Medical examination and treatment of urological kidney disease

2021-07-09 10:34 AM

The glomerulus has the function of filtering, the tubules, and the loop of Henle have the function of reabsorption, and secretion, these tubules unite to empty into the collecting duct, and finally into the renal pelvis.

Pathology

Kidney

Normally, humans have two kidneys located in the lumbar fossa, behind the peritoneum. The adult kidney is oval, 12cm long, 6cm wide, 3cm thick, weighing 130 - 150 grams.

The kidney is related to the upper pole with ribs 11-12, anteriorly to the peritoneum and visceral organs

The kidney is encased in a fibrous capsule, which is composed of more than one million Nephron units. Each Nephron begins in the capillary coil in the Bowman's capsule.

The glomerulus has a filtering function, the tubules and loops of Henle have the function of reabsorption and secretion. These tubules merge into the collecting duct, and finally into the renal pelvis.

The kidneys in infants and young children cannot concentrate urine effectively. So, the color of urine is light yellow or clear.

Infants and children excrete a urine output of 400 to 500 ml per day. Older children and adults usually urinate about 1500 - 1600 ml a day.

The kidneys concentrate urine very efficiently, giving it an amber color.

The renal pelvis

The renal calyces form the collecting and storing chambers associated with the renal peduncle.

Renal calyx system: small calyces extend from two or more renal spines and drain into 2-3 large upper, middle, and lower calyces. The large calyx empties into the renal pelvis.

The funnel-shaped renal pelvis is located partly intrarenal and partly extrarenal, directly related to the renal peduncle anteriorly.

The renal calyx system is mainly composed of a sphincter layer running in the direction from the renal calyx down to the ureter, creating peristalsis in the direction of urine excretion.

Ureters

The ureter continues from the renal pelvis to the bladder about 25cm long. The ureter lies posterior to the abdominal wall, descends straight down the upper waist, crosses in front of the iliac artery, runs into the pelvis, then anteriorly, and empties into the posterior bladder. The ureter has three narrow spots:

The segment connecting the renal pelvis to the ureter is 2 cm.

The ureter crosses the iliac artery 4 mm.

The ureteral junction, the ureteral opening is 3-4 mm.

The other segments of the ureter are larger in diameter.

The ureter is divided into 4 segments related to neighboring organs.

Waist piece:

The right side is related to the vena cava, the left side to the aorta. This segment of the ureter goes parallel to the iliac fossa with the genital artery.

Pelvic segment:

Cross the main iliac artery 1.5 cm above the bifurcation.

Pelvic hip segment:

In males, the splenic ureter is located between the bladder and seminal vesicles, crossing the seminal vesicles posteriorly.

In women, the ureter, when passing through the base of the broad ligament, crosses the uterine artery from above.

Bladder segment (parietal ureter):

The ureter enters the bladder wall with a downward tilt into the wall of a physiological valve that works to avoid vesicoureteral reflux.

The ureter has a structure: the longitudinal muscular layers outside the inner sphincter form the directional peristalsis of the ureter from the kidney to the bladder.

Clinically, it is divided into 3 sections:

Superior ureter: has 2 points, located on the lateral border of the rectus muscle and at the level of the umbilicus. The middle ureter: has 2 points, located on the lateral border of the rectus muscle and the line connecting the 2 anterior superior iliac spines.

Lower ureter (parietal ureter): located in the wall of the bladder.

Bladder

Is a hollow, spherical cap-shaped organ located below the peritoneum, in the pelvis of the baby, behind the pubic bone, in front of the genital organs and the rectum?

The bladder has a muscular structure, including the outer longitudinal fiber, the middle sphincter, and the internal oblique muscle, creating the function of the bladder to store and open urine physiologically and actively. The two orifices of the ureter and the opening of the urethra form the three angles of the triangle of the bladder.

Urethra

The female urethra passes from the neck of the bladder to the perineum at the vulva. The path is slightly downward and forwards parallel to the vagina. The male urethra, from the bladder neck through the perineum to the penis, is 17cm long and includes:

The prostatic urethra just below the bladder neck is surrounded by the prostate gland.

The membranous urethra passes through the medial perineal fascia surrounded by a striated sphincter.

The urethra of the penis passes in the spongy matter.

Prostate

The prostate is a gland that secretes semen under the bladder neck, around the urethra. The prostate gland at the age of sexual activity weighs about 20-25 grams, has a thin fibrous sheath surrounding the gland.

Clinical examination of the urinary system includes an examination of the kidneys, ureters, bladder, and urethra, in men, also an examination of the prostate gland. Examination of the urinary system requires a systematic examination from top to bottom in anatomical order. In addition, like other organs, when examining the urinary system, it is necessary to coordinate with the whole-body examination.

Physical symptoms

Kidney pain

The characteristic of the pain is usually in the lumbar region, the back flanks with sudden onset of easily recognizable attacks. The pain appears after the patient does heavy work, carries burdens, goes far (when exerting). The severity may be severe, sweating, leg flexing, or leaning over the bed. The pain in the lower back and lower back radiates down the pelvis to the external genitalia.

The pain can last for hours, the pain is relieved when the patient lies down, taking painkillers. The pain also often recurs.

Signs accompanying kidney pain: patients often straining, needing to urinate, urinating, vomiting or nauseous, abdominal distension, unable to defecate.

When there is pain, examination of the lumbar region shows spinal and lumbar muscle spasms. Abdominal examination: abdominal wall reaction on the painful side.

Atypical form: the patient only has low back pain, dull pain daily, weekly.

Back pain: distinguishing spinal pain, abdominal pain under the ribs like right iliac fossa pain, distinguishing appendicitis, colitis, and adnexitis.

Renal pain needs to be determined by laboratory methods: X-ray, ultrasound, retrograde urethrography...

Cause: 2/3 of cases due to urolithiasis, in which mainly ureteral stones. The congenital malformation is the second most common cause after urolithiasis, ureteral junction syndrome, and pyelonephritis. Other causes include blood clots in the ureters due to cancer, tumors of the urinary tract, tumors outside the urinary tract (uterine tumors). Renal colic requires differential diagnosis with:

Liver pain.

Appendicitis on the right side.

Ectopic pregnancy.

Hollow visceral perforation, intestinal obstruction.

Acute pancreatitis.

Pelvic and genital pain

For patients with pain in the area below the navel, bladder, and pelvic region, the pain of urinary origin has the following characteristics:

Dull, heavy pain with onset and progression is often accompanied by urinary disorders: urinary incontinence, painful urination, hematuria.

Bladder pain associated with urgent urination is often seen in patients with ureteral stones or prostate tumors.

Prostate pain is a pain in the anorectal region, perineal area. The pain often increases when sitting or defecating.

Pain in the testicles, the epididymis is often very severe from the scrotum to the groin, pelvis, and waist.

Irritation syndrome

Diarrhea:

Normally, urinating only about 4-6 times/day and not urinating at night. Diarrhea is a phenomenon that always needs to urinate even though you have just finished urinating, urinating several times a day with little urine each time and especially at night, sometimes urgently needing to urinate.

The causes of urinary incontinence are diverse:

Bladder irritation due to cystitis, foreign body, pelvic tumor.

Urine stagnation in the bladder due to prostatic hypertrophy, diverticulum.

Change in urine composition (alkaline), phosphaturia.

Neurological (emotional) or endocrine (during puberty).

Dysuria:

It is a burning pain when urinating, clinical manifestations range from pain, tightness, burning to a burning sensation in the bladder and spreading to the urethra when urinating.

Dysuria always accompanied by frequent urination:

Inflammation of the bladder, the bladder wall is edematous, so there is a feeling of burning at the end of the beach.

Urethritis, painful urination when urine flows through the urethra: painful urination at the beginning.

Bladder stones: intense pain at the end of the bladder spreading along the urethra and penis.

Obstructive syndrome

Difficulty urinating:

Difficulty urinating is the inability to urinate completely in the bladder, so the urine must be strained, the small rays are not strong, the stream is not strong, and the urine drops down the legs. Difficulty urinating is the result of an imbalance of bladder muscle thrust and urethral sphincter opening. There are also causes of the urethra not circulating.

Clinical manifestations of dysuria when there is urinary retention in the bladder, but not distension: after each urination, the amount of urine remains less than 100ml, this phenomenon occurs very quietly, but often there is a risk of urinary tract infection urinary.

Difficulty urinating with bladder strain (stagnation of urine over 300ml) the patient feels uncomfortable, mood changes or anxious, irritable, tired, dare not eat.

Urinary retention:

Urinary retention is the phenomenon of stagnation of urine in the bladder, the patient has a strong urge to urinate without being able to urinate, urine continues to be collected in the bladder, causing the bladder wall to relax and cause a feeling of pressure and discomfort. Urinary retention is different from anuria, anuria is no urine in the bladder, monitored for hours/day, bladder catheterization has no urine (normally 40-60 ml / h) because the kidneys stop excreting. Complete urinary retention occurs acutely, the patient has a strong urge to urinate, pain in the lower umbilicus region is persistent, but cannot pass. The enlarged bladder bridge is palpable, increasing the sensation of pain, discomfort, and need to urinate.

Incomplete urinary retention is the case when after each urination, there is still more than 300ml of urine remaining in the bladder, the bladder bridge is always palpable.

The main signs of acute urinary retention are no urine for several hours and a distended bladder. Patients under the influence of local anesthetics and analgesics may experience only hypogastric discomfort, but awake patients may experience severe pain when the bladder is distended. With intense urinary retention, the bladder can hold about 2000 to 3000 ml of urine.

Urinary retention can result from urethral obstruction, surgical injury, sensory and motor nerve damage of the bladder, drug side effects, and patient anxiety.

Involuntary urination (peeling):

It is the phenomenon of urine outflow, the patient can't control himself, the patient may or may not know it. Diarrhea also occurs with exertion or persistent leakage of urine in girls due to low ectopic ureteral emptying. Persistent urine leakage in the elderly due to bladder sphincter dysfunction caused by brain lesions (tumor, cerebrovascular accident, Parkinson's syndrome).

Other clinical forms:

Urgent pee.

Bedwetting at night...

Blood in the urine

Hematuria is when urinating red urine with red blood cells, Addis sediment count > 500,000 hc/min. Distinguishing red urine but not hematuria: red color of food and drink, caused by rifampicin, phenothiazine, or cases of hemoglobinuria due to red blood cell breakdown.

To the naked eye, the urine is red, with blood in the urine and blood clots. The progression is increased when the patient has blood in the urine accompanied by low back pain. When urinating with dark blood, the color gradually changes to brown, then yellow, the bleeding stops spontaneously and has stabilized.

Way of onset: suddenly without any warning symptoms or bloody urine appearing after renal colic, after labor, going away, after trauma to the bladder and urethra.

With the 3-cup test, it is possible to identify the location of the lesions.

Three red cups are the same: bloody urine, lesions in the ureters, kidneys.

The first cup is red: bloody urine, lesions in the urethra, bladder.

The third cup is red: bloody urine at the end of the field, damage to the bladder.

Urinary hematuria usually presents with bright red blood in the urine and blood clots, although infrequent, but very specific.

Urinating pus

Observe urine in clear glass: cloudy urine (cloudy urine, or cloudy urine like rice water, like milk).

Distinguishing cloudy urine due to phosphate deposits: when instilled acetic acid urine will be clear and sediment.

Cloudy urine due to albumin urination: when heated, albumin will coagulate.

Urate urine: when heated, the urine will be clear.

Purulent urine when urine is cloudy, white pus with degenerated white blood cells, count Addis residue, white blood cell count 5000 bc/min.

Urinary tract infections with pathogenic bacteria are confirmed only when microbiological tests have a bacterial count above 105/ml. Common pathogens in the urinary tract such as E Coli, Klebsiella, Enterobacter, Proteus, Pseudomonas.

Pyuria and urinary tract infections do not always go hand in hand. Pyuria without infection (no bacteria in the urine) accounts for 20-25% of common urinary pathologies due to stones and congenital malformations.

Systemic symptoms

The body loses weight quickly, the state of collapse is common in patients with urinary diseases. Subjectively, the patient knew how to lose weight, fatigue, loss of appetite, and insomnia.

Anemia, loss of electrolytes as in pyelonephritis, pyelonephritis, pyelonephritis, kidney failure, high blood urea, cancer.

High fever lasting 38 - 39.5οC. Prolonged or unexplained fevers can also be a sign of kidney cancer.

Edema: the characteristic of edema due to kidney disease is swelling of the face first, then edema of the legs, and finally, edema of the whole body.

Cardiovascular: hear a low, rapid heart sound or pericardial rub when uremia is elevated. Hypertension is common in glomerular diseases...

Ophthalmoscopy: lesions in hypertensive chronic kidney disease.

Physical symptoms

Examination of the urinary system: principles of a comprehensive examination, examining both the urinary and genitourinary systems. Patient position: the patient lies supine with the thighs slightly low.

Look at the abdominal breathing, the shape of the abdomen, the pelvic cavity, below the navel, compare both sides, comment on the change.

Palpation is the main, assesses the abdominal wall, detects pain, detects tumors in the lumbar region with the following characteristics: size, shape, density, surface, border, movement according to breathing and sets of muscles. surrounding part.

Tests to examine the kidneys

Lumbar touch test

Method of examination: on which side to examine, the doctor stands on the same side with the patient, the opposite hand is placed on the kidney area (back angle). The other hand is placed above the abdomen parallel to the ribs or along the lateral border of the rectus muscle. The lower hand is close to the back ribs, the upper hand is pressed down, normally there is no feeling. If the kidney is enlarged, there will be a feeling of a tumor touching the lower hand: positive lumbar touch sign.

Renal wobble test

The hand on the lower back is raised slightly in waves and the hand on the abdomen is gently pressed down. If the kidneys are enlarged, the kidneys will be seen bobbing between the hands: this is called a positive renal floater sign.

One hand can be examined: the thumb in front, the other four fingers behind, presses on the dorsal region. If the kidney is enlarged when the patient breathes, the kidney will move up and down in the palm of the hand. Usually applied when examining children's kidneys.

Enlarged kidneys are clinically defined as positive lumbar palpitations or radiographic or ultrasonographic findings of an enlarged kidney or whole kidney.

On physical examination, positive renal palpation should be differentiated from prolapsed kidneys (non-enlarged kidneys), adrenal tumors, retroperitoneal tumors, right segment of the liver, and left spleen. In contrast, physical examination can sometimes be difficult to detect enlarged kidneys because of the thick lumbar muscle mass in obese people.

Enlarged kidneys are detected from urinary symptoms (hematuria, low back pain, general body collapse) or can also be detected by X-ray examination, ultrasound examination to detect enlarged kidneys by mass physical examination.

Bladder examination

When patients with urinary retention have low urinary tract obstruction syndrome. The bladder was distended just above the pubic bone, below the navel, and there was around, orange-sized lump in the hypogastrium or up to the navel.

The tumor was rounded with a convex apex, well-demarcated, opaque, and the tumor was tense and non-motile.

Pressing makes you feel the urge to urinate.

On catheterization, urine came out and the tumor disappeared.

Rectal or vaginal examination revealed a smooth, round, tender mass.

Differentiate from pelvic tumors: pregnancy, uterine fibroids, ovarian cysts.

Prostate exam

Rectal examination is mainly performed in the supine position, with the legs extended and flexed. The examiner stands between the thighs or on the right side. Use a gloved and lubricated index finger to examine.

Normally, the prostate gland is under 20 grams, the density is soft, stretchy like rubber, there is a groove between the two lobes, the boundary is clear, and the pressure is painless.

Benign prostatic hypertrophy: palpable tumor over 3-4cm in diameter, or as big as a lemon over 30g, density is soft and tight, no groove, unclear boundary

Prostate cancer: the prostate is solid or a solid, disproportionate, undefined, non-motile mass.

Examination of the scrotum

Mainly when the patient has an enlarged scrotum. Normally the whole block is only as big as a fist, balanced on both sides, the skin is very elastic and soft.

Visible changes: scrotum deformity is enlarged, disproportionate sometimes on one side, skin changes in color, edema, redness or ulceration in one area.

Palpate mainly with the thumb and compare with 3 or 4 other fingers of one hand or two hands holding both sides.

Signs of testicular clamping: Normally, the epididymis skin can be clamped between two fingers. When there is water in the testicle membrane or when the testicle is too large, we cannot make this sign.

Palpate the epididymis and testicles: Normally, the epididymis is palpable like a cap on the epididymis. The epididymis is smooth and painless, the testicles are smooth, oval, and painless.

Feel the spermatic cord: like a strong rope, it rolls under the hand and the veins are also soft and easy to squeeze.

Light examination: using a flashlight to shine light through or not shows that it contains solid or liquid tissue.

Some factors are necessary when examining the urinary system

Ask the history and functional symptoms: History plays a very important role in the diagnosis, often thanks to the medical history the examiner has the necessary data to detect the disease. The following points should be emphasized:

Family factors: there are familial diseases such as polycystic kidney disease, urolithiasis, especially Cystin stones, Xanthin stones, birth defects such as undescended testicles, abnormal urinary openings.

History factor: there are current diseases that are recurrent forms of a previous disease such as kidney stones, renal tuberculosis, testicular atrophy due to mumps.

Occupational factors: some diseases are associated with occupation, such as toxic bladder tumors in people exposed to toxic chemicals.

Examination of the urinary system requires examination with specialized instruments: probes, endoscopes.

Examination of the urethra and bladder

Tool

Urethral and bladder catheters: flexible rubber (yellow or red) or synthetic (white) catheters.

Straight tip catheter, Nelaton catheter with side holes, Harris, Robinson straight end catheter with two side holes.

Curved end catheter: Tieman catheter is used for bladder catheterization in cases of urinary retention due to benign prostatic hypertrophy, bladder neck stenosis.

The straight and curved Foley catheters have a balloon tip to hold the catheter in the bladder. Folley catheters are available in single- or dual-line versions for bladder lavage and drainage.

Types of Catheter: The tip pezzer has a flat ball with a hole in the side. Malecot catheter with bulge tip with lateral groove.

Dimensions of the tubes:

The urinary bladder catheter is 40 cm long.

The drain tube has a length of 35 cm.

The diameter of the catheters is equivalent to 1/3 mm.

The dilator is often used to examine the urethra, made of stainless steel or nickel-plated. The dilator has a curved shape of 1/3 of a circle or just curved at the tip, following the main curvature of the male urethra. The length of the stick is about 35cm. 1/6mm diameter.

Bladder catheterization

After examination, the patient should assess the bladder urethral circulation and continue to probe the bladder urethra.

Equipment: must prepare sterile instruments in advance. Plastic rubber catheters can be autoclaved or boiled at 100°C for 15 minutes. Some silicone-coated urethral catheters must be sterilized and stored in an ethylene oxide cabinet or Cidex solution. Currently, Silicon coated catheters are sealed in nylon bags twice sterilized by disposable gamma rays, avoiding infection, AIDS.

When examining the examiner or assistant, wear gloves, disinfect the external genitals, turn the foreskin (or separate the labia majora) to disinfect, and then inject the gel into the urethra.

Take the selected catheter, withdraw from the gel-lubricated nylon sheath into the catheter.

Left-hand erect penis (labia majora in females).

With the right hand, insert the catheter into the mouth of the flute, gently push into the urethra until the urine comes out, normally the urine is clear yellow. Then lower the catheter and remove a few ml of urine from the tip of the dump, collect urine midstream for testing.

Bladder catheterization without touching the catheter: Use forceps to push the catheter into the bladder.

In difficult cases of bladder catheterization, one finger of the left hand should be inserted into the rectum to determine the position of the catheter tip and push the catheter tip toward the anterior wall of the urethra to avoid damage to the membranous and anterior urethra. glandular.

Bladder catheterization in patients with benign prostatic hypertrophy: using a Tieman curved oil catheter.

Urethral dilatation

Urethral dilation is still indicated in cases of urethral stricture after trauma, sequelae of urethral stricture due to inflammation, urethral stricture surgery.

Tools: Use a Beniquee spatula to select the number of barrels from 12 - 40B.

Principle: sterile and do not cause further trauma to the urethra.

Technique: the left-hand holds the penis erect, the right hand performs the procedure of inserting the dilator into the mouth of the flute, letting the dilator slide through the anterior urethra, gradually lowering the dilator down past the posterior urethra into the bladder neck.

In the case of urethral stricture, use a guide-shaped dilator or a Council catheter as a dilator to widen the urethra.

Urinary endoscopy

Since the early 20th century, M. Nitze has used an illuminating device for cystoscopy: the cystoscope. Cystoscopes include:

Lens system, lighting system, an endoscope with 6V small bulb, conduit system. The endoscopic system is embedded in a metal catheter that can be inserted through the urethra into the bladder and inserted into ureteral catheters, instruments to intervene in the bladder such as burning knives, biopsy pliers, foreign body pliers.

A new generation endoscope detects lesions in the bladder, ureteral orifice, thereby interfering with lesions more easily. The most popular scanners today: Karl Storz, Wolf, Olympus.

Ureteral catheters

There are many types of plastic ureteral catheters. The catheters are all graduated in cm to know the length to put up the ureter. catheters are contrast-enhanced.

Catheters placed in the ureter upstream from the bladder to the renal pelvis: J-shaped catheters or bi-curved catheters.

Catheter inserted into the ureter to remove ureteral stones with metal mesh to collect stones: Dormia catheter, Zeiss.

Urethroscopy of the bladder

A method of examination through a urethroscopy or cystoscope to directly see lesions of the urethra or bladder. Can indirectly know the damage to the bladder due to tumor, bleeding, acute or chronic inflammation.

Interventional endoscopy

The methods of urological endoscopy have been expanded to provide effective treatment interventions: machine urethroscopy to cut urethral strictures, congenital urethral valves. Laparoscopic resection of benign prostatic hypertrophy is a step in the development
of laparoscopic techniques.

Renal ureteroscopy:

With 9.5 - 12.5Ch metal ureteroscope or 7 - 9Ch soft ureteroscope, it is possible to conduct renal ureteroscopy to diagnose lesions and bleeding of the upper urinary tract (pyelonephritis and ureters). as well as treatment of acquired or congenital ureteral stricture and especially ureteral lithotripsy, ablation of ureteral pyelonephritis.

Percutaneous endoscopy:

Unlike retrograde endoscopy, percutaneous endoscopy allows downstream for diagnosis and interventional treatment of diseases in the renal pelvis and upper ureter.

The important step is under the guidance of ultrasound and X-ray position by injecting contrast material into the vein with two pre-placed ureteral catheters and then accurately inserting the needle into the lower calyx, renal pelvis, inserting the metal cannula into the ureter. kidney and gradually expand to 28-30Ch. Place a Nephoscope with a lithotripsy system with an ultrasound probe to dissolve large nephrolithiasis, a small probe to dissolve ureteral obstruction or a knife to cut the narrow segment of the ureteral junction.