Renal/Male GU Flashcards
1
Q
kidney functions include
A
removal of waste products, maintenance of fluid balance/volume, regulation of electrolytes, regulation of plasma osmolality, regulation of BP, regulation of acid/base, regulation of RBC production (EPO), maintenance of hormone levels, vitamin D activation, and gluconeogenesis (converting amino acids into glucose)
2
Q
renal hilum
A
includes the renal artery, vein, lymphatics, nerves, and the ureter
3
Q
location of kidneys within the body
A
retroperitoneal around the level of L1-L3 where the left kidney is slightly higher than the right, surrounded by a fibrous capsule and embedded in renal fat (perinephric and paranephric) and fascia (anterior and posterior) which holds the kidney in place
4
Q
renal cortex
A
extends between renal pyramids as columns and contains the glomeruli, the proximal tubule, and some of the distal tubule
5
Q
renal medulla
A
contains 8-10 renal pyramids which taper at the papilla, contents from the papilla then drain into the minor calyces followed by the major calyces of the renal pelvis which ultimately drains into the ureter
6
Q
number of nephrons within the kidney
A
1.2 million nephrons/kidney which do not regenerate (after age 40, people lose about 10% every 10 years)
7
Q
renal blood supply
A
renal arteries which come off the aorta divide into anterior and posterior branches at the hilum, then into segmental arteries, interlobar arteries, arcuate arteries, cortical radiate arteries, afferent arterioles, glomerular capillaries, efferent arterioles, peritubular capillaries, and vasa recta within the kidneys
8
Q
percentage of cardiac output going to the kidneys
A
20-25% of CO
9
Q
location of arcuate artery/vein within the kidney
A
runs along the cortical-medullary junction
10
Q
nephron blood supply
A
arcuate artery branches into the afferent arteriole, the glomerular capillaries, the efferent arteriole, the peritubular capillaries, the vasa recta network, and then into renal venous circulation
11
Q
part of the kidney that enhances the regulation of hydrostatic pressure
A
its 2 sets of capillary beds - the glomerular and peritubular which are separated by efferent arterioles
12
Q
functional unit of the kidney
A
the nephron which filters and concentrates urine
13
Q
location of the renal corpuscle
A
within the renal cortex
14
Q
location of the loop of Henle
A
the descending limb (thin segment) travels down within the renal pyramid/medulla whereas the ascending limb travels back up from the medulla into the cortex (thick segment)
15
Q
renal corpuscle
A
includes the glomerulus, Bowman’s capsule, and the mesangial cells
16
Q
glomerulus
A
contains capillaries that loop together within Bowman’s capsule covered with modified epithelial cells referred to as podocytes
17
Q
Bowman’s capsule
A
composed of 2 layers - the visceral epithelial layer which contains podocytes and is tight around the glomerular capillaries, forming a network of intracellular clefts (moderates filtration), and the parietal layer which is the capsular outer layer
18
Q
glomerular filtration membrane
A
includes the capillary endothelium, basement membrane (negatively charged), and podocytes which help with filtration and prevent large proteins and RBCs from passing through into the urine
19
Q
medullary collecting duct
A
where 8-10 cortical collecting ducts come together (each collects urine from about 4,000 nephrons)
20
Q
proximal convoluted tubule (PCT)
A
contains cuboidal cells with brush border microvilli and is continuous with Bowman’s capsule, attaching to the descending loop of Henle
21
Q
PCT function
A
reabsorbs 90% of HCO3- into peritubular capillaries, actively reabsorbs sodium (which helps with the cotransport of other electrolytes), and reabsorbs glucose and amino acids, this area also secretes urate and creatinine
22
Q
urea formation
A
amino acids are broken down into carbohydrates through deamination and release ammonia (NH3) which is converted to urea within the mitochondria of the liver, urea is then excreted within the urine
23
Q
loop of Henle function
A
the location where urine concentration is primarily determined (in addition to the distal tubule), includes the thin descending limb which is passively permeable to H2O, the thin ascending limb which is permeable to ions but not H2O, and the thick ascending limb which actively transports ions including NaCl
24
Q
distal convoluted tubule (DCT) function
A
extends from the macula densa to the collecting duct and is poorly permeable to H2O unless ADH is present, allowing reabsorption of ions including potassium (determined based on aldosterone) diluting the urine and regulating calcium excretion
25
renal pelvis function
contains contractile properties which push urine to the bladder for storage
26
ureter function
smooth muscle bundles that are 33 mm in diameter and 25-35 cm in length which will generate peristalsis when stretched (innerved by sympathetic and parasympathetic systems), function to carry urine from the kidney to the bladder, during micturition the bladder muscles close the ureters to prevent urine reflux
27
blood supply to ureters
renal arteries, iliac arteries, abdominal aorta, gonadal arteries, and internal iliac arteries
28
ureter sensory innervation
10th thoracic nerve root which sends pain to umbilicus
29
location of bladder within the body
"basket weave" of smooth muscle (detrusor) that sits within the pelvis in adults but above the pubic symphysis in children, fills with urine passively and will stimulate micturition reflex (autonomic spinal cord reflex) when above the volume threshold which can be inhibited by cerebral cortex or brain stem
30
location of ureter insertion into bladder
posterior and inferior on either side of the trigone muscle
31
urethra
3-4 cm in women and 18-20 cm in men, lined by uroepithelium and contains glands that secrete mucous
32
bladder innervation
the detrusor muscle and internal urethral sphincter are under involuntary control and innervated by the parasympathetic nervous system, the trigone muscle is innervated by the sympathetic nervous system (L2), and the external urethral sphincter is made of skeletal muscle and innervated by the pudendal nerve whereas it is under voluntary control
33
juxtaglomerular apparatus
includes granular cells (or JG cells), which are smooth muscle cells that sense stretch, the macula densa, and the mesangial cells and is the area in which the afferent arteriole comes in contact with the thick ascending limb of Henle and the DCT
34
juxtaglomerular apparatus function
functions to sense blood pressure or perfusion pressure as well as sodium concentration in urine, regulate renin release, and cause afferent vasoconstriction
35
juxtaglomerular apparatus response to increased urine sodium
inhibits renin release from JG cells and causes afferent vasoconstriction
36
macula densa
composed of modified epithelial cells that have chemoreceptor function which marks the end of the ascending thick limb of Henle and the beginning of the DCT
37
macula densa function
monitors NaCl concentration in the DCT, releasing adenosine, which causes vasoconstriction of the afferent arteriole to decrease GFR, and inhibiting renin release from JG cells if NaCl concentration is high, if NaCl concentration is low (sensed by macula densa) or BP is low (sensed by JG cells), it stimulates renin release from JG cells and nitric oxide increases vasodilation of both the afferent and efferent arterioles
38
systemic and renal effects of angiotensin II
causes systemic vasoconstriction to elevate BP and constricts the efferent arteriole to increase glomerular capillary pressure and maintain GFR, increases reabsorption of sodium and H2O in the PCT to increase intravascular volume
39
immediate effect of systemic drop in BP on the kidney
drop in BP will stimulate baroreceptor stimulation and release of catecholamines which causes afferent arteriole vasoconstriction leading to decrease renal blood flow and decreased GFR
40
creatinine
filtered readily by the glomerulus and should remain constant but will go up with increased creatinine creation (muscle breakdown, PO intake) or decreased excretion
41
blood urea nitrogen (BUN)
not as reliable as creatinine and indicates the amount of systemic urea, either from consumption, hydration status, tissue breakdown, or decreased excretion - 50% of urea is passively absorbed in PCT (goes up with dehydration)
42
GFR
typically an estimated measurement most commonly calculated from creatinine using a formula that takes age and sex into consideration (Cockcroft-Gault equation), normal GFR = 120 mL/min
43
volume filtered by glomeruli per day
180 L/day (99% of filtrate reabsorbed), typically 30 mL urine produced per hour
44
components of urine
water and urea are the main components, typically no glucose or RBCs, specific gravity of 1.001 - 1.035, contains trace proteins primarily uromodulin (Tamm-Horsfall proteins) which is made in the loop of Henle and binds uropathogens preventing stone formation
45
pH of urine
4.6 - 8, typically acidic
46
total body water includes
intracellular fluid (2/3), interstitial fluid, plasma (both interstitial and plasma = 1/3), and insensible fluid (fluid lost by sweating, exhaling, urinating, and bowel movement) where water is able to readily pass between compartments via osmotic and hydrostatic forces
47
primary driver of osmosis within the body
osmolality = the number of osmoles of solute per kilogram of fluid
48
primary driver of fluid movement in ECF
sodium
49
primary driver of fluid movement in ICF
potassium
50
primary driver of intravascular fluid
albumin
51
tonicity
the ability of a solution to affect the fluid volume and pressure in a cell which determines cellular size
52
tonicity is maintained by
intact thirst, functioning GFR, a functioning loop of Henle and DCT, appropriate functioning of ADH, and an appropriate response of the kidney to ADH
53
tonicity is determined by
extracellular sodium level and osmolality whereas when it is increased, ADH is released stimulating increased H2O retention and increased thirst
54
normal EC potassium range
3.5 - 5
55
normal chloride range
95 - 105
56
normal bicarbonate range
22 - 26
57
normal glucose range
90 - 120
58
normal calcium range
8.5 - 10
59
normal EC magnesium range
1.4 - 2.1
60
normal urea nitrogen range
10 - 20
61
normal IC potassium range
130 - 140
62
normal IC magnesium
20
63
normal EC sodium range
135 - 145
64
major drivers of fluid shift from intravascular to interstitial space
plasma or interstitial hydrostatic pressure (BP) and oncotic pressure (osmolality)
65
renal clearance
removal of waste (400 mL/day minimum), excess ions, urea, creatinine, hydrophobic drugs, and some hormones where there is a lower concentration of waste products within the renal venous system compared to the arterial system
66
creatinine clearance (CrCl)
a measure of GFR and helps to indicate the functional status of the kidneys
67
effect of low BP on the kidney
JG cells release renin which stimulates RAAS
68
effect of low BP on the liver
releases angiotensinogen which is converted to angiotensin I by renin (released from the kidney)
69
effect of low BP on the adrenals
angiotensin II stimulates release of aldosterone which causes increased sodium reabsorption in the collecting duct and DCT
70
effect of low BP on the brain
releases ADH which stimulates sodium and H2O reabsorption in the collecting duct and DCT
71
effect of low BP on the heart
decreases production on ANP (BNP)
72
effect of low BP on the lungs
release angiotensin-converting enzyme (ACE) that converts angiotensin I to angiotensin II causing stimulation of the brain to release ADH and increased sodium reabsorption in the PCT
73
percentage of plasma entering Bowman's capsule as filtrate
20%
74
normal urinary output
30 mL/hour (determined by renal blood flow)
75
juxtaglomerular cell function (JG cells)
release renin in response to low urine osmolality and EPO in response to low circulating oxygen
76
effect of angiotensin II on glomerulus
stimulates vasoconstriction of the efferent arteriole to increase GFR in response to low renal blood flow (decreased GFR)
77
carbon dioxide (CO2)
a result of the cellular metabolism of carbs and fat which is 20X more soluble than O2 and will diffuse very quickly, the primary trigger for central chemoreceptors - increases with an increase in cellular metabolism (on average we produce 200 mL/min
78
bicarbonate (HCO3-)
made in the kidneys to buffer acids, for every molecule of HCO3- made in the kidney, one molecule on H+ is eliminated in the urine, HCO3- is reabsorbed in the PCT
79
normal CO2 range
35 - 45
80
processes requiring pH balance
metabolic functioning, protein structure, enzymatic functioning, and cell wall integrity, etc.
81
effects of acidosis on the cardiovascular system
decreased cardiac output and LV contraction leading to compensatory tachycardia, vasodilation leading to hypotension, increased ectopic rhythms from unstable cellular function, and hyperkalemia (peaked T waves, P wave flattening, PR prolongation, and wide QRS complexes)
82
effects of alkalosis on the cardiovascular system
cardiac excitability, ventricular tachyarrhythmias, SVT, and hypokalemia (T wave inversions, ST depression, and prominent U waves)
83
effects of acidosis on the respiratory system
tachypnea, a drop in CO2 to about 10 at the lowest point, and a right shift in oxyhemoglobin
84
effects of alkalosis on the respiratory system
low respiratory rate and a left shift in oxyhemoglobin
85
effects of acidosis on the CNS
decreased neurotransmitter release, decreased mental status, and lethargy
86
effects of alkalosis on the CNS
increased action potentials, seizures, and tetany
87
medications effected by pH level
vasopressors, anesthetics, and insulin
88
components of a buffering system
contain a weak acid and conjugate base with a positive and negative charge that can bind either H+ or OH-
89
hemoglobin buffer system
a protein buffer that can help stabilize pH in the blood during the transportation of gases such as CO2 which can be diffused into plasma or bound to hemoglobin, within the RBC CO2 is converted to bicarbonate via the formation of carbonic acid from H2O and CO2 which then diffuses out into the plasma, the process must be reversed upon arrival in the pulmonary capillaries
90
central chemoreceptors detect
changes in blood pH and blood CO2 concentration
90
ionic shift that can occur with acidosis
an increase in H+ concentration outside the cell seen in acidemia (low pH) can cause H+ to enter the cell and be exchanged for K+ ions causing resultant hyperkalemia within hours
91
ionic shift that can occur with alkalosis
a decrease in H+ concentration outside the cell seen in alkalemia (high pH) can cause H+ to exit the cell and be exchanged for K+ ions causing resultant hypokalemia within hours
92
effect of insulin on ionic shifts
insulin drives K+ and glucose into the cell and as a general rule - if low = less K+ is inside the cell
93
renal buffer system
most systemic HCO3- is reabsorbed in the PCT during filtration to keep pH neutral whereas for every H+ secreted into the urine, an HCO3- is regenerated and secreted into the bloodstream (maximum urine acidity = pH of 4.4 - 4.7)
94
acid/base compensation
adjustments within the respiratory or renal systems to compensate for the primary pH abnormality which allows the pH to return to normal but the HCO3:CO2 ratio to be changed
95
anion gap (AG)
distinguishes between acid gain and bicarb loss, calculated by subtracting primary serum anions (Cl + HCO3) from primary serum cation (Na+) where normal gap = 8 (> 10-12 is abnormal)
96
causes of anion gap metabolic acidosis (AGMA)
MUDPILES = Methanol, Uremia, DKA, Paraldehyde, Isoniazid, Lactic acid (Hypotension), Ethylene glycol, and Salicylates
97
nephrotic syndrome
basement membrane and podocyte injury causing disruption of negative charge allowing for inappropriate dumping of proteins into urine and excess loss of albumin and immunoglobulins resulting in decreased oncotic pressure and peripheral edema where filtered protein > reabsorption capability (greater than or equal to 3.5 g of proteinuria/day), compensation occurs by increasing ADH production to try and increase intravascular volume and aldosterone secretion
98
minimal change disease
a most commonly idiopathic primary nephrotic syndrome that is most commonly seen in children and causes thinning of the podocyte foot processes due to abnormal T cell activation and cytokine release resulting in a loss of negative charge of the basement membrane, increased filtration membrane permeability, hypoalbuminemia, and proteinuria
99
membranoproliferative glomerulonephritis
idiopathic complement activation or autoimmune response to antigen causing inflammation, thickening of the glomerular basement membrane, and deposits of inflammatory proteins (cytokines, complement, antibodies) leading to increased membrane permeability and proteinuria
100
focal segmental glomerulosclerosis
idiopathic (or sometimes associated with other disease processes - IgA nephropathy, HIV) thinning of podocytes, formation of hyaline deposits in mesangial cells and endothelial cells resulting in increased pore size, proteinuria, and fibrosis
101
secondary nephrotic syndrome
glomerular dysfunction caused by systemic diseases including DM, amyloidosis, SLE, IgA vasculitis, infections, malignancies, and vascular disorders
102
effect of NSAIDs on the glomerulus
constrict the afferent arteriole reducing GFR and can lead to kidney damage
103
effect of ACEi/ARBs on the glomerulus
dilate the efferent arteriole increasing GFR and are renal protective
104
nephrotic syndrome presentation
proteinuria causing edema and infection, hypoalbuminemia causing edema, hyperlipidemia causing atherosclerosis, lipiduria causing fat in the urine, low vitamin D causing low calcium and osteoporosis, and hypothyroidism
105
nephritic syndrome
inflammation of the mesangium due to antigen deposition causing endothelial damage and RBC loss resulting in hematuria with RBC casts, it may be associated with infection (HBV, HCV, PSGN) or autoimmune causes
106
post-infectious glomerulonephritis (nephritic syndrome)
associated with group A strep infection in children and staphylococcus infection in adults leading to IgG and complement deposits in the subepithelial area, this results in increased infiltration of neutrophils, cellular proliferation, and decreased GFR
107
rapidly progressive glomerulonephritis
associated with initial injury and subsequent alterations of the glomeruli that occurs rapidly over days to months, a crescent formation can be seen within the glomeruli
108
IgA nephropathy aka Berger disease
most common cause of primary glomerulonephritis that can be infection-related (post-URI or GI bug) causing increased serum IgA levels and IgA granular deposits leading to nephropathy and hematuria, may have oliguria and HTN
109
Anti-GBM disease aka Goodpasture syndrome
nephropathy causing linear IgG deposits within the glomerular basement membrane and/or crescent formations that is associated with pulmonary hemorrhage and hemoptysis (will have positive anti-GBM antibodies)
110
Polyangiitis with granulomatosis aka Wegener granulomatosis
ANCA small vessel vasculitis which is most commonly seen in older adults with few or no basement membrane deposits, can involve the nose and lungs, will have positive c-ANCA
111
Alport syndrome
basement membrane collagen disorder causing nephritic syndrome and results in abnormally split and laminated GBM, presents with hematuria, edema, and HTN
112
function of principle cells within the DCT and collecting duct
respond to ADH and aldosterone by reabsorbing sodium and water back into circulation when stimulated
113
function of intercalated cells within the DCT and collecting duct
secrete H+ into urine ridding the body of excess acid (making urine acidic)
114
acute kidney injury (AKI)
elevated serum urea and creatinine due to toxic waste accumulation which causes an increase in nitrogenous waste products presenting with fatigue, N/V, pruritis, anorexia, and neurologic dysfunction
115
prerenal AKI
decreased renal blood flow leading to hypoperfusion and decreased GFR causing increased aldosterone (RAAS activation) and ADH secretion and increased sodium and water reabsorption in the DCT resulting in oliguria - improves with fluid administration
116
causes of prerenal AKI
hypovolemia (dehydration), hypotension, shock, cardiac failure, massive PE, stenosis of renal artery, increased intraabdominal pressure, and medications such as NSAIDs
117
intrarenal AKI
renal tubular injury most commonly associated with ischemia causing cast formation, necrosis, and tubular obstruction leading to increased tubular pressure and leakage and decreased GFR resulting in oliguria
118
causes of intrarenal AKI
ATN, AIN (contrast, medications - RSVP), glomerulonephritis, vascular damage or embolism (DIC, vasculitis), malignant HTN, and acute bilateral pyelonephritis
119
postrenal AKI
bilateral obstruction downstream of the kidney that causes increased intraluminal pressure, inflammation resulting in vascular endothelial cell injury, vasoconstriction, cellular/interstitial edema, and reduced GFR resulting in oliguria (can lead to intrarenal AKI)
120
causes of postrenal AKI
obstructive disorders such as bilateral kidney stones, BPH, tumors, ureteral destruction, and neurogenic bladder
121
complications of AKI
encephalopathy (uremic toxins), heart failure (fluid overload) and/or arrhythmia due to hyperkalemia, intestinal and microbiota disruptions, bone marrow and immune system effects, liver dysfunction (fluid overload), and lung injury (fluid overload), metabolic acidosis, decreased toxin clearance, uremia, volume overload, coagulopathy, and HYPERKALEMIA
122
acute on chronic kidney injury
a sudden change in GFR in a patient with a chronic low GFR in the setting of increased physiological stress, increases risk of developing CKD
123
CKD
reduced GFR that lasts > 3 months causing epithelial damage, inflammation, and fibroblast deposition resulting in increased urine protein, RBC, WBC, and casts (patient can remain asymptomatic due to compensation until renal function drops to < 25% that of normal)
124
causes of CKD
DM, HTN, SLE, chronic glomerulonephritis, obstructive pathology, and vascular disorders
125
azotemia
elevated blood urea nitrogen (BUN > 28 mg/dL), creatinine (> 1.5 mg/dL), and nitrogenous compounds
126
uremia
azotemia with signs or symptoms of renal failure, uremic syndrome
127
uremic syndrome
associated with elevated urea and other toxins not removed by the kidneys causing platelet dysfunction, uremic pericarditis, uremic neuropathy, muscle spasms, fatigue, N/V, and acidosis
128
systemic changes seen in CKD
fractures due to low vitamin D, pulmonary edema, Kussmaul respirations, LVH, cardiomyopathy, ischemic heart disease, HTN, accelerated atherosclerosis, encephalopathy, anemia due to reduced EPO, abnormal skin pigmentation, pruritis (increased waste, elevated calcium, and neuropathy), and reduced immune function
129
effect of hyperglycemia on osmotic pressures
increased blood glucose leads to a change in osmotic gradients causing electrolyte shifts, a renal glucose threshold of 200 results in glucose dumping into the urine when reaching that level increasing urine concentration and amount of fluids excreted (polyuria), this results in dehydration which triggers osmoreceptors leading to an increase in thirst (polydipsia)
130
CKD related to DM
elevated glucose causes inflammation and macro/microvascular changes leading to atherosclerosis of efferent arterioles and RAAS activation, elevated glomerular pressure causes podocyte injury and fibrosis of the GBM and mesangial cells leading to reduced GFR, vascular changes will also reduce oxygen delivery to renal tubules causing decreased reabsorption
131
CKD related to HTN
increased pressure through glomerular capillaries causes increased filtration and protein dumping which corrects itself for the short term but will cause hypertrophy of the vascular walls long term and hyaline arteriosclerosis resulting in decreased oxygen delivery to the interstitium and tubules, inflammation is triggered by mesangial cells and fibrosis occurs leading to glomerulosclerosis
132
acute tubular necrosis (ATN)
intrarenal cause of AKI most commonly associated with ischemia injury (hypovolemia, systemic vasodilation, coagulopathy), toxins (abx, contrast, etc.), and sepsis (systemic hypotension), corticomedullary junction more likely to be damaged, not limited to the tubules - may not lead to necrosis
133
polycystic kidney disease
autosomal dominant pathology leading to thousands of renal cysts which can impede the normal function of the kidney, most commonly due to a chromosome 16 mutation that affects the PKD gene which normally assists with cellular signaling, helps with cellular growth, and kidney function - PKD1 codes for polycystin-1 which is very active in childhood within the cell membrane whereas PKD2 codes for polycystin-2 which transports Ca2+ into the cell (PKD1 has more severe presentation, PKD2 has a later onset of symptoms)
134
PKHD1 gene
autosomal recessive mutation leading to polycystic kidney disease that is very rare but has a high mortality at a young age
135
complications of polycystic kidney disease
patients are at increased risk for cysts in other organs such as the liver, HTN, hematuria, UTIs, stones, and aortic aneurysm
136
WBC casts in urine indicate
interstitial nephritis (AIN) or pyelonephritis
137
RBC casts in urine indicate
glomerulonephritis
138
broad or waxy casts in urine indicate
chronic renal failure (CKD)
139
hyaline casts in urine indicate
exercise, diuretics, or concentrated urine (formed of Tamm-Horsfall mucoprotein)
140
fatty casts (oval fat bodies) in urine indicate
nephrotic syndrome
141
muddy brown/granular casts in urine indicate
ATN
142
renal tubular epithelial cell casts in urine indicate
ATN
143
UTI
inflammation of the epithelium of the urinary tract which is most common in females secondary to the proximity of the anus and length of the urethra where infection moves in retrograde and causes inflammation of the bladder wall if reaches it, typically associated with E.coli, staph, klebsiella, proteus, pseudomonas, and candida
144
UTI risk factors
female, young, sexually active, pregnant, recent antibiotic use, postmenopausal, catheter use, DM, and neurogenic bladder
145
urinary defenses against bacteria
acidity, high osmolality, uromodulin, and uroepithelial secretions, the ureterovesical junction typically prevents reflux of urine back into the ureter
146
UTI presentation
urinary frequency, urgency, dysuria, suprapubic discomfort, hematuria, pyuria, odor, and cloudy urine
147
CAUTI
UTI caused by uropathic E.coli which have fimbriae that bind to latex catheters and flagella that allow them to move against the flow of micturition, have hemolysin, and are able to alkalinize the urine, fimbriae associated with pyelonephritis
148
acute cystitis
inflammation of the bladder wall associated with typical UTI that causes edema, erythema, and suppurative exudates (WBC in UA), may have hemorrhage resulting in RBC in UA, can develop into ulcerative cystitis if prolonged infection with sloughing of the epithelial layer
149
interstitial cystitis
painful bladder syndrome with symptoms of UTI but sterile environment thought to be autoimmune which can increase risk for UTI and may progress to fibrosis or hemorrhagic ulcers
150
interstitial cystitis presentation
symptoms similar to UTI for > 6 months, frequency, urgency, nocturia, chronic pain, and increased rates of depression
151
acute pyelonephritis
ascending UTI into the ureter, renal pelvis, and/or kidney interstitium most common in females associated with the same pathogens as UTIs leading to tubulointerstitial inflammation and renal edema, increases the risk for abscess (in renal medulla), necrosis of renal tubules and papillae, and may become bacteremic particularly if bilateral
152
causes of acute pyelonephritis
stones causing obstruction, stasis, bacterial entrapment, vesicoureteral reflux, pregnancy due to dilation and relaxation of the ureter, neurogenic bladder which reduces sphincter tone and residual urine, instrumentation that may directly introduce bacteria, and sexual trauma
153
complications of acute pyelonephritis
can develop into sepsis, scarring, fibrosis, atrophy of renal tubules, or AKI
154
chronic pyelonephritis
associated with recurrent risk factors and progressive inflammation leading to the inability of tubules to concentrate urine, more commonly seen in CKD
155
nephrolithiasis
collection of protein, crystals, or other substrates in the kidney, ureter, or bladder classified by the primary mineral that comprises the stone most commonly calcium oxalate or phosphate, uric acid, struvite, or other rare types as a result of supersaturation or overabundance of stone-forming mineral which precipitates into crystals (dehydration can increase rate of growth), can be staghorn calculi which fill minor or major calyces or non-staghorn calculi which vary in size and location, increases risk for MI due to increased atherosclerotic plaque buildup
156
risk factors for calcium nephrolithiasis
alkaline urine, altered natural stone inhibitors within the kidneys/urine, genetic deficiencies, urine stasis, hypercalciuria, and hyperuricemia
157
struvite nephrolithiasis
more likely to form if urine is alkaline due to urease-releasing bacteria such as Klebsiella, pseudomonas, and Proteus, can develop into staghorn
158
nephrolithiasis will typically spontaneously pass if
< 5 mm (if 5-7 mm, 70% spontaneously pass)
159
nephrolithiasis presentation
renal colic (location of pain may correlate with obstruction), N/V, hematuria
160
male perineum muscles
include the external anal sphincter, the bulbospongiosus, and the ischiocavernosus
161
bulbospongiosus function
sits around the lateral aspect of the bulb of the penis and proximal body, innervated by the pudendal nerve, and functions to support the pelvic floor, expel semen, and push blood from the bulb into the body of the penis
162
ischiocavernosus function
helps maintain erection and compress venous flow
163
root of the penis components
contains 3 sections of erectile tissue which are the crus laterally, the bulb centrally encasing the urethra, and the external urethral sphincter at the apex of the prostate
164
body of the penis
suspended from the pubic symphysis, attached via the suspensory ligament, and contains erectile tissue - 2 corpora cavernosa dorsally and the corpus spongiosum ventrally (containing the urethra)
165
glans of the penis
expansion of the corpora cavernosa which contains the external urethral orifice and the prepuce (foreskin)
166
blood supply to penis
dorsal arteries between corpora cavernosa and deep arteries that facilitate erection that branch off of internal pudendal arteries, arteries of the bulb that supply the bulbous part of the corpus spongiosum, and superficial and deep branches of the external pudendal nerve
167
innervation of penis
branches off of the pudendal nerve including the dorsal nerve (provides somatic innervation to the spongy urethra)
168
blood supply to scrotum
anterior scrotal arteries come off of the external pudendal arteries and the posterior scrotal arteries come off the internal pudendal arteries
169
lymph drainage for the scrotum
superficial inguinal lymph nodes
170
innervation of scrotum
anterior scrotal nerves come off of the ilioinguinal nerve and genital branch of the genitofemoral nerve
171
spermatocord
includes the vas deferens, the testicular artery, and the pampiniform plexus
172
function of cremaster muscle
extension off the external oblique muscle which pulls the spermatocord upward
173
testes
oval 3-6 cm in length and 3-4 cm wide and contain tortious duct of seminiferous tubules which leave the lobe through tubules rectus, all collecting toward the rete testis, then the efferent tubules, and finally the epididymis, the testes descend into the scrotum 3 months before birth through the inguinal canal and are suspended by the spermatocord, covered internally by the tunica albuginea and externally by the tunica vaginalis
174
temp required for spermatogenesis
2-7 degrees Celsius below body temp or 3.5 - 12.6 degrees Fahrenheit below body temp which is adjusted by the cremasteric and dartos muscles
175
blood supply to testes
internal spermatic artery
176
innervation of the testes
adrenergic fibers
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location where sperm is produced
made by Sertoli cells in the seminiferous tubules, stimulated by Leydig cells, during/after puberty in the outer aspect of the testes (basal lamina) and then move centrally to the lumen when mature
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pampiniform plexus
venous vascular attachment for the testes which helps to regulate temp and is part of the spermatic cord
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epididymis
situated posteriorly over the top of the testes measuring about 5-7 cm (6 meters when uncoiled) and helps with the continued maturation and motility of sperm, takes 12 days for sperm to move along the epididymis where they obtain nutrients and testosterone, they are then stored in the epididymal tail which attaches to the vas deferens
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vas deferens
muscular duct that peristalses sperm through the inguinal canal and toward the urethra when stimulated by the sympathetic nervous system, it connects to the ampulla, seminal vesicles which create seminal fluid, and the ejaculatory duct
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inguinal canal
contains the spermatic cord, gonadal vessels, and lymphatics which extends from the internal inguinal orifice and exits at the external inguinal orifice (about 4-6 cm in length)
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Leydig cells
stimulated by LH in males and produce testosterone
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Sertoli cells
stimulated by FSH in males to produce androgen bonding protein and create spermatogonia (diploid cells) which continue to mature as stimulated by chemicals within the seminiferous tubules (testosterone and androgen bonding protein)
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spermatozoa
consists of a head that contains the nucleus with DNA and an acrosome, a midpiece that contains large amounts of mitochondria, and a tail with flagella that is composed of filaments
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seminal vesicles
sit posterior to the bladder above the prostate and produce seminal fluid which accounts for the majority of semen, can contract to help push semen along the ejaculatory duct where the semen contains fructose for sperm metabolism and prostaglandins which alkalize the fluid to protect from the vagina
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prostate
size of a walnut and surrounds the urethra consisting of alveoli of glands surrounded by fibromuscular tissue which contracts during ejaculation, glandular tissue secretes PSA, cytokeratin, and prostate-specific membrane antigen which contributes to ejaculate
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prostate function
regulated by androgens and functions to alkalinize semen further and add fibrinolysis to increase sperm motility (gives milky appearance)
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bulbourethral glands
secrete mucous near the base of the penis
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semen pH
7.5
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normal ejaculation contains
2 - 6 mL of fluid and 75 - 400 million sperm which accounts for about 10% of total fluid volume, the rest is seminal fluid (the bulk which forms a mucoid consistency), prostatic fluid (forms a white color and allows sperm to initially form a coagulated body at the cervix which is broken down over 15 minutes), and urethral fluid
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sperm motility
minimal movement occurs while sperm is within the male because of a heavy cholesterol coating around the acrosome, this is lost when entering the vaginal environment allowing an influx of calcium causing the flagellum to become more motile
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common ejaculatory duct
formed by the vas deferens and the seminal vesicle which produces seminal fluid
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erection
stimulated by the parasympathetic nervous system (which may begin centrally in the hypothalamus - paraventricular nucleus) that sends fibers to the pelvic nerve (S2-S4) which acts on the erectile tissue of the corpus cavernosum releasing Ach resulting in the release of NO in Helicine arteries causing vasodilation and filling of erectile sinusoidal tissue with blood, increased volume in the erectile tissue compresses venous drainage out of the penis, detumescence occurs when there is a loss of NO
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ejaculation
stimulated by the sympathetic nervous system (T4-L2) when the cerebral cortex inhibits parasympathetic activity causing the release of norepinephrine at the epididymis followed by contraction resulting in sperm being pushed down the vas deferens, upon reaching the seminal vesicles that are simultaneously being constricted, it joins the seminal fluid and flows down the common ejaculatory duct through the prostate and into the prostatic urethra, sympathetic stimulation causes constriction of the internal urethral sphincter to prevent exchange between urine and semen, the pudendal nerve release Ach in bulbospongiosus causing contraction and pushes semen down the penile urethra
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capacitation of the spermatozoa occurs
1 - 10 hours after ejaculation into the vagina which releases hyaluronic acid and proteolytic enzymes
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hypospadias
idiopathic or congenital abnormality resulting in a ventral location of the urethral opening where the urethral groove forms inappropriately and does not close completely that is androgen-mediated, placement may be near the glans, in the scrotum, perineum, or anywhere in between, the prepuce is unable to close distally and there is a hooded foreskin, may also see chordee - leads to abnormal or poor urine stream, increased bed wetting, incomplete voiding, and spraying of stream
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epispadias
urethral opening on the dorsal side of the penis in which severity can differ greatly, causes incontinence, reflux, and UTI, and severe cases can lead to bladder exstrophy
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paraphimosis
urological emergency!! prepuce that has been retracted proximal to the glans that occurs when a patient has pulled the prepuce back and not returned it to its typical location, edema ensues which becomes constrictive causing a tourniquet effect and can result in necrosis of the glans
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phimosis
when the prepuce is stuck over the glans of the penis and in unable to be retracted, it can develop a scar tissue ring, may be physiological in children with the formation of adhesions that will eventually separate
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complications of phimosis
can become pathologic if associated with skin conditions or balanitis and can cause scarring or urinary obstruction, smegma may increase risk or continue to develop if not improved
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erectile dysfunction
inability of a man to form or maintain an erection sufficient for satisfying sexual activity due to several underlying causes including issues with NO and inability to compress venous structures, atherosclerosis, DM, CVD, decreased testosterone, surgery complication, neurological issues, endocrine dysfunction, psychological problems (psychogenic), or medication SE
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Peyronie's disease
fibrous deposition within the tunica albuginea of the corpora cavernosa associated with plaque deposition with a vasculitis-like inflammatory reaction, the fibrosis and calcium deposition which forms a fibrous plaque is palpable along the dorsal aspect of the penis causing a bend in the penis associated with Dupuytren contracture (degree of bend/change is typically 15-22 degrees), can cause pain with intercourse and difficulty with erection
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priapism
erection lasting > 4 hours not associated with sexual stimulation which is a urological emergency!! that can be low-flow (more common and due to decreased venous return) or high-flow (less common and associated with trauma due to increased arterial flow) caused by spinal cord trauma, sickle cell disease, tumors, infection, penile trauma, cocaine use, mediations (trazodone, lithium, and those for ED), or can be idiopathic - can lead to edema, fibrosis, and ED
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dihydrotestosterone (DHT)
metabolite of testosterone metabolized by 5-alpha-reductase that is required for prostate growth
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prostate growth
grows fairly rapidly from puberty to age 30 y/o and then stops and starts to grow again in the 40-50 y/o range
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BPH
hyperplasia of the prostate which affects 50% of men > 50 y/o and 90% of men > 70 y/o, is thought to be caused by dysregulation of hormonal balance in DHT and estrogen (estrogen is metabolized from testosterone via aromatase) causing enlargement, remodeling, inflammation, angiogenesis, and increased fibroblast activity of the prostate at the periurethral gland site resulting in urethral compression, bladder outflow obstruction, urinary urgency, urinary retention, overflow incontinence, and difficulty starting and stopping stream
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complications of BPH
increases the risk for hematuria, UTI, pyelonephritis, hydroureter, and hydronephrosis
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prostatitis
inflammation of the prostate which can be caused by acute bacterial infection, chronic bacterial infection, or inflammation without infection typically associated with ascending infection with GI pathogens such as E. coli, also can be associated with STI, causes enlarged, tender, firm, and boggy prostate in which the pain may be worse with standing because of the muscles of the perineum tightening around the prostate more
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acute bacterial prostatitis presentation
symptoms of enlarged prostate and infection including fever, perineal pain, dysuria, urinary retention, nocturia, dysorgasmia, and possibly bacteremia - can develop into chronic bacterial infection
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hydrocele
painless collection of fluid between the parietal layer and the visceral layer of the tunica vaginalis most commonly causing scrotal swelling common in newborns (patent processus vaginalis) where primary hydroceles are typically idiopathic and secondary are associated with infection or trauma, tunica vaginalis usually reabsorbs fluid
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varicocele
commonly occurring dilation of the pampiniform plexus vessels referred to as a "bag of worms" where 95% occur on the left side, caused by poorly functioning valves resulting in venous backflow and blood pooling that may be associated with a tumor or compression, can reduce fertility and blood flow to the testes
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epididymitis
inflammation of the epididymis most commonly associated with STIs such as gonorrhea and chlamydia and with anal bacterial like E. coli, H. flu, and Tb in MSM, if > age 35 y/o, Enterobacteriaceae from intestinal flora most common cause, may be associated with chemical irritation such as urine reflux
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epididymitis presentation
scrotal pain/inflammation, acute discomfort, swelling on the epididymis starting at the tail and ascending, urethra abutting the spermatic cord causing urinary obstruction, +/- pyuria - increases the risk for abscess formation, infertility, and infarction
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orchitis
inflammation of the testes associated with bacteremia or direct spread up the urethra, through the prostate, up the vas deferens, and through the epididymis and testes referred to as epididymo-orchitis which is classically associated with mumps beginning 3-4 days after parotitis causing fever and may be bilateral
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testicular torsion
urological emergency!! twisting of the testes resulting in rotation and cessation of blood flow from the spermatic cord which can be spontaneous or after exertion, may twist and then untwist spontaneously, decreased blood flow in the spermatic cord causes testicular pain, swelling, elevated testis, and loss of cremasteric reflex
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blue dot sign
seen in testicular torsion as the testis becomes necrotic, the testicular appendage will necrose becoming cyanotic and appearing as a weird little vestigial dingleberry
