Anatomy and Physiology

General Mechanisms of Nontraumatic

Tissue Problems
General Pathophysiology, Assessment,
and Management
Renal and Urologic Emergencies

The Urinary
System

Female
Male

Urology &
Nephrology
The
Kidneys

STRUCTURE OF THE KIDNEYS

The
Kidneys

Hilum
Medulla
Pyramids
Papilla
Renal Pelvis

Nephrons

Glomerulus
Bowmans
capsule
Proximal Tubule
Loop of Henle
Distal Tubule
Collecting Duct

Functions of the Kidneys

Forming and Eliminating Urine

Maintaining blood volume with proper

balance of water, electrolytes, and pH.

Retaining key compounds such as glucose,
while excreting wastes such as urea.

Controlling Arterial Blood Pressure

Regulating Erythrocyte Development

Formation of Urine

Glomerular Filtration
GFR

Reabsorption & Secretion

Simple diffusion and osmosis
Facilitated diffusion
Active transport

Tubular Handling of Water and

Electrolytes

Tubular Handling of Glucose and Urea

BUN and Creatinine

Control of Arterial Blood Pressure

Diuresis and Antidiuresis

The Renin-Angiotensin System

Control of Erythrocyte Production

Erythropoietin

Ureters
Urinary
Bladder
Urethra
Testes
Epididymus
and Vas
Deferens
Prostate
Gland
Penis

Inflammatory or ImmuneMediated Disease

Infectious Disease
Physical Obstruction
Hemorrhage

Differentiating GI and Urologic

Complaints
Pathophysiologic Basis of Pain

Causes of Pain
Types of Pain

Visceral pain
Referred pain

Initial Assessment
Focused History

Prior History of Similar Event

History of Nausea, Vomiting, and Weight Loss
Change in Bowel Habits and Stool
Last Oral Intake
Presence of Chest Pain

Physical Exam

Appearance

Posture

Uncomfortable appearance.
Lying with knees drawn up.
Relief with walking.

Level of Consciousness

Determine if changes are acute or

chronic.

Apparent State of Health

Skin Color
Examination of the Abdomen

Inspection for distention, ecchymosis, or scarring

Pain associated with percussion of abdomen
Palpation

Normal or ectopic pregnancy

Masses

Assessment Tools
Vital Signs

Management

Airway, Breathing Circulation

Pharmacologic Interventions

Nonpharmacological Interventions

IV access and analgesics.

Nothing by mouth (NPO).
Maintain position of comfort.
Reassess mental status and vital signs
frequently.

Transport Considerations

Risk Factors

Older Patients
History of Diabetes
History of Hypertension
Multiple Risk Factors

Renal and Urologic Emergencies

Acute Renal Failure

Chronic Renal Failure
Renal Calculi
Urinary Tract Infection

Pathophysiology

Prerenal Acute Renal Failure

Dysfunction before the level of kidneys
Most common and most easily reversible

Renal Acute Renal Failure

Dysfunction within the kidneys themselves

Postrenal Acute Renal Failure

Dysfunction distal to the kidneys

Assessment

Focused History

Change in urine output

Swelling in face, hands, feet, or torso
Presence of heart palpitations or irregularity
Changes in mental function

Physical Assessment
Altered mental status
Hypertension
Tachycardia
ECG indicative of hyperkalemia
Pale, cool, moist skin

Physical
Assessment
Edema of face,

hands, or feet
Abdominal
findings
dependent on
the cause of
ARF

Management
Airway, Breathing, Circulation
IV Access

Protect fluid volume.

Positioning and Transport

Chronic Renal Failure

Permanent Loss of Nephrons
End-Stage Renal Failure (ESRF)

Pathophysiology

Similar to Renal ARF

Microangiopathy, glomerular injury
Tubular cell injury
Insterstitial injury

Impairment of Kidney Functions

Maintenance of blood volume with proper

balance of water, electrolytes, and pH

Increased sodium, water, and potassium

retention

Retention of key compounds such as glucose

with excretion of wastes such as urea

Loss of glucose and buildup of urea within the

blood

Control of arterial blood pressure

Disruption of the renin-angiotensin loop
resulting in HTN
Regulation of erythrocyte development
Development of chronic anemia

Assessment
Differentiate chronic and acute problems.
Focused history and physical exam.

Gastrointestinal complaints
Changes in mental status
Marked abnormalities during physical exam
Uremic frost

Immediate Management
Monitor and support ABCs.
Establish IV access.

Regulate fluid volume.

Monitor vital signs and cardiac rhythm.

Expedite transport to an appropriate
facility.

Long-Term
Manageme
nt

Renal Dialysis
Hemodialysis
Common

complications

Long-Term
Management

Renal Dialysis
Peritoneal dialysis
Common

complications

Pathophysiology

Risk Factors
Increased risk in female or catheterized patients
Sexual activity

Lower and Upper UTIs

Urethritis
Cystitis
Prostatitis
Pyelonephritis
Community-acquired vs. nosocomial infections

Assessment

Focused History
Abdominal pain
Frequent, painful urination
A burning sensation associated with

urination
Difficulty beginning and continuing to void
Strong or foul-smelling urine
Similar past episodes

Physical Exam
Restless, uncomfortable appearance.
Presence of a fever.
Vital signs vary with degree of pain.

Management
Maintain ABCs.
Establish IV access.
Consider analgesics.
Transport to appropriate facility.

Pathophysiology
Results when too
much insoluble stuff
accumulates in the
kidneys.
Stone types

Calcium salts
Struvite stones
Uric acid
Cystine

Assessment

Focused History
Severe pain in one flank that increases in

intensity and migrates from the flank to the

groin
Painful, frequent urination with visible
hematuria
Prior history of calculi

Physical Exam
Difficult due to patient discomfort
Tachycardia with pale, cool, and moist skin

Management
Maintain ABCs.
Maintain position of comfort.
Establish IV access.

Fluid bolus may promote stone movement

and urine formation.

Consider medication administration.

Parenteral narcotic analgesics may be

indicated.

EPIDEMIOLOGY
STONE

2-4% of general population

2-3 x more common in
males
Caucasian > Oriental >
African American
Hot climates > temperate

RISK FACTORS

Male Gender
Age (to 65)
Low urine vol.
Situational
Geography
Heredity
Diet
Meds

PRESENTATION
Abdominal Pain
Renal Colic:
Sudden; Not Relieved
Hematuria

DIFFERENTIAL Dx

Gynecologic Processes
Testicular Processes
Appendicitis
Cholecystitis
Hernia
Aneurysm
Tumors

Relationship of Stone
Location to Symptoms

elationship of Stone
Location to Symptoms

Stone Location

Common Symptom

Proximal Ureter

Renal colic, flank pain,

upper abdominal pain

elationship of Stone
Location to Symptoms

Stone Location
Kidney

Common Symptom
Vague Flank Pain,
Hematuria

elationship of Stone
Location to Symptoms

Stone Location

Common Symptom

Middle section of
ureter

Renal colic, anterior

abdominal pain, flank pain

elationship of Stone
Location to Symptoms

Stone Location
Distal ureter

Common Symptom
Renal colic, dysuria,
urinary frequency, anterior
abdominal pain, flank pain

Imaging
Essential to confirm
Dx & to size and
locate stone
Several Options

Imaging Options
Ultrasonography
KUB
Intravenous
Pyelography (IVP)
Noncontrast Helical C.T.

Imaging modality Sensitivity (%) Specificity (%)

Ultrasonography

19

Advantages
Accessible
Good for diagnosing
Hydronephrosis and renal
stones
Requires no ionizing radiation

97

Limitations
Poor visualization of
of ureteral stones

Imaging modality Sensitivity (%) Specificity (%)

Plain radiography

Advantages

45 to 59

71 to 77

Limitations

Accessible

Stones in middle section

& expensive

of ureter, phleboliths,
radiolucent calculi,
extraurinary calcifications
and nongenitourinary
conditions

Imaging modality Sensitivity (%) Specificity (%)

Intravenous
pyelography

Advantages

64 to 87

92 to 94

Limitations

Accessible

Variable-quality imaging

Provides information

Requires bowel preparation

on anatomy and
functioning of both
kidneys

& use of contrast media

Poor visualization of nongenitourinary conditions
Delayed images required in
high-grade obstruction

Imaging modality Sensitivity (%) Specificity (%)

Noncontrast helical
computed tomography

95 to 100

Advantages
Most sensitive & specific
radiologic test (i.e., facilitates
fast, definitive diagnosis)
Indirect signs of the degree of
obstruction
Provides information on nongenitourinary conditions

94 to 96

Limitations
Less accessible and
relatively expensive
No direct measure of
renal function.

A SUGGESTION
Patient with abdominal pain

History and physical examination

Renal colic suspected

Diagnostic imaging ???

Patient is pregnant, or
cholecystitis or gynecologic
process is suspected

Patient has history of

radiopaque calculi

All other patients

Ultrasound
Examination

Plain-film
radiography

Intravenous
pyelography if
CT is not
available

Noncontrast
helical CT

Stone
detected

Stone detected

Stone not
detected

Clinical suspicion of urolithiasis

Stone not
detected

MANAGEMENT
(3 Principles)

Recognize Emergencies
Adequate Analgesia
Impact of size and location

Emergencies
Sepsis with obstruction
(struvite stones?)
Anuria
ARF
Urologic consultation

Hospitalization?
Emergencies
Refractory Nausea
Debilitation
Extremes of age
Refractory Pain

Analgesia
NSAIDs : also spasmolytic
Narcotics
No NSAIDs < 3 days before
lithotripsy (ASA < 7 days)
Ketorolac

Composition
Staghorn renal calculi to
urology (assoc. with
infections and kidney
damage)

Other Parameters
Location
Composition
Larger Size
Occupation

SUGGESTIONS
Stones 4 5 mm
Decide based on other
parameters

SUGGESTIONS
Stones > 5 mm
Urologic Consultation

SUGGESTIONS
Stones < 4 mm
Passage in 1-2 wks
Analgesia
Strain Urine
F/U KUB Q 1-2 wks
Urology if not passed in 2 wks.
(certainly 4 wks as comps 3X)
RTC signs of sepsis

anage The Stone

After adequate analgesia and ruling out

emergencies
Principles here are stone size and
location

Treatment Modalities for Renal and

Ureteral Calculi
Treatment

Indications

Advantages

Extracorporeal

Radiolucent calculi

Minimally invasive

shock wave

Renal stones < 2 cm

Outpatient

lithotripsy

Ureteral stones < 1 cm

Limitations
Requires spontaneous passage
of fragments
Less effective in patients with
morbid obesity or hard stones

procedure

Complications
Ureteral obstruction by
stone fragments
Perinephric hematoma

Treatment Modalities for Renal and

Ureteral Calculi
Treatment

Indications

Advantages

Ureteroscopy

Ureteral stones

Definitive
Outpatient procedure

Limitations
Invasive
Commonly requires
postoperative ureteral stent

Complications
Ureteral stricture or
injury

Treatment Modalities for Renal and

Ureteral Calculi
Treatment

Indications

Ureterorenoscopy

Advantages

Renal stones < 2 cm

Definitive
Outpatient procedure

Limitations
May be difficult to clear
fragments
Commonly requires
postoperative ureteral stent

Complications
Ureteral stricture or injury

A SUGGESTED PATHWAY
Confirmed stone
Emergency:
UROSEPSIS, Anuria, Renal Failure

YES

NO

Consider hospital admission:

Refractory pain, Refractory nausea,
Extremes of age, Debillated condition

Urgent urologic
consultation

YES
Urologic
consultation

NO

Symptoms amenable to medical management

Ureteral stone < 5 mm

Renal stone or ureteral

stone > 5 mm

Trial of conservative
management
Weekly KUB radiographs
Stone passes

Stone fails to pass

within 2-4 weeks

Referral to
urologic clinic

Definition of CKD
Kidney damage for >3 months
Defined by structural or functional abnormalities of
the kidney,
with or without decreased glomerular filtration rate
(GFR)

Reduced GFR for >3 months

New staging for chronic kidney disease (CKD)
is primarily based on kidney function.

National Kidney Foundation (NKF). Am J Kidney Dis. 2002;39(2 suppl 1):S1-S266.

Glomerulonefritis
Penyakit ginjal
herediter
Hipertensi
Uropathy obstruktif
Infeksi
Nefropati diabetik

Hipertrofi
sel renal
Ggn
konstentrasi
urin
Penurunan
GFR

Ggn fs
ekskresi

CKD

Ggn fs non
ekskresi

Pe Reabs
Na
Pe eksr
sisa metab
Pe ekskr
kalium
Pe ekskr
PO4
Pe ekskr
ion
H
Ggn

Reproduks
i
Ggn Imun
prod
eritropoeti
Penabs
Ca

JENIS PEMERIKSAAN
PENUNJANG
Urinalisis
Evaluasi Fungsi Ginjal
Evaluasi Serologis
Pemeriksaan Radiologis
Biopsi Ginjal

CKD Progresses in Stages Defined by

Kidney Function: GFR
CKD
Stage

Description

GFR

Prevalence

Patients/
Nephrologist

Kidney damage
90 5,900,000
normal incr. GFR
Mild decr. in GFR 60-89 5,300,000

1060

Mod dec. in GFR

30-59 7,600,000

1520

Severe decr in
GFR
Kidney failure

15-29

400,000

<15

300,000

1180

80
70 (145-160
by 2010)*

20 Million People With CKD (1 in 9 adults) in the United States,

Many More at Risk
*Estimated maximal load of kidney failure patients/nephrologist.
Adapted from NKF. Am J Kidney Dis. 2002;39(2 suppl 1):S1-S266.; Coresh et al. Am J Kidney Dis. 2003;41:1-12; and Wish.
Nephrol News Issues. 1999;13:23, 27, 53.

Clinical Features CKD 3-5

Blood in the vomit or in stools

Decreased alertness; Muscle cramps
Seizures; Agitation; Hypertension
Peripheral sensory neuropathy
Breath fetor; Loss of appetite;
Uremic frost on the skin
Uremic pericarditis, CHF

Clinical Features CKD 3-5

Unintentional weight loss
Nausea, vomiting General ill
feeling
Fatigue; Headache; Frequent
hiccups
Generalized itching (pruritus)
Increased or decreased urine
output

STAGES OF CKD

NORMAL

INCREASED RISK

COMPLICATIONS

CKD
DEATH

DAMAGE

LOW GFR

RENAL FAILURE

Considerations for Patients with CKD?

Susceptibility
Risk Factors
Diabetes
Hypertension
Older age

Progression
Factors
Higher level of
proteinuria
Higher BP

Family history of CKD

Poor glycemic
control

Racial or ethnic
minority

Smoking
Hyperlipidemia

Other: low income,

Drug use
minimal education,
kidney-mass
reduction, known
kidney disease
Levey et al. Ann Intern Med. 2003;139:137-147.

USRDS. 1999 Annual Data Report. Available at: www.usrds.org.

Complications
CVD
Anemia
Altered bone &
mineral
metabolism