral sphincter of the male bladder.
(this is how men pee; stretching causes bladder to contract then sphincter to relax) (SNS can cause internal sphincter to contract)
prevent release of urine via which sphincters
which for voluntary and involuntary urine
internal and external urethral sphincters
The internal urethral sphincter controls involuntary urine flow from the bladder to the urethra
the external urethral sphincter controls voluntary urine flow from the bladder to the urethra.
–> in males the internal one is also to prevent semen flow into bladder when ejactulate
male urethra
prostatic plexus
hypogastric plexus
prostate nerves
T12–L2 (or L3) spinal cord segments.
splanchnic nerves and the hypogastric and pelvic plexuses
inferior hypogastric/pelvic plexuses.
nerves for female urethra
vesical (nerve) plexus and the pudendal nerve. .
pelvic splanchnic nerves, but the termination receives somatic afferents from the pudendal nerve.
micturition (urination) goal
low pressure bladder filling with periodic voluntary bladder emptying (voluntary switch btwn storage and voiding)
bladder filling
which nerves
sympathetic (hypogastric nerve) and somatic (pudendal nerve)
contract internal smooth and external striated urethral sphincters, respectively
sympathetic mediated inhibition of what muscle allows the bladder to accommodate increasing volumes at low intravesical pressures
detrusor muscle
what center is released from tonic inhibitory control or higher cortical and subcortical centers of the brain when time to void/pee
which other system turns on causing the contraction and relaxation of what muscles
pontine micturition center
The parasympathetic system then switches “on,” stimulating a detrusor contraction and relaxation of the pelvic floor and external and internal urethral sphincters
which brain areas to switch between storage and voiding phases of micturition
periaqueductal gray (PAG)
Frontal, Midcingulate, and Subcortical areas of the brain all contribute as separate levels of control over the PAG and regulation of the LUT (lower urinary tract)
slide 26
umbrella cells are where and for what function
what is their shape and for what function
in urinary bladder for impermeability of bladder wall; resistant to urine
folds/plaques/ridges for expansion and contraction of bladder during filling and emptying (increase surface area)
apical membrane of umbrella cells so impermeable to leak urine
hexagonally arranged Uroplakin plaques
tight junctions
channels in umbrella cells to reabsorb water from urine during dehydration
aquaporin water channels
what protein does umbrella cells keep making for the plaque to maintain integrity in apical membrane and ensure barrier function
continuously synthesize and turnover uroplakins, the major protein components of the urothelial plaques.
role of umbrella cells
maintain bladder integrity
prevent leakage of urine
and protect the underlying tissues from the potentially harmful substances present in urine.
vesicoureteric
what is the junction and its function
junction where ureter enters the bladder AKA ureterovesical junction
preventing the backflow of urine from the bladder into the ureter
vesicoureteric reflux
urine flows back from bladder into ureters and possible kidney
vesicoureteric junction/ valve isn’t working so urine goes back up during bladder filling or voiding
flow of urine
kidneys –> ureter –> bladder
grades of vesicoureteral reflux
grade I (mildest) to grade V (most severe), with grade V involving the reflux of urine all the way up to the kidneys.
urinary tract infection includes
asymptomatic bacteriuria (ASB), cystitis, prostatitis, and pyelonephritis.
asymptomatic bacteriuria and urinary tract infection include
what is the differnece
bacteria in urinary tract, w white blood cells and inflammatory cytokines in urine
ASB has no sx and doesnt require treatment
UTI is more sx and needs antimicrobials
most common way to get UTI
bacteria ascend from urethra to bladder (if get bacteria in bladder i.e. sex, it wont always cause sx infection)
asymptomatic bacteriuria
bacteriuria detected incidentally when do urine screening
no sx
uncomplicated vs complicated cystitis
uncomplicated: bladder infection in healthy person
-sx: dysuria, urinary frequency, urgency, nocturne, hestistency, suprapubic discomfort
complicated: back or flank pain means involves upper urinary tract, fever means involved kidney, prostate, bloodstream. this in in pt with risk factors i.e. pregnant, diabetes…
pyeloneprhtis (kinden infection)
mild vs severe
mild: low grade fever, with or w/o low back or costovertebral angle pain
severe: high fever, rigours, N/V, flank or loin pain
main distringuishing feature btwn cystitis and pyelonephrtitis
fever
fever of pyelonephritis typically exhibits a high spiking “picket-fence” pattern and resolves over 72 h of therapy.
signs of pyelonephritis
increase serum creatine
papillary necrosis
emphysematous pyelonephritis
who does it occur in
gas in renal and perinephritc tissues in diabetic people
Xanthogranulomatous Pyelonephritis
cause
chronic urinary obstruction (often by staghorn calculi), together with chronic infection, leads to suppurative destruction of renal tissue
lipid laden macrophages, yellow, intraparenchymal abscess
urosepsis
bacteria in urinary tract, from bladder or kidneys, enters bloodstream and causes sepsis (systemic)
low BP, fever, chills, rapid HR and breathing, confusion, decreased urine
IV antibiotics, stabilize vitals, manage organ dysfunction
normal vaginal microbiomes
lactobacillus species
L. crispatus, L. gasseri, L. jensenii, and L. iners
environment in vaginal
acidic via lactic acid production (from lactobacilli)
also make antimicrobials: hydrogen peroxide and bacteriocin-like substances
normal vaginal microbiota
dominance of Lactobacillus species and a stable acidic pH, which helps to maintain the vaginal ecosystem and protect against infections.
UTI risk factors
obstruction i.e. renal stone, urethral stricture
short urethra length
bladder catheterization
microorganism causing UTI
E. coli 75%
klebsiella 15%
proteus 5%
15% of cystitis cases in young, sexually active women from
s. saprophyticus
nosocomial infections of UTI (hospital)
Enterobacter, Pseudomonas, enterococci, Candida, S. epidermidis, and Corynebacterium.
e coli. causing UTI have what virulence factors
adhesins
–> P. fimbriae (interact with receptor on renal epithelial cells) ;; can cause pyelonephritis
–> type 1 pilus (fimbria) (bind uropethial cells in bladder via mannose) ;; for bladder infection
operons; respond to envo; turn on and off flagella
what does P fimbriae from e coli bind to
blood group antigen P, which contains a D-galactose-D-galactose residue
what do type 1 pilus fimbriae on e coli bind
mannose on the luminal surface of bladder uroepithelial cells.
impact of type 1 pilus (fimbria) on e coli
This increased ability to adhere to the epithelial cells of the urethra in addition to increased resistance to serum cidal activity and hemolysin production makes them very invasive
what on e coli respond to envo to turn on or off flagella
operons
The expression of flagella and other surface molecules allows bacteria to alternate between migrating up the urethra and ureters and adhering to epithelial cells in the urinary tract.
proteus bacteria need to synthesize what for optimal growth
guanine, arginine, and glutamine
proteus mirabilis produces what that causes pyeloneprhtitis
and how does it do so
make ureases
which generate ammonium and raise urine pH >7
alkaline urine= bacterial growth and renal stones
what does proteus bacteria make
ureases
IgA proteases
hemolysin
operons (turn on and off flagella)
endotoxin
what does endotoxin in proteus bacteria do to cause pyelonephritis
decreasing ureteral peristalsis, slowing the downward flow of urine and enhancing the ability of gram-negative bacteria to ascend into the kidneys.
klebsiella bacteria causing nosocomial UTIs via
what factors they have
bladder or kidney via fimbriae and adhesins
form biofilms to protect against host immune response and antibiotics
virulence factors: polysaccharides, LPS, toxins, siderophores
antibiotic resistnat
enterococci causing UTI via what
indwelling catheterization
instrumentation
or anatomic abnormalities of the genitourinary tract
enterococci and s. epidermis virulence
biofilms
virulence factors: surface proteins, adhesins, toxins, and enzymes.
interstitial cystitis
chronic bladder pain (and outside i.e. pelvis, abs, genitals) and inflammation
lower urinary tract symptoms
causes of interstitial cystitis
Infection and the urinary microbiota (dysbiosis; no specific microbe)
Autoimmunity
Inflammation
Urothelial dysfunction
autoimmune and interstitial cyctitis
anti-urothelial antibodies
inflammatory infiltrate: lymphoplasmacytic infiltrates, stromal edema and fibrosis, urothelial denudation, and detrusor mastocytosis.
inflammation in interstitial cystitis
Hunner lesions—discrete inflammatory lesions
interstitial cystitis and ureothelial dysfunction
urothelrium (stratified epithelium in the bladder)
urothelium has GAGs and tight junctions and umbrella cells for robust barrier
defects in barrier then could cause bladder pain syndrome
sx of interstitial cystitis
men and female
pain In bladder associated w urinary storage
urinary frequency + urgency
complications of interstitial cystitis
mental health and quality of life, suicide
associated with fibromyalgia, RA, peripheral neuropathy
most common tumor for bladder cancer
urothelial malignant neoplasms/ urotwhelial carcinomas
most common site for tumor in urinary tract
bladder
risk factors for bladder cancer
Cigarette smoking and exposure to industrial dyes or solvents
Cigarette smoking (fourfold increased risk)
Industrial exposure to azo dyes
Infection with S. haematobium (in endemic regions)
Drugs, such as cyclophosphamide and analgesics
Radiation therapy (following cervical, prostate, or rectal cancer)
3 papillomas (bengign epethial tumor) in bladder cancer
- urothelial papilloma (classic exophytic and inverted)
- exophytic papilloma: papillary fronds in transitional epithelium (grows outward to epithelial surface)
- inverted papillomas: nodular mucosal lesions in trigone area (grows inward into underlying epithelium)
urothelial carcinoma in situ
callular atypia: loss of nuclear polarity, nuclear irregularity, enlargement, hyperchromatism, and prominent nucleoli. The basement membrane is intact, and there is no invasion into underlying stroma.
where does papillary cancer occur most often
lateral or posterior bladder walls
Papillary urothelial neoplasms of low malignant potential
larger than papillomas but lack cytologic and architectural atypia that is seen in low grade carcinomas
Low-grade papillary urothelial carcinoma:
vs high grade
Low-grade papillary urothelial carcinoma: Low-grade tumors have fronds lined by neoplastic urothelial epithelium with minimal architectural and cytologic atypia . The cells are moderately hyperchromatic with little nuclear pleomorphism and low mitotic activity. Papillae are long and delicate. Invasion of the lamina propria or the deep muscularis propria occurs in 10%.
High-grade papillary urothelial carcinoma: These tumors show significant nuclear hyperchromasia and pleomorphism. The epithelium is disorganized with mitoses in all layers. Approximately 80% of all high-grade tumors invade the lamina propria and, less often, the muscularis propria, or through the entire thickness of the bladder wall. Regional lymph nodes contain metastatic tumor in half of patients with these invasive tumors.
invasie urothelial caricnoma
highly malignant
from papillary lesion or flat carcinomas in situ
tumor extension and subsequent recurrence of bladder cancer increases with
Increased tumor size
High stage
High grade
Presence of multiple tumors
Vascular or lymphatic invasion
Urothelial dysplasia (including carcinoma in situ) at other sites in the bladder
sx of bladder cancer
hematuria
dysuria
cystoscopy shows tumor
bladder cancer stages via
most common metastases?
tumor node metastasis (TNM) system In order of decreasing frequency, metastases involve the regional and periaortic lymph nodes, liver, lung, and bone.
