Urinary system dysfunction

Impaired renal function
 Can be pre-renal, renal, post-renal
 Causes-
 Azotemia- increase in blood urea and/or
creatinine, due to reduced GFR
 Oliguria- decreased urine output, usually
<500 ml. per day in adult
 Covered later as ARF & CRF

Hematuria
Presence of RBC in urine
Microscopic or macroscopic

Causes
 Lower urinary tract
 BPH (age >50), prostatitis
 Stones (age <40), UTI/STD
 Malignancy- TCC
 Trauma
 Upper urinary tract
 Nephritic syndrome- PSGN/RPGN, IgA nephropathy
 Papillary necrosis- DM, analgesics, sickle cell disease
 Interstitial nephritis- antibiotics
 RCC
 Other- change in color without RBC

Work-up
 History- timing of blood in urine,
associated symptoms
 Examination- HT, edema, mass,
PR exam. for prostate
 Investigation-
 Urine analysis- RBC, WBC, protein, casts, malig.
cells
 CBC, RFT
 X-ray KUB, IVP, CT scan
 Cystoscopy +/- biopsy

Proteinuria
Excretion of >150 mg. protein/d.
Massive - >3.5 gms./day

Urinary proteins
 α2 microglobulins
 Tamm-Horsfall mucoprotein
 Albumin- 10-15 mg./day
 β2 microglobulins, lysozyme etc.

Causes
 Glomerular diseases
 Nephrotic syndrome
 Glomerulonephritis
 Diabetic nephropathy
 IgA nephropathy
 SLE
 Overflow proteinuria
 Multiple myeloma- Bence Jones protein
 Low reabsorption at proximal tubule
 Fanconi syndrome

Evaluation
 Dipstick- qualitative
 24 hour urine- quantitative
 Protein:Creatinine ratio >45 mg./mmol.,
in spot urine sample provides
alternative estimate of 24 hr proteinuria

Polyuria
Urine output >3 litres/day

Causes
 Inadequate vasopressin secretion
 Pituitary damage
 Inadequate vasopressin response
 Tubular damage- pyelonephritis, analgesic nephropathy,
obstructive uropathy, MM, ADPKD, Amphotericin,
hypercalcemic or hypokalemic nephropathy
 Solute diuresis
 Glucose, mannitol, urea
 Natriuresis
 Diuretic phase of ATN, Bartter’s syndrome
 Primary polydipsia

Water deprivation test
 >3% weight loss or after 14 hours
 Normally- urine<0.5 ml/min, osm.>700
 Psychogenic polydipsia- osm.>400
 Diabetes insipidus- urine>0.5 ml/min,
osmolality commonly <200 mosmol/kg.
 Vasopressin- 5 mU/min infusion
 Central DI- urine osm. increases >9%
 Nephrogenic DI- no change

Dysuria, Frequency, Urgency
 Lower urinary tract symptoms
 Commonly due to infection
 Cystitis in females, urethritis in males
 Fever & flank pain suggest pyelonephritis
 Prompt treatment & follow-up warranted-
 Pregnancy
 Structural abnormality,
 Immunosuppressed, Diabetic
 Recent LUT instrumentation

Urinary incontinence
Voluntary or involuntary
Leakage of urine

Types
 Urge- detrusor overactivity
Rule out bladder stone/tumor
 Overflow- detrusor underactivity
Neurogenic bladder, increased PVR
 Stress- urethral incompetence
Leakage of urine in response to any stress
 Functional

Evaluation
 History- diary, associated symptoms
 Examination
 Investigation-
 Urinalysis
 Ultrasound
 Urodynamics
 Cystoscopy

Treatment
 Urge-
 Bladder training
 Pelvic floor muscle exercises
 Drugs- Tolterodine, Darifenacin/Solifenacin
 Overflow
 CIC, indwelling catheter
 Stress
 Timed voiding
 Pelvic floor muscle exercises
 Duloxetine
 Surgery
 Other- BPH
 Alpha-blockers- Tamsulosin
 5-alpha reductase inhibitors- Finasteride
 Surgery- TURP

Urinary system dysfunction

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Urinary system dysfunction