Urinary disorders

Overview

The urinary tract is your body's pee drainage system. Urine is made up of waste and water. Your kidneys, ureters, and bladder are all part of your urinary system. To urinate correctly, the urinary system must function in the correct order.

Urologic illnesses and ailments include, among other things, urinary tract infections, kidney stones, bladder control issues, and prostate issues. Some urologic problems are temporary, while others are chronic.

 

How Does the Urinary Tract Work?

The urinary tract's function is to produce and store pee. Urine is one of your body's waste products. Urine is produced in the kidneys and goes to the bladder via the ureters. Urine is stored in the bladder until it is released by peeing via the urethra, a tube that links the bladder to the skin. The urethra opens at the end of the penis in men and above the vaginal opening in women.

The kidneys are a pair of fist-sized organs in the back that filter liquid waste from the blood and excrete it as urine. The kidneys regulate the amounts of various substances in the body (such as sodium, potassium, calcium, phosphorus, and others) as well as the acidity of the blood. The kidneys also produce some hormones. These hormones aid in blood pressure management, red blood cell creation, and bone formation.

Normal urine contains no microorganisms, and the one-way flow aids in infection prevention. Bacteria can still enter the urine through the urethra and migrate up into the bladder.

 

What are Urinary disorders?

The kidneys, ureters, bladder, and urethra make up the urinary tract. Your kidneys filter your blood and produce urine, which goes down the ureters to the bladder and is stored there. When the moment comes, your bladder muscles contract and pee escapes your body through your urethra. Urinary disorders are any diseases, disorders, or problems that affect or are caused by your kidneys, ureters, bladder, or urethra.

Urinary tract malignancies, incontinence (inability to control urine flow), interstitial cystitis, kidney stones, renal failure, and urinary tract infections are all examples of urinary diseases. Abdominal, pelvic, or lower back pain or discomfort; blood in the urine; changes in the urine; difficulties generating pee; fever and chills; frequent urination; urine leakage; and an urgent need to urinate are all common signs of urinary diseases. Some urinary problems, such as infections, may manifest immediately, whilst others, such as malignancy, manifest later. 

 

Kidney Failure

Diabetic nephropathy and PKD can both develop to kidney failure (also known as end-stage kidney disease), in which the kidneys are no longer able to filter metabolic wastes from the blood properly. Another major cause of kidney failure is uncontrolled high blood pressure for an extended period of time.

Nausea, more or less frequent urination, blood in the urine, muscular cramps, anemia, swelling of the extremities, and shortness of breath owing to fluid accumulation in the lungs are all symptoms of kidney failure. If kidney function falls below the level required to preserve life, the only therapeutic options are kidney transplantation or some form of artificial blood filtration, such as hemodialysis.

 

Hemodialysis

is a medical technique that filters blood outside through a machine. Waste materials such as urea and excess water are removed from the patient's blood during dialysis before the blood is returned to the patient. Hemodialysis is commonly performed as an outpatient procedure at a hospital or specialized dialysis facility. It is done in the patient's home less regularly. The blood is filtered for 3 to 4 hours three times a week, depending on the patient's size and other parameters. Hemodialysis is one of the most common treatments performed in US hospitals due to the frequency with which it is required.

 

Urinary Tract Infections

A UTI occurs when bacteria enter your urine and travels to your bladder. Each year, UTIs result in about 8.1 million visits to health care professionals. Approximately 60% of women and 12% of men will get at least one UTI in their lives.

Bacterial infections of the bladder and surrounding tissues are classified as uncomplicated urinary tract infections, sometimes known as cystitis or lower urinary tract infections. Uncomplicated urinary tract infections occur in female individuals who do not have any anatomical abnormalities or comorbidities, such as diabetes, advanced age, pregnancy, or immunocompromised state. In individuals with anatomical defects or comorbidities, complicated urinary tract infections arise.

 

Urinary Tract Infections Causes

Pathogenic bacteria enter the urinary tract through the perineum and rectum, predisposing women to urinary tract infections. Women's urethras are also shorter than men's, which adds to their higher vulnerability to UTIs. Few simple UTIs are caused by blood-borne bacteria. By far the most frequent bacterium in simple UTIs is Escherichia coli, followed by Klebsiella.

The use of a urinary catheter is a major risk factor for UTIs. Urethral manipulation is also a risk factor. Sexual activity, as well as the use of spermicides and diaphragms, are risk factors for UTIs. Frequent pelvic examinations and the presence of urinary system anatomical anomalies might also predispose one to a UTI.

UTIs are quite prevalent following a kidney donation. The use of immunosuppressive medications and vesicoureteral reflux are the two causes. Antibiotic usage and diabetes mellitus are two further risk factors.

 

Symptoms of UTIs 

Symptoms of uncomplicated UTIs are

• Pain on urination (dysuria),
• Frequent urination (frequency), 
• Inability to start the urine stream (hesitancy),
• Sudden onset of the need to urinate (urgency), and 
• Blood in the urine (hematuria). 

Patients with simple UTIs typically do not experience fever, chills, nausea, vomiting, or back pain, all of which are symptoms of kidney involvement or upper tract disease/pyelonephritis. Clinical signs might overlap, making it difficult to identify an uncomplicated UTI from a kidney infection in some circumstances. When in doubt, treat for upper urinary tract illness aggressively.

The diagnosis of a urinary tract infection is based on a combination of indications, symptoms, and urinalysis results confirmed by urine cultures. Be careful of medical literature based on urine findings from asymptomatic individuals. Patients with spinal cord injuries or those who are paralyzed may exhibit the following symptoms:

• Autonomic instability (autonomic dysreflexia) which presents with severe hypertension and headache
• Unexplained fatigue
• Fever
• Cloudly, foul-smelling urine (although odor and cloudy appearance are insufficient for a diagnosis without other symptoms)
• Chills

Patients with permanent indwelling Foley catheters or suprapubic tubes may experience ambiguous symptoms such as an increased WBC count and a low-grade fever. The majority of catheterized individuals will have pyuria and high bacterial colony counts in their urine. Unless there are systemic indications or symptoms of discomfort, hematuria, or other aberrant bladder activity, this is not a real urinary tract infection 

 

Diagnosis of UTIs 

The workup requires a nice, clean urine (UA) specimen. In non-obese women, a clean catch specimen is recommended. Most obese women cannot provide a clean specimen, and epithelial cells in the UA indicate that the urine sample was exposed to the vaginal surface and did not exit the urethra directly. Obtain a sample that is free of epithelial cells. This may necessitate a rapid catheterization. 

In uninfected women, in-and-out catheterization of the bladder causes UTI around 1% of the time. Men should begin the urine stream to clear the urethra before collecting a midstream sample. Urine should be delivered to the lab promptly or frozen since bacteria multiply fast at room temperature, creating an overestimation of the severity of the infection.

A UTI should not be diagnosed only based on a visual examination of the urine. Cloudy urine can be aseptic; the cloudiness may be caused by protein or calcium phosphate detritus in the sample, rather than an infection. Urine that is crystal clear can be contaminated. Dipstick testing is performed on all urines, which can be done at the bedside. pH, nitrites, leukocyte esterase, and blood are all useful dipstick readings. Remember that in patients with UTI symptoms, a negative dipstick does not rule out the possibility of a UTI, but positive results might imply and aid in the diagnosis. On microscopic urinalysis, look for the presence of bacteria and/or white blood cells (WBC).

The pH of normal urine is somewhat acidic, with typical readings ranging from 5.5 to 7.5, while the normal range is 4.5 to 8.0. A urea-splitting bacterium, such as Proteus, Klebsiella, or Ureaplasma urealyticum, is typically found in urine with a pH of 8.5 or 9.0. An alkaline urine pH might indicate the presence of struvite kidney stones, often known as "infection stones."

Because bacteria must be present in the urine to convert nitrates to nitrites, the nitrate test is the most reliable dipstick test; this takes 6 hours, which is why urologists frequently request first-morning pee for testing, particularly in men. This test has a sensitivity of more than 90%. In individuals with symptoms, this test offers a direct confirmation of bacteria in the urine, which is a UTI by definition. Several bacteria do not convert nitrates to nitrites, although they are commonly seen in complex UTIs caused by Enterococcus, Pseudomonas, and Acinetobacter.

The presence of WBCs in the urine is detected by leukocyte esterase (LE). The LE is apparently released by the WBCs in reaction to germs in the urine. As a result, the dipstick LE is a secondary test with a 55% specificity for UTIs. Although LE is effective in detecting WBCs in urine, WBCs can also be found in the bladder for other causes, such as inflammatory illnesses.

Hematuria can be beneficial because bacterial infections of the bladder's transitional cell lining can induce bleeding. This distinguishes UTI from vaginitis and urethritis, both of which do not result in blood in the urine.

Many laboratories will automatically do a microscopic examination of the urine for microorganisms, WBCs, and RBCs if nitrites or leukocyte esterase are present. Because there should be no visible bacteria in uninfected pee under high field microscopy, any bacteria on Gram-stained urine is substantially linked with bacteriuria and UTIs. In symptomatic individuals, a good urine sample with more than 10 WBC/HPF is atypical and strongly suggests a UTI.

Urine cultures are not normally required in simple UTIs, however they are suggested owing to rising drug resistance and to distinguish recurring from relapsing infections. Urine should be cultured in all men, as well as all diabetic patients who are immunocompromised and pregnant women. The gold standard for infectious pee is higher than 10 colony forming units (CFU) per milliliter, according to traditional urine culture instruction.

A urinary tract infection is diagnosed in a patient who has symptoms and has more than 10 CFU/mL. Except for recurring UTIs, urine cultures seldom assist in the emergency room, although they can make following therapy simpler if patients do not react to the first antibiotic administered.

Urine collection is crucial. If the patient uses the proper procedure, midstream voided specimens are fairly precise. Contamination is indicated by lactobacilli and squamous cells, and a catheterized specimen may be required. Suprapubic aspiration may be required in young infants and people with spinal cord injuries to collect a good urine specimen.

 

Management of UTIs

Historically, the therapy ranged from 3 days to 6 weeks. "Mini-dose therapy," which consists of three days of treatment, has an outstanding cure rate. E. coli resistance to popular antimicrobials varies across the country, and if the resistance rate exceeds 50%, another antibiotic should be used.

Trimethoprim/sulfamethoxazole for three days is an effective mini-dose treatment, however resistance is common in many places. It should not be utilized if local resistance is more than 20%. Mini-dose treatment is best served by first-generation cephalosporins. Nitrofurantoin is an effective treatment for simple UTIs, however it is bacteriostatic rather than bacteriocidal and must be taken for 5 to 7 days.

Fluoroquinolones have significant resistance yet are popular among urologists because to their high tissue penetration levels, particularly in the prostate. As a result, fluoroquinolones are not recommended unless the illness is severe or involves the prostate. The FDA's recent warnings regarding fluoroquinolone adverse effects should be taken seriously.

The FDA has authorized fosfomycin as a single-dose treatment for uncomplicated E coli UTIs. Adjunctive phenazopyridine medication for a few days may assist give additional symptom alleviation.

Most UTIs will cure spontaneously in around 20% of women even without treatment, especially if greater hydration is employed. A healthy nonpregnant female has an extremely low chance of developing acute pyelonephritis. Asymptomatic bacteriuria is fairly frequent and does not require therapy, except in pregnant women, immunocompromised individuals, those who have had a transplant, or those who have just undergone a urological surgical surgery.

 

Kidney Stones

Nephrolithiasis, or kidney stones, is the most frequent urinary system ailment, affecting around 12% of the global population and impacting 600,000 Americans each year. It is caused by a crystalline concretion that travels from the kidney via the genitourinary system. Chronic kidney disease, end-stage renal failure, cardiovascular disease, diabetes, and hypertension are all associated with kidney stones.

The majority of nephrolithiasis patients (80%) develop calcium stones, the majority of which are formed mostly of calcium oxalate or calcium phosphate. Uric acid, struvite (magnesium ammonium phosphate), and cystine stones are the other major forms. It should be noted that a single patient may have a stone that comprises more than one type of crystal.

 

Risk Factors - Influenced by certain diseases, habits, composition of urine. 

• Prior kidney stone history raises the chance of kidney stones by 15% during the first year and by 50% over the next 10 years.
• A family history of kidney stones more than doubles the risk.
• Increased enteric oxalate absorption, usually owing to malabsorption, promotes the development of calcium oxalate crystals.
• Urine tract infections cause urinary pH to change in the presence of urease-producing bacteria, resulting in the formation of struvite crystals.
• Low fluid intake 
• History of diabetes, obesity, gout, and hypertension 
• Acidic urine (pH< 5.5), which promotes uric acid formation in the setting of chronic diarrhea and gout

 

Kidney Stones Symptoms

When nephrolithiasis is localized to the kidney, patients are asymptomatic. Once the stone begins to descend the ureters from the kidneys, the usual symptoms associated with kidney stones, including severe pain radiating to the groin, appear. Pain is frequently characterized as dull, colicky, acute, and intense.

The discomfort is typically linked with nausea and vomiting owing to the degree of agony. These symptoms are caused by the smooth muscle of the genitourinary tract peristalsis against the stone. Hematuria is also typically observed as a result of the stone's harm to the genitourinary tract; this is confirmed by urinalysis. 

If the stone becomes contaminated, patients may have fever, chills, or other symptoms of a worsening systemic illness (i.e., shock). Costovertebral soreness may be discovered during the physical examination. Obstruction can develop, resulting in pyelonephritis with concomitant hydronephrosis. This can be a serious and life-threatening scenario that necessitates immediate decompression surgery.

 

Kidney Stones Diagnosis

A simple or full metabolic panel, as well as laboratory tests to determine renal function, may be employed. A urinalysis, urine electrolytes, and urine pH can also assist narrow down the sort of stone.

A KUB (kidney-ureter-bladder) X-ray is also a possibility, however it is difficult to identify uric acid stones with this imaging. A CT scan of the abdomen and pelvis without contrast is also possible and has a better sensitivity. When a kidney stone is suspected, contrast medium is normally avoided because augmentation of the arteries and ureters might hide stone results.

 

Management of Kidney Stones

Kidney stones are excruciatingly painful. Pain management is critical with NSAIDs because they reduce smooth muscle stimulation and ureteral spasm. It is also critical to boost hydration consumption. Tamsulosin may also help with stone passing by reducing smooth muscle activation. It is often beneficial in distal ureter diameters ranging from 5 to 10 mm.

Stones larger than 6mm will almost certainly necessitate intervention, such as percutaneous nephrolithotomy, rigid and flexible ureteroscopy, and shock wave lithotripsy.

 

Bladder control problems (Urinary incontinence)

The involuntary flow of urine is known as urinary incontinence. This medical ailment is most frequent in the elderly, particularly in nursing facilities, although it can also afflict young adult males and girls. Urinary incontinence can have a negative influence on both patient health and quality of life. The prevalence may be underestimated because some people may not disclose their health care providers that they have urine incontinence for a variety of reasons.

The 5 types of urinary incontinence and their causes are listed below: 

1. The involuntary leaking of urine that happens with increases in intraabdominal pressure (e.g., with exertion, effort, sneezing, or coughing) owing to urethral sphincter and/or pelvic floor dysfunction is known as stress Urinary incontinence. This sort of incontinence can occur in young women who participate in athletics. Furthermore, pregnant women and women who have given birth may be prone to stress urine incontinence.
2. Urge urinary incontinence is the involuntary leaking of urine caused by detrusor overactivity that is preceded or accompanied by a sensation of urinary urgency (but can also be asymptomatic). Contraction symptoms might be caused by bladder irritation or a lack of neurologic control.
3. The involuntary leaking of pee induced by a mixture of stress and urge urinary incontinence, as described above, is known as mixed urinary incontinence.
4. Overflow urinary incontinence is the involuntary leaking of urine from an overdistended bladder caused by poor detrusor contractility and/or a blocked bladder outlet. Detrusor function can be impaired by neurological illnesses such as spinal cord injury, multiple sclerosis, and diabetes. External compression by abdominal or pelvic masses, as well as pelvic organ prolapse, can induce bladder outlet blockage. Benign prostatic hyperplasia is a prevalent cause in males.
5. The involuntary flow of urine caused by environmental or physical impediments to toileting is known as functional urinary incontinence. This sort of incontinence is also known as toileting problem.

 

Management of urinary incontinence

The kind of urine incontinence determines treatment and management. There are conservative, pharmaceutical, and surgical treatment options. Treatment and care should begin with the least intrusive treatments and progress as needed:

• Stress urinary incontinence

• Conservative management - Behavioral treatment (managing fluid intake, encouraged urination, constipation management, and so on), electrical stimulation, and mechanical devices are also options (cones, pessaries, urethral plugs), Weight reduction, pelvic floor muscle strengthening (Kegel and floor muscle workouts),
• Pharmacologic management - alpha-adrenergic agonists (e.g., phenylpropolamine), duloxetine (not FDA approved)
• Surgical management - intravesical balloons, trans- or periurethral injections of bulking agents, sling procedures, urethropexy

• Urge urinary incontinence

• Conservative management - similar to the treatment for stress urinary incontinence with the exception of mechanical devices
• Pharmacologic management - antimuscarinics (e.g., darifenacin, solifenacin, oxybutynin, tolterodine, fesoterodine, trospium), topical vaginal estrogen (not FDA approved), mirabegron
• Surgical management - neuromodulation, onabotulinumtoxinA injection

• Mixed urinary incontinence

• Treatment and management as above, focusing on dominant symptoms

• Overflow urinary incontinence

• Conservative management - clean intermittent catheterization, indwelling urethral catheter, relief of obstruction
• Pharmacologic management - alpha-adrenergic antagonists (e.g. terazosin, tamsulosin) 
• Surgical management - suprapubic catheter

• Functional urinary incontinence

• Underlying causes should be addressed or alleviated if possible

Medications should be balanced, and coffee and alcohol should be avoided if they are leading to incontinence. Urinary incontinence can be challenging to control in end-of-life care and should be treated on a case-by-case basis. In rare cases, an indwelling catheter or condom catheter may be required to provide maximum comfort to the patient in their latter stages of life.

 

Polycystic Kidney Disease

Polycystic kidney disease (PKD) is a hereditary illness characterized by the formation and growth of many abnormal cysts in the kidneys. Cysts can arise at any stage of life in those who inherit PKD, from infancy to maturity. Both kidneys are usually impacted. High blood pressure, headaches, stomach discomfort, blood in the urine, and frequent urination are all symptoms of the disease.

PKD is classified into two categories. An autosomal dominant allele causes the more frequent kind, whereas an autosomal recessive allele causes the less common type. With over 500,000 persons affected by both forms, PKD is one of the most common genetic disorders in the United States. There is little or no variation in the prevalence of PKD among genders or ethnic groups. Other than a kidney transplant, there is no known cure for this illness.

 

What are the potential complications of urinary disorders?

Complications from untreated urinary diseases can be severe, even fatal in certain situations. You can reduce your risk of major consequences by adhering to the treatment plan that you and your health care practitioner have created particularly for you. Urinary problems can lead to the following complications:

• Anemia (low red blood cell count)
• Chronic pain
• Decreased bladder capacity
• Impotence
• Infertility
• Kidney disease or failure
• Pain during sexual intercourse
• Perinatal transmission of infection to newborn
• Proctitis
• Reiter syndrome (joint and ocular inflammation)
• Spread of a sexually transmitted infection to a partner
• Spread of cancer
• Spread of infection to nearby structures
• Urethral scarring and narrowing

 

Conclusion 

The urinary tract is your body's pee drainage system. Urine is made up of waste and water. Your kidneys, ureters, and bladder are all part of your urinary system. To urinate correctly, the urinary system must function in the correct order. Kidney stones, urine incontinence, polycystic kidney disease, and chronic kidney disease are all prevalent urinary system problems.