V.

Anatomy and Physiology

The urinary system comprises the kidneys, ureters, bladder, and urethra. A thorough understanding of the urinary system is necessary for assessing individuals with acute or chronic urinary dysfunction and implementing appropriate nursing care.

ANATOMY OF THE UPPER AND LOWER URINARY TRACTS The urinary systemthe structures of which precisely environment maintain of the the internal chemical various

bodyperform

excretory, regulatory, and secretory functions.

Kidneys The kidneys are a pair of brownish-red structures located retroperitoneally (behind and outside the peritoneal cavity) on the posterior wall of the abdomen from the 12th thoracic vertebra to the 3rd lumbar vertebra in the adult (Fig. 43-1). An adult kidney weighs 120 to 170 g (about 4.5 oz) and is 12 cm (about 4.5 inches) long, 6 cm wide, and 2.5 cm thick. The kidneys are well protected by the ribs, muscles, Gerotas fascia, perirenal fat, and the renal capsule, which surround each kidney.

The kidney consists of two distinct regions, the renal parenchyma and the renal pelvis. The renal parenchyma is divided into the cortex and the medulla. The cortex contains the glomeruli, proximal and distal tubules, and cortical collecting ducts and their adjacent peritubular capillaries. The medulla resembles conical pyramids. The pyramids are situated with the base facing the concave surface of the kidney and the apex facing the hilum, or pelvis. Each kidney contains approximately 8 to 18 pyramids. The pyramids drain into 4 to 13 minor calices that, in turn, drain into 2 to 3 major calices that open directly into the renal pelvis. The hilum, or pelvis, is the concave portion of the kidney through which the renal artery enters and the renal vein exits. The renal artery (arising from the abdominal aorta) divides into smaller and smaller vessels, eventually forming the afferent arteriole. The afferent arteriole branches to form the glomerulus, which is the capillary bed responsible for glomerular filtration. Blood leaves the glomerulus through the efferent arteriole and flows back to the inferior vena cava through a network of capillaries and veins. Each kidney contains about 1 million nephrons, the functional units of the kidney. Each kidney is capable of providing adequate renal function if the opposite kidney is damaged or becomes nonfunctional. The nephron consists of a glomerulus containing afferent and efferent arterioles, Bowmans capsule, proximal tubule, loop of Henle, distal tubule, and collecting ducts

Collecting ducts converge into papillae, which empty into the minor calices, which drain into three major calices that open directly into the renal pelvis. Nephrons are structurally divided into two types: cortical and juxtamedullary. Cortical nephrons are found in the cortex of the kidney, and juxtamedullary nephrons sit adjacent to the medulla. The juxtamedullary nephrons are distinguished by their long loops of Henle and the vasa recta, long capillary loops that dip into the medulla of the kidney. The glomerulus is composed of three filtering layers: the capillary endothelium, the basement membrane, and the epithelium. The glomerular membrane normally allows filtration of fluid and small molecules yet limits passage of larger molecules, such as blood cells and albumin. Kidney function begins to decrease at a rate of approximately 1% each year beginning at approximately age 30.

Ureters, Bladder, and Urethra Urine, which is formed within the nephrons, flows into the ureter, a long fibromuscular tube that connects each kidney to the bladder. The ureters are narrow, muscular tubes, each 24 to 30 cm long, that originate at the lower portion of the renal pelvis and terminate in the trigone of the bladder wall. There are three narrowed areas of each ureter: the ureteropelvic junction, the ureteral segment near the sacroiliac junction, and the ureterovesical junction. The angling of the ureterovesical junction is the primary means= of providing antegrade, or downward, movement of urine, also referred to as efflux of urine. This angling prevents vesicoureteral reflux, which is the retrograde, or backward, movement of urine from the bladder, up the ureter, toward the kidney. During voiding (micturition), increased intravesical pressure keeps the ureterovesical junction closed and keeps urine within the ureters. As soon as micturition is completed, intravesical pressure returns to its normal low baseline value, allowing efflux of urine to resume. Therefore, the only time that the bladder is completely empty is in the last seconds of micturition before efflux of urine resumes. The three areas of narrowing within the ureters have a propensity toward obstruction because of renal calculi (kidney stones) or stricture. Obstruction of the ureteropelvic junction is the most serious because of its close proximity to the kidney and the risk of associated kidney dysfunction. The left ureter is slightly shorter than the right. The lining of the ureters is made up of transitional cell epithelium called urothelium. As in the bladder, the urothelium prevents reabsorption of urine. The movement of urine from the renal pelves through the ureters into the bladder is facilitated by peristaltic waves (occurring about one to five times per minute) from contraction of the smooth muscle in the ureter wall (Walsh, Retik, Vaughan & Wein, 1998). The urinary bladder is a muscular, hollow sac located just behind the pubic bone. Adult bladder capacity is about 300 to 600 mL of urine. In infancy, the bladder is found within the abdomen. In adolescence and through adulthood, the bladder assumes its position in the true pelvis. The bladder is characterized by its central, hollow area called the vesicle, which has two inlets (the ureters) and one outlet (the urethrovesical junction), which is surrounded by the bladder neck. The wall of the bladder comprises four layers. The outermost layer is the adventitia, which is made up of connective tissue. Immediately beneath the adventitia is a smooth muscle layer known as the detrusor. Beneath the detrusor is a smooth muscle tunic

known as the lamina propria, which serves as an interface between the detrusor and the innermost layer, the urothelium. The urothelium layer is specialized, transitional cell epithelium, containing a membrane that is impermeable to water. The urothelium prevents the reabsorption of urine stored in the bladder. The bladder neck contains bundles of involuntary smooth muscle that form a portion of the urethral sphincter known as the internal sphincter. The portion of the sphincteric mechanism that is under voluntary control is the external urinary sphincter at the anterior urethra, the segment most distal from the bladder (Walsh et al., 1998). The urethra arises from the base of the bladder: In the male, it passes through the penis; in the female, it opens just anterior to the vagina. In the male, the prostate gland, which lies just below the bladder neck, surrounds the urethra posteriorly and laterally.

PHYSIOLOGY OF THE UPPER AND LOWER URINARY TRACTS The urinary system performs various roles that are essential for normal bodily homeostasis .These functions include urine formation; excretion of waste products; regulation of electrolyte, acid, and water excretion; and autoregulation of blood pressure.

Urine Formation

Urine is formed in the nephrons through a complex three-step process: glomerular filtration, tubular reabsorption, and tubular secretion. Figure 43-3 illustrates the three processes of urine formation and typical values of water and electrolytes associated with each process. The various substances normally filtered by the glomerulus, reabsorbed by the tubules, and excreted in the urine include sodium, chloride, bicarbonate, potassium, glucose, urea, creatinine, and uric acid. Within the tubule, some of these substances are selectively reabsorbed into the blood. Others are secreted from the blood into the filtrate as it travels down the tubule. Some substances, such as glucose, are completely reabsorbed in the tubule and normally do not appear in the urine. Amino acids and glucose are usually filtered at the level of the glomerulus and reabsorbed so that neither is excreted in the urine. Glucose, however, appears in the urine (glycosuria) if the amount of glucose in the blood and glomerular filtrate exceeds the amount that the tubules are able to reabsorb. Normally, glucose is completely reabsorbed when the blood glucose level is less than 200 mg/dL (11 mmol/L). In diabetes, when the blood glucose level exceeds the kidneys reabsorption capacity, glucose appears in the urine. Glycosuria is also common in pregnancy.

Protein molecules are also generally not found in the urine; however, low-molecular-weight proteins (globulins and albumin) may periodically be excreted in small amounts. Transient proteinuria in amounts less than 150 mg/dL is considered normal and does not require further evaluation. Persistent proteinuria usually signifies damage to the glomeruli.

The steps of urine formation are: Glomerular filtration: The normal blood flow through thekidneys is about 1,200 mL/min. As blood flows into the glomerulus from an afferent arteriole, filtration occurs. The filtered fluid, also known as filtrate or ultrafiltrate, then enters the renal tubules. Under normal conditions, about 20% of the blood passing through the glomeruli is filtered into the nephron, amounting to about 180 L/day of filtrate. The filtrate normally consists of water, electrolytes, and other small molecules, because water and small molecules are allowed to pass, whereas larger molecules stay in the bloodstream. Efficient filtration depends on adequate blood flow maintaining a consistent pressure through the glomerulus. Many factors can alter this blood flow and pressure, including hypotension, decreased oncotic pressure in the blood, and increased pressure in the renal tubules from an obstruction. Tubular reabsorption and tubular secretion: The second and third steps of urine formation occur in the renal tubules and are called tubular reabsorption and tubular secretion. In tubular reabsorption, a substance moves from the filtrate back into the peritubular capillaries or vasa recta. In tubular secretion, a substance moves from the peritubular capillaries or vasa recta into tubular filtrate. Of the 180 L (45 gallons) of filtrate that the kidneys produce each day, 99% is reabsorbed into the bloodstream, resulting in 1,000 to 1,500 mL of urine each day. Although most reabsorption occurs in the proximal tubule, reabsorption occurs along the entire tubule. Reabsorption and secretion in the tubule frequently involve passive and active transport and may require the use of energy. Filtrate becomes concentrated in the distal tubule and collecting ducts under the influence of antidiuretic hormone (ADH) and becomes urine, which then enters the renal pelvis. Excretion of Waste Products The kidney functions as the bodys main excretory organ, eliminating the bodys metabolic waste products. The major waste product of protein

metabolism is urea, of which about 25 to 30 g is produced and excreted daily. All of this urea must be excreted in the urine; otherwise it will accumulate in body tissues. Other waste products of metabolism that must be excreted are creatinine, phosphates, and sulfates. Uric acid, formed as a waste product of purine metabolism, is also eliminated in the urine. The kidneys serve as the primary mechanism for excreting drug metabolites. Regulation of Electrolyte Excretion When the kidneys are functioning normally, the volume of electrolytes excreted per day is exactly equal to the amount ingested. For example, the average American daily diet contains 6 to 8 g each of sodium chloride (salt) and potassium chloride. Nearly all of this is excreted in the urine. Electrolyte excretion includes sodium and potassium.

SODIUM More than 99% of the water and sodium filtered at the glomeruli is reabsorbed into the blood by the time the urine leaves the body. Water from the filtrate follows the reabsorbed sodium to maintain osmotic balance. By regulating the amount of sodium (and therefore water) reabsorbed, the kidney can regulate the volume of body fluids. If more sodium is excreted than ingested, dehydration results; if less sodium is excreted than ingested, fluid retention results. The regulation of sodium volume excreted depends on aldosterone, a hormone synthesized and released from the adrenal cortex. With increased aldosterone in the blood, less sodium is excreted in the urine because aldosterone fosters renal reabsorption of sodium. Release of aldosterone from the adrenal cortex is largely under the control of angiotensin II. Angiotensin II levels are in turn controlled by renin, an enzyme that is released from specialized cells in the kidneys (Fig. 43-4). This complex system is activated when pressure in the renal arterioles falls below normal levels, as occurs with shock, dehydration, or decreased sodium chloride delivery to the tubules. Activation of this system increases the retention of water and expansion of intravascular fluid volume.

POTASSIUM Potassium is the most abundant intracellular ion, with about 98% of the total-body potassium located intracellularly. To maintain a normal potassium balance in the body, the kidneys are

responsible for excreting more than 90% of the total daily potassium intake. Several factors influence potassium loss through the kidneys. Aldosterone causes the kidney to excrete potassium, in contrast to aldosterones effects on sodium described previously. Acidbase balance, the amount of dietary potassium intake, and the flow rate of the filtrate in the distal tubule also influence the amount of potassium secreted into the urine. Retention of potassium is the most life-threatening effect of renal failure. Regulation of Acid Excretion The catabolism, or breakdown, of proteins results in the production of acid compounds, in particular phosphoric and sulfuric acids. The normal daily diet also includes a certain amount of acid materials. Unlike carbon dioxide (CO2), phosphoric and sulfuric acids are nonvolatile and cannot be eliminated by the lungs. Because accumulation of these acids in the blood would lower its pH (making the blood more acidic) and inhibit cell function, they must be excreted in the urine. A person with normal kidney function excretes about 70 mEq of acid each day. The kidney is able to excrete some of this acid directly into the urine until the urine pH reaches 4.5, which is 1,000 times more acidic than blood. More acid, however, usually needs to be eliminated from the body than can be excreted directly as free acid in the urine. These excess acids are bound to chemical buffers so they can be excreted in the urine. Two important chemical buffers are phosphate ions and ammonia (NH3). When buffered with acid, ammonia becomes ammonium (NH4). Phosphate is present in the glomerular filtrate, and ammonia is produced by the cells of the renal tubules and secreted into the tubular fluid. Through the buffering process, the kidney is able to excrete large quantities of acid in a bound form, without further lowering the pH of the urine.

Regulation of Water Excretion Regulation of the amount of water excreted is also an important function of the kidney. With high fluid intake, a large volume of dilute urine is excreted. Conversely, with a low fluid intake, a small volume of concentrated urine is excreted. A person normally ingests about 1 to 2 L of water per day, and normally all but 400 to 500 mL of this fluid is excreted in the urine. The remainder is lost from the skin, from the lungs during breathing, and in the feces.