1
Q
The urinary system includes
A
- Two kidneys
- A ureter for each kidney
- A urinary bladder
- A urethra
2
Q
Kidneys and ureters make up the
A
upper urinary tract
3
Q
Urinary bladder and urethra form the
A
lower urinary tract
4
Q
Ultrasound examinations of urinary system are indicated for:
A
- Renal size
- Detection and composition of renal masses and cysts
- Urinary system obstruction
- Renal abscess
- Renal hematoma
- Enlarged ureters
- Urinary bladder masses
- Renal transplantation
- Doppler evaluation of renal blood flow abnormalities
- Ultrasound-guided biopsies of renal parenchyma or masses
- Ultrasound-guided fluid aspirations
5
Q
what kind of organs are kidneys and where are they located between what?
A
Kidneys are retroperitoneal organs
Lie one on each side of the spine between the peritoneum and back muscles
6
Q
the kidney has what?
A
The kidney has a lateral convex and a medial concave border
7
Q
What displaces the right kidney and where?
A
The liver displaces the right kidney inferiorly; hence, it is located lower than the left kidney and has a slightly shorter ureter
8
Q
characteristics of kidneys
where is it located relative to what?
Along what borders?
A
- Retroperitoneal
- Lie on each side of the spine
- Between the peritoneum and the back muscles
- Lateral convex border, medial concave border
- Liver displaces right kidney inferiorly
- Located lower than the left kidney
9
Q
characteristics of Ureters
Originates where?
Extends along what muscle to enter what?
A
Retroperitoneal
Originate at renal hilum
Extend inferiorly along psoas muscle to enter the urinary bladder posteriorly
10
Q
Urinary Bladder
where is it?
location related to what?
A
Within the pelvis
Posterior to the pubis symphysis
11
Q
Urethra
allows for what?
male vs female
A
Membranous canal the allows urine to be expelled from the bladder
Male urethra is longer than the female urethra
Male urethra also serves as a pathway for seminal fluid
12
Q
male urinary bladder compared to female urinary bladder
anterior to and superior to?
A
Male:
Anterior to:
Seminal vesicles
Rectum
Superior to:
Prostate
Female:
Anterior to:
Vagina
PCDS
Rectum
13
Q
right kidney is posterior to?
A
Right Kidney
Posterior to:
- Right lobe of liver
- 2nd part of duodenum
- Hepatic flexure
- Jejunum
- Morrison’s Pouch
- Hepatorenal recess/subhepatic recess
- Peritoneal space that separates liver and right kidney
- One of the most dependent peritoneal spaces
14
Q
right kidney is anterior to?
A
- Diaphragm
- Costodiaphragmatic recess of the pleura
- Twelfth rib
- Psoas muscle
- Quadratus lumborum, and transversus abdominis muscles.
15
Q
left kidney is posterior to:
A
- Left adrenal gland
- Spleen
- Stomach
- Pancreas
- Left colic flexure
- Coils of jejunum.
16
Q
left kidney is anterior to:
A
- Diaphragm
- Costodiaphragmatic recess of the pleura
- Eleventh and twelve ribs
- Psoas muscle
- Quadratus lumborum
- Transversus abdominis muscles
17
Q
ureter
how long?
does what with renal pelvis?
receives what?
what type?
A
- 25-cm tubular structure
- Expanded and continuous with renal pelvis
- Renal pelvis receive the major calyces (hilum)
- Retroperitoneal
18
Q
adrenal glands
A
Anterosuperior and slightly medial to kidney
19
Q
right ureter is posterior to:
A
- Duodenum
- Terminal ileum
- Right colic and ileocolic
- Gonadal vessels
- Vas deferens/uterine artery
20
Q
right ureter is anterior to:
A
- Psoas muscle
- Bifurcation of CIA
21
Q
left ureter is posterior to:
A
- Colon
- Left colic
- Gonadal vessels
22
Q
left ureter is anterior to:
A
- Psoas muscle
- Bifurcation of CIA
23
Q
gross anatomy - kidney
how long?
separated into what 3 parts?
A
- Dark red, reniform (bean) shaped organs
- Approx. 9-12cm in length
- If a solitary kidney there will be compensatory hypertrophy
- Separated in 3 parts:
–> UPPER, MID, LOWER
24
Q
Kidney Has multiple protective coverings:
A
- Tough fibrous capsule - not adherent to the parenchyma
- Perirenal fat - surrounds the capsule and is continuous with the fat in the sinus
- Gerota’s fascia - surrounds the kidney and perirenal fat
Anchors the kidney - Pararenal fat - another layer of fat, thicker posterior to Gerota’s fascia
25
Kidney has four layers surrounding kidney:
1) Renal capsule
- True capsule
- Fibrous capsule
2) Perinephric fat
- Adipose capsule
- Packing fat of Zuckerkandl
3) Perirenal fascia
- Perinephric fascia
- Fascia of Gerota
4) Pararenal fat
- Pararenal body
26
Why do the kidneys need all of these layers?
Perirenal fat and Pararenal fat (layers 2 and 4)
--> accommodate movement during respiration
The renal fascia anchors the kidneys and limits any infection arising from them.
27
Alternate names: Kidney
1. Perinephric fat = adipose capsule = packing fat of Zuckerkandl
2. Fascia of Gerota = perirenal fascia = perinephric fascia
3. Pararenal fat = pararenal body
4. Renal capsule = true capsule = fibrous capsule
28
2 distinct areas of Kidney
- Peripheral parenchyma
- Central sinus
29
Renal parenchyma consists of two areas:
- Cortex
- Medulla
30
Renal cortex
what portion?
contains what?
- Outer portion
- Contains the renal corpuscle and the proximal and distal convoluted tubules of the nephron
- Nephrons are the functional units of the kidney
31
Medulla
- Inner portion
- Consists of 8 to 18 medullary pyramids, which contain the loops of Henle
32
Medullary pyramids
Apex
- Narrow tip
- Sits within a minor calyx
Base
- Abuts the renal cortex
33
Renal pyramids:
a series of triangular structures that compose the medullary substance
Vary from 8 to 18 in number
Base of pyramid is toward the outer circumference of the kidney
The apices (narrow tip) converge toward the renal sinus
34
Renal Papilla
- apex of medullary pyramid
- The prominent Papilla project into the lumen of minor calyces
Separated from each other by bands of cortical tissue
--> Column of Bertin
35
Columns of Bertin
- Bands of cortical tissue
- Separate the medullary pyramids
36
Renal lobes
Portion of the kidney that consists of a single pyramid bordered by arteries and veins
37
Renal sinus
- Central portion of the kidney
- Houses the renal artery and vein, fatty fibrous tissue, nerves, and lymphatics
- Divided into collecting system and hilum
38
Collecting system
Where urine flows out and makes its way to the bladder
Infundibulum
- Minor and major calyces
Renal pelvis
- Upper expanded end of ureter
- Receives urine from major calyces
39
Renal hilum
- Indentation of the medial aspect of MP
- Medial portion of the renal sinus, where the renal artery enters the kidney and the renal vein and ureter exit
40
Infundibulum
- Consists of major calyces and minor calyces
- There are 2-3 major calyces that further divide into 2-3 minor calyces
41
Renal Pelvis
- Upper expanded end of the Ureters
- Receives urine from the major calyces
42
Main renal arteries
- Arise from the abdominal aorta
- Segmental
- Interlobar
- Arcuate
- Interlobular
43
Renal veins
- Drain into inferior vena cava
- Left renal vein receives blood from left suprarenal and gonadal veins
44
Sonographic appearance:Renal Cortex
Homogeneous & hypoechoic/isoechoic to liver parenchyma
45
Sonographic appearance: Renal Medulla
- Consists of the pyramids
- Triangular or round
- Anechoic when filled with urine, otherwise not visible
46
Sonographic appearance: Renal Sinus
- Hyperechoic ovoid central portion
- Irregular borders
- Echogenic due to dense fat and fibrous tissue
- Renal pelvis and infundibulum are not seen if collapsed, if urine filled they appear anechoic
47
Criteria for changes on sonograms: Type 1 changes
1) The echo intensity in the cortex must be equal to or greater than that in the adjacent liver or spleen
2) the echo intensity in the cortex must be equal to that in the adjacent renal sinus.
--> Minor signs would include the loss of identifiable arcuate vessels and the accentuation of corticomedullary definition.
48
Criteria for changes on sonograms: Type 2 changes
focal disruption of normal anatomy with any mass lesion, including cysts, tumors, abscesses, and hematomas
49
Sonographic Appearance of the Kidneys - Adult: Renal capsule
Hyperechoic thin, continuous, highly reflective line visualized along periphery of kidney
50
Sonographic Appearance of the Kidneys - Adult: Renal cortex
- Midgray or medium- to low-level homogeneous echo pattern
- Hypo- to isoechoic to normal liver or spleen
51
Sonographic Appearance of the Kidneys - Adult: Renal medulla
Triangular, round, or blunted anechoic areas when urine filled and are otherwise not visible
Anechoic pyramids have a distinctive and readily identifiable appearance
52
Sonographic Appearance of the Kidneys - Adult: Renal sinus
Bright, echo-dense, ovoid central portion of the kidney with irregular borders
53
Sonographic Appearance of the Kidneys - Pediatric: Renal cortex
Hyperechoic relative to cortex in adult kidney
54
Sonographic Appearance of the Kidneys - Pediatric: Renal medulla
Easily visible
Anechoic
55
Renal Contour and Size
Smooth borders
- 9-12 cm length
- Varies with size of person and age
- Cortex outer layer decreases with age
--> Known as “parenchymal reduction” measure of AP thickness
--> Minimum of 1cm cortical thickness
56
Muscles
Sonographic Appearance of Perinephric fat
- Quadratus Lumborum
- Psoas muscle
Hyperechoic to cortex (*with a normal kidney)
57
Renal detail may be obscured if the patient has
hepatocellular disease, gallstones, rib interference or other abnormal collection between the liver and kidney.
58
If collecting system full will appear
anechoic
59
Sonographic appearance in hydrated patient
- May be anechoic areas due to collecting system being dilated
- Called transient pyelectasis (occurs with some patients when they have a full bladder)
- Post void scan- pyelectasis should mostly resolve
60
Renal Vasculature
- Anechoic lumens surrounded by bright walls
- In the transverse kidney the vessels are in long axis
- RRA courses posterior to the IVC
- LRV courses anterior to the Aorta, posterior to the SMA
61
Ureters
No typically visualized, unless dilated
Urethral Jets
- Observed in real time
- Where the ureters enter the bladder at the trigone
--> Ureterovesical junction
- Use colour doppler to assess urine passing into bladder
62
bladder
size and shape depending on?
should be ...
short axis:
long axis:
- Size and shape varies depending on quantity of urine
- Should be symmetric
Short axis
- Somewhat squared by lateral psoas muscles
Long axis
- Posterior maybe indented by the uterus or prostate
63
Bladder
- Lumen not visible if the bladder is collapsed (empty)
- If distended the lumen is anechoic
Wall
--> Distended: appears smooth, hyperechoic outline
--> Collapsed: thicker and echogenic
Bladder Volume
- Prevoid and Postvoid
64
Bladder Volume
L (cm) x W(cm) x H(cm) x 0.523= cc or mL
65
Urethra
Difficult to visualize due to location
Anechoic lumen with hyperechoic walls
Can be seen transvaginally
66
how to position patient when scanning renal vessels?
what renal vessels?
arteries --> LLD (Left Lateral Decubitus) or supine
RRA – Right Renal Artery
RRV – Right Renal Vein
LRA – Left Renal Artery
LRV – Left Renal Vein
67
Principle functions of urinary system
Kidneys:
Ureters:
Bladder:
Urine production and homeostasis
Function independently
Kidneys: remove waste from blood and produce urine
Ureters: connects the hilum of the kidneys to the bladder, drains urine from kidney to bladder
Bladder: collects urine, stores it and eventually expels it through the urethra.
68
Urinairy system
produces what?
regulates what?
- Produces urine and erythropoietin
- Influences blood pressure, blood volume, and intake of excretion of salt and water through the renin – angiotensin system
- Regulates serum electrolytes
- Regulates acid-base balance
69
kidneys control what
Kidneys control the amounts of water and electrolytes leaving the body
70
what is the basic functional unit of the kidney
The nephron is the basic functional unit of the kidney
71
urine formation involves:
Glomerular filtration
Tubular reabsorption
Tubular secretion
72
Nephron
Functional unit of the kidney
Function: filter the blood and to produce urine
2 main structures: renal corpuscle and renal tubal
Renal corpuscle: filters blood
--> Includes: bowman's capsule and glomerulus
Renal tubule: filtered fluid pass through
--> Includes: proximal and distal convoluted tubules, loop of Henle and collecting duct
As the filtrate is passing through tubule substances needed by the body are reabsorbed into the blood
Waste products and excess water pass into collecting ducts as urine
73
Renal corpuscle
Glomerulus- a network of capillaries, surrounded by bowman capsule – a cuplike structure
74
Afferent arterial:
Efferent arterial:
Blood reaches nephron via:
Afferent arterial: blood flow into the Glomerulus
Efferent arterial: blood flow from the Glomerulus
Blood reaches nephron via:
--> Renal artery to interlobar artery to arcuate arteries to interlobular arteries that branch into afferent arterioles
75
Nephron Filtration:
- 1st step
- Takes place at the glomerulus
- Afferent arterioles carry blood in and due to a pressure gradient plasma-like fluid is filtered into Bowman’s capsule
- Filtrate contains: water, salts, glucose, urea and amino acids
- Osmotic pressure forces water to return to the blood stream
76
Tubular reabsorption
what is it?
includes what?
occurs where?
happens via what?
Substances in the filtrate that are useful to the body are reabsorbed into the bloodstream
Include: water, glucose, vitamins, amino acids, bicarbonate ions and chloride salts of magnesium, sodium, calcium and potassium
Occurs in the proximal convoluted tubule and the ascending and descending loop of Henle
Happens via active transport
77
Tubular secretion
- Waste substances are secreted into the distal convoluted tubule
--> Includes: ammonia, drugs, hydrogen and potassium
- Controlled via active transport
- Urine exits the distal tubule into the collecting tubule/duct
- The urine is then conveyed to the renal pyramid, then the minor calyx, major calyx and into the renal pelvis
78
Nephron - Protective Mechanisms to sustain homeostasis
- Antidiuretic hormone (ADH)
- Aldosterone hormone
- Juxtaglomerular apparatus
- Erythropoietin hormone
79
Antidiuretic hormone (ADH)
- A decrease in blood volume stimulates the release of ADH from the pituitary gland
- Increase the amount of water returned to the bloodstream from the distal tubule
80
Aldosterone hormone
- Produced by adrenal cortex
- Causes salt and water to be reabsorbed into the bloodstream from the distal tubule
81
Juxtaglomerular apparatus
Helps regulate BP
- modified cells of the distal convoluted tubule and afferent arterial to help regulate blood pressure.
- When a decrease in blood volume is detected renin is released, from cells in the afferent arteriole, acting on angiotensinogen in the blood to increase systemic pressure
82
Erythropoietin hormone
Released in response to decreased oxygen
Causes RBCs to be produced and released into the bloodstream, this enhances the ability of the blood to carry oxygen
83
PRINCIPLE METABOLIC WASTES:
Water
Carbon dioxide
Nitrogenous wastes (urea, uric acid, creatinine (Cr)
84
URINALYSIS
Urine pH
Specific gravity
Blood
85
SPECIFIC GRAVITY
Ability of the kidneys to concentrate urine
Dependant on quantity of dissolved waste products
Decreased SG with low fluid intake and XS perspiration or diarrhea
Renal failure, glomerulonephritis and pyelonephritis that case tubular damage
86
BLOOD TESTS
Hematocrit
Hemoglobin
Protein
Creatinine clearance
Blood Urea Nitrogen
87
Hematocrit
Ratio plasma to packed cell volume in blood
With acute hemorrhagic processes from disease or trauma
88
Hemoglobin
Destruction of erythrocytes
Renal injury
Acute renal failure
89
Protein
- Glomerular damage
- Albumin and plasma proteins get filtered excessively
- Proteins then enter urine lowers blood serum albumin concentration
- Benign and malignant neoplasms, calculi, chronic infection, pyelonephritis
90
Blood Urea Nitrogen (BUN) & Creatinine (Cr)
Measure the amount of nitrogenous waste
Dictate the ability to get rid of waste
91
BUN
Blood Urea Nitrogen (BUN)
Urea = end product of protein metabolism and is readily excreted , CONCENTRATION IS NORMALLY LOW
- BUN level measures RENAL FUNCTION
BUN level rises:
- Kidneys ability to excrete urea is impaired or reduced renal blood flow (dehydration and urinary tract obstructions)
Elevated BUN:
May lead to mental confusion, disorientation and coma
92
There may be a ____ loss of renal function before the blood levels are elevated on these tests
50%
93
Serum Creatinine
- Nitrogenous compound formed as an end product of muscle metabolism
--> Formed in muscle in small amounts, passed into blood and excreted in urine
- Elevation in creatinine means disturbance in renal function
94
Indications for an U/S
Increase in Cr or BUN levels
Urinary tract infection (UTI)
Flank pain/back pain
Hematuria
Hypertension
Decrease in urine output
Trauma
Evaluate mass or structures seen on previous imaging (CT, MRI etc. )
Abdominal Sonography
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