Module: Urological System

Key Terms

 Acute cystitis
 Acute glomerulonephritis
 Calculi
 Diuretics
 Enuresis
 Loop diuretics
 Oligura
 Prostate enlargement
 Thiazide diuretics
 Urinary incontinence
 Urinary tract infection

Summary

Urinary tract obstruction

 Obstruction can occur anywhere in the urinary tract and it may be anatomic or
functional, including renal stones (calculi), an enlarged prostate gland or urethral
strictures.
 The most serious complications are hydronephrosis, hydroureter, and infection
caused by the accumulation of urine behind the obstruction.
 Persistent obstruction of the bladder outlet leads to residual urine volumes, low
bladder wall compliance and risk for vesicoureteral reflux and infection.
 The aetiology of renal stones (calculi) includes supersaturation of the urine with
precipitation of stone-forming substances like salt crystals and proteins, changes in
urine pH or urinary tract infection.
 The pathophysiology of renal calculi formation involves the crystallization of small
crystals into large stones in the presence of super saturated urine. Typically the
person has insufficient oral fluid intake over time. Altered urine pH can also
influence formation of stones. If the kidney stone creates a blockage anywhere along
the urinary tract this can create additional pathophysiology.

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  Blockage may occur in the ureter and cause reduced flow or backflow of urine into
the kidney. This can result in pain, kidney infections and other problems.
 Blockage may occur in the bladder urethral opening and reduce or stop the flow of
urine via the urethra. This can result in pain, urine accumulation and bladder
infections (cystitis).
 The aetiology of prostate enlargement includes prostatitis (inflammation or infection
of the prostate), benign prostatic hyperplasia or prostate neoplasia (cancer).
 The pathophysiology of prostate enlargement involves partial obstruction of the
bladder outlet or urethra initially. This causes an increase in the force of detrusor
contraction. If the blockage persists, afferent nerves within the bladder wall are
adversely affected, leading to urinary urgency and, in some cases, overactive
detrusor contractions. When obstruction persists, there is an increased deposition of
collagen within the smooth muscle bundles of the detrusor muscle, possibly in an
attempt to increase the force of its contraction strength. Ultimately, the bladder wall
loses its ability to stretch and accommodate urine and the detrusor loses its ability to
contract efficiently.

Urinary tract infection

 Aetiology: urinary tract infection (UTI) is commonly caused by the retrograde

movement of bacteria into the urethra and bladder. Typically faecal bacteria.
 The most common infecting microorganisms are Escherichia coli.
 UTI is uncomplicated when the urinary system is normal or complicated when there
is an abnormality.
 Pathophysiology of UTI includes inflammation and infection of any section of the
urinary tract. Typically this involves the urethra. Inflammation and infection can
cause redness, swelling, oedema and pain along the urethra.
 Aetiology: cystitis is an inflammation of the bladder commonly caused by bacteria
and may be acute or chronic.
 Pathophysiology of acute cystitis: infection initiates an inflammatory response and
the symptoms of cystitis. The inflammatory oedema in the bladder wall stimulates
discharge of stretch receptors initiating symptoms of bladder fullness with small
volumes of urine and producing the urgency and frequency of urination associated
with cystitis.
 Inflammation and infection can cause redness, swelling, oedema of the mucosal
lining of the bladder.
 Typical signs and symptoms include frequency of urination, burning/pain sensation
on urination, feeling of fullness or dull pain in bladder, offensive urine, cloudy urine
and abnormalities in routine ward level urinalysis. E.g. positive for leucocytes or
blood.
 Dysuria is defined as difficulty in urination and is commonly associated with urinary
tract infection and cystitis. The patient may describe altered sensation or pain on
micturition.

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Glomerular disorders

 Glomerular disorders are a group of related diseases of the glomerulus that can be
caused by immune responses, toxins or drugs, vascular disorders and other systemic
diseases.
 Aetiology of glomerulonephritis: acute glomerulonephritis commonly results from
inflammatory damage to the glomerulus as a consequence of immune reactions after
a streptococcal infection.
 Chronic glomerulonephritis is related to a variety of diseases that cause deterioration
of the glomerulus and a progressive loss of renal function.
 Pathophysiology of glomerulonephritis: immune mechanisms in glomerulonephritis
are the deposition of antigen-antibody complexes, often with complement
components, and the formation of antibodies specific for the glomerular basement
membrane.
 Glomerulonephritis in children may follow infections, especially those of the upper
respiratory tract caused by strains of group A β-haemolytic streptococcus. Increases
in glomerular capillary permeability lead to haematuria and proteinuria.

Low urine output

 Oliguria is defined as low urine output and less than 30mls/hr for adult males and
females.
 Oliguria can be caused by low blood pressure, dehydration, blood volume loss and
other pathophysiology.

Structural abnormalities

 Congenital renal disorders affect 10–15% of the population. These disorders range in
severity from minor, easily correctable anomalies to those incompatible with life.
 Enuresis refers to the involuntary passage of urine. Enuresis may occur during the
day (diurnally) or during the night (nocturnally). The disorder tends to occur during
non-REM sleep and can have a variety of organic and psychological causes.
 A combination of factors is likely to be responsible for enuresis. Organic causes
account for 2–10% of cases and include urinary tract infection; neurological
disturbances; congenital defects of the meatus, urethra and bladder neck; and
allergies. Disorders that increase the normal output of urine, such as diabetes
mellitus and diabetes insipidus, or disorders that impair the concentrating ability of
the kidneys, such as chronic kidney disease, must be considered in the evaluation of
enuresis.
 Genetic factors as a cause of enuresis are likely and the condition shows a familial
tendency. Bed-wetting occurs with high frequency among parents, siblings and other
near relatives of symptomatic children.

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 Pharmacotherapy

 Diuretics are important drugs used for the treatment of hypertension and for other
conditions in which fluid volume excess is a problem, such as congestive heart
failure, cirrhosis and nephrotic syndrome.
 Diuretics modify renal function and induce diuresis (increased rate of urine flow) and
enhanced excretion of sodium chloride.
 There are three major classes of diuretics: the loop diuretics (e.g. frusemide), the
thiazide diuretics (e.g. hydrochlorothiazide) and the potassium-sparing diuretics (e.g.
amiloride).
 The loop diuretics are potent inhibitors of the reabsorption of sodium and chloride in
the thick ascending limb of the loop of Henle.
 A wide variety of drug interactions occur with the loop diuretics.
 A common side effect of loop diuretics is potassium loss and serum potassium levels
need to be monitored.
 Thiazide diuretics inhibit absorption of sodium and chloride in the proximal (diluting)
segment of the distal convoluted tubule and are considered less potent than the loop
diuretics.
 Thiazide diuretics primarily promote the renal excretion of water, sodium, chloride,
potassium and magnesium, whereas excretion of uric acid and calcium is decreased.
 Hyperglycaemia, or impaired glucose tolerance, has been reported with thiazide
diuretics but rarely with loop diuretics.
 The potassium-sparing diuretics are amiloride and spironolactone. Both are
considered to have limited diuretic efficacy and are primarily considered useful when
combined with potassium-depleting diuretics such as the thiazides.
 The commonest adverse reactions are electrolyte disturbances ([Link]
and hypomagnesaemia).
 Urinary antispasmodic drugs exert a direct effect on bladder smooth muscle and
inhibit the muscarinic action of acetylcholine on bladder smooth muscle. E.g.
Oxybutynin.
 Urinary antispasmodic drugs are used for the treatment of detrusor over activity
where conservative measures have failed.

Glossary

 Acute cystitis: is an inflammation of the bladder and is the most common site of
UTI
 Acute glomerulonephritis: is an inflammation of the glomerulus. The inflammation
can be caused by numerous factors, including immunological abnormalities,
ischaemia, drugs, toxins, vascular disorders and systemic diseases such as diabetes.
 Calculi: or urinary stones are masses of crystals, protein or other substances that
are common causes of urinary tract obstruction.
 Diuretics: is any agent that enhances the flow of urine. Clinically, diuretics interfere
with renal sodium reabsorption and reduce extracellular fluid volume.
 Enuresis: refers to the involuntary passage of urine by a child who is beyond the
age when voluntary bladder control should have been acquired. In 80% of children
enuresis occurs at night only and is called nocturnal enuresis.
 Loop diuretics: inhibitors of loop sodium or chloride transport, which decrease
reabsorption and therefore increases urine volume.
 Oliguria: low urine output.

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  Prostate enlargement: is caused by acute inflammation, benign prostatic
hyperplasia or prostate cancer
 Thiazide diuretics: blocks sodium and chloride reabsorption; mildly suppresses
carbonic anhydrase.
 Urinary incontinence: involuntary loss of urine. Can be urge, stress, overflow,
mixed or functional incontinence.
 Urinary tract infection (UTI): is an inflammation of the urinary epithelium
usually caused by bacteria from gastrointestinal flora. A UTI can occur anywhere
along the urinary tract including the urethra, prostate, bladder, ureter or kidney.

Key Drugs: Learning activity > list some common side effects in the tables
below. Go to MIMS online (right click hyperlink and open)

Pharmaceutical Frusemide Hydrochlorothiazide Oxybutynin

name
Brand name Lasix Dithiazide Ditropan
Indications for use Treatment of Treatment of Treatment of
oedema oedema and HTN detrusor over
activity where
conservative
measures have
failed
Drug class Diuretic (Loop) Diuretic (Thiazide) Bladder function
disorders
Pharmacological Inhibits sodium Interferes with the Antispasmodic,
action/mechanism and chloride distal renal tubular anticholinergic.
of action absorption in the mechanism of exerts a direct
ascending limb of electrolyte antispasmodic
the loop of Henle reabsorption. effect on smooth
and in both the muscle and
proximal and the inhibits the
distal tubules muscarinic action
of acetylcholine
on smooth muscle
Physiological Increases the Increases the Ditropan relaxes
effect production of excretion of bladder smooth
urine sodium and muscle
chloride in
approximately
equivalent
amounts
Route of Oral and IV Oral Oral
administration
Common side Hypokalemia, uric Hypokalemia Palpitations,
effects acid retention tachycardia,
constipation,
dizziness

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 Pharmaceutical Amoxicillin- Cephalexin
name clavulanic acid
Brand name Augmentin Duo Keflex
Indications for use Urinary tract Genitourinary tract
infections infections,
(uncomplicated including acute
and complicated). prostatitis. Caused
by E. coli, P.
mirabilis and
Klebsiella sp
Drug class Antibiotic Cephalosporin
Antibiotic
Pharmacological bactericidal effect bactericidal
action/mechanism on sensitive because they
of action organisms during inhibit cell wall
the stage of active synthesis
multiplication
Physiological Targets active against
effect susceptible beta-haemolytic
bacteria Streptococci,
Staphylococci,
Streptococcus
(Diplococcus)
pneumoniae,
Escherichia coli,
Proteus mirabilis,
Klebsiella sp.
Route of Oral Oral
administration
Common side Diarrhoea, Nausea
effects nausea, headache,

References:

Bryant, B., Knights, K., Rowland, A., & Darroch, S. (2019). Pharmacology for Health
Professionals. (5thed.). Elsevier Australia

Craft, J., Gordon, C., Huether, S. E., McCance, K. L., Brashers, V., & Rote, N. (2019)
Understanding pathophysiology-ANZ adaptation. (3rd ed.). Elsevier Australia.

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LeMone, P., Bauldoff, G., Gubrud, P., Ann Carno, M., Levett-Jones, T., & Dwyer, T. (2020).
LeMone and Burke's medical-surgical nursing: Critical thinking for person-centred
care (4 ed.). Pearson Australia.
Reproduced with the permission of Elsevier Australia.

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