DIRE DAWA UNIVERSITY

COLLEGE OF MEDICINE AND HEALTH SCIENCES

DEPARTMENT OF NURSING

Disorders of GUS

Mehammedamin J. (BScN,
MScN)
April, 2022
DDU

07/21/2024 1
Anatomy &Physiology
The urinary system can be classified in to:
1. Upper urinary system consists of:

 2 kidneys and 2 ureters

2. Lower urinary system consists of:

 A urinary bladder and urethra

 Urine is formed in the kidneys, drains through the ureters to be
stored in the bladder and then passes from the body through
the urethra

07/21/2024 2
Anatomy &Physiology
 The kidney has 2 layers:
1. Cortex- the outer layer of the kidney

2. Medulla-The inner layer of the kidney

 The medulla consists of a number of pyramids
 The apics of these pyramids are called papillae, through
which urine passes to enter the calyces
 minor and major calyces transport urine to renal pelvis, from
which it drains through the ureter to the bladder.
 renal pelvis can store a small amount of urine (3ml)
07/21/2024 3
Urine formation

4
07/21/2024
Anatomy &Physiology...
 The kidneys are paired, bean-shaped organs
– Each human kidney has approximately one million
nephrons
• Nephrons are functional units of kidney
– Each nephron is composed: glomerulus, Bowman’s
capsule, and a tubular system
– transfer waste products from the blood to urine.
– Glomeruli are the filtration units of the nephron.
07/21/2024 5
Anatomy &Physiology...
 The tubular system:
 proximal convulated tubule,
 Loop of Henle,
 distal convulated tubule, and
 collecting ducts
 Cortex of kidney: glomerulus, Bowman’s capsule, proxi-
mal tubule, and distal tubules
 Medulla: loop of Henle and collecting tubules

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 7
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Glomerular function
 The process of urine formation are:
1. Filtration
2. Reabsorption
3. Secretion
4. Excretion
Water, electrolytes, and metabolic waste products

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Ureters and urinary bladder

9 9
07/21/2024
Function of Kidneys
• Regulate fluid, electrolyte and acid base composition
• Remove toxic waste products, excess water &salts
• Play a part in controlling blood pressure
• Produce erythropoietin which stimulates red cell produc-
tion
• Help to keep calcium and phosphate in balance for healthy
bones
• Maintains proper pH for the blood

07/21/2024 10
Composition of urine
• water- normal person ingests ~1-2L of water/ day
– about 400-500 ml excreted in urine
• Creatinine: end products of muscle & protein metabolism.
– Creatinine clearance is a good measure of glomerular filtra-
tion
– normal adult GFR is 100-120ml/minute
N.B. amino acids & glucose are usually filtered in glumerulus &
reabsorbed, so not excreted in urine

07/21/2024 11
Composition of urine...
• Electrolytes: Na, K, Cl, bicarbonates and others
• Urea nitrogen (UN): nitrogenous waste in urine.
• Blood urea nitrogen (BUN): a by product of protein metabolism in the
liver
– indicate the extent of renal clearance of nitrogenous waste products.
– is not always elevated with kidney diseases and is not best indicator
of kidney function.
– But its elevation is highly suggestive of kidney disease. Normal
value: 10-20 mg/dl

07/21/2024 12
Composition of urine...
Filtered/d Reabsorbed/d Excreted/d
Na+ 540.0gm 532.0gm 3.3gm
Chloride 630.0gm 625.0gm 5.3gm
Bicarbonate 300.0gm ~300.0gm 0.3gm
Potassium 28.0gm 24.0gm 3.9gm
Glucose 140.0gm 140.0gm 0.0gm
Urea 53.0gm 28.0gm 25.0gm
Creatinine 1.4gm 0.0gm 1.4gm
Uric acid 8.5gm 7.7gm 0.8gm
07/21/2024 13
 Composition of urine...
• Human urine is composed primarily of water (95%).
• The rest is
– urea (2%),
– creatinine (0.1%),
– uric acid (0.03%),
– chloride, sodium, potassium, sulphate, ammonium, phos-
phate and other ions and molecules in lesser amounts

07/21/2024 14
Bladder pressure
• Normally very low urine accumulation is there
• b/c the bladder smooth muscle adapts to the increased stretch
as the bladder is slowly filled.
• The first sensation of bladder filling occurs w/n about 100-
150ml of urine are present in bladder.
• In most cases desire to void occurs w/n bladder contains ap-
proximately 200-300ml of urine.
• With 400 ml a marked feeling of fullness is usually present.

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Assessment of the Urinary System

16
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1. Clinical findings of urinary dysfunction

A) Pain
– Kidney pain
– Pain in the flank
– Bladder pain
– Scrotal pain
– Back and leg pain

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Clinical presentations...
b) Change in voiding
– Voiding is normally a painless function
– occurring 3-6 times daily and occasionally once at night.
– Averegically person forms and voids 1200-1500ml of
urine/24hrs
– Amount modified by fluid intake, sweating, environmental
temperature, vomiting, diarrhea

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Common voiding problems
• Frequency: voiding that occurs more than usual
• Urgency: strong desire to void
• Dysuria: painful or difficult voiding
• Hesitancy: undue delay & difficult in initiating voiding
• Nocturia: excessive urination at night
• Urinary incontinence: involuntary loss of urine
• Enuresis: involuntary voiding during sleep

07/21/2024 19
Common voiding problems...
• Polyurea: excessive amount of urine voided in a given time
• Hematuria: reed blood cells in the urine
• Proteinuria/albuminuria: abnormal amount of protein in the
urine
• Oligurea:100-500ml urine/d usually <400ml/d
• Anuria: urine out put <100ml/24hrs
• complete anuria: urine out put <50ml usually indicate ob-
struction of urinary tract

07/21/2024 20
Clinical presentations...
C) Gastrointestinal symptoms
– nausea/vomiting
– diarrhea
– abdominal discomfort
– paralytic ileus and etc.
D) Others
– Edema
– Shortness of breath
– Vital sign change
07/21/2024 21
2. Physical examinations
a. Inspection

 Skin: for pallor, yellow-gray cast, excoriations,

changes in turgor, bruises, textures
 Mouth: stomatitis, ammonia breath odor

 Face and extremities: generalized edema, peripheral

edema, bladder distention, mass, enlarged kidneys

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2. Physical examinations...
Inspection…cont.
 Abdomen: skin changes described earlier, as well as
striae, abdominal contour for midline mass in lower
abdomen
 Weight: weight gain secondary to edema; weight loss
and muscle wasting in renal failure

07/21/2024 23
2. Physical examinations...
b. Palpation of the Right Kidney
 Place your left hand behind the patient just below and parallel to
the 12th rib
 Place your right hand in the upper quadrant, lateral and parallel
to the rectus muscle
 Ask the patient to take a deep breath.
 At the peak of inspiration, press your right hand firmly and
deeply, just below the costal margin, and try to “capture” the
kidney between your two hands.
07/21/2024 24
Palpation of the Right Kidney...

 If it is palpable, describe its size, shape, and

any tenderness.
Palpation of BLADDER
 palpate for enlarged bladder.
 Palpate for tenderness, distention

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Bimanual Palpation of kidney
Kidney Normally not palpable

Right kidney
07/21/2024 Left kidney 26
2. Physical examinations...
C. Percussion
 Fist percussion

• Place the ball of one hand in the costovertebral angle &

strike it with ulnar surface of your fist
• Pain with pressure or fist percussion suggest pyelonephri-
tis, but may also have a musculoskeletal cause.
 Normally a bladder has no percussion sound until it contains
150 ml of urine.
07/21/2024 27
2. Physical examinations...
 Causes of positive (C-
VAT):
-Pylonephritis
- renal stone .

07/21/2024 28
2. Physical examinations...
4. Auscultation

 With this technique, the abdominal aorta and renal

arteries are auscultated for a bruit (an abnormal
murmur), which indicates impaired blood flow to the
kidneys.

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Diagnostic evaluations
I. Urine studies
A. Urinalysis- Normal findings
Components Normal values
Colour Pale, yellow to deep amber
Specific gravity 1.002 - 1.035
PH 4.5 – 8
Opacity Clear
Glucose Negative
Ketone Negative
Protein/albumin Negative
Billuribin negative
Bacteria None
Parasites None
Casts None
Crystals none
RBCs 0-3
WBCs 0-5
07/21/2024 30
 3. Diagnostic Studies...
B. Urine culture/”Clean catch”, “Midestream”
 Confirms suspected urinary tract infection and identi-
fies causative organisms
 <103 organisms/ml usually indicates no infection
 <103-105/ml is usually not diagnostic, and test may
have to be repeated
 >105/ml usually indicates infection

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3. Diagnostic Studies...
C. Residual urine
 Determines amount of urine left in bladder after urinating

 Finding may be abnormal in problems with bladder in-

nervation, sphincter impairment, BPH, or urethral stric-
tures.
 Reference interval: < 50ml urine

 But Increases with age

07/21/2024 32
3. Diagnostic Studies...
II. Blood studies
A. Blood Urea Nitrogen
 Used to identify presence of renal problems
 Reference interval: 6-20mg/dl
• Cause: Rapid cell destruction from infection, fever, GI
bleeding, trauma, athletic activity, and excessive muscle
breakdown, corticosteroid therapy and excessive protein
intake
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3. Diagnostic Studies...
B. Creatinine

 More reliable than BUN as a determinant of renal

function.
 Reference interval:

- 0.7 to 1.2 mg/dL- for male - -

0.5 to 1.0 mg/dL- for Female

07/21/2024 34
3. Diagnostic Studies...
C. Uric acid
 Used as screening test primarily for disorders of purine
metabolism but can also indicate kidney disease
 Values depend on renal function, rate of purine metabo-
lism & dietary intake of food rich in purines
 Reference interval: Female: 2.3-6.6mg/dl
Male: 4.4-7.6mg/dl

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3. Diagnostic Studies...
D. Sodium
 Main extracellular electrolyte determining blood vol-
ume
 Usually values stay within normal range until late
stage of renal failure
 Reference interval: 135-145mEq/l

07/21/2024 36
3. Diagnostic Studies...
E. Potassium
 In renal disease, potassium determinations are critical
because potassium is one of the first electrolytes to
become abnormal
 Elevated potassium levels of >6mEq/L can lead to
muscle weakness and cardiac dysrhythmias
 Reference interval: 3.5-5.0 mEq/l

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 3. Diagnostic Studies...
H. Bicarbonate
 Most patients in renal failure have metabolic
acidosis and low serum HCO3- levels
 Reference interval: 22-26 mEq/l

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 Disorders of the Urinary Tract

07/21/2024 39
1. Urinary Tract Infection/UTI/
 is an acute infection of the urinary tract
• The most common organisms causing UTI are found in the
fecal /by ascending from the perineum to the urethra and
bladder.
 sub-divided into two general anatomic categories:
 Lower UTI: urethritis, cystitis & Prostatitis
 Upper UTI: pyelonephritis, ureteritis

07/21/2024 40
1. UTI...
Epidemiologically, UTIs are subdivided into:
 Non-catheter-associated (community-acquired)
 Catheter-associated (nosocomial)
• UTIs are Common in females than males b/c of:
– Short female urethra
– Anatomical proximity to vagina and rectum
– Pregnancy
– bactericidal properties of prostatic fluid protects men from
UTIs
07/21/2024 41
Etiologies
 community acquired are
 E. coli (80%),
 S. aureus (10%),
 Klebsiella pneumoniae (5%) and others (5%)
 In acute uretheral syndrome (Sexually transmitted organ-
isms)
 Hospital acquired UTI
 E. coli (30%), Enterococci (15%)
 Pseudomonas (10%)
07/21/2024 42
Pathogenesis
 Bacteria causing UTIs usually originate from bowel flora
of the host acquired via
 Ascending, Hematogenous or Lymphatic pathways
 Three factors determine the development of UTIs
 The size of the inoculum
 Virulence of the microorganism, and
 Competency of the natural host defense mechanisms

07/21/2024 43
Pathogenesis...
 An important virulence factor of bacteria is their ability to
adhere to urinary epithelial cells by fimbriae
 Other virulence factors include hemolysin
– a cytotoxic protein produced by bacteria
– Lyses a wide range of cells including erythrocytes,
polymorphonuclear leukocytes
• Facilitates the binding and uptake of iron by Es-
cherichia coli
07/21/2024 44
Risk factors for UTI
 Obstruction: (eg: tumor, stricture, stone, or BPH)
 Catheterization /especially prolonged
 Neurogenic Bladder Dysfunction: - Eg.: in spinal cord injury,
diabetes, and other diseases)
 Diabetes mellitus
 Immune deficiency
 Bacterial Virulence Factors
 Genetic Factors

07/21/2024 45
Other Classifications
Uncomplicated UTI
– UTI that occurs in individuals who lack structural
or functional abnormalities in the UT that interfere
with normal flow of urine
– Mostly in healthy females of childbearing age

07/21/2024 46
Other Classification...
Complicated UTI
– UTI that occurs in individuals with structural or
functional abnormalities i.e. congenital distortion
of the UT, a stone, a catheter, prostatic hypertro-
phy, obstruction, or neurological deficit
– UTI in men are usually complicated-why?

07/21/2024 47
Other Classification...
Recurrent UTI
Refers to multiple symptomatic UTIs with asymp-
tomatic periods in between
It is considered significant when there is two or
more symptomatic episodes per year or it inter-
feres with patient’s quality of life
It is usually a reinfection than a relapse
07/21/2024 48
Sign and symptoms
 Dysuria, frequency, urgency, and nocturia
 Suprapubic pain and discomfort
 urine often becomes cloudy and malodorous,
 Hematuria and back pain
 CVA tenderness
 Fever, tachycardia, and generalized muscle tenderness
 Syndromes of urosepsis- If complicated

07/21/2024 49
Sign and symptoms...
 A distinction should be made between women infected
with STI and low-count of E. coli or staphylococcal.
 Chlamydial or gonococcal infection: gradual onset
of illness, no hematuria, no suprapubic pain, and
more than 7 days of symptoms.
 E. coli: Gross hematuria, suprapubic pain, an abrupt
onset of illness, a duration of illness of < one wk

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Diagnosis
1. Urinalysis
 Urine dipstick-may react positively for blood WBC
 Urine microscopy- shows RBC and many WBC

2. Culture of the urine

3. CBC: increased WBCs in the blood
4. Radiologic urologic evaluation (for identifying urolithiasis,
BPH)

07/21/2024 51
Management
Principles underlie the treatment of UTIs:
1. Rapid diagnostic test should be performed to confirm in-
fection before treatment.
2. Obstruction and calculi, should be identified
3. Relief of clinical symptoms does not always indicate bac-
teriologic cure.
4. Infections to the LUTI respond to short courses therapy,
while UUTI require longer treatment.
07/21/2024 52
Management...
• The management of a patient with UTI includes:
– Initial evaluation
– Selection of an antibacterial agent and duration of therapy
– Follow-up evaluation
• Selection of antimicrobial agent based on:
– severity of signs and symptoms
– site of infection
– complicated or uncomplicated UTI

07/21/2024 53
General Management principles
– Relieve discomfort and provide rest (catheter-
ization if needed)
– Antibiotics
– Follow up culture to prove treatment effectiveness
– Increase fluid intake- water is best
– Avoid irritants - Coffee, tea, alcohol, cola drinks
– Promote urinary output- Q 2 to 3 hrs

07/21/2024 54
Management ...
Acute Uncomplicated lower UTI
– Trimethoprim-Sulfamethoxazol 960mg PO BID for 3-5days OR
– Norfloxacin 400 PO BID for 5-7dys OR
– Ciprofloxacin 500 mg PO BID for 5-7dys
Acute uncomplicated upper UTI
– Norfloxacin 400 PO BID for 7-14 days OR
– Ciprofloxacin 500mg PO BID for7-14days OR
– Ceftriaxone 1gm stat or
– Gentamicin 80 mg IV/IM +Trimethoprim-Sulfamethoxazol
960mg PO BID for 14 days
07/21/2024 55
Management ...
Severe illness or possible urosepsis:
 Hospitalization is required.
 Ceftriaxone 1gm IV daily or BID plus
 Gentamicin 80 mg IV TID OR
 Ampicillin 1gm IV QID and then 500 mg IV QID
PLUS
 Gentamicin 80 mg IV TID
07/21/2024 56
Management ...
• Recurrent UTI in women
– First line: Cotrimoxazole 240mg P.O. daily or 3x per week
• Alternatives:
– Cephalexin, 125–250mg, P.O. QD for six months
– Norfloxacin, 200mg, P.O., QD for six months
– Ciprofloxacin, 125mg, P.O., QD for six months
• If recurrent UTI comes again the prophylaxis can be prolonged
for 1-2years

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Pyelonephritis
• Inflammation of the structures of kid-
ney:
– the renal pelvis
– renal tubules
– interstitial tissue
• Almost always caused by [Link]
• Classifications
– Acute pyelonephritis
– Chronic pyelonephritis
07/21/2024 58
Pyelonephritis
• The kidney becomes edematous
and inflamed and the blood vessels
are congested
• The urine may be cloudy and con-
tain pus, mucus and blood
• Small abscesses may form in the
kidney

07/21/2024 59
Acute pyelonephritis
• It is sudden onset & self-limited bacterial disease of the kidneys.
• Etiologies
– Bacteria: E-coli (80%), Proteus, Pseudomonas, S. aures,
Strep. faecalis (entrococcus)
– Procedures: Catheterization, Urologic surgery
– Systemic infections (such as tuberculosis)
– Other causes: Urinary obstruction, Neurogenic bladder
(Vesicourethral reflux)

07/21/2024 60
Acute Pyelonephritis... (C/M)
– Flank, Low back pain
– CVA tenderness
– Dysuria
– Nocturia, hematuria, cloudy urine with fishy odor
– Burning, urgency, frequency
– Shaking chills, generalized fatigue
– Fever, tachycardia, tachypnea
– Anorexia, nausea/vomiting, headache, malaise

07/21/2024 61
Acute Pyelonephritis... (Dx)
• Appropriate history taking & Physical examination
• Urinalysis:
– Dark color, cloudy appearance, foul odor
– Proteinuria, glycosuria, rarely ketonuria
– Casts, decreased urine specific gravity
• Urine culture reveals the causative organism
• CBC- elevated WBC, elevated neutrophils
07/21/2024 62
Acute Pyelonephritis... (Dx)
• Erythrocyte sedimentation rate (ESR) will be elevated

• Intravenous pyelogram

– If functional and structural renal abnormalities are sus-

pected (calculi, structural, or vascular abnormalities)

• Ultrasound or CT scan

07/21/2024 63
Complications
– Secondary arteriosclerosis
– Calculi formation
– Renal damage
– Renal abscess
– Septic shock
– Chronic pyelonephritis
– Chronic renal failure
– Hypertension
07/21/2024 64
Decision To Hospitalize Acute Pyelonephritis
 Inability to maintain oral hydration or take medica-

tions

 Uncertainty about the diagnosis

 Severe illness with high fevers, pain, and marked in-

capacity

07/21/2024 65
Management
• Acute uncomplicated Pyelonephritis:
– Mild and moderate (able to tolerate oral therapy with
no vomiting, no dehydration, no evidence of sepsis):
• First line
– Ciprofloxacin 500mg PO BID for 7-10 days
• Alternatives
– Cotrimoxazole (Trimethoprim-sulphamethoxazole),
160/800mg P.O BID for 14 days
07/21/2024 66
Management
• Severe acute uncomplicated pyelonephritis (high fever,
high white blood cell count, vomiting, dehydration, or evi-
dence of sepsis) or fails to improve for the initial outpatient
treatment period
– Intravenous therapy should be started and continued until
the patient improves (usually at 48–72 hours)
– On discharge oral therapy is continued to complete 10-14
days course

07/21/2024 67
Management...
• Severe acute uncomplicated pyelonephritis...
• First line
– Ciprofloxacin 400mg I.V BID till patient improves and
continue oral ciprofloxacin 500mg PO BID to complete
10-14 days course
• Alternatives
– Ceftriaxone 2gm I.V daily or 1gm I.V BID till patient im-
proves and continue oral ciprofloxacin 500mg PO, BID to
complete 10-14 days course
07/21/2024 68
Chronic pyelonephritis
• It is a persistent inflammation of kidneys
• Repeated infections that cause progressive inflammation
& scarring
• Etiology:
– Bacteria
– Urinary obstruction
– Vesicoureteral reflux (Neurogenic Bladder)

07/21/2024 69
Clinical manifestations
– Usually have no symptoms of infection
– Noticeable signs (Fatigue, Headache, Poor ap-
petite)
– Polyuria
– Low specific gravity of urine
– Excessive thirst
– Weight loss
– Flank pain
07/21/2024 70
Diagnosis
• History taking & physical examination
• Urinalysis
– Proteinuria (Albuminuria)
– Intermittent bacteriuria
– Leukocytes in urine
– Low specific gravity of urine
– Urine culture to identify the pathogen

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Diagnosis...
• Blood
– Decreased Hgb
– Measuring BUN & creati-
nine may increase
• Radiologic Intravenous Uro-
gram

07/21/2024 72
Complications
• End-stage renal disease (from progressive loss of

nephrons secondary to chronic inflammation and scar-

ring)

• Hypertension

• Formation of kidney stones (from chronic infection with

urea-splitting organisms)
07/21/2024 73
Management
– The same as acute pyelonephritis (Long-term

use)

– Monitor HTN

– Monitor intake and out put

• How Do you Monitor??

07/21/2024 74
2. RENAL FAILURE
 Renal failure is sever impairment or total lack of kidney
function, resulting in inability to:
 Remove metabolic end products from the blood
 Regulate the fluid, electrolyte, and PH balance of the
Extra Cellular Fluid (ECF)
 Respond to functional disturbances of all body system
 can be acute or chronic

07/21/2024 75
Acute renal failure/ARF/
 ARF is a sudden and almost complete loss of kidney
function (decreased GFR), over a period of hours or
days, with progressive azotemia
 Has an abrupt onset and is reversible with prompt inter-
vention
 manifests as an increase in serum creatinine and BUN
 Urine volume may be normal or changed

07/21/2024 76
Pathophysiology and etiology
 The causes and pathophysiology of ARF categorized
as:
prerenal (60-70%)

intrinsic /intrarenal/ (40%)

postrenal acute renal failure

07/21/2024 77
Pre-renal ARF
 Results from conditions that affect renal blood flow and
perfusion
 The kidney normally receives 20% to 25% of the cardiac
output to maintain the GFR
 A drop in renal blood flow less than 20% of normal
causes the GFR to fall.
 As a result, kidney cells require less energy and oxygen,
and their metabolism slows
07/21/2024 78
Pre-renal ARF...
 Continued ischemia can lead to tubular cell necrosis

and significant nephron damage.

 Pre-renal ARF is rapidly reversed when blood flow is

restored and the renal parenchyma remains undam-

aged.

07/21/2024 79
Pre-renal.…
Causes
 Hypovolemia
– E.g.: Hemorrhage, dehydration, excess fluid loss from
GIT, burns, wounds
 Low cardiac output
– E.g.: Heart failure, cardiogenic shock
 Altered vascular resistance (Vasodialatation)
– E.g.: Sepsis, anaphylaxis, vasoactive drugs

07/21/2024 80
Intrinsic/intra-renal ARF

 is the result of actual parenchymal damage to

glomeruli or renal tubules

 It is due to direct damage to functional kidney tissue

and responsible for another 40% of ARF

07/21/2024 81
Pathophysiology and etiology
Causes
 Glomerular microvascular injury
– E.g.: Glomerular nephritis, vasculitis, hypertension, etc

 Acute tubular necrosis

– E.g.: Ischemia due to conditions associated with prer-
enal failure, toxins such as drugs

07/21/2024 82
C. Post-renal ARF (obstruction to urine flow)
• is usually the result of an obstruction distal to the kid-

neys

 Pressure rises in the kidney tubules and eventually,

the GFR decreases

 Any condition that prevents urine excretion can lead to

postrenal ARF
07/21/2024 83
C. Post-renal ARF...
Causes

 Ureteral obstruction

– E.g.: Calculi, cancer, external compression

 Urinary Bladder

– E.g. Tumor, calculi, stricture

 Urethral obstruction
– E.g.: Prostatic enlargement, calculi, cancer, stricture

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 85
07/21/2024
Incidence and risk factors of ARF
 Approximately 5% of all hospitalized clients develop
ARF; the incidence jumps to as much as 30% in critical
and special care units

 mortality rate of ARF in seriously ill pts is up to 75%.

 Major trauma or surgery, infection, heart failure, severe

hemorrhage, liver failure, hypertension, DM, nephro-
toxic drugs.

07/21/2024 86
Clinical Courses of ARF
 Clinically ARF may progress through the phases of:
 Initiation
 Oliguria
 Diuretics, and
 Recovery
A. Initiation period
 Begins with the initial insult and ends when oliguria
develops
07/21/2024 87
B. Oliguric phase
 The most common initial manifestation
 Caused by a reduction in the GFR
 Usually occurs with in 1 to 7 days of causative event
 Accompanied by a rise in urea, creatinine, uric acid, organic
acid and the intracellular cations like potassium & magnesium.
 The average duration is about 10-14 days
 But it rarely exceeds 4 weeks
 The longer the oliguric phase lasts the poorer for the prog-
nosis of renal function
07/21/2024 88
B. Oliguric phase...
 Common changes occur:
 Urinary changes
 Fluid volume
 Metabolic acidosis
 Potassium and magnesium excess
 Waste product accumulation--›azotemia
 Neurologic disorders

07/21/2024 89
C. Diuretic phase (high output phase)
 Begins with a gradual increase in the daily urine out put of
1 to 3 liter per day, but may reach 3 to 5L per day or more
 Caused by osmotic diuresis from the high urea concentra-
tion in the glomerular filtrate and the inadequate concen-
trating ability of the tubules
 Signals that glomerular has started to recover
 Lab values stop to increase and eventually decrease

07/21/2024 90
C. Diuretic phase...
 Because of the large losses of fluid and electrolytes,

the patient must be monitored for hyponatremia, hy-

pokalemia and dehydration.

 The phase may last for 1 to 3 weeks.

07/21/2024 91
D. Recovery phase (convalescent phase)
 Begins when the GFR increases so that BUN and serum crea-
tinine levels start to stabilize and then decrease
 Although the major improvements occur in the first 1 to 2
weeks of this phase, renal function can continue to improve for
up to 12 months after ARF.
 The patient may experience slight reduction in kidney function
for the rest of his/her life, so he/she will still be at risk for fluid
and electrolyte imbalances.
 Some patients may progress to CRF

07/21/2024 92
Comparing Clinical Characteristics of ARF

07/21/2024 93
C/Ms
 IV overload: weight gain, hypertension, elevated cen-
tral venous pressure (raise JVP) and peripheral, face,
Pulmonary edema
 Electrolyte disturbance
 Hyperkalemia: (serum K+ >5.5 mEq/L)
 Hyponatremia: (serum Na+ < 135 mEq/L )
 Hyperphosphatemia: > 5.5 mg /dl
07/21/2024 94
C/Ms...

 Metabolic acidosis : arterial blood PH < 7.35

 Hyperuricemia: due to decreased uric acid excretion

 Seizure: may occur related to uremia and hyperkalemia

• NB: if not treated lead to Chronic Renal failure

07/21/2024 95
Diagnosis
1. Urinalysis

 Specific gravity greater than 1.025

 Proteinuria- cause glomerular damage

 The presence of : RBCs and WBCs

 Positive tests for occult blood indicate hemoglobinuria

or myoglobinuria
07/21/2024 96
Diagnosis...
2. Blood tests
– Serum creatinine and BUN

 In ARF serum creatinine levels increase rapidly, within 24

to 48 hours of the onset
3. Serum electrolyte

 Serum potassium rise at a moderate rate

 Hyponatremia is common due to the water excess asso-

ciated with ARF
07/21/2024 97
Diagnosis...
4. ABG analysis
 Show metabolic acidosis due to kidney’s inability to ade-
quately eliminate metabolic wastes & H+
5. Complete blood cell count/CBC/
 ARF affects RBC production
 Shows reduced RBCs, moderate anemia and low hematocrit
 Iron and folate absorption may also be impaired further
contributing to anemia.

07/21/2024 98
Diagnosis...
6. CT scan

 To evaluate kidney size and identify possible ob-

struction

7. Renal Biopsy

 May be necessary to differentiate between acute and

chronic renal failure

07/21/2024 99
Preventing ARF
 Adequate hydration to pts at risk of dehydration
 surgical patients before, during & after surgery.
 Patients undergoing intensive diagnostic studies
 Patients receiving chemotherapy
 Treat Shock promptly
 Monitor BP & hourly urine output of critically ill pts to
detect onset of RF as early as possible.
 Treat hypotension promptly.

07/21/2024 100
Preventing ARF...
 Avoid severe transfusion reactions, which can precipitate
renal failure.
 Prevent and treat infections promptly.

 Pay special attention to wounds, burns and other precur-

sors for sepsis
 Prevent ascending UTI
 Give meticulous care to patients with indwelling
catheters
07/21/2024 101
Management
Nutritional Therapy

 Restriction of Foods and fluids containing potassium

or phosphorous

• E.g. banana, citrus fruits and juices, coffee

07/21/2024 102
Management...
Pharmacologic therapy
1. Hypervolemia:
 restriction of salt and water intake
 Give diuretics
2. Metabolic acidosis: when serum bicarbonate concentra-
tion falls below 15 mmol/L or arterial pH falls below 7.2.
• Oral or intravenous sodium bicarbonate

07/21/2024 103
Management...
3. Hyperkalemia
• Restrict dietary K+ intake
• Give calcium gluconate 10 ml of 10% solution over 5
minutes
• Glucose solution 50 ml of 50 % glucose plus Insulin 10
units IV
• Dialysis: if medial therapy fails or patient is very toxic

07/21/2024 104
Management...
4. Hyperphosphatemia

• Restriction of dietary phosphate

• Oral aluminum hydroxide or calcium carbonate,

• which reduce gastrointestinal absorption of

phosphate

07/21/2024 105
Management...
Dialysis- replaces renal function until regeneration and re-
store renal function
1. Hemodialysis- a procedure that circulates the patient’s
blood through a dialyzer to remove waste products and ex-
cess fluid
2. Peritoneal dialysis (PD)- a procedure that uses the pa-
tient’s peritoneal membrane as semipermeable membrane
to exchange fluid and solutes
07/21/2024 106
Absolute indications for dialysis:
 Symptoms or signs of the uremic syndrome
 confusion, asterixis, myoclonus, wrist or foot drop, in se-
vere cases, seizures
 Persistent metabolic disturbances that are refractory to
medical therapy
 Sever hyperkalemia, hypercalcemia, hyperphosphatemia,
Metabolic acidosis
 Fluid overload refractory to diuretics (Refractory hyper-
volemia)
07/21/2024 107
Hemodialysis system

07/21/2024 108
2. Chronic RF/ End Stage Renal Disease (ESRD)

 Is a progressive, irreversible deterioration in renal func-

tion in which the body’s ability to maintain metabolic,

fluid and electrolyte balance fails, resulting in azotemia.

• Azotemia is an accumulation of nitrogenous waste prod-

ucts such as urea, nitrogen, uric acid and creatinine in the

blood.
07/21/2024 109
CRF...
• Chronic Kidney Disease (CKD) is Kidney damage for ≥3
months, with or without decreased GFR
• Markers of kidney damage
– Urinary abnormalities (proteinuria)
– Blood abnormalities (BUN & creatinine)
– Imaging abnormalities
– Need for Kidney transplantation

07/21/2024 110
CRF...
Causes
1. DM, HPN, chronic Glomerulonephritis, pyelonephritis, ob-
struction of urinary tract, hereditary lesions as in polycystic
kidney disease, vascular disorders, infections, medications
2. Environmental and occupational agents
• lead, mercury and chromium.
 Dialysis or kidney transplantation eventually becomes neces-
sary for patient’s survival.

07/21/2024 111
Pathophysiology CRF
• The prognosis and course of CRF are highly variable, in
which some individuals may:
– Live normal active lives with compensated RF
– Rapidly progress to ESRD
• As renal function declines, the end products of protein
metabolism accumulate in the blood uremia which ad-
versely affects every system in the body

07/21/2024 112
Clinical Stages CRF
• Although there are no distinct stages in CRF the disease
progression may be divided in to three stages
1. Diminished renal reserve
• Characterized by:
– 40- 75% loss of nephrons’ function
– Normal BUN and serum creatinine level
– Absence of symptoms

07/21/2024 113
Clinical Stages CRF...
2. Renal insufficiency

– Occurs when 75% to 90% of nephrons’ function is lost

– Creatinine and BUN rise

– The kidney losses its ability to concentrate urine

– Anemia develops

07/21/2024 114
Clinical Stages CRF...
3. End stage renal disease (ESRD) or uremia
– The final stage of CRF
– Occurs when there is < 10% nephrones functioning
remaining or when the GFR is < 5% to 10% of normal
– All of the normal regulatory, excretory, and hormonal
functions of the kidney are severely impaired
– Evidenced by elevated creatinine & BUN levels as
well as electrolyte imbalances
07/21/2024 115
07/21/2024 116
Classification of Chronic Kidney Disease (CKD)
Stage GFR, mL/min per 1.73 m2
0 >90 (With risk factors for CKD)
1 >90 (kidney damage with normal or GFR)
2 60–89 (Kidney damage with mild GFR)

3 30–59 ((Kidney damage with Moderate GFR) )

4 15–29 ((Kidney damage withSevere GFR) )

5 <15-- Kidney failure

Normal adult GFR is 100-120ml/minute
07/21/2024 117
Clinical Manifestations
 CV manifestations:
• HPN – due to Na+ & H20 retention or from R-AAS
• heart failure and edema - due to fluid overload
• pericarditis – due uremic toxins
 Dermatologic manifestations
• severe pruritus is common

07/21/2024 118
Clinical Manifestations
 GI manifestations:
• anorexia, nausea and vomiting, and hiccup
• The patient’s breath may have the odor of urine
(uremic fetor);
 Neurologic manifestations
• Altered Level of Consciousness (LOC), inability to
concentrate, confusion and seizures.

07/21/2024 119
Diagnosis of CRF
 History and Physical examination

 Serum creatinine & BUN

 GFR
 Dipstick test- for proteinuria
 Serum electrolytes (Na+, K+, Cl-,...)
 U/A- to detect RBCs, WBCs, protein, casts, glucose

07/21/2024 120
 Renal ultra-sound
Complications
1. Hyperkalemia: due to decreased excretion
2. Hypertension: sodium and water retention and malfunction of
the R-A-A system
4. Anemia: decreased erythropoietin production, bleeding in the
GIT from irritating toxins and blood loss during hemodialysis
5. Bone disease: due to retention of phosphorous, abnormal vi-
tamin D metabolism
6. Pericarditis and pericardial effusion due to retention of uremic
waste products and inadequate dialysis.
07/21/2024 121
Management
Pharmacologic Therapy
 Calcium carbonate or aluminum hydroxide:
to treat hyperphosphatemia
 Antiseizure agents: diazepam or phenytoin
 Antihypertensive and CV drugs- digoxin and dobu-
tamine
 Erythropoietin: to treat anemia.

07/21/2024 122
Management
Nutritional Therapy
 low sodium, phosphate and K diet
 Protein restriction (but high biologic value proteins are al-
lowed)
 Encourage Calorie intake
 Encourage Vitamins
Other Managements- Renal Replacement Therapy
 Dialysis
 Renal transplantation especially if GFR is <10ml/min
07/21/2024 123
• Note:
– In the past, the terms acute and chronic renal failure
were commonly used.
– At present, acute renal failure (ARF) has been re-
placed by acute kidney injury (AKI) and chronic
renal failure (CRF) has been replaced by chronic
kidney disease (CKD)

07/21/2024 124
3. Glomerular Diseases

– Nephritic syndrome/acute glomeru-

lonephritis (AGN)/

– Chronic glomerulonephritis (CGN)

– Nephrotic syndrome (NS)

07/21/2024 125
Nephritic syndrome (AGN)
 Is an inflammation of the glomerular capillaries
 Refers to a specific set of renal disease in which an im-
munologic mechanism triggers acute inflammation and
proliferation of glomerular tissues
 Is primarily a disease of children older than 2 years of age,
but it can occur at nearly any age

07/21/2024 126
Nephritic syndrome (AGN)

 Characterized by sudden onset of:

 Hematuria
 Variable degrees of proteinuria
 Diminished GFR
 Oliguria, and
Hematuria
 Signs of impaired renal function

07/21/2024 127
Causes
 Infectious diseases
 Group A beta-hemolytic streptococcal infections:
 Pharyngitis, Tonsillitis
 cellulitis that precedes the onset of glomerulonephritis
by 2 to 3 weeks
 Other specific agents include parasites, systemic and renal
disease, visceral abscesses, endocarditis, infected grafts or
shunts and pneumonia
07/21/2024 128
Causes...
• Antigens outside the body
– Medications and Foreign serum -resulting in antigen–
antibody complexes being deposited in the glomeruli.
• Goodpasture's syndrome
– A rare autoimmune disease in which antibodies attack
lungs and kidney-->bleeding from lungs and kidneys

07/21/2024 129
Pathophysiology (AGN)

07/21/2024 130
C/Ms
 Acute Hematuria (may be microscopic or gross)
 Cola colored urine
 Variable degrees of Proteinuria
 Foamy/Smoky urine
 Edema (primarily periorbital, facial and dependent area)
 Protein plugs, erythrocyte casts
 Hypertension

07/21/2024 131
C/Ms...
 Decreased GFR
 Decreased urine output
 Flank pain
 CVA tenderness in severe cases
 Headache, malaise, confusion, anorexia, nausea and
vomiting

07/21/2024 132
Diagnosis
 History and Physical exam
Edema or fluid over load signs
 Laboratory studies
Decreased GFR to 50ml/min
Increased BUN and serum creatinine
Decreased serum albumin
Hematuria
Proteinuria --500mg to 3g/24hr
07/21/2024 133
Management
 Pharmacologic management:

 Appropriate antibiotics (penicillin, erythromycin or

azithromycin) to treat underlying infection

 Loop diuretic (e.g., Furosemide/lasix)

 Antihypertensive agents

07/21/2024 134
Management...
 Nutritional Management
 Sodium and water restriction
 Potassium and protein restriction
 Liberal intake of carbohydrates
 Goodpasture’s syndrome- treated with immunosuppressants
– corticosteroids, cyclophosphamide with plasmapheresis, in
which the antibodies are removed from the blood.
– Dialysis may be recommended
07/21/2024 135
Complications
Hypertensive encephalopathy

CHF

Pulmonary edema

Acute or chronic renal failure

ESRD

07/21/2024 136
Chronic Glomerulonephritis (CGN)
 Is the advanced stage of a group of kidney disorders, re-
sulting in inflammation and gradual, progressive destruc-
tion of the glomeruli
 Lead to renal deterioration or failure that develops over 20
to 30 years or even longer

07/21/2024 137
Etiologies of CGN
 Can be caused by:

 Repeated episodes of AGN

 Hypertensive nephroseclerosis

 Hyperlipidemia

 Chronic tubulo-interstitial injury

 Homodynamically mediated glomerular sclerosis

07/21/2024 138
Etiologies...
 Secondary glomerular diseases
 Lupus erythematous
 Goodpasture’s syndrome (caused by antibodies to the
glomerular basement membrane)
 Diabetic glomerulosclerosis
 Amyloidosis

07/21/2024 139
Pathophysiology of CGN
Numerous glomeruli and their tubules become scarred and
the branches of the renal artery are thickened--sclerosis

No adequate blood supply

Severe glomerular damage

End stage renal disease (ESRD)
07/21/2024 140
Clinical Manifestations of CGN
 Hematuria
 Blood pressure may be normal or severely elevated
 General symptoms--loss of weight and strength, and
nocturia
 Headaches, dizziness, and increasing irritability
 Digestive disturbances

07/21/2024 141
Clinical Manifestations...
 S/S of renal insufficiency and chronic renal failure:
 The patient appears poorly nourished
 Yllow-gray pigmentation of the skin
 Periorbital and peripheral (dependent) edema
 Retinal findings:
 Hemorrhage, exudate and papilledema

07/21/2024 142
Clinical Manifestations...
 Pale mucous membrane---due to hematuria
 Cardiomegaly
 A gallop rhythm
 Distended neck veins
 CracklesPulmonary edema (PE)
 Peripheral neuropathy with diminished deep tendon re-
flexes late in the disease

07/21/2024 143
Diagnosis
 History
 Previously identified health problems
 Physical examination
 Signs of circulatory overload
 Chest X-rays –cardiomegaly & pulmonary edema
 Renal biopsy

07/21/2024 144
Diagnosis...
 U/A
 Proteinuria (usually <2g/in a 24hr collect)
 RBCs casts
 GFR is reduced from the normal range to 50ml/min
 Increased serum Creatinine (>6mg/dl and can be as
high as 30mg/dl or more)
 Increased BUN – often b/n 100 and 200 mg/dl

07/21/2024 145
Diagnosis...
 As renal failure progresses and the GFR falls below 50 mL/min:
 Hyperkalemia
 Metabolic acidosis
 Hypo-albuminemia (loss through kidneys)
 ed serum phosphorus level (ed renal excretion)
 ed serum calcium level (Ca2+ binds to phosphorus to compen-
sate its elevation)
 Hypermagnesemia
 Impaired nerve conduction
07/21/2024 146
Management
 Sodium and water restriction

 Antihypertensive agents

 Diuretics to treat fluid over load

 Providing proteins of high biologic value– to replace

the lost proteins

ex: dairy products, eggs, meat

07/21/2024 147
Management...
 Monitoring daily weight

 Dialysis or transplantation

 Monitoring for changes in fluid and electrolyte status

 Offering emotional supports

07/21/2024 148
Nursing diagnosis
 Fluid volume excess related to sodium and water retention

 Self care deficit (Bathing, Toileting and hygiene) related

to musculoskeletal impairment...

 Altered tissue perfusion (renal) related to decreased cellu-

lar exchange

 Altered nutrition less than body requirement related to in-

ability to digest or absorb nutrients

07/21/2024 149
Nursing Management
I. Maintaining normal body fluid:
 Evaluating degree of peripheral edema
 Daily measurement of abdominal girth
 Administering drugs as prescribed
 Monitoring intake & out put
 Restriction of sodium diets & fluids
 Encourage the patient to cough and deep breath every 2
to 4 hours
07/21/2024 150
Nursing Management...
II. Achieving optimal self-care practice:
 Observe patient’s functional level every shift
 Encourage the patient to voice feeling and concerns about
self-care deficit
 Monitor the patient’s ability for dressing and grooming
 Encourage family to provide clothing easily managed by
the patient
 Assist with or perform dressing or grooming
07/21/2024 151
Nursing Management...
III. Improving renal perfusion
 Monitor and document output every 1hr until output is
greater than 30ml/hr
 Document urine color and characteristics
 Assess for presence of dependent edema
 Monitor urine specific gravity, serum electrolytes,
BUN, and Creatinine.
 Monitor vital signs
07/21/2024 152
NEPHROTIC SYNDROME
 It is a clinical complex characterized by:
 Massive Proteinuria of >3.5 g/1.73m2/24hrs (for prac-
tical purpose >3.0 to 3.5 g/24hrs) is the most important
clinical feature (cardinal sign)
 Hypoalbuminemia (< 3g/dl)
 Edema
 Hyperlipidemia (> 300mg/dl)
 Hypercoagulability
07/21/2024 153
Proteinuria Edema

Hypertension
07/21/2024 154
Pathophysiology
• NS results from a marked increase in glomerular perme-
ability to protein and other macromolecules.
• Hypoalbuminemia is in part a consequence of urinary
protein loss.
– also due to catabolism of filtered albumin by the proxi-
mal tubule, as well as redistribution of albumin within
the body.

07/21/2024 155
Pathophysiology...
• Edema is the most common presenting symptom of patients
with the nephrotic syndrome.
• Pathophysiology of edema in NS is poorly understood
• It may occur through at least two different major mechanisms.

1. Arterial underfilling as the low plasma oncotic pressure

leads to plasma volume depletion (The underfilling hy-
pothesis)
2. Sodium retention directly induced by the renal disease
(primary renal salt and water retention)

07/21/2024 156
 The underfilling hypothesis
NEPHROTIC SYN-
DROME
Proteinuria
Hypoalbuminemia
Plasma oncotic pressure
Transcapillary fluid shift
Intravascular volume depletion
Underperfussion of the kidneys

Activation Activation Release Suppression of

of RAAS of SNS of AVP ANP release

Renal Na+ & volume retention EDEMA

157 07/21/2024
Pathophysiology...
• Hyperlipidemia is believed to be due to:
– Increased hepatic lipoprotein synthesis that is trig-
gered by reduced oncotic pressure.
– Increased urinary loss of proteins that regulate lipid
homeostasis
– Defective lipid catabolism.

07/21/2024 158
Pathophysiology...
• Low-density lipoproteins and cholesterol are increased
in the majority of patients, whereas very low density
lipoproteins and triglycerides tend to rise in patients
with severe disease.
• Hyperlipidemia may accelerate atherosclerosis and
progression of renal disease.

07/21/2024 159
Pathophysiology...
• Hypercoagulability is due to:
– Increased urinary loss of antithrombin III
– Hyperfibrinogenemia due to increased hepatic synthesis
– Impaired fibrinolysis
– Increased platelet aggregability.
• Consequences of these impairments are:
– Spontaneous peripheral arterial or venous thrombosis
– Renal vein thrombosis
– Pulmonary embolism
07/21/2024 160
Etiologies
 Multisystem diseases account for 50 –70 % of adult nephrotic
syndrome.
– a. Diabetes mellitus
– b. Collagen vascular diseases
– c. Amyloidosis
 Primary glomerulopathies (Idiopathic):
 account for 30 –50 % of adult nephrotic syndrome
 Neoplasms: - leukemias, lymphomas and solid tumors
 Infections: - viral, bacterial, protozoan and helminthic
07/21/2024 161
C/Ms
 Proteinuria and hypoalbuminemia
 Edema
 Hyperlipidemia
 Hypercoagulability
• NB: Spontaneous peripheral arterial or venous throm-
bosis, renal vein thrombosis, and pulmonary embolism
may occur
07/21/2024 162
Diagnosis
1. Confirming significant proteinuria
 Quantify 24 hours urine protein
 Comparing with urinary creatinine level on a single void urine
 Measurement of urinary protein by a dipstick (+3 or +4 diag-
nostic if the first two are not available)
2. Renal biopsy ( if available ): to identify the underlying
histopathologic abnormality

07/21/2024 163
Treatment
1. Use disease-specific therapy when possible
2. Lower proteinuria to less than 1 g/24 hr
 Dietary protein restriction- must be balanced against the
risk of contributing to malnutrition
 Angiotensin-converting enzyme inhibitors (ACEI) ,
ARBs, and NSAIDs
 Controlling hypertension: keeping BP below 130/80 re-
duces proteinuria

07/21/2024 164
Treatment...
3. Treatment of complications
 Edema
 Moderate salt restriction, usually 1 to 2 g/day
 Loop diuretics
 Thromboembolism: Anticoagulation is indicated. Heparin may
not be effective because of urinary loss of anti- thrombin III.
 Hyperlipidemia: lipid lowering agents/ statins/
 Vitamin D deficiency: Vit.D supplementation

07/21/2024 165
Complications
– Infection

– Thromboembolism – due to hyperlipidemia

– Accelerated atherosclerosis—due to hyperlipi-

demia

– Acute renal failure

07/21/2024 166
 Urinary Tract Calculi
(Urolithiasis)

07/21/2024 167
Urinary Tract Calculi
 Stones are formed in the urinary tract
 Urinary concentrations of substances such as calcium
oxalate, calcium phosphate, and uric acid increased
(supersaturated)
 Urolithiasis- is the presence of calculi (stone) in UT
 Nephrolithiasis- formation of stone in the kidney
 Ureterolithiasis- formation of stone in the ureter

07/21/2024 168
Prevalence and Types of Renal Stones
Sto ne Prevale nce

1 Calcium (phosphate and oxalate) 70-80%

2 Magnesium ammonium phosphate 10-15%

(Struvite)

3 Uric acid 5-10%

4 Cystine 1-2%
07/21/2024 169
Factors Favoring Formation of Stone
 Infection caused by urea-splitting bacteria (e.g. struvite)
 Persistent change in urinary pH
 The higher the PH (alkalized), the less soluble are cal-
cium, struvite and phosphates
 The lower the PH (acidic), the less soluble are uric
acid and cystine
 Super saturation
07/21/2024 170
Factors Favoring...
 Deficiency of substances that normally prevent crystal-
lization like:
 Citrate, magnesium
 Medications like:
 Antacids, loop diuretics, vitamin D,
 Laxatives—>loss of water, electrolytes and minerals –
>dehydrationstone formation
07/21/2024 171
Clinical Manifestations
 Stones in the renal pelvis
 Intense, deep ache in the costovertebral region
 Hematuria
 Pyuria- Presence of WBCs or pus in the urine
 Pain originating in the renal area which radiates ante-
riorly and downward toward the bladder in females
and toward the testis in the males

07/21/2024 172
Clinical Manifestations...
 Stones lodged in the ureter
 Ureteral colic
 Acute, excruciating, colicky pain, radiating down to
the thigh and to the genitalia
 Patient has a desire to void, but little urine is passed
and it usually contains blood

07/21/2024 173
Clinical Manifestations...
 Stones lodged in the bladder

UTI

Hematuria

Urinary retention

07/21/2024 174
Diagnosis
• History & P/E •24hrs urine: Ca2+, Na+
• U/A: uric acid, pH,
– Hematuria
•Blood Chemistries
– Pyuria
•X-ray KUB
– Stone forming crystals
•Ultrasonography
• Urine culture:
– For struvite stone

07/21/2024 175
Medical Management
Managing acute attacks
 Narcotics /opioid analgesics/ e.g. morphine and pethidine
 High fluid intake e.g. 3-4L/day
 About 90% of stones pass spontaneously
 Stones > 4 mm are unlikely to pass through the urethra
 Hot baths or moist heat to the flank areas
 Dilate tubes and increase blood flow
07/21/2024 176
Medical Management...
Calcium based Stones
 Calcium restriction in diet
 Abundant fluid intake
 Restriction of protein and sodium
 high-protein diet may be associated with increased
urinary excretion of calcium and uric acid
 high sodium intake has been shown in some studies to
increase the amount of calcium in the urine
07/21/2024 177
Medical Management...
Calcium based Stones...
 Acidification of the urine to dissolve them
 Ammonium chloride
 Acetohydroxamic acid
 Cellulose sodium phosphate (Calcibind)
 Decreases absorption of calcium from small intestine

07/21/2024 178
Medical Management...
Uric acid stones
 Low-purine diet
 Avoiding foods high in purine (legumes, mushrooms,
and organ meats etc.)
 Allopurinolto reduce serum uric acid levels and urinary
uric acid excretion
 Alkalization of urine
 Potassium citrate, Sodium citrate/ bicarbonate

07/21/2024 179
Medical Management...
Cysteine stones
 Low protein diet
 Increase hydration to dilute urine
 Alpha-Penicillamine
 To prevent cysteine crystallization
 Alkalization of urine

07/21/2024 180
Medical Management...
Oxalate Stones
 Urine dilution
 Limited intake of oxalate like spinach, strawberries, choco-
late, tea, peanuts
Struvite Stones
 Control of infection with an appropriate antibiotic
 Acetohydroxamic acid
 For acidification of urine

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Chemolysis
 Dissolute stone using infusions of chemical solutions (eg,
alkylating agents, acidifying agents)
 Is an alternative treatment:
 Patients who are at risk for complications of other
types of therapy
 Who refuse to undergo other methods
 Who have stones (struvite) that dissolve easily

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Surgical (Endoscopic, or Lithotripsy)
 Indications
 Stones too large for spontaneous removal
 Stones associated with bacteria or symptomatic infection
 Stones causing impaired renal function
 Stones causing persistent pain, nausea
 Inability of patient to be treated medically
 Patients with only one kidney

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Endourological procedures
 Used for removing small stones located in the ureter close
to the bladder
 The stone is fragmented or captured and removed
 Involves first visualizing the stone then destroying it
through electrohydraulic lithotriptor, or ultrasound device
through the ureteroscope

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Cystoscopy/Ureteroscopy…

07/21/2024 185
Percutaneous Nephrolithotomy
 After percutaneous tract is formed and a nephroscope is
inserted through it then stone is extracted or pulverized &
pelvis is irrigated
 Extract renal calculi that cannot be removed by other pro-
cedures (chemolysi or uretroscopy )
 Used to treat larger stones

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Percutaneous Nephrolithotomy

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Lithotripsy
 Is a procedure used to eliminate calculi from the urinary
tract by breaking to small fragments
 Lithotripsy techniques include:
 Laser lithotripsy
 Extracorporeal shock-wave lithotripsy
 Percutaneous ultrasonic lithotripsy
 Electrohydraulic lithotripsy (EHL)

07/21/2024 188
1. Laser lithotripsy
 Used to fragment ureteral and large bladder stones
 To access ureteral stones, a ureteroscope is used to get
close to the stone.
 A small fiber is inserted up the endoscope so that the tip
(which emits laser energy) can come in contact with
stone.
 The intense energy breaks the stone into small pieces,
which can be extracted or flushed out.
07/21/2024
No other tissue is affected 189
2. Extracorporeal shock wave lithotripsy(ESWL)
 Is a noninvasive procedure used
 To break up stones in the calyx of the kidney with a
high-energy amplitude of pressure, or shock wave
(electromagnetic)
 Voided gravel or sand should be sent to the laboratory for
chemical analysis

07/21/2024 190
ESWL

07/21/2024 191
3. Percutaneous ultrasonic lithotripsy
 An ultrasonic probe is placed in the renal pelvis via a per-
cutaneous nephroscope inserted through a small incision
in the flank
 Then positioned against the stone
 The probe procedures ultrasonic waves, which break the
stone in to sand-like particles

07/21/2024 192
4. Electrohydraulic lithotripsy
 Probe positioned directly on a stone, but it breaks the
stone into small fragments that are removed by forceps or
by suction.
 A continuous saline irrigation flushes out the stone parti-
cles and all of the outflow drainage is strained so that the
particles can be analyzed.
 Hematuria is common after lithotripsy procedures

07/21/2024 193
Surgical removal
 Open surgical procedures
 Was the major mode of therapy before the advent of
lithotripsy
 Indicated if the stone does not respond to other forms of
treatment—medical, uretroscopic, lithotripsy
 May also be performed to correct anatomic abnormalities
within the kidney to improve urinary drainage

07/21/2024 194
Surgical removal…
 Types of open surgery- depends on the location of the stone
 Nephrolithotomy: an incision into kidney to remove stone
 Pyelolithotomy: an incision in to renal pelvis for stone re-
moval
 Ureterolithotomy: stone located in the ureter
 Cystotomy: stone in the bladder
 Hemorrhage is common complication

07/21/2024 195
Prostate Gland
 In the male, the three lobes of the prostate gland surround
the urethra.
 The two lateral lobes lie against the anterior rectal wall,
where they are readily palpable as a rounded heart shaped
structure about 2.5 cm in length.
 They are separated by a shallow median sulcus or groove,
also palpable.
 The third, or median lobe is anterior to the urethra and
cannot be examined through palpation.
07/21/2024 196
 PROSTATE GLAND

07/21/20244/3/2011 197
Benign Prostate Hypertrophy or Hy-
perplascia
• Enlargement of prostate gland resulting from an in-
crease in number or size of prostate cell and stromal
tissue
– 50% men >50yrs
– 90% men >80yrs

07/21/2024 198
RISK FACTORS
 Aging

 Genetics

 Sex steroid hormones: dihydrotestosterone and estrogen

 5-alpha reductase: Testosterone to DHT

 Diet [saturated fatty acids]

 Reduced exercise

 DM type 2 and disruptions in glucose homeostasis

07/21/2024 199
 C/Ms
OBSTRUCTIVE IRRITATIVE
• Reduced force of urine • Frequency
stream
• Difficulty in initiating • Urgency
voiding
• Intermittency • Dysuria
• Dribbling at the end of • Bladder pain
urination
• Nocturia
• Incontinence
• Inflammation/ infection
07/21/2024 200
Complications
 Acute urinary retention

 UTI

 Stone formation

 Hydronephrosis

 Pyelonephritis

 Bladder damage

07/21/2024 201
DIAGNOSTICS
 History & clinical findings
 Digital Rectal examination
 Uroflowmetry:
 max flow rate and volume of
residual urine after voiding
 10 ml to 21 ml / second
 Measuring residual urine
 Cystourethroscopy

07/21/2024 202
Pharmacologic Therapy
• Alpha-adrenergic blockers
– relax the smooth muscle of the bladder neck and
prostate
• 5-alpha-reductase inhibitors
– used to prevent the conversion of testosterone to DHT
and decrease prostate size

07/21/2024 203
Surgical Management
 Several approaches can be used to remove the hypertro-
phied portion of the prostate gland:
 CLOSED
 TURP
 TUIP
 TUMT
 OPEN- involves the surgical removal of the inner portion
of the prostate via a suprapubic, retropubic, or perineal
07/21/2024 204
Transurethral resection of the prostate (TURP)

 surgical removal of the inner portion of the prostate

through an endoscope inserted through the urethra

 no external skin incision is made

 can be performed with ultrasound guidance

07/21/2024 205
Transurethral incision of the prostate (TUIP)

 One or two cuts are made in the prostate and prostate cap-

sule to reduce constriction of the urethra and decrease re-

sistance to flow of urine out of the bladder

 no tissue is removed.

07/21/2024 206
Transurethral microwave heat treatment (TUMT)

 involves the application of heat to prostatic tissue

 A transurethral probe is inserted into the urethra, and mi-

crowaves are directed to the prostate tissue.

 The targeted tissue becomes necrotic and sloughs

07/21/2024 207
PREOPERATIVE INTERVENTIONS
 Avoid cold as it causes smooth muscle contraction
 Advise to urinate in every 2-3 hrs

 Normal fluid intake to avoid volume overload.

 Catheterization
 Antibiotic before any invasive procedures

07/21/2024 208
POSTOPERATIVE
 Prevention of complications- hemorrhage, bladder
spasms, urinary incontinence, infections
 Bladder irrigations with normal saline [pink, no
clots]
 Monitor inflow & outflow of irrigation
 Catheter care

 To relieve pain
07/21/2024 209
Hydrocele

• collection of fluid most commonly between the visceral

and parietal layers of the tunica vaginalis of the testis

• most common cause of scrotal swelling

• can be differentiated from a hernia by transillumination;

– a hydrocele transmits light, whereas a hernia does not.

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07/21/20244/3/2011 211
Hydrocele
• may be communicating or noncommunicating
• Communicating hydroceles
– usually develop as a result of failure of the processus vagi-
nalis to close during development;
– the fluid around the testis is peritoneal fluid
• Noncommunicating hydroceles
– have no connection to the peritoneum;
– the fluid comes from the mesothelial lining of the tunica
vaginalis
07/21/20244/3/2011 212
07/21/20244/3/2011 213
Noncommunicating hydrocele

07/21/20244/3/2011 214
Hydrocele...
• Acute hydroceles primarily develop in adults older than
40 years of age
– occur in association with local (eg. epididymitis) or
systemic (eg. mumps) infections
• Chronic hydroceles may occur related to the imbalance
between fluid secretion and reabsorption in the tunica
vaginals

07/21/20244/3/2011 215
Management
• Treatment is usually not required unless it is;
– large, bulky, tense, or uncomfortable;
– compromises testicular circulation; or
– causes an undesirable appearance.
• Surgical excision (hydrocelectomy)- excising tunica
vaginalis or sclerosing the visceral and parietal layers.
– involves resection or suturing together the two layers.
• Needle aspiration

07/21/20244/3/2011 216
Testicular torsion
• is a surgical emergency requiring immediate diagnosis to
avoid loss of the testicle.
• Torsion of the testis is rotation of the testis,
– twists the blood vessels in the spermatic cord
– impedes arterial and venous supply to the testicle and
surrounding structures
– After 6 hours of impaired blood supply, the risk for
loss of the testicle increases.
07/21/20244/3/2011 217
Testicular torsion...
• extravaginal torsion
– involves twisting of the spermatic cord,
– resulting in compromise to the testes
• intravaginal torsion
– when the testis twists within its tunica vaginalis
– resulting in compromise to the testes
• N.B: If blood flow is not restored in a timely fashion, testicular
ischemia, infarction, and subsequent atrophy will occur

07/21/20244/3/2011 218
07/21/20244/3/2011 219
Testicular torsion

Sign and Symptoms

– sudden pain in the testicle, developing over 1-2 hours

– swelling of the scrotum

– testicular tenderness, elevated testis, a thickened sper-

matic cord

07/21/20244/3/2011 220
Testicular torsion

Management

 manual reduction

 surgery

 to untwist the spermatic cord and anchor both testes in

their correct position

07/21/20244/3/2011 221
 Sexually Transmitted Infections
(STIs)

07/21/2024 222
STI Vs STD
What’s the difference?
• Sexually Transmitted Infection (STI) has replaced the
term Sexually Transmitted Disease (STD)
Why?
• STI is a more encompassing term that includes infections
that are asymptomatic (show no symptoms)

07/21/2024 223
STIs
 are infections that can be transmitted through sexual con-
tact with an infected individual.
 Some STIs can be transmitted through nonsexual means
– mother to baby during childbirth

– Skin to Skin contact

– Sharing equipment

– Exchange of bodily fluids

• Can be bacterial, viral or parasitic

07/21/2024 224
STI Diagnostic Approaches
 Etiologic: Identifying causative agent(s) using laboratory
tests and treatment targeting pathogen identified.
 Clinical: Clinical experience to identify symptoms typical
for a specific STI, and giving treatment targeting sus-
pected pathogen(s).
 Syndromic: Identification of clinical syndrome and giving
treatment of all the locally known pathogens which can
cause the syndrome.
07/21/2024 225
Bacterial STIs
• Can generally be cured with antibiotics.
• However, if left untreated they can lead to further com-
plications.
• Common bacterial STIs are
– Chlamydia,
– Gonorrhea and
– Syphilis
– Chancroid- rare
07/21/2024 226
Viral STIs
• Cannot be cured, although many can be treated with medi-
cations.
– Some viral STIs, such as Human Papilloma Virus (HPV),
can disappear on their own.
• Common viral STIs include
– HIV,
– genital herpes,
– HPV (Genital Warts),
– Hepatitis B and Hepatitis C
07/21/2024 227
Parasitic STIs
• can be cured with medications and creams.
• Common examples include
– scabies
– pubic lice

07/21/2024 228
Gonorrhea
Usually affects mucous membranes (mainly urethra
and genital tract)
Adolescent women (ages 15 to 19) currently have the
highest rates of infection.
Etiologic agent: Neisseria gonorrhoeae
Can cause pelvic inflammatory disease, which can
cause infertility in women.

07/21/2024 229
How’s It Spread?

 Unprotected Vaginal, anal, or oral sex with

someone who has gonorrhea

 A pregnant woman infected with gonorrhea can

give the infection to her baby during childbirth

07/21/2024 230
Clinical Manifestations
• Male symptoms

– Discharge from penis

– Painful urination

– Painful/swollen testicles

07/21/2024 231
Clinical Manifestations
• Female symptoms

– 50% of females are asymptomatic

– Vaginal discharge

– Burning with urination

– abnormal uterine bleeding

– lower abdominal pain

07/21/2024 232
Diagnosis
– Clinical exam
– Cervical culture
– Polymerase chain reaction (PCR) or ligase chain reac-
tion (LCR)
– Gram stain–polymorphonucleocytes with gram nega-
tive intracellular diplococci

07/21/2024 233
Treatment
– Ceftriaxone 500mg IM once

– Doxcycycline 100mg PO BID for 07 days added in

case where chlamydial co-infection has not been

ruled out

07/21/2024 234
Chlamaydia
• Caused by the bacterium Chlamydia trachomatis.
• Passed by having unprotected oral, anal or vaginal sex
– Can spread from an infected mother to her unborn child
• Most people have no symptoms
• can be cured with a single dose of antibiotics
• Can lead to pelvic inflammatory disease, which can cause
infertility in women.

07/21/2024 235
Chlamaydia
• Females symptoms
– Vaginal discharge
– burning sensation during urination
– bleeding between menstrual cycles
– Lower abdominal pain
– LGF

07/21/2024 236
Chlamaydia...
• Male symptoms
– Discharge from penis
– burning sensation during urination
– Burning and itching around the opening of the penis
– pain and swelling in the testicles
– LGF

07/21/2024 237
Treatment
• First line for uncomplicated infections
– Doxcycycline 100mg PO BID for 07 days
– Azithromycin 1g po once for pregnant women
• Alternatives
– Ofloxacin 300 mg PO BID for 07 days or
– Levofloxacin 500 mg PO once daily for 07 days

07/21/2024 238
Treatment...
• Co-infection with gonorrhea

– Doxcycycline 100mg PO BID for 07 days plus

– Ceftriaxone 250 mg IV/IM single dose

07/21/2024 239
Syphilis
• Syphilis is an infection that is characterized by sequential
stages
• caused by bacteriumTreponema pallidum.
• Rare sexually transmitted bacterial infection
• Can cause serious damage to the body if not cured, including
death
• Passed by having unprotected oral, anal or vaginal sex
– Can spread from an infected mother to her unborn child

07/21/2024 240
Syphilis...
Primary Syphilis (1st Stage) (Infectious stage)
• Appears 3 days to 3 months after contact
• involves the formation of a chancre
– A painless open sore with a hard and round edge and a
clean base develops, usually in genital area
• The sore will heal on its own, but the infection remains
• Heals with scarring in 3-6 weeks and 75% of patients show no
further symptoms
07/21/2024 241
Syphilis...
• Secondary Syphilis (2nd Stage)
– 2 to 24 weeks after exposure
– Typically begins with Non-itchy rash developement any-
where on the body
– Flu-like symptoms develop, like headache, slight fever, fa-
tigue, loss of appetite, weight loss, and sore throat
– Will go away without treatment, but infection will progress
to next stage of syphilis
07/21/2024 242
Syphilitic Rash

07/21/2024 243
Syphilis...
• Latent Syphilis (3rd Stage)
– Latent syphilis occurs after secondary syphilis
– Typically, there are no symptoms
– Can damage almost any part of the body including the
heart, brain, spinal cord, eyes and bones

07/21/2024 244
Treatment
• Early latent syphilis
– Benzathine penicillin G 2.4 million units IM in a sin-
gle dose
• Late latent syphilis
– Benzathine penicillin G 7.2 million units total, admin-
istered as 3 doses of 2.4 million units IM each at 1-
week intervals

07/21/2024 245
Chancroid
 uncommon infection caused by a bacterium Hemophilus
ducreyi
 C/Ms
erythematous papule that rapidly evolves into a pus-
tule, which erodes into an ulcer
Infected persons commonly have more than one ulcer
the lesions are almost always confined to the genital
area and its draining lymph nodes.
07/21/2024 246
Treatment of Chancroid
– Azithromycin 1 g orally in a single dose or
– Ceftriaxone 250 mg IM in a single dose or
– Ciprofloxacin 500 mg orally 2 times/day for 3 days or
– Erythromycin base 500 mg orally 3 times/day for 7
days

07/21/2024 247
Human papillomavirus
• Caused by human papillomavirus (HPV).
• Some strains can lead to genital warts (symptoms usually
do not emerge for 1-3 months).
• Some strains can lead to certain cancers.

07/21/2024 248
Pubic Lice
• Caused by the insect Phthirus pubis.
• Symptoms:
– itching in the genital region
– visible lice or eggs.
• Can be cured with insecticides

07/21/2024 249
Scabies
• Caused by the mite Sarcoptes scabiei (related to the spi-
der)
• Symptoms:
– Itching
– rash.
• Cured with insecticides

07/21/2024 250
Trichomoniasis
• Caused by the parasitic protozoan Trichomonas vaginalis.
• Symptoms (usually occur only in females):
– genital discharge
– itching
• Can be cured with drugs.

07/21/2024 251
Lymphogranuloma venereum (LGV)
• is a genital ulcer disease caused by the L1, L2 and L3
serovars of Chlamydia trachomatis
• Three stages have been identified:

1. Primary infection
– characterized by a genital ulcer or a mucosal inflamma-
tory reaction at the site of inoculation.
– lesions spontaneously heal within a few days.

07/21/2024 252
Stages of LGV
• Secondary infection
– appears two to six weeks later
– is related to local direct extension of the infection to regional
lymph nodes (ie, inguinal and/or femoral nodes)
– In contrast to the urogenital infections due to Chlamydia tra-
chomatis (serovars A through K), LGV can cause severe in-
flammation and invasive infection

07/21/2024 253
Stages of LG...
• Late lymphogranuloma venereum

 characterized by Fibrosis & strictures in anogenital tract

 Late complications include;
genital elephantiasis,
anal fistulae and strictures,
frozen pelvis, and
infertility
07/21/2024 254
Treatment
• First line

– doxycycline 100 mg PO BID for 21 days

• Alternatives

– erythromycin 500 mg QID

– azithromycin 1 g once weekly for three weeks

07/21/2024 255
Anogenital warts (condylomata acuminata)
• are the most common viral sexually transmitted disease
• caused by human papilloma virus (HPV) infection.
• Symptoms
– vary depending upon number of lesions and their location.
– Patients with a small number of warts are often asympto-
matic.
– Other patients may have pruritus, bleeding, burning, ten-
derness, vaginal discharge (women), or pain.

07/21/2024 256
Recommended Regimens
– Imiquimod 3.75% or 5% cream† or

– Podofilox 0.5% solution or gel or

– Sinecatechins 15% ointment

– Surgical removal

07/21/2024 257
Complications of STIs
– Infertility (male and female)
– Pelvic inflammatory disease (PID) in woman
– Epididymitis in men
– Urinary tract complications
– Cervical cancer
– Psychological impact
– Serious illness and death

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 THANK YOU !!

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