Chapter 29 Disorders of the Lower Urinary Tract I Lower Urinary Tract Physiology a The Lower Urinary Tract is everything beneath the kidneys beginning II Voiding Dysfunction Incontinence a Etiology with the ureters the body via the urethra movement b Function is to transport urine from the kidney allowing removal from c Urine movement via gravity and facilitated by peristaltic ureter i Peristalsis is the wavelike muscular movement d Requires integrity of ureters and bladder competent urethral sphincters and functioning nervous system e Mechanisms of Micturition i Bladder innervation 1 Sympathetic nerves that exit the spinal cord at L1 L2 and allow relaxing and filling Involuntary ii Parasympathetic nerves from S2 S4 1 Bladder contraction internal sphincter relaxation Involuntary iii Micturition requires central autonomic and peripheral nervous system functioning 1 A mix of parasympathetic and voluntary control f Note The external sphincter is innervated by the somatic pudendal nerve which is voluntary keeps you from peeing yourself i Disorders of the lower urinary tract ii Pathologies affecting the central autonomic and peripheral nervous systems iii Factors affecting micturition control 1 Medication access to toilet facilities b Neurogenic Bladder pudendal nerve i Specific cause is pathology that produces disruption of nervous communication governing micturition c Treatment d Types i Behavioral ii Drugs iii Surgical To strengthen muscles iv Physical Therapy to work on pelvic floor muscles i Urge incontinence can t make it to the bathroom Idiopathic 1 2 Bladder infection irritate the lining of the bladder also most common 3 Radiation 4 Tumors Stones 5 CNS damage ii Stress 1 Weakening of pelvic muscles 2 iii Mixed Intrinsic urethral sphincter deficiency 1 Combination of stress and incontinence iv Overflow 1 Obstruction of the urethra or an underactive inactive detrusor muscle Inability to completely void the bladder 2 3 Diabetes MS GB Syndrome v Functional 1 Related to physical or environmental limitations in reaching a bathroom vi Risk Factors for Incontinence 1 Immobility 2 Medications 3 Smoking 4 Environmental Barriers 5 Low Fluid Intake 6 Pelvic Muscle Weakness 7 Pregnancy Vaginal Delivery Episotomy a Epistotomy snip vaginal opening to allow baby delivery easier which leads to overall weakness vii Pathologies 1 UTI 2 Diabetes 3 Stroke 4 MS 5 Spinal Cord Injury viii Enuresis is an inappropriate wetting of clothing or bedding Usually children 1 Maturational delay 2 Treatment is usually behavior modification III Urinary Tract Infection a Presence of bacteria in urine i 100 000 colonies mL ii e coli is most common b Site of Infections i Urethra Urethritis ii Bladder Cystitis iii Kidneys Pyelonephritis c Diagnosis i High WBC and RBC in urine ii High WBC casts in urine 1 Pyelonephritis usually bacterial infection that spreads through the urinary tract through the urethra ecoli Klesbsiella stangnant urine IV Recurrent UTI a Urethritis Inflammation of urethra i ii Etiology 1 Infection of the urethra Burning dysuria a Can ascend to the bladder Infection from the bladder 2 3 STD Gonorrhea a Limited to urethra b Foul smell 4 External Factors a Hygine b Water c Tight clothes d Sexual activity e Sexual assault 5 Tight clothing iii Treatment 1 Depends on cause b Cystitis Inflammation of bladder lining i ii Suprapubic pain iii Etiology 1 Infection 2 Chemical Irritants 3 Stones 4 Trauma iv Predisposing Factors a Most common most originate in urethra Increased Age Immune Response 1 Female Anatomic 2 3 Catheterization Foreign Body 4 Diabetes Immune Response 5 Bladder Dysfunction 6 Poor Hygiene Other 7 Urinary Stasis Intrinsic a Build up oof bacteria when not going to the v Clinical Manifestations bathroom 1 Frequency urgency dysuria suprapubic pain cloudy 2 Older Adults Lethargy anorexia confusion anxiety urine vi Treatment 1 Females based on symptoms 2 Males Children Complicated cases need urine culture and further assessment vii Symptoms of Recurrent Urinary Tract Infection V Interferes with urine flow Urinary Tract Obstruction a b Can occur at Any Point in the urinary tract c Nephrolithiasis i Renal Calculi mineral deposits ii Kidney Stones d Pathophysiology i Crystal aggregates composed of organic and inorganic materials located within the urinary tract e Etiology i Recurrent UTI ii Urine Supersaturated by large quantities of calcium uric acid cysteine xanthine purine metabolism usually form uric acid iii Contributing Factors 1 Hypertension 2 UTI 3 Excess meat sodium oxalate 4 Diabetes 5 Immobility i Renal Colic tenderness sharp pain when tapping ii Hematuria stones travelling down and scraping f Manifestations endothelium iii Signs of UTI iv Signs of UTO g Types i Calcium Oxalate 75 ii Struvite 7 10 Urea splitting bacteria Proteus Klebsiella Pseudomonas iii Uric Acid 7 10 iv Cystine 1 3 v Ephedrine Guaifenesin Indainavir Xanthine All 1 h Management i General Interventions Increased fluid intake 2 L per day oral or IV 1 Narcotic analegsics pain 2 3 Antimicrobials for UTI 4 Ureteral Stenting 5 Dietary modifications based on stone type 6 Medications based on stone type allopurinol for uric acid stones ii Dietary Modifications Increased water intake 1 2 No calcium supplements 3 No excess vitamin D or C 4 Limit coffee tea and cola 5 Avoid high purine foods i Urolithiasis i Lower Uriniary Tract Obstruction ii Pathogenesis 1 Stones traveling to ureters bladder and urethra from kidney 2 Bladder urolithiasis a Stones travelling from ureters b Can form in bladder due to urinary stasis