URINARY SYSTEM
URIN – OSPE
FAISAL W. ALKHARJI
F.W.K - URIN
Anatomy _________________________________________________ 3
Embryology [Not complete/confirmed yet] ________________________ 14
Histology ________________________________________________ 21
Pathology _______________________________________________ 25
Microbiology_____________________________________________ 32
Radiology _______________________________________________ 40
https://learningcenter.unc.edu/tips-and-tools/enhancing-your-memory/
Dr.Alkharji@protonmail.com
‫ ويا مؤتي لقمان الحكمة وفصل الخطاب آتني الحكمة وفصل الخطاب‬،‫ ويا مفهم سليمان ف ّهمني‬،‫اللهم يا مع ّلم موسى ع ّلمني‬
‫ حسبنا هللا ونعم الوكيل‬،‫ إنك على كل شيء قدير‬،‫ وأسرارنا بطاعتك‬،‫ وقلوبنا بخشيتك‬،‫ اللهم اجعل ألستنا عامرة بذكرك‬- .
Good luck! :)
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Anatomy
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Identification: Kidney
Fibrous capsule of the kidney
Renal Column, Extension of Cortex
Renal A.
Renal Medulla
Major Calyx
Renal Papilla
Renal Cortex
Renal V.
Renal Pelvis
Renal Sinus
Renal Pyramid
Ureter
Minor Calyx
Renal Column
Renal Cortex
Renal Pyramid
Renal Fat
Renal Cortex
Renal Medulla
Renal Pelvis
Minor Calyx
Fibrous capsule of
the kidney
Major Calyx
Ureter
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Renal A.
Renal Pyramid
Renal Column
Origin: Aorta
Renal V.
Drains into IVC
Renal A.
Ureter
Renal Cortex
Renal V.
Psoas Muscle
Ureter
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In Anterior view, vessels are in order as
Renal V. → Renal A. → Ureter
Left Kidney
From the posterior view it is opposite
Posterior View
Anterior view
Left Kidney
IVC is closest to the right kidney with
shortest renal V.
Where Aorta on the Left kidney, with
shortest Renal A.
Anterior relations to Right Kidney:
Suprarenal gland, Liver, Duodenum,
Right Colic Flexure, Illeum
Anterior relations to Left Kidney:
Suprarenal gland, Stomach, Spleen,
Splenic artery, Pancreas, Jejunum, Left
colic flexure
Right Kidney
Posterior Relations to Both Kidneys:
Right Kidney
12th rib on right kidney,
11th,12th rib on left kidney,
Diaphragm, Psoas major, Quadratus
lumborum, Transversus abdominis
muscles
Subcostal, Illiohypogastric, ilioinguinal
nerves
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Renal Corpuscle includes Glomerulus & Bowman’s Capsule
Arcuate A.
Segmental A.
Podocytes found in visceral layer of Bowman’s Capsule
Macula Densa present in DCT
Interlobular A.
Distal Convoluted Tubule
Interlobar A.
Proximal Convoluted Tubule
Loop of Henle
Thin descending limb
Collecting duct /
distal = Papillary duct
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PCT
DCT
Renal Corpuscle includes.
Glomerulus
Bowman’s Capsule
Glomerulus
Afferent Arteriole
Interlobular A.
Podocytes on visceral
layer of Bowman’s
capsule
Afferent Arteriole
Arcuate A.
Loop of Henle
thin descending limb
Macula Densa in DCT
tube
Collecting duct =
Distal portion ~ Papillary duct
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Ureteric Orifice
LT. Ureter
Posterior Surface (Base)
Trigone of bladder
Internal Urethral Orifice
Detrusor Muscle
Ureter
Female urethra
External Urethral sphincter
Posterior
Surface [Base]
Ampulla of Vas
Superior Surface
Apex
Urachus /
Median Umbilical Ligament
Detrusor Muscle
Internal urethral sphincter
/ Neck of bladder
Urogenital
Diaphragm /
External Sphincter
Inferolateral Surface
Prostate
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Male
Female
Ureteric Orifices / Opening of ureter
Superior Surface
Trigone of Bladder
Detrusor Muscle
Inferolateral Surface
Prostatic Urethra
Inferolateral Surface
Neck of bladder
Trigone of Bladder
External Urethral Sphincter
Within urogenital Diaphragm
Female Urethra
Internal Urethral Opening
Trigone of Bladder
External Urethral Opening
Trigone of Bladder
Prostatic Urethra
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Rectum
Internal Urethral
Opening / (Meatus)
Internal Urethral Sphincter
External Urethral Sphincter
Navicular Fossa
External Urethral
Opening / (Meatus)
Prostate
Prostatic Urethra
Membranous Urethra
Prostatic Urethra
Membranous Urethra
Penile/Spongy Urethra
Penile/Spongy Urethra
Navicular Fossa
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Inferior surface:
Superior surface:
Prostate gland in males
• Covered with
peritoneum
•
•
Urogenital diaphragm in females
coils of ileum & sigmoid
colon in males
Posterior Surface (Base):
In females body of uterus
& uterovesical pouch
▪ Males: Rectovesical
Pouch, Vas deferens,
Seminal Vesicle,
Rectum
▪ Females:
Apex of bladder:
• pubic Symphysis
• umbilicus by Median
umbilical ligament
(Remnant of
urachus)
Vagina
Pubis
Inferolateral surface:
▪ Retropubic pad of fat
▪ Pubic bones
Penile/Spongy Urethra
▪ Levator ani muscle
Navicular Fossa
External Urethral Opening
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Uterus
Internal Urethral Opening
External Urethral Sphincter
External Urethral Opening
Female Urethra
Vagina
Vulva Vestibule
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Embryology
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Renal agenesis
Too many kidneys (doubling)
Rotational anomalis:
This anomaly is relatively
frequent.
If the pyelo-ureteral
connection is oriented:
Ventrally (missing rotation)
Polycystic Kidneys
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Disorder of the ascent of the
kidneys or ectopic kidneys:
•A kidney is ectopic when,
without ptosis, it does not lie
in the lumbar fossa.
•The ectopia is the result of an
incomplete or missing ascent.
Horseshoe kidney
The two kidneys are most
often bound together at the
lower pole.
It is usually at the lumbar
level since its ascent is
usually arrested by the
inferior mesenteric artery
In a crossed ectopia a kidney
migrates to the other side.
•Its ureter crosses the midline
and inserts normally into the
bladder.
•In the case of a unilateral
crossed ectopia a fusion of the
two kidneys often occurs.
•It can occur in the upper or
lower region (pelvic kidney) or
even crossed.
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Congenital ureteral abnormalities
Course anomalies of the
ureter Retrocaval ureter:
In this abnormality the right
ureter traces out an "S" at the
L4 level behind the vena cava
(retrocaval ureter).
Anomalies of the ureteral
diameter Primary
megaloureter
due to an obstruction: The
cause of this abnormality is a
constriction in the terminal
part of the ureter, leading to a
dilatation.
Complete doubling of ureter:
Here a complete doubling of
the ureters with a second renal
pelvis is involved. The ureters
empty into the bladder.
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Bladder Defects
Urachal fistula=
Urachal cyst=
Urachal sinus=
Persistance of intraembryonic
portion of the allantois ( urine
drains through umblicus).
Persistance of local area of
allantois
Persistance of the upper part
of allantois
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Hypospadius
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Exstrophy of the cloaca:
is a severe ventral body wall defect
Exstrophy of the bladder:
is a ventral body wall defect
The defect includes exstrophy of the
bladder, spinal defects ,imperforate anus,
and usually omphalocele.
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Histology
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Kidney
#
1
Identification Points
Cortex & Medulla
2
Renal corpuscles
3
Tubules (Proximal , Henle & Distal)
4
Collecting ducts.
Macula Densa
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Ureter
#
Urinary Bladder
#
1
Identification Points
Stellate Lumen
1
Identification Points
//////////////////////////////////////////
2
Transitional epithelium & Submucosa
2
Transitional epithelium
3
Muscle layers:
(inner longitudinal, middle circular,
Outer longitudinal)
Adventitia
3
Muscle layers:
(inner longitudinal, middle circular,
Outer longitudinal)
Adventitia
4
4
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Penile Urethra
#
Female Urethra
#
1
Identification Points
Pseudostratified columnar
epithelium & stratified columnar
1
Identification Points
Transitional epithelium
2
Corpus spongiosum
2
Adventitia
3
Urethral Glands of Littre
(Mucus glands)
3
Muscle layers:
(inner longitudinal, middle circular,
Outer longitudinal)
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Pathology
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Case-1
A 5-year-old boy is noted to have generalized edema.
Urine analysis reveals, pH 6.5, no glucose, 4+ protein, no blood, no ketones.
A renal biopsy was taken and the child improved following a course of corticosteroid therapy.
What is the most probable diagnosis of the case?
Minimal change glomerular disease.
What is the most common cause of the same syndrome in adults?
Membraneous glomerulonephritis.
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Case-2
An 8-year-old boy presents with headaches and malaise. He was seen for a severe sore throat 2 weeks ago .
Physical examination reveals periorbital edema. The blood pressure is 180/110 mm Hg.
A 24-hour urine collection demonstrates oliguria, and urinalysis shows hematuria. A renal biopsy was taken.
What is the diagnosis of the case?
Post streptococcal glomerulonephritis .
What is the expected outcome ?
Good prognosis.
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Case-3
A 70-year-old obese woman presents with a 3-month history of progressive renal insufficiency. She has a longstanding history of
hypertension. Ultrasonography shows that both kidneys are small. The patient subsequently suffers a massive stroke and died.
Examination of the kidneys at autopsy reveals symmetrically shrunken small kidneys, with coarsely granular surface. The pelvicalyceal
system was distorted and covered by yellowish exudate.
What is your diagnosis of the case?.
Chronic pyelonephritis.
Mention two possible complications.
Bilateral/ chronic renal failure.
Hypertension.
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Case-4
A 59-year-old man notes blood in his urine for the past week. Urine analysis confirms presence of blood, but no proteinuria or glucosuria.
A urine culture is negative. A cystoscopy is performed, and a 9 cm exophytic mass is seen in the dome of the bladder. A biopsy of this mass
is performed and microscopic examination reveals fibrovascular cores covered by a thick layer of transitional cells.
The musculosa propria is free.
What is your diagnosis of the case?
Papillary transitional cell carcinoma.
What are the risk factors that most likely lead to development of this lesion?
Cigarette smoking, Bladder stones, Schistosoma Haematobium
exposure/Usage of Naphthylamine, Analgesics, Cyclophosphamide, Radiation to bladder
What is the stage of this lesion?
pT 1
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Case-5
A 60-year-old woman died of a renal tumor. At autopsy, the kidney was enlarged and shows a well circumscribed golden
yellow mass measures about 9 X7 cms. Infiltrated kidney capsule and renal vein. – Microscopic examination of the lesions
revealed nests of epithelial cells with clear cytoplasm surrounded by vascular stroma.
What is your Diagnosis?
Clear cell renal cell carcinoma.
What are the risk factors that most likely lead to development of this lesion?
Cigarette smoking, Obesity, Hypertension
Unopposed estrogen therapy, Exposure to asbestos, petroleum products, & heavy metals.
Acquired polycystic kidney disease secondary to dialysis.
Mention the stage of this tumor.
3rd Stage
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Case-6
A child aged 4 years admitted to the hospital
due to a left renal mass. He underwent
left nephrectomy and the kidney was
examined microscopically.
- What is your diagnosis?
Wilms tumor nephroblastoma.
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Microbiology
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1,2- fMethods of urine cultivation & 3- determination of antibiotic sensitivity
1- Four Quadrant streaking method
Method
Name
C.L.
Significance /
Principle of
test
2- Network streaking method
3- Antibiotic Sensitivity Test
Four quadrant streaking
Network streaking
Plate spreading method
Isolation of different bacterial species in case
of urinary tract Co-infection
[e.g. E.coli & Staphylococcus co-infection]
⎯ Calculation of CFU/ml in urine or
⎯ Detection of significant bacterinuria
[e.g.: for midstream catch urine X > 105 CFU/ml]
Disc-diffusion;
(Antibiotic diffusion in agar)
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Isolation of Lactose Fermenter Bacilli
Isolation of Lactose Fermenter Bacilli
Species
Gram’s negative bacilli
Sample
On CLED agar: (Urine Sample)
& MacConkey’s Agar
E.coli | Klebsiella | Others
Suspected
Microbe
Tests required
for further
identification
1- IMVC Test
2- API-20-E Test
CLED agar
MacConkey’s Agar
E.coli
Klebsiella
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Tests required for further identification of Lactose fermenter bacilli
1- IMVC Test
Test name
2- API-20-E Test
IMVC Test
[For lactose fermenter Gram’s negative bacilli]
Base I.D
Suspected
E.coli
Suspected
Klebsiella
E.coli
API-20 E System
[Biochemical identification of Gram’s negative bacilli
isolated from urine]
Indole
+
Methyl-red
+
Vogus-Prosk
-
Citrate
-
-
-
+
+
Klebsiella
Define the microbe number after substrate color changes
induced by microbial enzymes
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Isolation of Non-lactose fermenter bacilli
Isolation of Non-lactose Fermenter Bacilli
Species
Gram’s negative bacilli
Sample
On CLED agar: (Urine Sample)
Suspected
Microbe
Tests required
for further
identification
Proteus | Pseudomonas Aeruginosa
1- Swarming growth on blood agar &
I.D: Proteus
Confirmatory Test: Urease positive
Caused by: Cystitis | Pyelonephritis | Sepsis
2
1
2- Exopigment production on nutrient agar &
I.D: Pseudomonas Aeruginosa
Confirmatory Test: oxidase positive
Caused by: Cystitis | Pyelonephritis | Sepsis
`
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Gram’s Positive Cocci
Isolation of Gram’s Positive Cocci from urine sample
Selective media required for I.D:
Mannitol Salt Agar:
▪ Suspecting organisms: Staph. Aureus | Staph. Saprophyticus
⎯ Confirmatory Test for Differentiation – Coagulase Test:
1- Positive Coagulase: Staph. Aureus
2- Negative Coagulase: Staph. Saprophyticus
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Candida Albicans from Urine Sample on Sabouraud’s Dextrose agar:
Selective Media: Sabouraud’s Dextrose Agar
Rapid Confirmation test: Positive Gram Tube Test
Infection Cause by: C. Albicans [Urethritis, Cystitis, and vaginitis]
Microscopy of:
Gram’s positive budding yeast cells – Suspected microbe Candida Species
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Microscope:
Couples of Schistosomiasis Hematobium
Classification: Trematodes
Diagnostic Stage: Ova w/ Terminal Spine
Infective Stage: Cercaria
Disease cause by it:
Parasitic Cystitis or Kidney-liver fibrosis
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Radiology
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Imaging modality:
Imaging examination:
Abdominal X-ray
X-ray – Intravenous Urography
Name of the instrument [Yellow arrows] :
Anatomy in descending order:
⎯ Double J stent.
Left Kidney, Right Ureter , Urinary bladder
Imaging examination:
Ultrasound
Anatomy:
Urinary bladder
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(a)CT Section through a bladder without contrast opacification.
(b) CT after contrast - an opacified bladder showing.
Normal CT of kidneys
(a) Before the intravenous contrast
(b) CT after intravenous contrast (Early)
(c) CT following the contrast infusion (Late)
(d) CT after contrast - Section through pelvis showing ureters (arrows).
Imaging examination: CT scan
Anatomy:
A- Left Kidney
D- Left Ureter
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Imaging examination:
Imaging examination: MRI: [B. Transverse | C. Coronal]
CT reformat – The ureter has been
reformatted in the coronal plane
Anatomy
Anatomy in Descending order:
Kidney, Ureter, Bladder
A, C Kidney
D. Urinary Bladder
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Imaging modality / examination:
Imaging modality / examination:
Imaging modality / examination
99mTc DTPA renogram, serial images.
Renal arteriography
Coronal – Magnetic resonance angiogram
Anatomy Descending order:
Anatomy:
Anatomy: Renal artery & Kidney
Kidney & Urinary bladder
Kidney & Renal Artery
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Imaging modality / examination:
Conventional (Catheter) Angiography
Imaging modality / examination:
Magnetic Resonance Angiography
Anatomy:
Anatomy:
Renal Artery
Kidney, Renal Artery
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Imaging modality: Ultrasound
Structures:
Renal capsule
Renal cortex
Renal medulla (Pyramids)
Imaging modality: CT 3D of kidneys
Imaging modality:
Coronal MRI of kidneys
Anatomy:
Left Kidney
Renal sinuses
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