CHAPTER 29

DISORDERS OF THE LOWER URINARY TRACT

LOWER URINARY TRACT• Role is to transport urine formed by the

kidneys and allow removal from the body• Urine movement due to the effect of gravity

and facilitated by peristaltic movement of the ureters• Released through the urethra; requires

integrity of ureters and bladder, competent urethral sphincters, functioning nervous system

LOWER URINARY TRACT (CONT.)

Diagnostic Tests• Urinalysis: for diagnosis of infection• Ultrasonography: visualization of the

urinary system• Fluoroscopic voiding cystourethrography or

radionuclide voiding cystography: used to identify reflux or urethral abnormalities• Urodynamic testing: used for diagnosing

voiding dysfunctions

LOWER URINARY TRACT (CONT.)

Mechanics of Micturition• Bladder innervation is supplied by the

sympathetic nerves that exit the spinal cord at L1 and L2 and allow relaxation and filling• Stimulation of parasympathetic nerves from

S1-S4 results in bladder contraction and relaxation of the internal sphincter

LOWER URINARY TRACT (CONT.)

LOWER URINARY TRACT (CONT.)

Mechanics of Micturition • The somatic pudendal nerve innervates the

external bladder sphincter• The sympathetic system innervates blood

vessels via the hypogastric plexus• Micturition requires central, autonomic, and

peripheral nervous system functioning • It is a result of parasympathetic and

voluntary motor control

VOIDING DYSFUNCTION• May be secondary to:• Disorders of the lower urinary tract • Pathologies affecting the central, autonomic, and

peripheral nervous systems • A wide variety of factors affecting control of

micturition, including medication and access to toileting facilities

VOIDING DYSFUNCTION (CONT.)

Incontinence• Urge incontinence: may be idiopathic, due

to bladder infection, radiation therapy, tumors or stones, or CNS damage• Stress incontinence: due to weakening of

pelvic muscles or intrinsic urethral sphincter deficiency• Mixed incontinence: due to a combination

of stress and urge incontinence

VOIDING DYSFUNCTION (CONT.)• Neurogenic bladder: broad classification of

voiding dysfunction in which the specific cause is a pathology that produces a disruption of nervous communication governing micturition• Treatment options for voiding dysfunction

are behavioral, pharmaceutical, and surgical

VOIDING DYSFUNCTION (CONT.)Enuresis• Inappropriate wetting of clothing or bedding• Typically refers to incontinence in children,

particularly at night• Primary cause is maturational delay• Treatment: behavioral modification with or

without pharmaceutical intervention

CONGENITAL DISORDERSVesicoureteral Reflux• Reflux of urine from the bladder to the

ureter and renal pelvis• Due to incompetence of the valvular

mechanism at the ureter-bladder junction• Classified as primary or secondary etiology• Clinical manifestations may include

recurrent UTI, voiding dysfunction, renal insufficiency, or hypertension in children

CONGENITAL DISORDERS (CONT.)

• May resolve spontaneously or require surgery

VESICOURETERAL REFLUX

CONGENITAL DISORDERS• Include misimplantation of ureters,

strictures, an extra ureter, and ureterocele• Cause problems by obstructing normal

urine flow and predisposing to the retrograde flow of urine, urine stasis, and secondary infection• Usually treated with surgical interventions

CONGENITAL DISORDERS (CONT.)

Obstruction of the Ureteropelvic Junction• Blockage in urinary flow (partial or

complete) from the renal pelvis at the entry point of one or both ureters• Typically presents with hydronephrosis• May be managed conservatively or require

surgical intervention

CONGENITAL DISORDERS (CONT.)

Ureteral Ectopy• Ectopic ureter is a single ureter implanted

in an abnormal location or a duplicate ureter• Can increase risk of infection and reduction

in renal function• Typically found with other genitourinary

pathologies• Surgical interventions usually required

CONGENITAL DISORDERS (CONT.)

Ureterocele• Cystic dilation of the distal end of the ureter• Obstruction in the collecting system results

in ureteral and renal calyx dilation; reflux and infection• Clinical manifestations include

hydronephrosis, UTIs, voiding dysfunction, hematuria, urosepsis, or failure to thrive• Surgical intervention is necessary

NEOPLASMSBladder Cancer• Fourth most common cancer in males

eighth most common in females• Risk increases with age; predisposing

factors include smoking and exposure to carcinogenic chemicals• Most tumors originate from the transitional

epithelium (urothelium) lining the urinary tract

NEOPLASMS (CONT.)Bladder Cancer• Primarily manifested as hematuria;

frequency and urgency may be present• Cystoscopy used for diagnosis with tissue

biopsy and washings• Treatment protocols based on type, grade

and stage of bladder cancer; primary options are surgery, radiation therapy, chemotherapy, and immunotherapy

INFLAMMATION AND INFECTIONUrethritis• Inflammation of the urethra• Caused by infection from the bladder, STD-

related or from external factors• STDs confined to the urethra; infection of

other etiologies may ascend to the bladder before symptoms present• Treatment depends on the cause

INFLAMMATION AND INFECTION (CONT.)

Cystitis• Inflammation of the bladder lining• From infection, chemical irritants, stones,

trauma• Most cases have an infectious etiology and

result from infection originating in the urethra• Predisposing factors include female gender,

increased age, catheterization, DM, bladder dysfunction, poor hygiene, and urinary stasis

INFLAMMATION AND INFECTION (CONT.)

Cystitis• Manifestations: frequency, urgency,

dysuria, suprapubic pain, and cloudy urine• Symptoms in older adults may include

lethargy, anorexia, confusion, and anxiety• Most female patients treated based on

symptoms; males and children or more complicated cases may require urine culture and/or further assessment

CYSTITIS

INFLAMMATION AND INFECTIONInterstitial Cystitis/Painful BladderSyndrome• Chronic condition consisting of bladder

pain, urgency, frequency, and nocturia• Diagnosed based on symptoms• Treatment: identifying contributory lifestyle

factors, such as some foods and beverages; avoidance is primary intervention; medications may be helpful in relieving symptoms

OBSTRUCTIONLower Urinary Tract Urolithiasis• Most often caused by stones traveling to

the ureters, bladder, or urethra from the kidney• Manifestations include ureteral colic,

hematuria, tachycardia, tachypnea, diaphoresis, and N/V

OBSTRUCTION (CONT.)Lower Urinary Tract Urolithiasis• Bladder urolithiasis due to stones traveling

from ureters, but may form in bladder because of urinary stasis• Bladder stone symptoms include frequency

and dysuria; hematuria possible• If infection: antimicrobial therapy based on

culture and sensitivity• Stones that don’t pass spontaneously may

require endoscopic lithotripsy