ANATOMY AND PHYSIOLOGY

The Urinary System

The urinary tract is composed of four structures:

• Kidney
• Ureters
• Bladder
• Urethra

The kidneys balance the urinary excretion of substances against the

accumulation within the body through ingestion or production. Consequently, they are a
major controller of fluid and electrolytes homeostasis. The kidneys also have several no
excretory metabolic and endocrine functions, including blood pressure regulations,
erythropoietin regulation and vitamin D metabolism.

Filtration at the renal glumerulus is the first steps in urine formation. Normally, a
volume equal to plasma volume is filtered every 24 minutes and a volume equal to total
body water is filtered every 6 hours. This glomerular filtrate is similar to plasma, but it
lack cells and large-molecular-weight proteins. The glomerular filtrate is modified by
active transport, diffusion and osmosis as it passes through the renal tubules.
Reabsorption of filtrate components enhances elimination of organic acids and bases
(and some drugs). The remnants of the glomerular filtrate exit the kidney through the
uterus.

The ureters conduct urine from the kidney to the bladder by peristaltic
contraction. The bladder is distensible chamber that stores urine until it is excreted. The
urethra is the exit passageway from the bladder that carries urine for elimination from the
body.
Structures of the Urinary System

The kidneys are located retro peritoneal, in the posterior aspects of the
abdomen, on either side of the vertebral column. They lie between the 12th thoracic and
the third lumbar vertebrae. The left kidney is usually positioned slightly higher than the
right. Adult kidney average approximately 11 cm in length, 5 to 7.5 cm in width and 2.5
cm in thickness. Affixing the kidneys in position behind the parietal peritoneum is a mass
of perirenal fat (adipose capsule) and connective tissue called Gerota's (subserosa)
fascia. A fibrous capsule (renal capsule) forms the external covering of the kidney except
for the hilum. The kidney is further protected by layers of muscles of the back. Flank
abdomen as well as by layer of fat, subcutaneous tissues and the skin.

The kidney has a characteristics curve shape, with a convex distal edge and a
concave medial boundary. In the innermost part of the concave section is hilus, through
which pass the renal artery, renal vein, lymphatic, nerves and renal pelvis (the natural
upper extension of the ureter). A fibrous capsule surrounds each kidney and adheres the
renal parenchyma. Each kidney is divided in to three major areas: (1) cortex, (2) medulla
and (3) pelvis.
The cortex of the kidney lies just under the fibrous capsule, and portions of the
extend down into the medulla layer to form the renal columns (columns of Bertin) or
cortical tissue that separates the pyramids. The medulla is divided into eight to 18 cone
shaped masses of collecting ducts called the renal pyramids. The bases of the pyramids
are positioned on the corticomedullary boundary. Their apices extend toward the renal
pelvis, forming papillae. The papillae have 10-25 openings each on the surface, through
which the urine empties into the renal pelvis. Eight or more groups of papillae are
present in each pyramid; each empties into a minor calix and several minor calices join
to form a major calix. The two or three major calices are outpouching of the renal pelvis
(inner area of the kidney). They channel urine from the pyramids to the renal pelvis. The
renal pelvis is a cavity lined with transitional epithelium. The combined volume of the
pelvis and calices is approximately 8 ml. Volumes in excess of this amount damage the
renal parenchyma tissue. The renal pelvis narrows and reaches the hilus and becomes
the proximal end of the ureter.
 Within the cortex lies the nephron, the functional unit of the kidney, consisting
both vascular and tubular elements. Filtration begins at the glumerulus. The glomerular
tuft (glumerulus) contains capillaries and the beginning of the tubule system, Bowman's
capsule. Filtrate from the glumerulus enters the Bowman's capsule and the passes
through a series of tubule segments that modify the filtrate as it passes through the renal
cortex and medulla and finally, flows into the renal calices. A second capillary bed, the
peritubular capillaries, carries the reabsorbed water and solutes back towards the vena
cava.

Renal Blood Flow, Glomerular Filtration

The kidneys receive 20% to 25% of the cardiac output under resting conditions,
averaging more that 1 L of the arterial blood per minute. The renal arteries branch from
the abdominal aorta at the level of the second lumbar of vertebra, enter the kidney, and
progressively branch into lobar arteries, inner lobar arteries, accurate arteries and
interlobular arteries. Blood flows from the inerlobular arteries through the afferent
arteriole and the peritubular capillaries carry a small amount of blood (5% of renal blood
flow) to the renal medulla in the vasa recta (long, straight blood vessels) before entering
the venous drainage. The blood leaves the kidney in a venous system closely
corresponding to the arterial system: interlobular veins, accurate veins, interlobular
veins, and the renal vein. The renal circulation then empties the inferior vena cava.

Ureters

The ureters from the medial tapering of the renal pelvis at the hilus of the kidney.
Usually 25-35 cm long in the adult, the ureters lie in the extraperitoneal connective tissue
and descend vertically along the psoas muscle towards the pelvic cavity. After dipping
into the pelvic cavity, the ureters course anteriorly to join the bladder in its posterolateral
aspect. At each ureterovesical junction, the ureter runs obliquely through the bladder
wall for about 1.5 to 2 cm before opening into the lumen of the bladder.
 Each ureter has elastic characteristics and is made of three tissues layers; (1) an
inner mucosa (transitional epithelial membrane) lining the lumen, (2) a muscular layer
and (3) a fibrous outer layer. The musculature is generally designed as inner longitudinal
and outer circular. Along most of the ureter, however, the muscle fiber actually run
obliquely and blends with one another to form a mesh-like tissue. The muscle
arrangement allows urine to propel down by the ureter by peristaltic action. Peristalsis is
regulated by a myogenic pacemaker located near the renal calices.

Blood is supplied to ureters by one or more vessels that run longitudinal along
the tube. The number and assortment of articles anastomosing with the ureteric vessels
vary with each individual. Because the ureters travel through several anatomic areas,
the urethral vessels are fed several of the following arteries: (1) renal (frequently), (2)
testicular or ovarian, (3) aorta and common iliac, (4) internal iliac (frequently), (5) vesical,
(6) umbilical and (7) uterine.

Bladder

The urinary bladder is a hallow organ located in the anterior half of the pelvis
behind the symphisis pubis. The space between the bladder and symphisis pubis is filled
with a loose connective tissue that allows the bladder to stretch cranially as it fills. The
peritoneum covers the top border of the bladder, and the base is held loosely in place by
the true ligaments. The bladder is also enveloped by a loose fascia.

Urethra

The urethra is a tube that extends from the base of the bladder to the surface of
the body. The urethra differs greatly in females and males.

Male Urethra

In males, the urethra is a common outlet for the reproductive system and urinary
elimination. The prostate gland, although not a direct part of the urinary system, is a
major cause of urinary dysfunction in men. Located below the bladder neck, the prostate
completely enlarges, it constrict the urethra and obstruct the outflow of urine.
 The male urethra is about 20 cm long and is divided into three main sections.
The prostatic urethra extends about 3 cm below the bladder neck, the ejaculatory ducts
of the membranous urethra is about 1 to 2 cm in length and ends where the muscle layer
forms the external sphincter. The distal portion is the cavernous (penile) urethra.
Approximately 15 cm long, it travels through the penis to the urethra orifice at the tip of
the penis; it is also lined with epithelial cells.
THE PATIENT’S ILLNESS (Book-Based)
A. Synthesis of the Disease
1. Definition of the Disease
A urinary tract infection (UTI) is a bacterial infection that affects any part of the
urinary tract. The main causative agent is Escherichia coli. Although urine contains a
variety of fluids, salts, and waste products, it usually does not have bacteria in it. When
bacteria get into the bladder or kidney and multiply in the urine, they cause a UTI. The
most common type of UTI is a bladder infection which is also often called cystitis.
Another kind of UTI is a kidney infection, known as pyelonephritis, and is much more
serious. Although they cause discomfort, urinary tract infections can usually be quickly
and easily treated with a short course of antibiotics.
Since bacteria can enter the urinary tract through the urethra (an ascending
infection), poor toilet habits (such as wiping back to front for women) can predispose to
infection, but other factors (pregnancy in women, prostate enlargement in men) are also
important and in many cases the initiating event is unclear.
While ascending infections are generally the rule for lower urinary tract infections and
cystitis, the same may not necessarily be true for upper urinary tract infections like
pyelonephritis which may be hematogenous in origin.

2. Predisposing/Precipitating Factors
A. MODIFIABLE FACTORS
1. Toilet Habits
Women who wipe back to front can predispose them to infection. Avoiding the
urge to void is also a factor because urinary stasis leads to infection.
2. Socio-Economic Status
The lack of access to a toilet affects the person’s toilet habits.
3. Fluid Intake
Inadequate fluid intake makes the urine concentrated which increases the
person’s susceptibility to infections due to the high amount of waste products.
B. NON MODIFIABLE
1. Age
UTI is a prevalent disease among children and elderly.
2. Sex
UTI has a higher incidence rate with the female gender.

Signs and Symptoms With Rationale

• Frequent urination along with the feeling of having to urinate even though there
may be very little urine to pass.
• Nocturia: Need to urinate during the night.
• Urethritis: Discomfort, irritation or pain at the urethral meatus or a burning
sensation throughout the urethra with urination (dysuria).
• Pain in the midline suprapubic region.
• Pyuria: Pus in the urine or discharge from the urethra.
• Hematuria: Blood in urine (not always seen to the naked eye, but often revealed
during urine tests).
• Pyrexia: Mild fever
• Cloudy and foul-smelling urine
• Urinary incontinence: Involuntary leakage of urine
• Increased confusion and associated falls are common presentations to
Emergency Departments for elderly patients with UTI.
* Some urinary tract infections are asymptomatic.
Health Promotion and Preventive Aspects of the Disease

The following are measures that studies suggest may reduce the incidence of urinary
tract infections. These may be appropriate for people, especially women, with recurrent
infections:
• Do not delay urination when it is necessary.
• Cleaning the urethral meatus (the opening of the urethra) after intercourse has
been shown to be of some benefit; however, whether this is done with an
antiseptic or a placebo ointment (an ointment containing no active ingredient)
does not appear to matter.
• It has been advocated that cranberry juice can decrease the incidence of UTI
(some of these opinions are referenced in External Links section). A specific type
of tannin, called A Type Proanthocyanidin, found only in cranberries and
blueberries prevents the adherence of certain pathogens (eg. E. coli) to the
epithelium of the urinary bladder. However the tannins that are found in green tea
drunk in a daily dose of around 600mls will provide an excellent and cost
effective alternative to cranberry juice in the prevention and prevelance of chronic
infection.
• For post-menopausal women, a randomized controlled trial has shown that
intravaginal application of topical estrogen cream can prevent recurrent cystitis.
• Often long courses of low-dose antibiotics are taken at night to help prevent
otherwise unexplained cases of recurring cystitis.
• Acupuncture has been shown to be effective in preventing new infections in
recurrent cases. One study showed that urinary tract infection occurrence was
reduced by 50% for six months. However, this study has been criticized for
several reasons. All of the studies are done by one research team without
independent reproduction of results.
• Studies have shown that breastfeeding can reduce the risk of UTIs in infants.
• Keeping the Foley Catheter from clogging with biofilm will prevent stasis of urine
in the bladder, which serves as a culture medium for bacterial growth.
THE PATIENT’S ILLNESS (Patient-Based)

MODIFIABLE FACTORS
1. Toilet Habits
Avoiding the urge to void is a factor because urinary stasis leads to infection.
2. Fluid Intake
Inadequate fluid intake makes the urine concentrated which increases the
person’s susceptibility to infections due to the high amount of waste products.

NON MODIFIABLE
1. Age
UTI is a prevalent disease among children and elderly. The patient is years old.

Signs and Symptoms

The patient manifested the following:
• Increased WBC as the body’s response to foreign bodies
• Cloudy urine due to pus cells
• Fever