MEDICAL PATHOLOGY II

SECTION A: PATHOLOGICAL CNDITIONS OF THE URINARY SYSTEM

Review of anatomy and physiology of the urinary system
The urinary system is composed of the paired kidneys and the urinary tract. The kidneys filter the blood to
remove metabolic wastes and then modify the resulting fluid, which allows these organs to maintain fluid,
electrolyte, acid-base, and blood pressure homeostasis. This process produces urine, a fluid that consists of
water, electrolytes, and metabolic wastes. Then the remaining organs of the urinary system—those of the
urinary tract—transport, store, and eventually eliminate urine from the body.
Functions of the urinary system
1. Removal of metabolic wastes. As we have discussed, the kidneys filter the blood, removing
metabolic wastes. These wastes are eliminated from the body via the urine
2. Regulation of fluid and electrolyte balance. The kidneys regulate blood solute concentration, or
osmolality, by conserving or eliminating water and electrolytes such as sodium, potassium, and
calcium ions.
3. Regulation of acid-base balance. The kidneys assist in the long-term regulation of blood pH by
conserving or eliminating hydrogen (H+) and bicarbonate (HCO3-) ions.
4. Maintenance of blood pressure. The kidneys directly influence systemic blood pressure through
their control of blood volume. Additionally, they secrete an enzyme that influences both blood
volume and peripheral resistance.
5. Regulation of erythropoiesis. The kidneys regulate red blood cell production in the bone marrow
by releasing the hormone erythropoietin
6. Performing other metabolic functions. The kidneys play many important metabolic roles,
including detoxifying substances in the blood, activating vitamin D, and making new glucose
through the process of gluconeogenesis
The urinary system is one of the excretory systems of the body. It consists of the following structures:
• 2 Kidneys which secrete urine.
• 2 ureters which convey the urine from the kidneys to the urinary bladder.
• 1 urinary bladder where urine collects and is temporarily stored.
• 1 urethra through which the urine is discharged from the urinary bladder to the exterior.

Anatomy of the urinary System

 Kidneys– a pair of bean – shaped organs located retroperitoneal, responsible for blood filtering and
urine formation.
 Renal capsule – a layer of fibrous connective tissue covering the kidneys.
 Renal cortex – outer region of the kidneys where most enthrones is located.
 Renal medulla – inner region of the kidneys where some enthrones is located, also where urine is
collected to be excreted outward.
 Renal calyx – duct – like sections of renal medulla for collecting urine from nephrons and direct
urine into renal pelvis.
 Renal pyramid – connective tissues in the renal medulla binding various structures together.
 Renal pelvis – central urine collecting area of renal medulla.
 Hilum – concave notch of kidneys where renal artery, renal vein, ureter, nerves, and lymphatic
vessels converge.
 Ureter – a tubule that transport urine (mainly by peristalsis) from the kidney to the urinary bladder.
 Urinary bladder – a spherical storage organ that contains up to 400 ml of urine.
 Urethra – a tubule that excretes urine out of the urinary bladder to the outside, through the urethral
orifice

Lecture notes Medical Pathology II, AHID level 200 Nursing, Mr. EPAH 2019/2020, Tel: 670374166,
kukuepah@gmail.com
GROSS STRUCTURE OF THE KIDNEY
There are three areas of tissue which can be distinguished when a longitudinal section of the kidney is
viewed with the naked eye.
1. Fibrous capsule, surrounding the kidney.
2. The cortex is the reddish-brown layer of tissue immediately under the capsule and between the
pyramids.
3. The medulla is the innermost layer, consisting of pale conical-shaped striations, the renal pyramids.
Urine Formation
Urine formation involves 4 processes:
1. Filtration – small molecules are filtered from glomeruli to Bowman’s capsule.
2. Reabsorption – nutrient molecules are transported from PCT and DCT to per tubular capillaries.
3. Concentration – water is reabsorbed from descending limb of loop of handle and from collecting
duct into peri-tubular capillaries.
4. Secretion – waste or harmful substances are transported from peri-tubular capillaries to PCT and
DCT.

RENAL SYSTEM (PHYSICAL ASSESSMENT)

A. Inspection:
 Skin- pallor, yellow-gray, excoriations, changes in turgor, bruises, texture(e.g. rough, dry skin)
 Mouth: stomatitis, ammonia breath.
 Face & extremities- generalized edema, peripheral edema, bladder distention, masses, enlarged
kidney.
 Abdomen-abdominal contour for midline mass in lower abdomen (may indicate urinary
retention) or unilateral mass.
 Weight: weight gain 2nd to edema, weight loss & muscle wasting in renal failure.
B. General state of health- fatigue, lethargy, & diminished alertness.
C. Palpation- No costovertebral angle tenderness, non-palpable kidney & bladder, no palpable masses.
D. Percussion: Tenderness in the flank may be detected by fist percussion. If CVA tenderness & pain
are present, indicate a kidney infection or polycystic kidney disease.
E. Auscultation: The abdominal aorta & renal arteries are auscultated for a bruit, which indicates
impaired blood flow to the kidneys

DIAGNOSTIC TECHNIQUES FOR RENAL SYSTEM PATHOLOGIES

1. Urinalysis- evaluation of the renal system & for determining renal disease. Wash perennial area &
use a clean container. Obtain 10 to 15 mL of the 1st AM sample. If the client is menstruating,
indicate this on the laboratory requisition form.
2. Specific Gravity- measures the kidney’s ability to concentrate urine. Measured by multiple-test
dipstick (most common method), refractometer-instrument used in the lab, urinometer (least accurate
method). Cold specimens produce a false high reading. Factors that interfere with an accurate
reading include radiopaque contrast agents, glucose & proteins. A decrease in SG (less conc. urine)
occurs with increased fluid intake, diuretic administration, and diabetesinsipidus.
An increase SG (more conc. Urine) occurs with insufficient fluid intake, decreased renal perfusion,
or the presence of ADH.
3. Urine Culture & Sensitivity- identifies the presence of microorganisms & determines the specific
ATB. That will treat the existing microorganisms. Note that urine from a client who forced fluids
may be too dilute to provide a positive culture.
4. Vanillymandelic acid (VMA) - to diagnose pheochromocytoma, a tumor of the adrenal gland. The
test identifies an assay of urinary catecholamines in the urine. Instruct to avoid foods such as
caffeine, cocoa, cheese, gelatin at least 2 days prior to beginning of the collection & during

Lecture notes Medical Pathology II, AHID level 200 Nursing, Mr. EPAH 2019/2020, Tel: 670374166,
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 collection. Save all urine on ice or refrigerate. Instruct to avoid stress & to maintain adequate food &
fluids during the test.
5. Uric acid- A 24-hour collection to diagnose gout & kidney disease.Encourage fluids & a regular diet
during testing. Place the specimen on ice or refrigerate.
6. KUB (Kidney, ureters, bladder) radiograph-An x-ray film that views the urinary system &
adjacent structures; used to detect urinary calculi.
7. Bladder ultrasonography-A noninvasive method of measuring the volume of urine in the bladder.
8. Computed tomography (CT) & MRI- provide cross-sectional views of the kidney & urinary tract.
9. Intravenous pyelogram (IVP) - the injection of a radiopaque dye that outlines the renal system.
Performed to identify abnormalities in the system. Withhold food & fluids after midnight before the
test. Inform the client abt. Possible throat irritation, flushing of the face, warmth or salty taste that
may be experienced during the test.
10. Renal angiography- the injection of a radiopaque dye through a catheter for examination of the
renal arterial supply. Assess the client for allergies to iodine, seafood & radiopaque dyes. Inform
about possible burning feeling of heat along the vessel when the dye is injected. NPO after MN on
the night of the test. Instruct to void immediately before the procedure. Inspect the color &
temperature of the involved extremities. Inspect site for bleeding.
11. Renal Scan-an IV injection of a radiopaque for visual imaging of renal blood flow. Instruct that
imaging may be repeated at various intervals before the test is complete. Assess for signs of delayed
allergic reactions, such as itching & hives.
12. Cystometrogram (CMG) - A graphic recording of the pressures exerted at varying phases of the
bladder. Inform of the voiding requirements during & after the procedure.
13. Cystoscopy & Biopsy- the bladder mucosa is examined for inflammation, calculi or tumors by
means of a cystoscope, a biopsy may be obtained. NPO after MN before the test. Monitor for
postural hypotension. Note that pink-tinged or tea-colored urine is common. Monitor for bright, red
or clots & notify MD.
14. Renal biopsy- insertion of a needle into the kidney to obtain a sample of tissue for exam. NPO after
MN. Provide pressure to the biopsy site for 30 minutes. Check site for bleeding. Force fluids to
1500-2000 mL. Instruct to avoid heavy lifting & strenuous activity for 2 weeks.

URINARY TRACT DISODERS

Examples of urinary disorders include cancers of the urinary tract, incontinence (inability to control urine
flow), interstitial cystitis, kidney stones, kidney failure, and urinary tract infections. Common symptoms of
urinary disorders include abdominal, pelvic, or lower back pain or discomfort; blood in the urine; changes in
the urine; difficulty producing urine; fever and chills; frequent urination; leaking of urine; and urgent need to
urinate. Some urinary disorders, such as infections, may develop quickly, while others, such as cancer,
develop more slowly.

1. URINARY TRACT INFECTION

Definition: A urinary tract infection (UTI) is an infection involving the kidneys, ureters, bladder and urethra
that is characterized by bacteria in urine (bacteurea) and clinical symptoms (e.g. painful urination, fever,
etc.).
UTI involving the upper urinary system (kidneys) is called kidney infection or pyelonephritis. When
affecting the lower urinary system, it may be called cystitis or urethritis. Most infections involve the lower
urinary tract — the bladder and the urethra.
Signs and Symptoms
a) Lower urinary tract infection
 Burning sensation with urination
 Frequent urination in the absence of vaginal discharge
 Pain above pubic bone or lower back
Lecture notes Medical Pathology II, AHID level 200 Nursing, Mr. EPAH 2019/2020, Tel: 670374166,
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 b) Upper urinary tract infection
In addition to the classic symptoms of the lower urinary tract infection, patients experience;
 Flank pain
 Fever
 Nausea and vomiting
Causes of UTI
A. Through the spread of micro-oranisms from:
1. The gut eg E- coli 80-85%, Staphylococcus saprophyticus 5-10%
2. From health care intervention procedures such as urinary catheterizations transmitting;
 E-coli 27%
 Klegseilla 11%
 Pseudomonas 11%
 Candida albicans 9%
 Entrococcus 7%
 Secondary to blood borne infections eg Staphylococcus aureus.
B. Sexual activity accounts for about 70-90% of cases with risk of infection related to frequency of sex.
C. Sex: females are more exposed to UTIs than males. This may be due to the following reasons;
 Female urethra is much shorter and closer to the anus than that of male counterparts
 Menopause decreases estrogen levels leading to loss of protective vaginal flora
 Improper female toileting habits
 Vaginal secretions may habour bacteria
 Sexual intercourse may cause trauma to the urethra and bladder leding to
inflammation and infection.
 Male prostatic secretions have antibacterial effects, reducing risk of UTIs.
D. Other predisposing factors include;
 Family tendencies due to genetics
 Diabetes, being uncircumcised and having large prostate.
Pathogenesis
 Bacteria that cause UTI typically enter the bladder via the urethra. However, infection may also
occur via blood or lymph.
 Bacteria usually reach urethra from the bowel, with females at greater risk because of their anatomy
 After reaching the bladder, E-coli are able to attach to the bladder wall and form a biofilm that resists
body’s immune response.
 E-coli are the single most common microbe, followed by Klebsiella.
Diagnosis
1. Urinalysis: looking for the presence of urinary nitrates, WBCs, etc.
2. Urine microscopy: looks for the presence of RBCs, WBCs or bacteria in urine using microscope.
3. Urine culture: with or without bacterial sensitivity test.

1. Nursing Diagnosis 1: Acute pain r/t inflammation of mucosal tissue of UT as manifested by pain on
urination, flank pain, bladder spasms.
Provide relief by administering analgesics such as Pyridium or combination agents (Urised). Alert that urine
color will be orange & blue or green with combination agents. Teach the use of nonpharmacologic
technique- heating pad, warm showers

2. Nursing diagnosis 2: Impaired urinary elimination r/t UTI as manifested by bothersome urgency,
hematuria or concern over altered elimination pattern. Obtain midstream voided specimen for C/S.
Administer antimicrobial drugs. Teach signs & symptoms of UTI. Encourage adequate fluid to help prevent
infection and dehydration.
Lecture notes Medical Pathology II, AHID level 200 Nursing, Mr. EPAH 2019/2020, Tel: 670374166,
kukuepah@gmail.com
Treatment of UTI
Antibiotics usually are the first line treatment for urinary tract infections. Drug choices and duration of
treatment depend on the condition and the type of bacteria found in the urine.
1. Treatment of simple infection
Drugs commonly recommended for simple UTIs include:
 Trimethoprim/sulfamethoxazole (Bactrim, Septra, others)
 Cephalexin (Keflex)
 Ceftriaxone
Note:Fluoroquinolones, such as ciprofloxacin (Cipro), levofloxacin (Levaquin) and others are not
commonly recommended for simple UTIs, as the risks of these medicines generally outweigh the
benefits for treating uncomplicated UTIs.
 Pain is usually relieved soon after starting an antibiotic. But at times, pain medication (analgesic)
that numbs your bladder and urethra to relieve burning while urinating are also prescribed.
2. Treatment of reccurent infections
In cases of frequent UTIs, treatment recommendations may include:
 Low-dose antibiotics, initially for six months but sometimes longer
 Self-diagnosis and treatment, if you stay in touch with your doctor
 A single dose of antibiotic after sexual intercourse if infections are related to sexual activity
 Vaginal estrogen therapy if female is postmenopausal.
3. Severe infection: In severe UTI,
 Hospital admission is advised.
 Treatment with intravenous antibiotics may be necessary for 7-10 days.
Complications
Complications of a UTI may include:
 Recurrent infections, especially in women who experience two or more UTIs in a six-month period
or four or more within a year.
 Permanent kidney damage from an acute or chronic kidney infection (pyelonephritis) due to an
untreated UTI.
 Increased risk in pregnant women of delivering low birth weight or premature infants.
 Urethral narrowing (stricture) in men from recurrent urethritis, previously seen with gonococcal
urethritis.
 Sepsis, a potentially life-threatening complication of an infection, especially if the infection works its
way up your urinary tract to your kidneys.
Prevention
You can take these steps to reduce your risk of urinary tract infections:
 Drink plenty of liquids, especially water. Drinking water helps dilute your urine and ensures that
you'll urinate more frequently — allowing bacteria to be flushed from your urinary tract before an
infection can begin.
 Wipe from front to back. Doing so after urinating and after a bowel movement helps prevent bacteria
in the anal region from spreading to the vagina and urethra.
 Empty your bladder soon after intercourse. Also, drink a full glass of water to help flush bacteria.
 Avoid potentially irritating feminine products. Using deodorant sprays or other feminine products,
such as douches and powders, in the genital area can irritate the urethra.
 Change your birth control method. Diaphragms, or unlubricated or spermicide-treated condoms, can
all contribute to bacterial growth.

3. URETHRITIS
Definition: this is inflammation of the urethra, which can be acute or chronic.
Lecture notes Medical Pathology II, AHID level 200 Nursing, Mr. EPAH 2019/2020, Tel: 670374166,
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Causes
Can be classified into:
a) Gonococcal urethritis (caused by Neisseria gonorhoea) or
b) Non-gonococcal urethritis (caused by mico-organisms other than Neisseriagonorhoea. NGU is also
called non-specific urethritis. It has both infectious cause and non-infectious cause.
1. Infectious cause includes;
 Bacteria e.g. Chlamydia trachomatis, Hemophilusvaginalis, Mycoplasma genitalium,
etc.
 Viral causes such as Herpes virus, Adeno virus, etc.
 Parasitic e.g. Trachomatis vaginalis, Candida albicans.
2. Non-infectious cause include ;
 Mechanical injury from urinary catheter or cytoscope
 Use of irritating chemicals such as antiseptics, spermicides, etc.
Clinical Manifestations
 In men, symptoms include pain, dysuria, purulent gonococcal and white clear non-gonococcal
discharge from the penis, frequency, itching, irritation tenderness of penis, underwear stain.
 In women, symptoms include vaginal discharge, pain, dysuria, associated anal or oral infection,
abdominal pains, Pelvic Inflammatory Disease (PID). Some women are asymptomatic.
Complications
1. In males: prostatitis, epididymitis, urethral stricture and infertility.
2. In female: batholins abscess, urethral stricture, endometritis, salpingitis, Pelvic Inflammatory
Disease (PID).
Treatment of Urethritis
 It is important that both patient and all sexual contacts be treated.
 Drugs prescribed are based on the cause of the urethritis. Drugs for the treatment of urethritis
include: Doxycycline, Ceftriaxone, Metronidazole, Nystatine, Co-trimoxazole, etc.
 Proper personal hygiene should be stressed.
 Sexual intercourse should be avoided until symptoms subside.
Prevention
1. Avoiding unprotected sexual intercourse
2. Avoid chemicals that irritate the urethra
3. Minimize irritation during manual manipulation of the urethra.

DISEASES OF THE KIDNEY

1. PYELONEPHRITIS
Definition: it is a serious disease of the kidney of ascending urinary tract that has reached the renal pelvis or
simply, infection of the kidney. It can be acute or chronic, unilateral or bilateral.
Classification of pyelonephritis
1. Acute pyelonephritis: it is a sudden inflammation of the pelvis caused by ascending bacteria
infection. It primarily affects the interstitial area, renal pelvis and less often, the renal tubules.
2. Chronic pyelonephritis: it is persistent kidney inflammation leading to scarring and chronic renal
failure. It is common in patients who are predisposed to recurrent acute pyelonephritis eg those with
urinary obstruction and vesico-urethral reflux.
Etiology
Most common causes are due to Gram negative enteric (bowel) bacilli that enter the urinary tract. These
organisms include E. coli (70-80%), Enterococcus faecalis, etc. In rare cases, Staphylococus and
Streptococcus may be blood borne.
Other predisposing or risk factors include:

Lecture notes Medical Pathology II, AHID level 200 Nursing, Mr. EPAH 2019/2020, Tel: 670374166,
kukuepah@gmail.com
  Obstruction of urine flow due to renal calculus, new growth, stricture of ureter, scaring and
congenital anomaly of the urinary tract.
 Urine stasis
 Catheterization
 Pregnancy
 Enlarged prostate
 Spermicide use
 Positive family history
Clinical manifestations
Chills, high fever, joint pain, muscle pain, dysuria, malaise, sweating, nausea and vomiting, frequency and
urgency.
Diagnosis
1. From medical history and physical exams
2. Blood tests e.g. FBC and blood culture
3. Urinalysis and urine culture
4. Ultrasound study of the kidney
Management
a. Antibiotics are administered after lab results are made available
b. Potassium citrate may be added to render urine alkaline making it unfavourable to E-coli.
c. Analgesics for pain
d. Urinary antiseptics egNitrofurantoin may also be ordered.
Nursing care
 Encourage adequate bed rest especially during the acute phase
 Ensure adequate fluid intake to dilute the number of orgqnisms
 Monitor vital signs, fluid intake and output.
 Keep patient warm to avoid chills

2. GLUMERULONEPHRITIS (NEPHRITIC SYNDROME)

Definition: It is a renal disease characterized by inflammation of the glomeruli or small blood vessels of the
kidney. It is characterized by oedema, proteinurea, hematuria and high blood pressure.
Glomerulonephritis may be caused by disorders due to infections, inherited genetic disorder or auto-immune
disorders. Affected people may have tissue swellings, headache, visceral disturbances and seizures.
Glomerulonephritis can be Primary, affecting the kidneys only or may be secondary (caused by several
disorders that affect other parts of the body). Glumerulonephritis can either be acute (developing over a short
period of time) or chronic (develops and progresses slowly).

A. ACUTE GLUMERULONEPHRITIS
It is a condition characterized by inflammatory reaction of the glomeruli of both kidneys which typically
affect all glomerular diffusion.
Etiology
 It is thought to involve antigen-antibody reaction which produces damage to the glomerular
capillaries.
 Infectious causes: It most often occurs as a complication following Throat infection (e.g. tonsillitis),
skin infection (e.g. impetigo) or wound infection (caused by B-hemolytic streptococcus). Acute
glomerulonephritis that occurs following Streptococcal infection is called Post-streptococcal
glomerulonephritis. Other types of bacteria (Staphylococcus and Pneumococcus), viral infections
(chicken pox) and parasitic infections (malaria) may also be implicated. Acute glomerulonephritis
that occur from any of these infections is called Post-infectious glomerulonephritis.
 Non-infectious causes of acute glomerulonephritis include:
Lecture notes Medical Pathology II, AHID level 200 Nursing, Mr. EPAH 2019/2020, Tel: 670374166,
kukuepah@gmail.com
 1. Membrane proliferative GN: the cells of the glomerulus start growing abnormally leading o
inflammation causing acute GN.
2. Immunoglobulin A reaction: IgA is deposited on the walls of the glomerulus causing its
inflammation.
3. Thin basement membrane disease: usually hereditary, causing glomerular membrane to become
thin thus causing inflammation.
4. Systematic lupuserythermatosis: body secretes antibodies which fight against the body antigen
leading to bleeding.
5. Wegener’s granulomatosis
Pathophysiology
When immune complex are trapped in the glomeruli, it leads to inflammation. Naked eye exams of the
kidney show patches of hemorrhage all over the cortex. With microscopic exams of the kidneys, there is:
1. Swelling of endothelial cells
2. Proliferation of cells of the glomerular capillary wall
3. Accumulation of polymorphonuclear leucocytes in the blood capillaries and glomerular space
leading to swellings of the capillaries, therefore the kidney becomes swollen.
Because of inflammation, blood can no longer flow easily via the capillaries so renin is produced leading to
high BP. In some cases, there may be proliferation of the outer layers of the Bowman’s capsule making it
crescent in shape, compressing glomeruli therefore interfering with their functions. However, changes
resolve with clinical recovery and kidney returns to normal. Progressive cases leads to fibrosis with
formation of scare tissues.
Signs and Symptoms
 In children, onset is sudden with fever, epistaxis, headache, weakness and back pain. Occasionally,
there is nausea and vomiting.
 Odema is typical involving the face especially the eyes. If the lungs also become odematus,
breathlessness occurs.
 Urinary changes include oliguria, anuria, hematuria, albuminurea, cast (epithelial and glandular)
 High BP with few patients developing hypertensive encephalopathy.
 Increased blood urea and creatinine levels.
 Acidosis may be present in moderate degrees
Prognosis
There is about 90% recovery in children who suffer from the disease. Prognosis is poor in adults and after
middle age, recovery is only about 50%. About 6.1% of children and 25% of adults develop chronic renal
failure.
Complications
1. Nephrotic syndrome
2. Chronic kidney failure
3. Hypertension
4. Fluid overload may lead to congestive heart failure and pulmonary edema
5. End-stage kidney disease and recurrent urinary tract infection
Treatment and Nursing Care
Objectives of treatment
1. Ensuring rest and warmth
2. Dietary and fluid regulation
3. Treatment of infection
 The patient is nursed in bed in a warm ventilated room avoiding draught.
 Dietary protein restriction usually indicated especially in cases of increased BUN.
 In pulmonary edema, no fluid is given. Calories should be provided in the form of
carbohydrates (orang, lemon and grape fruit juice) and later, foods when symptoms subside.

Lecture notes Medical Pathology II, AHID level 200 Nursing, Mr. EPAH 2019/2020, Tel: 670374166,
kukuepah@gmail.com
  Salt should be restricted and if edema is severe, a diuretic may be required.
 Antibiotic is prescribed if an existing infection. Penicillin is given if Streptococcal infection
is suspected.
Nursing Care for Severely Ill Patients
a. Control and fill input and output chart
b. Daily bed bath
c. Frequent vital sign checks and recording
d. Pressure areas should be treated 3hourly
e. Mouth care should be given to patients every 4hours and after meal
f. Turn patient on bed every 2 hours
g. Bed pan and urinals served to patient where necessary
h. Tepid sponge if patient has high temperature
i. In the stage of oliguria, avoid drugs that will exert work on the kidneys
j. Symptomatic treatments given where necessary to alleviate pain, temperature, vomiting, severe
headache, anal pain, etc.
k. Ensure patient’s comfort and warmth
l. Reassure patients an guardians and show sympathy and love
m. Strengthen patient’s faith in God
n. If patient is a child, show love and concern. Persuade child to stay in bed.
o. Explain all that is needed for the recovery of the child to the mother reassure her and win her co-
operation.

B. CHRONIC GLOMERULONEPHRITIS
Definition: it is a syndrome characterized pathologically by diffused sclerosis of glomeruli, usually
hematuria and slow progressive loss of renal function. Due to slow progressive nature, it is asymptomatic for
years longer than it is symptomatic. Therefore majority of patients are undetected.
Etiology and Pathology
• At times, the actual cause is unknown
• May be from an outcome of the acute form which fail to resolve
• May occur with no history of previous renal disease or infection
• Occasionally, may be due to inherited disorder
The cause of the disease is variable which progresses slowly leading to loss of renal function. The disease
usually consists of:
 thickening of the renal cortex
 atherosclerosis, thickening of renal arteries
 progressive fibrosis of glomeruli and capillaries leading to obstruction
 Kidney atrophies and renal function progressively decreases.
Clinical manifestations
The signs and symptoms are similar to those of acute form but are usually very mild and may go undetected
for a long time in most people.
 Odema may occur
 High BP is common
 The disease may progress to kidney failure, which can cause itchiness, fatigues, decreased
appetite, nausea and vomiting and difficulties in breathing.
 Urinalysis reveals the presence of RBCs, protein and leucocytes.
Management
• Angiotensin Converting Enzyme (ACE) inhibitor and Angiotensin II receptor blockers (ARB)
either alone or in combination often slow the progression of chronic glomerulonephritis.
• Taking drugs to reduce high BP and reducing sodium intake are considered beneficial.

Lecture notes Medical Pathology II, AHID level 200 Nursing, Mr. EPAH 2019/2020, Tel: 670374166,
kukuepah@gmail.com
 • Restricting the amount of protein in the diet is mostly helpful in reducing the rate of kidney
deterioration
• End stage kidney failure can be treated by dialysis and kidney transplant.

C. NEPHROTIC SYNDROME (NEPHROSIS)

Definitions:
Nephrosis- denotes any degenerative non-inflammatory change in the kidneys. It affects all age groups and
occurs more often in males than females.
Nephrotic syndrome is a non-specific disorder of the kidneys characterized by clinical state of;
• Generalized odema
• Gross proteinurea (more than 3.5g/day)
• Hyperalbuminemia (less than 2.5g/day), normal value (3.5 – 5g/day)
• Hyperlipidemia
• Lipidurea may also occur
• Altered immunity
• High BP
Classification of nephrotic syndrome
1. Congenital nephrotic syndrome: it is an autosomal recessive disorder which is relatively rare.
2. Primary nephrotic syndrome: it results from diseases limited only to the kidneys e.g.
glomerulonephritis.
3. Secondary nephrotic syndrome: it results from diseases that affects the kidneys and other parts of
the body.
Aetiology
1. In some cases, causes are unknown (idiopathic), but is suggested that it may result from antigen-
antibody reaction in the body, more common in children.
2. It may be associated by the following diseases in which the patient has primary renal disease or
the kidney’s involvement is secondary.
a) Acute and chronic glomerulonephritis
b) Quartan malaria (P. malaria)
c) Collagen disease eg systematic lupus erythematous
d) Diabetes mellitus (about 10% of all cases)
e) Drug poisoning (IV heroin, Tridione) used in treating epilepsy.
f) Hepatitis B and C
g) Amyloidosis
h) Leprosy and syphilis
Pathophysilogy
• There is increased permeability of the glomerular membrane permitting the passage of albumin
via the membrane and is excreted in urine.
• Proteinuria result in decrease oncotic pressure and development of oedema as there is seepage of
fluid into interstitial spaces.
• Kidney reabsorbs salt and water further worsening the odema
• Immunoglobulins are lost resulting in altered immunity
• Liver respond to hyperalbuminaemia by increasing protein synthesis leading to overproduction of
Lipo-proteins, hence, hyperlipidaemia.
Clinical Manifestations
• Odema (gradual or sudden, first affecting the legs and ankles, then peri-orbital odema) may be
extreme with ascites (Fluid in the peritoneal cavity) and peritoneal effusion (fluid in the pleural
space).
• Breathlessness if pleural effusion and ascites
• Anorexia, diarrhea and vomiting may be present
Lecture notes Medical Pathology II, AHID level 200 Nursing, Mr. EPAH 2019/2020, Tel: 670374166,
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 • Gross albuminuria
• Urinary casts
• Occasionally, RBCs may be seen through the microscopic urine examination
• Hypoproteinaemia
• Anaemia
• Increased BP
Management
Objectives of management
1. To control proteinuria
2. To relief edema
3. To manage associated symptoms
4. To prevent infection
Treatment
1. Immunosuppression for the glomerulonephritis via administration of corticosteroid such as
Prednisolone (drug of choice) in three divided doses of four weeks followed by a single dose on
every alternate day for four weeks. Corticosteroids help to:
a) Induce diuresis
b) Produce protein free urine
c) Elevate serum albumin to normal level
d) Reduce lipidemia towards nomal.
A maintenance dose can sometimes be given for over one year when relapses occur. Another
immunosuppressive drug often used is Cyclophosphamide.
2. IV administration of albumin but has transient effects especially if patient is anorexic
3. Oral diuretics preferably Hydrochlorothiazide (HCT) for adults of Furosemide for children.
4. Broad spectrum antibiotics for infection
5. Blood glucose level control for diabetics
6. Treat anaemia with iron tablets
7. As long as blood urea is not elevated, give normal protein diet plus amount lost in urine.
8. Salt intake should be restricted
9. Potassium intake should not be restricted because it prevent water from seeping into interstitial
paracentesis for ascites or thoracenthesis for pleural effusion.
Nursing Management
1. Take care of a patient on bed rest (ie treat pressure areas, turning patient on bed, bed bath and
mouth care)
2. Activity within patient’s tolerance is encouraged
3. Check and record vital signs
4. Collect urine and blood specimen accordingly
5. Accurate care of input and output chart
6. Make sure patient is taking his meals
7. Observe patients for;
• Changes in respiration
• State and degree of odema
• Changes in blood pressure
• Signs of renal failure
• Urine output
• Signs of potassium depletion (muscle weakness, lethargy)
• Signs of side effects of prednisolone
• Weight gain
• Nausea and vomiting.

Lecture notes Medical Pathology II, AHID level 200 Nursing, Mr. EPAH 2019/2020, Tel: 670374166,
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 D. RENAL FAILURE (URAEMIA)
Definition: Renal or kidney failure describes a condition in which the kidney fails to adequately filter toxins
and waste products from the blood. It is also described as a decrease in the glomerular filtration rate (GFR).
Classification
There are two forms; acute and chronic renal failure.
Acute renal failure
• It occurs suddenly with rapidly progressive loss of renal functions
• It is characterized by oliguria, body water and body fluid disturbance and electrolyte imbalances
• Condition is potentially reversible
Chronic renal failure
• Gradual and slowly increasing uraemia that develops over the years
• It is irreversible loss of kidney functions which necessitates kidney dialysis or kidney transplant.
• Loss of renal function results to end stage renal failure systemic abnormalities.

1. ACUTE RENAL FAILURE (ACUTE KIDNEY INJURY)

This is the sudden loss of the ability of the kidney to remove waste and concentrate urine without losing
electrolytes leading to their accumulation in body fluids.
Causes
It results from a variety of causes generally classified into pre-renal, intra-renal and post renal causes.
1. Pre- renal causes
• Consists of factors outside or before the kidney that impair renal blood flow and result in
decrease glomerular perfusion and filtration
• Circulatory failure i.e. shock leading to renal iscaemia which leads to necrosis
• Renal blood flow may be reduced in;
a. Loss of blood from any cause
b. Loss of plasma e.g. during burns and injury
c. Loss of fluid and salt (dehydration)
d. Hypotension
e. IV hemolysis and breakdown of muscle cells, leads to reduce products which are
capable of reducing the renal circulation.
2. Intrinsic or intra-renal causes
This result from diseases that actually damage the renal tissues resulting in malfunction of the kidneys. These
include;
• Glomerulonephritis
• Pyelonephritis
• High BP
• Diabetes mellitus
• Septic abortion, blood transfusion (agglutination of RBCs)
• Disseminated intravascular coagulation (DIC)
• Nephrotic drugs which cause prostrusion of renal blood flow by crystalisation or actual damage
of the epithelial cells of the tubules egsulphonamides, penicillines, aminoglycosides, pesticides
etc.
3. Post- Renal Causes
These are conditions that lead to obstruction of outflow of urine. They include;
• Renal calculi
• Pelvic tumors
• Blood clot
• Prostatic enlargement
• Phimosis, may compress the urethra lumen from outside.
• Fibrosis or stricture following infection
Lecture notes Medical Pathology II, AHID level 200 Nursing, Mr. EPAH 2019/2020, Tel: 670374166,
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 • Accidental ligation of urethra during surgery
Clinical Manifestations
• Urinary changes which include oliguria, nocturia, and anuria in severe cases
• Urine may contain protein, casts, RBCs and WBCs.
• Swelling of the ankle, foot and leg which may latter be generalized leading to congestive heart
failure, pericardial and pleural effusion.
• High BP
• Symptoms of uremia occurs which include anorexia, nausea, vomiting, bleeding, episodes of
fatigue, apathy, breath odor, mental confusion and latter twitching, drowsiness and seizures.
• Increased serum potassium levels
Treatment of Acute Renal Failure
Once the cause if found, the goal of the treatment is to restore kidney functions and prevent fluid and wastes
from building up in the body while the kidney heals.
• The amount of fluid intake should be limited to the amount of urine you can produce
• Diet high in carbohydrates ( to prevent the breakdown of protein) and low in protein, salt and
potassium
• Antibiotics to treat or prevent infection; diuretics to decrease oliguria but helping kidney to lose
fluids; sodium bicarbonate or calcium glauconate given IV to decrease serum potassium levels.
• Dialysis is not always necessary but can serve a life if potassium levels are dangerously high. It
may also be used when mental status changes occur.
Nursing Care
1. Monitor intake and output adequately
2. Daily weighing
3. Monitor vital signs, signs and symptoms of heart failure and pulmonary effusion
4. Raise side rails incase patient is drowsy and disorientated and may even convulse
5. Emotional support
6. Position changes, deep breathing, coughing and treatment of pressure areas.

2. CHRONIC RENAL FAILURE (CHRONIC KIDNEY DISEASE)

Definition: This is slow progressive deterioration (loss) of kidney functions over time.
This irreversible damage to the nephrons results from a multitude which leads to disorder and insufficiency
of renal excretory and regulatory functions. Loss of functions usually take months or years to occur; may be
so slow that symptoms do not occur until kidney function is less than 1/10 of normal. The final stage of
chronic renal failure is called end-stage renal failure in which the kidney no longer function and patient
needs dialysis and or kidney transplant.
Aetiology and Pathology
Diabetes and hypertension are the two most common causes and accounts for most cases
1. Chronic infections, inflammatory processes leading to progressive fibrosis and destruction of
nephrons.
2. Chronic glomerulonephritis leading to chronic inflammations, fibrosing and destruction of
glomeruli and ensuring degeneration of respective tubules
3. Polysystic kidney disease (progressive enlargement of cysts compresses functional renal
parenchyma leading to high renal insufficiency
4. Hypertensive kidney disease (nephrosclerosis secondary to hypertension and renal
atherosclerosis)
5. Diabetic nephropathy
6. Analgesic nephropathy
7. Urinary schistosomiasis
8. Bilateral hydronephrosis (chronic obstruction of urinary tract by calculi or neoplasm)
9. Other diseases include;
Lecture notes Medical Pathology II, AHID level 200 Nursing, Mr. EPAH 2019/2020, Tel: 670374166,
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 • Systematic lupus erythematous
• Gout
• Persistent hypercalcemia
• Certain toxic chemicals or drugs.
Signs and symptoms
1. Fatigue
2. General itching and dry skin
3. Headaches
4. Anorexia and nausea
When kidney functions worsen, symptoms will include;
5. Bone pain
6. Neurological (drowsiness, numbness, twitching and cramp)
7. Breath odour
8. Low level of sexual interest and impotence
9. Amenorrhea
10. Sleep problems
11. Odema
Management
1. Controlling BP delays further kidney damage. ACE inhibitors (captopril, enatopril, ramipril,
etc.) and ARB (angiotensin receptor blockers e.g. candesartan, eprosartanetc) are most often
used.
2. Treatment of anemia using extra iron diets and iron tablets
3. Extra calcium and vitamin D
4. Restrict fluids and take low protein diets
5. Restrict salts, potassium, phosphorus and other electrolytes
6. When loss of kidney function is severe, prepare patient for dialysis and kidney transplant.

URINARY TRACT OBSTRUCTION (LITHIASIS, UROLITHIASIS)

 A calculus is a stone (a concentrated material, usually mineral salt) that forms in an organ or duct of
the body.
 Lithiasis is a condition in which a person develops a calculus
• The location of the stone is usually indicated by adding a prefix to the root eg
• Nephrolithiasis – stones in the kidneys
• Urolithiasis – stones anywhere in the urinary tract. May be found in the kidney, ureter,
bladder, or urethra.
 Stones vary in sizes, shape and texture. Some are small, hard and smooth while others are large,
rough and soft.
 One can have one or multiple stones
 Stones can occur at any age but peak age of occurrence is 20-55years
 Calculi are more frequent in men than women because they do more vigorous exercises
 Some institutional studies reveal that urolithiasis is more common in white children than blacks,
Asians and Latin Americans.
Types of Kidney Stones
Kidney stone type Population Circumstances Details
Calcium oxalate 80% When urine is acidic Dietary oxalate is found in fruits,
vegetables and nuts. Calcium is found in
bones.
Calcium phosphate 5-10% When urine is alkaline Especially when proteus bacteria are
present.
Uric acid 5-10% When urine is Diet rich in animal proteins and purines

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 persistently acidic
Struvite 10-15% Infection in the kidney Stay infection free to prevent it

Aetiology
Renal stones occur as a result of the following factors;
1. Super saturation of stones forming compounds in urine which eventually leads to their
precipitation. Super saturation of urine with calcium lead to the function of calcium besed stones,
super saturation with urate leads to the uric acid stones, etc.
2. Presence of chemical of physical stimuli in urine, that promote stone formation e.g. phenytoin-
used for epilepsy treatments.
3. Inadequate amount of compounds in the urine that inhibits stone formation e.g. citrate, magnesium.
4. Can also occur in healthy individuals with no apparent cause but it is suggested that it may be
inherited.
Factors promoting stone formation
a) Dehydration i.e. habitually low urine volume e.g. Climate and occupation can cause increased
sweting.
b) Hypercalciuria (high urine exretion of calcium) from hypercalcemia resulting from prolonged
immobilisations, cushing syndrome, vitamin D intoxication, excessive intake of milk and cheese.
c) Hyperuricemia (high urine exretion of uric acid), usually associated with gout.
d) Cysteinurea – which is a genetic metabolic disorder in which cysteine or other chemicals are
ecreted in excess by the kidneys
e) High urine excretion of oxalate (salt of oxalic acid from plants)
f) Changes in PH which influence the extent to which some of these conditions lead to stone
formation
g) Alkaline urine (high PH) leads to precipitation of calcium phosphate stones and struvite.
h) Acid urine (low PH) leading to precipitation of uric acid stones and cysteine.
i) Urine stasis – which can result from urinary obstruction, immobilization, neurological imparement
of the bladder. Crystals precipitate more easily in stagnant fluid
j) Infection – with urea spliing microorganism may also be important.
Clinical Manifestations
1. The clinical manifestations depend on the following;
• Size of the stones
• Whether stone remains stationary or not
• Position of stone
• Presence and nature of underlying conditions
2. Majority of renal calculi cause some pain, hematuria, infection and if larger, patients complain of
pain at the back due to irritation of of tissues by movement of the stones or back pressure and
accumulation of fluid. If stone starts moving and has entered the ureter, it causes ureteral colic or
renal colic which radiates from flank to groin. Pain increases in intensity to maximum and patient
becomes restless, pale, sweating and often vomits and groans in agony.
3. Frequency and hematurea may occur. Hematuria results from the membranous linning of the pelvis
or ureter.
4. With infection, there is chills, fever, leukocytosis and pyurea
5. With complete obstruction, there will be low urinary output and low elimination of wastes.
Diagnosis
1) History of renal colic
2) X-ray of kidneys, ureters and bladder. Calculus show as a dense area.
3) Urinalysis to determine crystals, PH and urine culture for micro-organisms
4) Blood exams show increase serum calcium and increased uric acid
5) Cystoscopy to outline and view the bladder
Lecture notes Medical Pathology II, AHID level 200 Nursing, Mr. EPAH 2019/2020, Tel: 670374166,
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 6) Pyelogram both IV and retrograde.
7) Ultrasound.
Management
1. Medical management
• Analgesics and antipyretics for pain and fever
• Antispasmodics for colicky pains eg atropine sulphate
• Adequate hydration and consumption of large amount of water facilitates the passage of
many calculi. Ambulation also facilitate passage of stones
• In case of any infection, antibiotics are ordered
• Bendrofluazide (urinary diuretics) in doses of 5mg/day reduces urinary excretion by about
30%
• Alkalination of urine by giving NaCO3 or citrate mixture to decrease stone formation from
uric acid.
• Allopurinol is given to lower serum uric acid
• If stone is too large and symptoms continue, surgery may be required to remove the calculi.
2. Surgical management
Indications for surgical endoscopic stone removal include the following;
• Stone too large and not capable of spontaneous passage
• Stone associated with bacteuria or symptomatic infection
• Stone causing impared renal function
• Stone causing persistent pain
• Inability of pain to be treated medically
The surgical procedures include;
a) Lithotripsy: shortening or crushing of the calculus
b) Cystotomy: insertion of ureteric catheter leading to passage of urine
c) Nephrolithotomy: incision to remove stone from the kidney
d) Pyelithotomy: incision into the pelvis to remove a stone
e) Ureterolithotomy: surgical removal of stones from the ureters
3. Nutritional management
• High fluid intake about 3-4L/day
• High urine output prevents supersaturation of minerals, flushes them out before the
• If stone formation is due to high calcium level, lower the intake of calcium
• Diet low in methionine prvent from cysteine stones.
4. Nursing management
• Encourage bed rest
• Warmth application at pain site
• Encourage ambulation
• Encourage adequate fluid intake
• Administer medications as prscribed
• Monitor diet to avoid further stone formation.

STRICTURES
This is the constriction or narrowing of a body passage (any tubule structures). Usually caused by;
• Growth of a tumor within an affected area
• Inflammation
• Muscular spasm
• Compression (pressure) on it by a neighboring organ
Location in the urinary system
• Bladder

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 • Ureter
• urethra

URETHRAL STRICTURE
This is an abnormal narrowing of the tube that carries urine out of the body from the bladder to the exterior
of the body (urethra).
Causes
1. May be caused by itching scare tissue from an injury or surgery
2. May also be caused by pressure from an enlarged tumour near the urethra
3. Other risk factors include;
 History of STI eg gonorrhea,
 Instrumentation used on the urethra such as catheter or cystoscope
 Benign prostatic hyperplasia
 Injury or trauma from accident to the pelvic area
 Repeated episodes of urethritis
4. Congenital strictures are rare.
Clinical Manifestations
• Blood in semen
• Bloody or dark urine
• Decreased urine output
• Difficulty urinating
• Discharges from the urethra
• Frequent or urgent urination
• Urine retention
• Incontinence
• Dysuria
• Pain in the lower abdomen
• Pelvic pain
• Slow urine stream, may occur suddenly or gradually
• Spraying of urine stream
• Swelling of the penis
Complications
• Urinary retention
• Peri urethral abscess
• Urethral fistula
• Urinary tract infection eg cystitis
• Urinary calculus
• Hernia, hemorrhoeds and rectal prolapse
Treatments
1. Instrumental treatment: inserting a thin instrument into the urethra to stretch the urethra during
cystoscopy while the patient is on local anesthesia
2. Operative treatment: internal urethrotomy by surgical incision and removal of the stricture.
Uretheroplasty, which is surgical repair of reconstruction after removal of diseased part.
3. Supportive treatment: a light analgesic, antibiotics, and hot sitz bath may be given.

CANCEROUS CONDITIONS AFFECTING THE URINARY SYSTEM

1. BENIGN PROSTATIC HYPERPLASIA
Definition: Benign prostatic hyperplasia (BPH), also called prostate enlargement, is a noncancerous increase
in size of the prostate gland.

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Symptoms may include frequent urination, trouble starting to urinate, weak stream, inability to urinate, or
loss of bladder control. Complications can include urinary tract infections, bladder stones, and chronic
kidney problems.
Signs and Symptoms
• Difficulties in starting micturition
• Difficulties stopping micturition
• Frequency and urgency
• Poor flow and force of urine passed
• Dribbling and incontinence
• A feeling that the bladder is never completely empty
Pathophysiology
Stasis of urine in the bladder and a build-up of pressure in the bladder and ureters predispose the individual
to infection, the formation of stones and possible renal failure. The bladder becomes enlarged forming
bundles called traberculae. Diverticular may also be noted. If left untreated, obstructive effects will develop.
Investigations
Diagnosis can be made by rectal exam; the prostate gland will feel large, elastic and uniform. Other
diagnostic investigative measures include;
• Urinary flow rates
• Renal function tests
• FBC
• Serum acid phosphatase or serum prostate-specific antigen (PSA) to eliminate diagnosis of
carcinoma
• MSU
• Transurethral ultrasound scan and or biopsy
Complications
• Urethral stricture
• Incontinence
• Impotence
• Retrograde ejaculation
• Bladder neck stenosis
Management
When treating and managing benign prostatic hyperplasia, the aim is to prevent complications related to the
disease and improve or relieve symptoms. Approaches used include;
 lifestyle modifications,
 medications, and
 surgery.
1. Lifestyle: Lifestyle alterations to address the symptoms of BPH include;
• Physical activity,
• Decreasing fluid intake before bedtime,
• Moderating the consumption of alcohol and caffeine-containing products and
• Following a timed voiding schedule.
Patients can also attempt to avoid products and medications with anticholinergic properties that may
exacerbate urinary retention symptoms of BPH, including antihistamines, decongestants, opioids, and
tricyclic antidepressants; however, changes in medications should be done with input from a medical
professional.
2. Medications
The two main medication classes for BPH management are alpha blockers and 5α-reductase inhibitors.
• Alpha blockers

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 Selective α1-blockers are the most common choice for initial therapy. They include
alfuzosin, doxazosin, silodosin, tamsulosin, terazosin, and naftopidil. They have a small to
moderate benefit at improving symptoms.
• 5α-Reductase inhibitors
The 5α-reductase inhibitors finasteride and dutasteride may also be used in men with BPH.
These medications inhibit the 5α-reductase enzyme, which, in turn, inhibits production of
DHT, a hormone responsible for enlarging the prostate
• Others
Antimuscarinics such as tolterodine may also be used, especially in combination with alpha blockers. They
act by decreasing acetylcholine effects on the smooth muscle of the bladder, thus helping control symptoms
of an overactive bladder.
• Self-catheterization
Intermittent urinary catheterization is used to relieve the bladder in people with urinary retention. Self-
catheterization is an option in BPH when it is difficult or impossible to completely empty the bladder.
3. Surgery
If medical treatment is not effective, surgery may be performed. Surgical techniques used include:
• Transurethral resection of the prostate (TURP): A procedure to treat urinary problems that
are caused by enlarged prostate. TURP is thought to be the most effective approach for
improving urinary symptoms and urinary flow; however, this surgical procedure may be
associated with complications in up to 20% of men. Surgery carries some risk of
complications, such as retrograde ejaculation (most commonly), erectile dysfunction, urinary
incontinence, urethral strictures
• Open prostatectomy: not usually performed nowadays, even if results are very good.
• Transurethral incision of the prostate (TUIP): rarely performed; the technique is similar to
TURP but less definitive.

2. CANCER OF THE BLADDER

Definition: Bladder cancer is one of the most common cancers, affecting approximately 68,000 adults in the
United States each year. Bladder cancer occurs in men more frequently than it does in women and usually
affects older adults, though it can happen at any age.
Bladder cancer most often begins in the cells (urothelial cells) that line the inside of the bladder. Although
it's most common in the bladder, this same type of cancer can occur in other parts of the urinary tract
drainage system.
Symptoms
Signs and symptoms of bladder cancer may include:
• Hematuria, urine retention due to tumur growth and tumor spread
• Dysuria, urgency, frequency due to stimulation of reflex micturition arc and secondary
infection.
• Urinary incontinence due to irritability of the bladder
• Chills and cystitis due to obstruction and infection
• Backache and pain due to ureteric obstruction and depending of the stage
• Lower limb oedema due to due to venous obstruction and lymphatic obstruction
• Infection due to obstruction and tumour necrosis
• Malaise, anemia due to frequent lack of sleep and rest and bleeding.
Causes
Bladder cancer develops when cells in the bladder begin to grow abnormally. Rather than grow and divide in
an orderly way, these cells develop mutations that cause them to grow out of control and not die. These
abnormal cells form a tumor.
Causes of bladder cancer include:
1. Smoking and other tobacco use
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 2. Exposure to chemicals, especially working in a job that requires exposure to chemicals
3. Past radiation exposure
4. Chronic irritation of the lining of the bladder
5. Recurrent parasitic infections
6. Chronic inflammations due to indwelling catheter
7. It's not always clear what causes bladder cancer, and some people with bladder cancer have no
obvious risk factors.
Types of bladder cancer
Different types of cells in the bladder can become cancerous. The type of bladder cell where cancer begins
determines the type of bladder cancer. The type of bladder cancer determines which treatments may work
best. Types of bladder cancer include:
a) Urothelial carcinoma:Urothelial carcinoma, previously called transitional cell carcinoma,
occurs in the cells that line the inside of the bladder. Urothelial cells expand when your bladder
is full and contract when the bladder is empty. These same cells line the inside of the ureters and
the urethra, and tumors can form in those places as well. Urothelial carcinoma is the most
common type of bladder cancer.
b) Squamous cell carcinoma: Squamous cell carcinoma is associated with chronic irritation of the
bladder, for instance from an infection or from long-term use of a urinary catheter. Squamous
cell bladder cancer is rare. It's more common in parts of the world where a certain parasitic
infection (schistosomiasis) is a common cause of bladder infections.
c) Adenocarcinoma: Adenocarcinoma begins in cells that make up mucus-secreting glands in the
bladder. Adenocarcinoma of the bladder is rare.
Some bladder cancers include more than one type of cell.
Risk Factors
Factors that may increase bladder cancer risk include:
1. Smoking. Smoking cigarettes, cigars or pipes may increase the risk of bladder cancer by causing
harmful chemicals to accumulate in the urine. When you smoke, your body processes the
chemicals in the smoke and excretes some of them in the urine. These harmful chemicals may
damage the lining of your bladder, which can increase the risk of cancer.
2. Increasing age. Bladder cancer risk increases as you age. Bladder cancer can occur at any age,
but it's rarely found in people younger than 40.
3. Being white. White people have a greater risk of bladder cancer than do people of other races.
4. Being a man. Men are more likely to develop bladder cancer than women are.
5. Exposure to certain chemicals, being around certain chemicals may increase the risk of bladder
cancer. Chemicals linked to bladder cancer risk include arsenic and chemicals used in the
manufacture of dyes, rubber, leather, textiles and paint products.
6. Previous cancer treatment. Treatment with the anti-cancer drug cyclophosphamide increases the
risk of bladder cancer. People who received radiation treatments aimed at the pelvis for a
previous cancer have an elevated risk of developing bladder cancer.
7. Chronic bladder inflammation. Chronic or repeated urinary infections or inflammations
(cystitis), such as might happen with long-term use of a urinary catheter, may increase the risk of
a squamous cell bladder cancer. In some areas of the world, squamous cell carcinoma is linked to
chronic bladder inflammation caused by the parasitic infection known as schistosomiasis.
8. Personal or family history of cancer.
Prevention
Although there's no guaranteed way to prevent bladder cancer, you can take steps to help reduce your risk.
For instance:
• Smoking ceasation
• Take caution around chemicals. If you work with chemicals, follow all safety instructions to
avoid exposure.
Lecture notes Medical Pathology II, AHID level 200 Nursing, Mr. EPAH 2019/2020, Tel: 670374166,
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 • Choose a variety of fruits and vegetables. Choose a diet rich in a variety of colorful fruits and
vegetables. The antioxidants in fruits and vegetables may help reduce your risk of cancer.
Diagnosing Bladder Cancer
Tests and procedures used to diagnose bladder cancer may include:
1. Cystoscopy: insertion a small, narrow tube (cystoscope) through the urethra. The cystoscope has a
lens that allows the doctor to see the inside of the urethra and bladder, to examine these structures
for signs of disease.
2. Biopsy. During cystoscopy, the doctor may pass a special tool through the scope and into your
bladder to collect a cell sample (biopsy) for testing. This procedure is sometimes called
transurethral resection of bladder tumor (TURBT). TURBT can also be used to treat bladder
cancer.
3. Urine cytology. A sample of urine is analyzed under a microscope to check for cancer cells in a
procedure called urine cytology.
4. Imaging tests. Imaging tests, such as computerized tomography (CT) urogram or retrograde
pyelogram, permits the doctor to examine the structures of your urinary tract.
Treatment
Treatment options for bladder cancer depend on a number of factors, including the type of cancer, grade of
the cancer and stage of the cancer, which are taken into consideration along with your overall health and the
treatment preferences.
Bladder cancer treatment may include:
• Surgery, to remove cancerous tissue
• Chemotherapy in the bladder (intravesical chemotherapy), to treat tumors that are confined to the
lining of the bladder but have a high risk of recurrence or progression to a higher stage
• Reconstruction, to create a new way for urine to exit the body after bladder removal
• Chemotherapy for the whole body (systemic chemotherapy), to increase the chance for a cure in a
person having surgery to remove the bladder, or as a primary treatment in cases where surgery
isn't an option
• Radiation therapy, to destroy cancer cells, often as a primary treatment in cases where surgery
isn't an option or isn't desired
• Immunotherapy, to trigger the body's immune system to fight cancer cells, either in the bladder or
throughout the body
A combination of treatment approaches may be recommended by your doctor and members of your care
team.
Bladder Cancer Surgery
Approaches to bladder cancer surgery might include:
a. Transurethral resection of bladder tumor (TURBT). TURBT is a procedure to remove bladder
cancers confined to the inner layers of the bladder, those which are not yet muscle-invasive
cancers. During the procedure, a surgeon passes a small wire loop through a cystoscope and into
the bladder. The wire loop burns away cancer cells using an electric current. Alternatively, a
high-energy laser may be used to destroy the cancer cells.
TURBT is performed under regional anesthesia — where medication given numbs only the lower
part of your body — or general anesthesia — where medication puts you to sleep during the
surgery
b. Cystectomy. Cystectomy is surgery to remove all or part of the bladder. During a partial
cystectomy, your surgeon removes only the portion of the bladder that contains a single cancerous
tumor. Partial cystectomy may only be an option if cancer is limited to one area of the bladder
that can easily be removed without harming bladder function. A radical cystectomy is an
operation to remove the entire bladder, part of the ureters and surrounding lymph nodes. In men,
radical cystectomy typically includes removal of the prostate and seminal vesicles. In women,
radical cystectomy also involves removal of the uterus, ovaries and part of the vagina.
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 c. Neobladder reconstruction. After a radical cystectomy, the surgeon must create a new way for
urine to leave your body (urinary diversion). One option for urinary diversion is neobladder
reconstruction. Your surgeon creates a sphere-shaped reservoir out of a piece of your intestine.
This reservoir, often called a neobladder, sits inside your body and is attached to your urethra. In
most cases, the neobladder allows you to urinate normally. A small number of people with a
neobladder have difficulty emptying the neobladder and may need to use a catheter periodically
to drain all the urine from the neobladder.
d. Ileal conduit. For this type of urinary diversion, your surgeon creates a tube (ileal conduit) using
a piece of your intestine. The tube runs from your ureters, which drain your kidneys, to the
outside of your body, where urine empties into a pouch (urostomy bag) the patient wears on the
abdomen.
e. Continent urinary reservoir. During this type of urinary diversion procedure, your surgeon uses a
section of intestine to create a small pouch (reservoir) to hold urine, located inside your body.
You drain urine from the reservoir through an opening in your abdomen using a catheter a few
times each day.

DISORDERS OF THE MALE REPRODUCTIVE SYSTEM

A. PROBLEMS OF THE PENIS
1. Phimosis: it is a condition where in uncircumcised men; the foreskin cannot be fully retracted from
the head of the penis. It makes washing difficult or impossible and often lead to irritation and
infection. It can be congenital or acquired
Treatment: common treatment include steroid creams (Betamethasone), manual stretching and circumcision

2. Paraphimosis: it is a condition in which the foreskin become trapped behind the glans penis and
cannot be reduced or pulled back to its normal flaccid position covering the glans penis.
• Foreskin becomes swollen
• If condition persists with lack of blood flow, gangrene and other serious complications
occurs.
Treatment: effectively treated by manual manipulation of swollen foreskin tissue with the aid of lubricant,
cold compression and in some cases, after local anesthesia. If it fails, circumcision may be performed
followed by treatment with antibiotics.
3. Hypospedias: it is a birth defect in which the male urinary opening is abnormally placed in the
penis ie it opens anywhere along the line (Urethral groove) running from the tip along the
underside (ventral) of the shaft to the junction of the penis and scrotum or perineum. Depending
on the area of opening, it can be classified into;
• First degree (glans penis 50-75%)
• Second degree (shaft 20%)
• Third degree (scrotum or perinium 30%)
Treatment: surgery before child reaches one year can correct the defect, permitting normal urination and
latter, sexual intercourse.
4. Epispadias: it is a condition in which the urethral opening is on the upper (dorsal) surface of the
penis, sometimes close to the body.
Treatment: corrective surgery of reconstruction by plastic surgery in early childhood replace urethral
opening to normal position.

B. PROBLEM OF SCROTUM AND CONTENTS

1. Cryptorchidism: it is a condition in which there is failure of one or both testes to descend from the
abdomen into the scrotum during fetal development.
• The testis is usually retained in the inguinal canal

Lecture notes Medical Pathology II, AHID level 200 Nursing, Mr. EPAH 2019/2020, Tel: 670374166,
kukuepah@gmail.com
 • About 3% of full term and 30% of premature infants are born with at least one undescended
testis but 80% descend by the first year of life.
Causes and risk factors
a. Causes usually unknown in full term babies
b. Causes can be associated with the following;
• Premature infants born before the descent of testes
• Low birth weight babies
• Narrow inguinal canal
• Shortened spermatic cord
• Testosterone differences
• Alcohol consumption, exposure to caffeine during pregnancy
• Gestational diabetes
Treatment
a. Management is by surgery (orchiopexy, orchidopexy)
b. Hormonal therapy is sometimes attempted and at times is successful.
Nursing care
• Educate child’s parents on symptoms and treatment options
• Administer hormone therapy eg HCG.
• Prepare child for surgery to prevent testicular atrophy, infertility and testicular cancer

2. Hydrocele: it is the accumulation of serous fluid in the membrane sac (turnicavaginalis) that
surrounds the testis. Is usually unilateral, painless and can swell to a considerable size.
Etiology
a. May be due to failure of closure or incomplete closure of the turnicavaginalis
b. May be secondary to acute or chronic inflammatory conditions of the testes or epididymis.
c. Can be a complication of testicular tumors, radiotherapy or trauma.
Clinical manifestations
• Usually asymptomatic
• There is increased scrotal size and associated discomfort
Diagnosis
• Dullness on percussion due to fluid accumulation
• During transillumination, a hydrocele will pass light
• A tense hydrocele is differentiated from a testicular tumor during transillumination as the latter
will not pass light.
Treatment
• Scrotal support
• Fluid aspiration, using fine trocar and canula.
• Periodic aspiration can be used to treat chronic hydrocele
• Hydrocelectomy is indicated for rapidly refilling hydrocele. It provides a permanent solution.
• Complications of aspiration
• Bleeding
• Infection
Nursing care
a. Monitor vital signs
b. Emotional support
c. Assist in wearing scrotal support
d. Administer medications as prescribed
e. Monitor bleeding and signs of infections on the wound.

Lecture notes Medical Pathology II, AHID level 200 Nursing, Mr. EPAH 2019/2020, Tel: 670374166,
kukuepah@gmail.com
KIDNEY DIALYSIS
Definition: It is the process of filtering the accumulated waste products of metabolism from the blood of
patient whose kidneys are not functioning properly using a kidney machine. OR
It is the separation of dissolved substances from a solution allowing the solution to diffuse through a semi-
permeable membrane.
Uses of Dialysis
1. Correction of fluid an electrolyte imbalance
2. Remove waste products in case of renal failure
3. To treat drug overdose (intoxication)
4. Supportive treatment in preparation for kidney transplant.
Indications for Dialysis
a) Acute indications
1. Metabolic acidosis in situations where correction by sodium bicarbonate is impractical or
may result in fluid overload.
2. Electrolyte abnormalities e.g. severe hypercalaemia
3. During intoxication with dialyzable drug e.g. lithium or aspirin-to carry out dialysis,
dialyzable drugs should be diffusible.
4. Fluid overload not expected to respond with diuretics
5. Complications of uremia e.g. pericarditis, encephalopathy or GI bleeding.
b) Chronic indication
1. Low GFR of less than 10-15ml and earlier in diabetes
2. Difficulties in medically controlling fluid overload, serum potassium or serum phosphorue
when the GFR is very low.
3. When chronic renal failure progresses to end stage renal failure;
Methods of Dialysis
There are two methods; peritoneal and hemodialysis
• Although the procedure in each method differs, the purpose and principles are the same.
• In hemodialysis, a semipermeable membrane separates the patient’s circulating blood from a
specially prepared solution a dialysate.
• In peritoneal dialysis, the peritoneum acts as a semi permeable membrane which separates
the dialysate from the interstitial fluid. The dialysate is introduced into the peritoneal cavity
• The dialysate is a specially prepared aqueous solution of Na+, Ca++, Mg++, K+, Cl-, lactate
or acetone and glucose.
• The concentration of the electrolyte varies according to the patient’s serum electrolyte
concentration
General principles involved in dialysis
Dialysis wworks with the principles of diffusion, osmosis and ultra-filtration.
1. Diffusion: There is movement of solution from an area of higher concentration to an area of lower
concentration across a semi-permeable membrane.
In renal failure, urea, creatinine, uric acid and electrolytes move from the blood to the dialysate thereby
lowering their concentration in the blood. Larger molecules such as RBCs, WBCs, and large proteins cannot
diffuse via the membrane because of small pores.
2. Osmosis: There is movement of fluid and water from an area of low salt concentration to area of
high salt concentration. Glucose is added to dialysate which promotes and creates an osmotic
gradient across the membrane to remove fluid from blood.
3. Ultra-filtration: Results when a pressure gradient across the dialyzer (part of which the dialysis
occurs in the machine) membrane is created by an increased pressure in blood compartment and
decreased pressure in the dialysate compartment. Extracellular fluid moves into the dialysate because
of the pressure gradient.

Lecture notes Medical Pathology II, AHID level 200 Nursing, Mr. EPAH 2019/2020, Tel: 670374166,
kukuepah@gmail.com
PERITONIAL DIALYSIS
• Easier to perform
• The dialysate is introduced into the peritoneal cavity following insertion of a special catheter
• Catheter is inserted around the umbilicus after local anesthesia
• Fluid is allowed to drain into the cavity and allowed to stay in the abdomen for a period of time
during which waste products, fluid pass via the peritoneal membrane into the dialysate.
• Fluid is drained and discarded and the procedure repeated again with a new dialysate depending on
the blood chemistry levels and patient’s reactions.

HAEMODIALYSIS
It is a more efficient method but is a more complex procedure and requires more sophisticated equipments
Blood from an entry is directed extra-corporally through an exchange unit (dialyzer) and return to the body
through a vein. This unit contains porous tubules through which the blood flows and a compartment via
which movements of waste products occur. Heparin I added at intervals during the process to prevent blood
clotting.
Complications of peritoneal dialysis
• Hypovolemic shock or hypotension
• Bleeding
• Pains, usually abdominal pains
• Peritonitis
• Infection
• Outflow problems due to improperly placed catheter, constipation
• Pulmonary complications
Complications of hemodialysis
• Hypotension
• Muscle cramping
• Sepsis
• Dialysis encephalopathy
• Hepatitis
• Blood loss
Nursing care before, during and after kidney dialysis
• Monitor client’s weight and vital signs before during and after procedure.
• During the procedure, warm the dialysate to body temperature to avoid hypothermia and shock
• Maintain asepsis during preparation of dialysate, advice client to wear mask during connection to
avoid introducing pathogens into the peritoneal cavity
• Place drainage bag below patient to facilitate drainage by gravity

RENAL TRANSPLANT
Definition: This is the organ transplant of a kidney into a patient with end-stage renal disease.
• According to donor, transplant may be from a deceased person (cadaver) to a donor or from a
living donor
• Living donor transplant can either be genetically related (living related) or unrelated (living
unrelated) between donor and recipient.
• It is mainly indicated in end-stage renal failure
• There must be cross matching (tissue typing) with blood groups, leukocytes and antigens to
ensure compatibility.
• Donor can be close relatives or a cadaver from an accident who had sudden death but was known
to be in good health.
Advantages of kidney transplant

Lecture notes Medical Pathology II, AHID level 200 Nursing, Mr. EPAH 2019/2020, Tel: 670374166,
kukuepah@gmail.com
 1. Discontinuance of the demanding dialysis schedule
2. Considerable time is saved
3. Patients occupation is uninterrupted and more productive
4. Dietary restrictions are lifted and constraint of activity is slight
Complications of renal transplant
1. Rejection due to incompatibility of recipient’s tissues with that of donor
2. Effects of immunosuppressant of rejection process
3. Infection
4. Electrolytes imbalance
5. Hematomas (swellings containing blood clots)
6. Abscess formation
Pre-operative care for patients with renal transplant
• Care is the same as for any patient going in for a major operation
• The donor must be mentally and physically prepared for the procedure
• Counseling for both donor and reciepient
• Immunosuppressants may be ordered to suppress immune system from rejecting donor kidney eg
corticosteroids or T-cell suppressors
• Recepients may be given transfusion of donor’s blood to decrease rejection
• Patient is dialyysed shortly before transplant
Post-operative care
• Monitor vital signs, intake and output
• Assist patient’s recovery from anesthesia
• If complications arise, additional medications (diuretics) may be administered to help the kidney
produce urine
• Grape fruits and other citreous products should be avoided as they decrease the effects of many
critical drugs after kidney transplant.

Lecture notes Medical Pathology II, AHID level 200 Nursing, Mr. EPAH 2019/2020, Tel: 670374166,
kukuepah@gmail.com