Difficulty urinating

The group
fourth
Scenario 3
A man who 63 years came to the doctor with
complaints of difficulty urinating,for one week
when urinating just a little, but no pain, cant
empty his bladder completely (not satisfied).
patients often feel pain in the waist. From the
result of rectal toucher prostate examination there
is enlargement. The result of USG there is a stone
in pelvis renalis.
 Learning objection
Anatomy
ANATOMY
Urinary System Organs
 Kidney Location and External
Anatomy
The bean-shaped kidneys lie in a retroperitoneal
position in the superior lumbar region and extend
from the twelfth thoracic to the third lumbar
vertebrae
The right kidney is lower than the left because it is
crowded by the liver
The lateral surface is convex and the medial
surface is concave, with a vertical cleft called the
renal hilus leading to the renal sinus
Ureters, renal blood vessels, lymphatics, and
nerves enter and exit at the hilus
 Layers of Tissue Supporting
the Kidney
Renal capsule fibrous capsule that
prevents kidney infection
Adipose capsule fatty mass that cushions
the kidney and helps attach it to the body
wall
Renal fascia outer layer of dense fibrous
connective tissue that anchors the kidney
Kidney Location and External
Anatomy
 Internal Anatomy
A frontal section shows three distinct regions
Cortex the light colored, granular superficial
region
Medulla exhibits cone-shaped medullary
(renal) pyramids
Pyramids are made up of parallel bundles of
urine-collecting tubules
Renal columns are inward extensions of
cortical tissue that separate the pyramids
The medullary pyramid and its surrounding
capsule constitute a lobe
 Internal Anatomy
Renal pelvis flat, funnel-shaped tube
lateral to the hilus within the renal sinus
 Internal Anatomy
Major calyces large branches of the renal
pelvis
Collect urine draining from papillae
Empty urine into the pelvis
Urine flows through the pelvis and ureters
to the bladder
Internal Anatomy
 Blood and nerve supply
Approximately one-fourth (1200 ml) of systemic
cardiac output flows through the kidneys each
minute
Arterial flow into and venous flow out of the
kidneys follow similar paths
The nerve supply is via the renal plexus
 Ureters
Slender tubes that convey urine from the kidneys
to the bladder
Ureters enter the base of the bladder through the
posterior wall
This closes their distal ends as bladder pressure
increases and prevents backflow of urine into
the ureters
 Ureters
Ureters have a trilayered wall
Transitional epithelial mucosa
Smooth muscle muscularis
Fibrous connective tissue adventitia
Ureters actively propel urine to the bladder via
response to smooth muscle stretch
Ureters
 Urinary Bladder
Smooth, collapsible, muscular sac that temporarily
stores urine
It lies retroperitoneally on the pelvic floor
posterior to the pubic symphysis
Males prostate gland surrounds the neck
inferiorly
Females anterior to the vagina and uterus
Trigone triangular area outlined by the openings
for the ureters and the urethra
Clinically important because infections tend to
persist in this region
 Urinary Bladder
The bladder wall has three layers
Transitional epithelial mucosa
A thick muscular layer
A fibrous adventitia
The bladder is distensible and collapses when
empty
As urine accumulates, the bladder expands
without significant rise in internal pressure
Urinary Bladder
Urinary Bladder
 Urethra
Muscular tube that:
Drains urine from the bladder
Conveys it out of the body
 Urethra
Sphincters keep the urethra closed when urine is
not being passed
Internal urethral sphincter involuntary
sphincter at the bladder-urethra junction
External urethral sphincter voluntary
sphincter surrounding the urethra as it passes
through the urogenital diaphragm
Levator ani muscle voluntary urethral
sphincter
 Urethra
The female urethra is tightly bound to the anterior
vaginal wall
Its external opening lies anterior to the vaginal
opening and posterior to the clitoris
The male urethra has three named regions
Prostatic urethra runs within the prostate
gland
Membranous urethra runs through the
urogenital diaphragm
Spongy (penile) urethra passes through the
penis and opens via the external urethral orifice
Uretrha
Physiology
 Kidney functions
Filter 200 liters of blood daily, allowing
toxins, metabolic wastes, and excess ions to
leave the body in urine
Regulate volume and chemical makeup of
the blood
Maintain the proper balance between water
and salts, and acids and bases
 Other Renal Functions
Gluconeogenesis during prolonged fasting
Production of rennin to help regulate blood
pressure and erythropoietin to stimulate
RBC production
Activation of vitamin D
 Other urinary system organs
Urinary bladder provides a temporary
storage reservoir for urine
Paired ureters transport urine from the
kidneys to the bladder
Urethra transports urine from the bladder
out of the body
 Mechanisims of Urine
Formation
Urine formation and
adjustment of blood
composition involves
three major processes
Glomerular filtration
Tubular reabsorption
Secretion
 A. Glomerular filtration
Glomerular Filtration
Urine formation begins when the fluid portion of
the blood leaves the glomerulus and enters the
glomerular capsule as glomerular filtrate.
 Filtration rate
1. The factors that affect the filtration rate are
filtration pressure, glomerular plasma osmotic
pressure, and hydrostatic pressure in the
glomerular capsule.
2. When the afferent arteriole constricts in response
to sympathetic stimulation,filtration pressure, and
thus filtration rate, declines.
3. When the efferent arteriole constricts, filtration
pressure increases, increasing the rate of
filtration.
4. When osmotic pressure of the glomerular plasma
is high, filtration rate decreases.
5. When hydrostatic pressure inside the glomerular
capsule is high, filtration rate declines.
6. On the average, filtration rate is 125 milliliters per
minute or 180 liters in 24 hours, most of which is
reabsorbed.
 Regulation of filtration rate
1. Glomerular filtration rate is relatively constant, although
sympathetic impulses may decrease the rate of filtration.
2. Another control over filtration rate is the renin-
angiotensin system, which regulates sodium excretion.

a) When the sodium chloride concentration in the tubular fluid

decreases, the macula densa senses the sechanges and causes the
juxtaglomerular cells to secrete renin.
b). Secretion of renin triggers a series of reactions
leading to the production of angiotensin II, which
acts as a vasoconstrictor; this may, in turn, affect
filtration rate.
c). Presence of angiotensin II also increases the
secretion of aldosterone, which stimulates
reabsorption of sodium.
 B. Tubular Reabsorption
Changes in the fluid composition from the time glomerular
filtrate is formed to when urine arrives at the collecting
duct are largely the result of tubular reabsorption of
selected substances.
2. Most of the reabsorption occurs in the proximal convoluted
tubule, where cells process microvilli with carrier proteins.
3. Carrier proteins have a limited transport capacity, so
excessive amounts of a substance will be excreted into the
urine.
4. Glucose and amino acids are reabsorbed by active
transport, water by osmosis,and proteins by pinocytosis.
Sodium and Water Reabsorption
1. Sodium ions are reabsorbed by active transport, and
negatively charged ions follow passively.
2. As sodium is reabsorbed, water follows by osmosis.
Regulation of Urine Concentration and Volume
1. Most of the sodium ions are reabsorbed before the
urine is excreted, and sodium is concentrated in the renal
medulla by the countercurrent mechanism.
2. Normally the distal convoluted tubule and collecting
duct are impermeable to water unless the hormone ADH
is present.
Urea and Uric Acid Excretion
1. Urea is a by-product of amino acid metabolism;
uric acid is a by-product of nucleic acid
metabolism.
2. Urea is passively reabsorbed by diffusion but
about 50% of urea is excreted in the urine.
3. Most uric acid is reabsorbed by active transport
and a small amount is secreted into the renal
tubule.
 Tubular secretion
1. Tubular secretion transports certain substances from the
plasma into the renal tubule.
2. Active transport mechanisms move excess hydrogen ions
into the renal tubule along with various organic
compounds.
3. Potassium ions are secreted both actively and passively
into the distal convoluted tubule and the collecting duct.
Urine Composition
1. Urine composition varies from time to
time and reflects the amounts of water and
solutes that the kidneys eliminate to
maintain homeostasis.
2. Urine is 95% water, and also contains urea,
uric acid, a trace of amino acids, and
electrolytes.
 Micturition (Voiding or Urination)
The act of emptying the bladder
Distension of bladder walls initiates spinal
reflexes that:
Stimulate contraction of the external urethral
sphincter
Inhibit the detrusor muscle and internal
sphincter (temporarily)
Voiding reflexes:
Stimulate the detrusor muscle to contract
Inhibit the internal and external sphincters
 The proses of micturition
1. Urine leaves the bladder by the micturation reflex.
2. The detrusor muscle contracts and the external urethral
sphincter (in the urogenital diaphragm) must also relax.
3. Stretching of the urinary bladder triggers the micturation
reflex center located in the sacral portion of the spinal
cord.
4. Return parasympathetic impulses cause the detrusor
muscle to contract in waves, and an urge to urinate is
sensed.
5. When these contractions become strong enough, the
internal urethral sphincter is forced open.
6. The external urethral sphincter is composed of skeletal
muscle and is under conscious control.
Micturition (Voiding or Urination)
Chemestry
 Buffers in the kidney
A. ACIDIFICATION OF URINE
The pH of blood plasma is kept within normal limits by
controlling the excretion of H+ ions in the urine and the
reabsorption of bicarbonate into blood plasma.
If acid is excreted in the urine, its is in effect removed
from the blood when an equal quantity of bicarbonate is
added to the blood.
Bicarbonate (as a base) neutralizes hydrogen ions in the
blood.
If the blood is too acidic more hydrogen ions are excreted,
if the blood is too basic, then less hydrogen ions are
excreted.
HCO3- + H+ <===> H2CO3 <===> CO2 + H2O
 The renal tubules excrete hydrogen ions by an unknown
series of reactions into the tubular urine.
The amount of hydrogen ions excreted is controlled by the
concentration of H+ (pH), bicarbonate, and the partial
pressure of CO2 (pCO2) in the blood plasma and by the
amount of Na+ and bicarbonate in the developing urine.
Hydrogen ions and sodium ions exchange places
throughout the formation of urine.
For every H+ which enters the urine, one sodium ion is
reabsorbed from the urine into the blood and is conserved.
For every H+ ion excreted and every Na+ ion conserved,
one bicarbonate ion is also reabsorbed into the blood.
The charges on sodium and bicarbonate are thus always
balanced.
 B. PHOSPHATE BUFFER IN

URINE
Normally phosphate is the only buffer in urine, although
carbonic acid/ bicarbonate is also present. The developing
urine contains NaH2PO4/Na2HPO4 in the same
concentration as present in blood plasma. Na2HPO4 is
actually the "salt" in the following dissociation reaction:
H2PO4- <===> H+ + HPO4 -2
In the developing urine the ratio of H2PO4-/HPO4 -2 is l : 4,
therefore the right side of the equilibrium is favored.
When the urine is acidified (hydrogen ions added), the
increase in H+ ion causes the equilibrium to shift left to
form H2PO4-.
HISTOLOGY
 URINARY SYSTEM

P
KIDNEY P

(ORGANIZATION)
P
CORTE P
X
- region immediately beneath renal capsule
- composed of two distinct regions:
P
(1) CORTICAL LABYRINTH
(2) MEDULLARY RAY R
P C
P
MEDULL
A
- located immediately beneath renal cortex
- consists of triangular blocks of tissue called the
PYRAMIDS
- RENAL COLUMNS are strands of cortical tissue that
extend down between adjacent pyramids
 URINARY SYSTEM Cortical Labyrinth
with
interdigitating
Medullary Rays
KIDNEY
P
(ORGANIZATION) P
RENAL LOBE
P
- a single pyramid with its P
associated overlying cortex

P
RENAL LOBULE
- defined within cortex and involves a P
single medullary ray (central axis of P
lobule) with adjacent adjacent cortical
labyrinth
- defined as a functional unit that
consists of a collecting duct and all
the nephrons that it drains
 URINARY SYSTEM

THE NEPHRON & COLLECTING DUCTS

1)
1) THE
THE NEPHRON
NEPHRON
- distributed throughout cortex and
various zones of medulla

a) RENAL CORPUSCLE
BOWMANS CAPSULE + GLOMERULUS

b) PROXIMAL TUBULE
CONVOLUTED AND STRAIGHT PORTIONS
c) HENLES LOOP
THICK AND THIN PORTIONS

d) DISTAL TUBULE
STRAIGHT AND CONVOLUTED PORTIONS

2)
2) COLLECTING
COLLECTING
DUCTS
DUCTS
 URINARY SYSTEM

THE NEPHRON & COLLECTING DUCTS

CORTEX:

CORTICAL LABYRINTH
1- RENAL CORPUSCLES
2- PROXIMAL CONVOLUTED TUBULES

3- DISTAL CONVOLUTED TUBULES

MEDULLARY RAY

1- STRAIGHT PORTIONS OF PROXIMAL

TUBULE (THICK DESCENDING)
2- STRAIGHT PORTIONS OF DISTAL
TUBULE (THICK ASCENDING)
3- COLLECTING DUCTS
 URINARY SYSTEM

THE NEPHRON & COLLECTING DUCTS

MEDULLA:

OUTER ZONE
1- STRAIGHT PORTIONS OF PROXIMAL
TUBULE (THICK DESCENDING)
2- STRAIGHT PORTIONS OF DISTAL
TUBULE (THICK ASCENDING)
3- THIN SEGMENTS OF LOOP OF HENLE
(DESCENDING & ASCENDING)
4- COLLECTING DUCTS

INNER ZONE
1- THIN SEGMENTS OF LOOP OF HENLE
(DESCENDING & ASCENDING)
2- COLLECTING DUCTS
 URINARY SYSTEM

THE NEPHRON & COLLECTING DUCTS

HISTOLOGICAL
HISTOLOGICAL STRUCTURE
STRUCTURE AND
AND
FUNCTION
FUNCTION
1)
1) THE
THE NEPHRON
NEPHRON
- distributed throughout cortex and
various zones of medulla

a) RENAL CORPUSCLE
BOWMANS CAPSULE + GLOMERULUS

b) PROXIMAL TUBULE
CONVOLUTED AND STRAIGHT PORTIONS
c) HENLES LOOP
THICK AND THIN PORTIONS

d) DISTAL TUBULE
STRAIGHT AND CONVOLUTED PORTIONS

2)
2) COLLECTING
COLLECTING
DUCTS
DUCTS
 URINARY SYSTEM

RENAL CORPUSCLE
BOWMANS CAPSULE +
GLOMERULUS
FILTRATION APPARATUS OF KIDNEY

1. BOWMANS CAPSULE:
- the beginning of the nephron that
consists of a blind sac lined with simple
squamous epithelium that is continuous
with the PCT
- parietal layer & visceral layer
(specialized)
2. GLOMERULUS:
- specialized tuft of capillaries which
housed in the capsular space (10-20
capillary loops)
- blood flowing through glomerulus
capillaries undergoes a filtration process
to produce the initial urine filtrate
 URINARY SYSTEM

RENAL CORPUSCLE
BOWMANS CAPSULE +
GLOMERULUS
FILTRATION APPARATUS OF KIDNEY

VASCULAR POLE
URINARY
POLE
GLOMERULUS (FILTRATION
MEMBRANE):
1- fenestrated capillaries;
discontinuous endothelium; fenestrae
have a diameter of 500-1000 and lack
a diaphragm
2- continuous basal lamina

3- podocytes of visceral layer; processes

contact basal lamina and are separated
by slits measuring approximately 250
 URINARY SYSTEM

CORTEX:
CORTEX:

CORTICAL
CORTICAL LABYRINTH
LABYRINTH
1- RENAL CORPUSCLES
2- PROXIMAL CONVOLUTED TUBULES
- longer than DCT and thus more numerous
- stain slightly darker and have a larger diameter than DCT
- cells are larger and have an irregular luminal surface due to the
presence of a brush border and glycocalyx
3- DISTAL CONVOLUTED TUBULES

- shorter than PCT and thus less prevalent

- stain slightly lighter and have a smaller diameter than PCT
- cells are smaller and cuboidal, thus more nuclei are apparent in a cross section of a
DCT
- luminal surface is more uniform since it lacks a brush border
KIDNEY H&E CORTEX:
CORTEX:

Bowmans
Bowmans
capsule
capsule CORTICAL
CORTICAL LABYRINTH
LABYRINTH

1- RENAL CORPUSCLES
glomerulus
glomerulus
2- PROXIMAL CONVOLUTED
TUBULES
3- DISTAL CONVOLUTED TUBULES

RENAL
RENAL CORPUSCLE
CORPUSCLE

DCT
DCT

PCT
PCT
 URINARY SYSTEM

CORTEX:
CORTEX:

CORTICAL
CORTICAL LABYRINTH
LABYRINTH
1- RENAL CORPUSCLES
2- PROXIMAL CONVOLUTED TUBULES
- 80-90% of H22O and NaCl in
glomerular filtrate is reabsorbed in
addition to most organic materials:
(glucose,
proteins, amino acids, etc.)
3- DISTAL CONVOLUTED TUBULES

- further resorption of H22O in presence of

ADH
- sodium resorption in response to aldosterone
- calcium resorption in response to PTH
KIDNEY SILVER METHENAMINE

DCT
DCT

VASCULAR
VASCULAR
POLE
POLE PCT
PCT

glomerulus
glomerulus

URINARY
URINARY
POLE
POLE
 URINARY SYSTEM

KIDNEY H&E
CORTEX:

MEDULLARY RAY

1- STRAIGHT PORTIONS OF PROXIMAL

TUBULE (THICK DESCENDING)
2- STRAIGHT PORTIONS OF DISTAL
TUBULE (THICK ASCENDING) TD
C
3- COLLECTING DUCTS
D
- cells are cuboidal in cortex and
become progressively more columnar C
in the medulla and papilla D

- cells stain very lightly with well-

defined boundaries
- transport urine from nephron to
excretory ducts and aids in further
H22O resorption in the presence of
ADH
 URINARY SYSTEM

THE NEPHRON & COLLECTING DUCTS

MEDULLA:

OUTER ZONE
1- STRAIGHT PORTIONS OF PROXIMAL
TUBULE (THICK DESCENDING)
2- STRAIGHT PORTIONS OF DISTAL
TUBULE (THICK ASCENDING)
3- THIN SEGMENTS OF LOOP OF HENLE
(DESCENDING & ASCENDING)
4- COLLECTING DUCTS

INNER ZONE
1- THIN SEGMENTS OF LOOP OF HENLE
(DESCENDING & ASCENDING)
2- COLLECTING DUCTS
KIDNEY H&E
OUTER MEDULLA

CD
TA

C
D
TD

TL
 URINARY SYSTEM

JUXTAGLOMERULAR APPARATUS
MACULA DENSA + JUXTAGLOMERULAR (JG)
CELLS
REGULATE BLOOD FLOW THROUGH
GLOMERULUS

MACULA DENSA
- cells located in the DCT in close contact
with the glomerulus and the afferent and
efferent arterioles

JG CELLS
- specialized smooth muscle cells in the
wall of the afferent arteriole which
contain and secrete RENIN to regulate
blood flow through the glomerulus
ALDOSTERONE
ANGIOTENSINGO RENIN SECRETION
GEN (PLASMA ANGIOTENSIN I ANGIOTENSIN II
PROTEIN) VASOCONSTR
 URINARY SYSTEM

JUXTAGLOMERULAR APPARATUS
MACULA DENSA + JUXTAGLOMERULAR (JG)
CELLS
REGULATE BLOOD FLOW THROUGH
GLOMERULUS
BARORECEPTOR
THEORY
- assumes JG cells function as stretch
receptors (high blood pressure would inhibit
release of renin)
MACULA DENSA THEORY
- assumes the secretion of renin is regulated by
the composition of the fluid in the DCT /
afferent arteriole (low sodium
would increase the release of renin)
ALDOSTERONE
ANGIOTENSINGO RENIN SECRETION
GEN (PLASMA ANGIOTENSIN I ANGIOTENSIN II
PROTEIN) VASOCONSTR
 URINARY SYSTEM

JUXTAGLOMERULAR APPARATUS
MACULA DENSA + JUXTAGLOMERULAR (JG)
CELLS

REGULATE BLOOD FLOW THROUGH

GLOMERULUS

ALDOSTERONE
ANGIOTENSINGO RENIN SECRETION
GEN (PLASMA ANGIOTENSIN I ANGIOTENSIN II
PROTEIN) VASOCONSTR
KIDNEY H&E

MACULA
MACULA
DENSA
DENSA
 URINARY SYSTEM

KIDNEY

CALYCES/
URETER

BLADDER

URETHRA

1- mucosa lined with transitional

epithelium
2- usually lacking submucosa
3- muscularis best developed in ureters (2-3
layers) and bladder (3 layers)
URETER H&E

1: IL 2: OC

MUCOSA LAMINA MUSCULARIS ADV

PROPRIA
 URINARY SYSTEM

URETER
 URINARY SYSTEM

URETER
 URINARY SYSTEM

BLADDER
 URINARY SYSTEM

BLADDER

transitional epithelium
Alhamdulilah
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