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Renal and Urinary 3 > Normal and Abnormal Transport of Urine After Leaving the Nephron > Flashcards

Normal and Abnormal Transport of Urine After Leaving the Nephron Flashcards

1
Q

Smooth muscle spasm in ureter

Or lack of smooth muscle tone

A

Very painful…most commonly from acute obstruction due to stone

Dec - pregnancy or chronic obstruction

ALso can have vesicouretral reflux

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2
Q

Stone passing through ureter

A

Causes renal colic

Where bladder and kidney will cause blood, reucrrent infections, pain

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3
Q

Renal colic

A

Acute, severe, worse than labor

Intermittnet

Starts in flank and can move to lower abdomen as stone moves

KIdney capsule distention —- N/V

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4
Q

Colic vs. peritonitis - physical exam

A

Peritonitis - main area of tenderness is the abdomen, guarding with or without rebound tenderness…hurts to move, pt stays still

Colic - CV angle tenderness, pt needed to keep moving

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5
Q

Suspected urinary stone analysis

A

Hematuria is classic

Main reason for doing UA is to eval for infection bc ureteral obstruction and infection is life-threatening emergency

Do not HAVE to have blood

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6
Q

Suspected stone - hemogram and electrolytes, BUN, creatinine

A

Anemia not typical for sotnes…main goal is to check WBC count

Electrolytes, BUN, and Cr normal unless abnormal kidney, dehydration from N/V, or sepsis

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7
Q

Imaging suspected urinary stone

A

Non-contrast CT

Exception - pregnancy, tones of CT, young child

Then get US or MRI

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8
Q

Infection with ureteral obstruction

A

Bacteria under pressure so pushed into ciruclation and can cause sepsis

When evaluating pt with renal colic, MUST rule out infection***

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9
Q

Obstruction plus infection hx and exam

A

Flank pain and tenderness may be worse

May have sx of bladder infection (pain while voiding or frequent voiding)

Sx and signs of sepsis

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10
Q

Obstruction and infection lab work

A

Negative UA does NO rule out UTI because trapped if completely occluded

Look at UA and hemogram together…if both are normal, probably okay…if one is not, order it STAT

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11
Q

Imaging obstruction and infection

A

CT stone protocol…if shows hydronephrosis or stone in setting of infection, call urologist STAT

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12
Q

Tx of obstruction with infection

A

Drainage - curls in kidney and bladder to hold in place

If you can’t do stent, radiologist places percutaneous nephrostomy tube

Surgery to remove stone after infection

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13
Q

Usual tx of stones

A

Observation okay if stone in kidney with no sx or obstruction

Surgery

Alpha 1 adrenergic antagonist for pt trying to pass a stone

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14
Q

alpha 1 antagonist

A

Ureter spasm distal to stone impedes its passage

alpha antagonist helps relax the smooth muscle to helpl stone to pass

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15
Q

Alpha 1 relevant receptor

A

lpha1A on urethra and ureter

Selective antgonist helps focus on fewer side effects

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16
Q

Oral meds for kidney stones

A

Uric acid stone MIGHT dissolve with oral bicarb or citrate to keep pH higher

Citrate, drugs with SH and UTI suppression (for struvite) may prevent new stoens from being formed

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17
Q

Which AB is best to give daily to prevent struvite stones?

A

Amoxicillin

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18
Q

Normal urine storage

A

Bladder (detrusor) smooth muscle relaxed and outlet stays closed

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19
Q

Normal voiding

A

Detrusor contracts and pushes urine out

Outlet opens - bladder neck, external urinary sphincter

20
Q

PS and sympathetic NTs relevant to voiding

A

PS - acetylcholine…muscarinic makes bladder contract

Symp - alpha 1 - keeps outlet tight, Beta 3 - keeps bladder relaxed

21
Q

How does detrusor stay relaxed

A

Cerebral cortex inhibits contraction - babies cannot doe this…cerebral lesions often lead to incontinence

Sympathetic system - beta 3 adrenergic receptors in detrusor keep bladder relaxed

22
Q

How does outlet stay closed

A

Alpha 1 receptors in bladder neck

Sacral spinal cord S2-S4 - pudendal nerve…external sphincter (skeletal)…active continence…do this voluntarily

23
Q

Neuro of normal voiding

A

Cerebral cortex stops inhibiting detrusor

Sacral cord 2-4 - efferent signals…detrusor contracts…pelvic nerves PS - pee
Acetylcholine, muscarinic receptors
External sphincter opens

Pons coordinates voiding, so external sphincter opens when bladder contracts

Bladder neck opens - pathways not worked out

24
Q

Lesion above the pons

A

Voiding uncontrolled (urge incontinence) but otherwise normal

Common - stroke, MS in cerebral cortex, normal pressure hydrocephalus, brain tumor

25
Q

At or distal to sacral spinal cord

A

Bladder sensation is decreased or absnet

Detrusor contraction weak or absnet…clinically incomplete empyting or can’t void at all

May lose voluntary contraction of the external sphincter

26
Q

At or distal to sacral spinal cord - clinical scenarios

A

Lumbar spine injury or stenossi

Injury or neoplasm of scrum

Radical surgery

27
Q

Between pons and sacral spinal cord

A

Voiding reflex occurs but is uncontrolled 9inhibiton blocked)

External shincter doesn’t relax as bladder contracts, creates functional obstruction

Coordination from pons blocker…increased voiding pressure is a health risk

Most dangerous of neuro lesions**

Detrusor-external sphincter dyssynergia

28
Q

Between pons and sacral cord clinical

A

Cervical and most htoracic spine injuries

Neoplasm or ischemia of C or T spine

MS often affects C spine

29
Q

Autonomic dysreflexia

A

Upper body flushing, HTN, low HR

Very high BP is life-threatening emergency

Neurologic lesion is above T6 below BS

30
Q

Why autonomic dysreflia happens

A

Noxious stimuli increases symp system…normally, increase dampened but lesion blocks these pathways

Excess sympathetic tone below the lesion - vasoconstriction and extreme HTN

HR won’t proportionally increase

Increased BP – increase baroreceptors – increase PS…flushing/sweating and bradycardia

31
Q

Hx and exam of auto dys

A

Spinal lesions about T6 bekow BS

Headache

Flushing/sweating

High BP with low HR

32
Q

Tx of auto dys

A

Remove noxious stimuli…put catheter in, fecal impaction, skin lesions

Usually BP improves after this…if not, apply nitropaste or sublingual nitroglycerine while staff calls ambulance

33
Q

Stress urinary incontinence

A

Bladder outlet not tight enough

Women - childbirth
Men - prostate surgery
Both - pelvic radiation or trauam

Hx - urine leak with cough, sneeze, lift

Exam - observe urethra, ask pt to cough and urine will come out with cough

34
Q

Stress incontinence tx

A

Pelvic muscle exercise and physical therapy

Surgery

No meds

35
Q

Urge urinary incontinence

A

Urge occurs and pt can’t get to bathroom in time…leaks urine

Cause - uninhibited bladder contractions
- idiopathic, due to bladder irrtation or could be nueorlogic lesion

36
Q

Normal pressure hydrocephalus

A

Wet, wobbly, wacky

37
Q

MS triad

A

Incontinence or difficulty voiding…can be either of these

Visual changes

Decreased hand function

Suspect MS if any 2 are present

38
Q

Urge incontinence dx

A

Patients get urge to urinate but can’t get to bathroom fast enough

Need to distinguish why

Idio, neuro, bladder

39
Q

Urge incontinence eval

A

Urinalysis - if pyuria, hematuria, or nitrites, send a culture

If UA abnormal and culture no growth, suspect bladder stone or cancer

40
Q

Urge incontinence tx

A

Tx underlying cause

Muscle exercises

Surgery

Muscarinic antagonists, mirabegron

41
Q

Muscarinic antagonists

A

Inhibit bladder contractions - oxybuynin

Come with a ton of side effects

42
Q

Muscarinic antagonists in elderly

A

Could make dementia worse

CAN’T give donepizil bc they are opposites

43
Q

Beta 3 adrenergic receptor

A

Expressed on bladder

Typical GPCR that works through cAMP…activated leads to smooth muscle relaxation

44
Q

MIrabegron

A

Beta-3 adrenergic agonist

Keeps bladder relaxed

NO cognitive impairment but new so expensive

45
Q

Voiding difficulty from meds

A

Muscarinic antagonists…decrease detrusor contractility

Alpha adrenergic agnosists - increased urethral closure pressure

46
Q

Pseudophedrine

A

Constricts BV in nose but also constricts smooth muscle fo the urethra

47
Q

Interstitial cystitis

A

Clinical scenario - pain with holding urine

Frequent urination

No incontinence

Urine culture no grwoth

Most are female

Renal and Urinary 3 (22 decks)

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