Urinary system diseases and disorders

The following section includes the etiology, signs, symptoms, diagnostic procedures, and treatments.

Common urinary signs and symptoms include the following:

• Dysuria: Painful or difficult urination
• Nocturia: Urination at night
• Polyuria: Excessive excretion of urine may be accompanied by polydipsia (excessive thirst)
• Frequency: Urination at short periods without an increase in the daily volume of urine output
• Urgency: The sudden, almost uncontrollable need to urinate
• Urinary incontinence: Inability to hold urine
• Urinary retention: Inability to release urine

Typically, common signs of urinary system disorders found on medical imaging and laboratory tests include these:

• Calculi: Stones formed in the kidneys, gallbladder, and other parts of the body
• Hydronephrosis: A backup of urine that causes dilation of the ureters and calyces; can increase pressure on the nephron units
• Azotemia: An abnormal increase in nitrogenous waste products in the blood; also called uremia
• Abnormal substances in the urine: Albuminuria or proteinuria (albumin), azoturia (excessive nitrogen compounds), bacteriuria (bacteria), glycosuria (glycose [sugar]), hematuria (blood), and pyuria (pus)

The following sections describe cancers, genetic and congenital disorders, infectious and inflammatory disorders, and structural and functional disorders of the urinary system.

Urinary system cancers

Bladder and kidney cancer are the most common types of urinary system cancers. The following sections discuss each of these types of cancers.

Bladder cancer

Bladder cancer is the sixth most common cancer in the United States. Bladder cancer tends to recur, so follow-up testing is critical. Transitional cell carcinoma (also called urothelial carcinoma) is the most common type of bladder cancer in the United States.

Smoking, chemical exposure, family history of the disease, some chemotherapy medications, and chronic bladder infections can increase the risk of bladder cancer. People over 40 years of age, men, and Caucasians are also more at risk. Common signs and symptoms include hematuria, frequency, urgency, dysuria, pelvic pain, and low back pain.

The provider will do a physical exam. Urine testing, cystoscopy, and a biopsy may be done to diagnose bladder cancer. Additional imaging tests are done to check if the cancer has spread to other parts of the body. Treatments used for bladder cancer include surgery, radiation therapy, and chemotherapy. Biological therapy or immunotherapy can be useful, as it increases the body’s ability to help fight the cancer.

Kidney cancer

Kidney cancer or primary kidney cancer, occurs when cancer starts in the kidney. There are three main types of primary kidney cancer:

• Renal cell carcinoma (RCC) (or renal adenocarcinoma): Most common type in adults; forms in the lining of the kidney tubules
• Wilms tumor (or nephroblastoma): Most common type in children younger than 5 years; occurs in the kidney tissue; improved treatments have increased the survival rate
• Transitional cell cancer: Occurs in adults; forms in the ureter and renal pelvis
• It is unclear what causes the mutation of the kidney cell that leads to a tumor development. With kidney cancer, pain and hematuria can be key symptoms.

Diagnostic procedures for the three types of kidney cancer are similar. During the exam, the provider may identify a kidney mass. Urinalysis and blood work may be done to check for hematuria and the person’s overall health. Once kidney cancer is diagnosed, imaging tests are done to check for cancer in other parts of the body. Treatment for kidney cancer can involve surgery. If no kidney function exists, then dialysis and a kidney transplant are done. If surgery is not an option, arterial embolization can be done. A catheter is inserted through an incision and passed into the main blood vessel of the kidney. A special gelatin sponge is inserted through the catheter into the blood vessel, creating a blockage and preventing blood flow, thus killing the tumor.

Genetic and congenital urinary system disorders

Genetic and congenital urinary system disorders cause kidney loss or malfunction later in life. Polycystic kidney disease is one of the more common genetic and congenital urinary system disorders.

Polycystic Kidney Disease (PKD)

Polycystic kidney disease (PKD) is an inherited condition. Cysts form in the kidneys, causing the kidneys to become enlarged. A cyst-filled kidney can weigh up to 30 pounds. There are two types of PKD:

• Autosomal dominant: If the gene is inherited from one parent, the child will get the disease. Often the parent also has the disease. This is the most common form of PKD and inherited kidney disorder. It is typically identified between the ages of 30 and 50, although it can occur in childhood.

People with PKD may also have cysts in their liver and pancreas. Aneurysms and diverticula of the colon may also be associated with PKD. Males can have cysts in their testes and tend to have more kidney failure. Women with PKD, hypertension (high blood pressure), and who have had three or more pregnancies are also more at risk for kidney failure. PKD can cause the following conditions:

• Pain in the flank, abdomen, and joints
• Nocturia and hematuria
• Drowsiness and nail abnormalities
• Pain or tenderness over the liver and an enlarged liver
• Heart murmur and hypertension

During the physical examination, the provider may order a computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound (US) to check the cysts on the kidneys. PKD is a chronic condition that slowly gets worse. The treatment goals are to control symptoms and prevent complications. Treatment often includes antihypertensive medications, diuretics , and a low-salt diet. PKD can increase the risk of urinary tract infections due to blockages. UTIs should be treated quickly with antibiotics. Surgery to remove one or both kidneys may be required. The patient may also need dialysis or kidney transplantation. With the chronic nature of this condition, it is important for patients to get support. Sometimes, support groups can help the patient and family cope with the disease process.

Additional genetic and congenital disorders

Besides PKD, several genetic and congenital disorders affect the urinary system:

• Hydronephrosis: Distention of the renal pelvis and calyces due to urinary tract obstruction; caused by a congenital defect or renal calculi.
• Prune belly syndrome (PBS): A group of genetic birth defects usually occurring in boys; it involves enlarged ureters and bladder, hydronephrosis (kidney swelling), poor development of the abdominal muscles, undescended testicles, and wrinkled skin over the abdomen.
• Ureterocele: The end of the ureter is malformed and bulges, creating a ureterocele, and may obstruct the ureter or bladder.
• Ureteropelvic junction (UPJ) obstruction: Blockage where the ureter joins the kidney, causing kidney swelling.
• Vesicoureteral reflux (VUR): Urine backs up into the ureter from the bladder due to a malformed or missing valve over the end of the ureter.

Infectious and inflammatory urinary system diseases and disorders

A urinary tract infection (UTI) is an infection in one or more of the urinary tract structures. There are several infections and inflammatory disorders that affect the urinary system. Examples of these disorders include the following:

• Interstitial cystitis (IC): Causes recurring bladder and pelvic region pain and discomfort, frequency, and urgency; also called painful bladder syndrome (PBS).
• Interstitial nephritis: Inflammation of the kidneys with an increase of interstitial tissue and thickening of blood vessel walls.
• Membranous glomerulonephritis: Inflammation occurs in the kidney due to glomerular changes, and large amounts of protein are excreted in the urine. The exact etiology is unknown.
• Nephritis: Inflammation of the kidney; can be chronic, acute, or nephrosis (also called nephrotic syndrome).
• Urethritis: Inflammation of the urethra due to bacteria, viruses, injury, or chemical sensitivity.

Acute cystitis, glomerulonephritis, and pyelonephritis are also conditions in this category and are described in the following sections.

Acute cystitis

Acute cystitis is an inflammation of the bladder. Due to the shorter urethra, women are more at risk than men of getting infections. Typically, acute cystitis is caused by a bacterial infection, most commonly Escherichia coli (E. coli). Other causes of inflammation can include medications, radiation therapy, spermicidal jellies, and long-term catheterization. Being pregnant, going through menopause, having a catheter, urinary tract procedure, experiencing urinary retention, having an obstruction, having bowel incontinence, or diabetes can increase the risk of cystitis. Signs and symptoms include the following:

• Nocturia, dysuria, urgency, frequency, and urinary retention
• Cloudy, bloody, or strong/foul-smelling urine
• Low abdominal pressure or cramping, low-grade fever
• With older adults: confusion and mental changes

Usually, the provider will order a urinalysis, a urine culture, and a sensitivity (C&S) test. The urinalysis provides information to help diagnose cystitis, and the C&S may take up to 3 days to identify the organism. If the urinalysis and culture come back negative for an infection, the provider may do additional tests (e.g., cystoscopy) to try to identify the cause of the symptoms. Treatment for bacterial cystitis consists of antibiotics.

Home care treatments may include drinking plenty of liquids; avoiding coffee, alcohol, and soft drinks; taking an analgesic; having a sitz bath, or using a heating pad to decrease the discomfort.

Glomerulonephritis

Several diseases affect kidney functioning because of their effects on the glomeruli. Glomerulonephritis is inflammation of the glomeruli. Damage to the glomeruli can cause protein and red blood cells to leak into the urine. Glomerulonephritis usually has an abrupt onset.

The cause is often unknown, and it can follow a streptococcal infection. Signs and symptoms include puffy eyes, fatigue, low-grade fever, headache, and pain in the kidney region. Hematuria, cola-colored urine, proteinuria, and oliguria can also be seen.

After the physical exam, the provider may order a urinalysis, blood urea nitrogen (BUN), creatinine, erythrocyte sedimentation rate (ESR), imaging tests (e.g., CT scan, x-ray, and ultrasound), and a renal biopsy. Treatment is based on the cause of the illness. Bed rest, antihypertensive medications, antibiotics, diuretics, and dietary restrictions (e.g., protein, salt, and potassium) may be ordered.

Pyelonephritis

Pyelonephritis is a urinary tract infection of one or both kidneys. Prompt treatment is required to prevent kidney damage and septicemia . The bacteria can spread to the bloodstream, causing an overwhelming infection that can be life threatening.

Pyelonephritis is caused by a bacterium or virus. The pathogen can move from the bladder to the kidneys, or carried by the bloodstream to the kidneys. An increased risk of pyelonephritis may be seen with structural defects, urinary reflux, obstruction, and bladder infection. The signs and symptoms consist of fever, chills, nausea, vomiting, dysuria, frequency, hematuria, foul-smelling urine, and low back, side (flank), or groin pain. Young children may only experience a fever, and some adults may have confusion and speech difficulties.

After the patient’s history has been taken and the physical examination has concluded, the provider will usually order a urinalysis, urine culture, blood culture, and blood work. For the most accurate results, all cultures need to be obtained before the patient starts on antibiotics.

Additional tests may include a US, a CT scan, avoiding cystourethrogram (VCUG), a digital rectal exam (DRE), and a dimercaptosuccinic acid (DMSA) scan. Initially, the provider will treat the infection with a broad-spectrum antibiotic. When the blood and urine culture results are known, the provider may have the patient take an antibiotic that is known to kill the pathogen. For severely ill patients, hospitalization, intravenous (IV) fluids and antibiotics, and close observation may be required. Repeat cultures may be taken after the antibiotics have been completed to ensure the infection is gone.