1. Chapter 18
The Urinary System
9/9/10 Classroom ed.

2. Urinary System Often called the excretory system Two kidneys
Two ureters
One urinary bladder
One urethra

3. Kidneys 2 bean shaped bodies situated behind peritoneum
Asymmetrical - left is slightly longer and narrower than right
How come Rt kidney slightly lower than Lt kidney?
Liver
Lie in an oblique plane (opposite si jt direction)
Normally extend from T-12 to L3

4. Kidney Function Remove waste products from blood
Maintain fluid and electrolyte balance
Secrete substances that affect blood pressure
How much urine excreted per day?
1 - 2 liters

5. Kidneys (cont’d) Minor calyces unite to form major calyces
Major calyces unite to form renal pelvis
Renal pelvis then drains into ureters
Hilum - longitudinal slit in medial border for transmission of blood vessels, nerves, lymphatic vessels, and ureter

6. Kidneys (cont’d)
Essential microscopic components of kidney called nephrons
How many nephrons per kidney? about 1 million

7. Neprons
Collecting ducts drain into minor calyx

8. Adrenal Glands Cannot be seen on plain radiographs
Not part of urinary system
Chiefly responsible for regulating stress response through adrenaline etc

9. Ureters Two tubes 10 - 12 “ long Retroperitoneal
Extend from renal pelvis
Enter bladder at ureteral orifice
How is urine moved through ureters?
peristalsis

10. Urinary Bladder
Musculomembranous sac situated immediately posterior and superior to symphysis pubis of pelvis
Serves as Urine reservoir

11. Urinary Bladder How much fluid can bladder hold?
up to 500 mL
Urethral orifice located in bladder neck
Area between ureteral openings and urethral orifices is trigone

12. Urethra Carries urine from bladder to? exterior of body
How long is it in females?
About 1.5
In males?
About 7 to 8
Sphincter at neck of bladder controls flow
Male urethra contains following parts:
Prostate
Membranous area
Spongy area

13. Prostate Gland surrounding proximal part of male urethra
Considered part of male reproductive system, but due to location, often described with urinary system
Prostate secretes fluid that mixes with seminal fluid to create ejaculate

14. Radiography of Urinary System aka Urography
Radiographic investigation of renal drainage or collecting system

15. IVU- Intravenous Urogram !
Formerly erroneously known as IVP-Intravenous pyelogram!
pyelo refers to renal pelvis and calyces only
study also shows ureters, bladder, and sometimes urethra

16. Indications For Urography
Demonstrate physiologic function and structure of urinary system
Evaluate abd. Masses, renal cysts and tumors
Urolithiasis (stones)
Pyelonephritis (Inflammation of kidney)
Hydronephrosis (distension of renal pelvis and calyces with urine)
Effects of trauma
Pre-op evaluation
Renal hypertension

17. Contraindications Inability to filter contrast medium from blood
Allergy to contrast
Abnormal BUN and Creatinine levels

18. Preparation Of Pt
Pt should follow low residue diet for 1-2 days prior to exam
laxative taken day before
NPO after midnight
Pts with multiple myeloma, high uric acid levels, or diabetes should be well hydrated before IVP exam
Dehydration leads to increased risk of renal failure

19. Contrast Media Antegrade filling
Must be used to visualize urinary tract
Iodinated, water-soluble contrast administered intravenously to examine system
Antegrade filling

20. Contrast Media
Excretory urography (IVU) generally uses a 50 to 70% iodine solution
Lower concentrations for bladder studies due to large amount required to fill bladder (30%)
Non-ionic contrast is generally used
More expensive, but-
Patients less likely to have reactions with nonionic

21. Contrast Media and Adverse Reactions
Crucial not to leave pt alone for first 5 minutes after injection!
Mild reactions
warmth
flushing
hives, Nausea/Vomiting, respiratory edema (accumulation of fluid in lungs)
Severe reactions
Anaphylactic shock (sudden allergic response associated with a sudden drop in blood pressure and difficulty breathing). Can lead to death in a matter of minutes)

22. Injection Procedure Obtain allergy history Explain exam to pt
Prepare contrast and supplies (sterile tech.)
Assist radiologist as necessary or
Perform injection if IVcertified

23. Injection Supplies (cont.d)
Tourniquet
IV arm board
Towels
Emergency kit
Emesis basin
Alcohol wipes, hibiclens, or povidone iodine wipes or swabs
Contrast
19-22 G needle, butterfly or angiocath for infusion
Extension tubing
Tape or clear-type dressing

24. IVU Procedure Scout – KUB Contrast is injected
Timed sequence of films obtained until bladder begins to fill-
Immediate image of kidneys
5 minute image of abd. or kidneys
Compression applied

25. Ureteral Compression Applied over distal ends of ureters
Inhibits flow of urine into bladder
Distends renal pelvis and calyces
Compression device should be centered at ASIS

26. Ureteral Compression (cont’d)
As much compression as pt can tolerate!
Should not be applied when:
stones, abd. mass or aneurysm, colostomy, suprapubic catheter, recent abd. surgery or trauma
(Because of improvement of contrast agents, compression no longer generally used)

27. IVU Procedure cont’d Tomograms are obtained once bladder is filled
Pt is measured, divide number by 3, cuts begin there
Pt. measures 30cm, beginning cuts at 10cm
Release compression slowly
Have pt void, and obtain post-void film

28. Radiation Protection Radiographer is responsible!
Gonadal shield - if it does not interfere with examination objective
Close collimation
Avoid repeat exposures
Shield males for all urinary studies, except when urethra is of primary interest

29. Radiation Protection Shield females when IR centered over kidneys
Rule out chance of pregnancy before examination
(Emergency cases may not allow time)

30. Radiographic Positions IVU

31. AP Projection-IVU
KUB
(All exposures at end of expiration for any urinary system study)

32. AP Projection- IVU (cont’d)
Must include entire KUB region
Should include prostatic region on older males

33. Time Delay - IVU
3 minute
6 minutes

34. Time delay- IVU
With compression
9 minutes

35. AP Projection Variations
Trendelenberg
Lower head degrees
Helps demonstrate lower ureters
Upright
Center lower - organs change position
Prone
Demonstrates ureteropelvic region
Fills obstructed ureter in cases of hydronephrosis (distension of renal pelvis and calyces with urine)

36. AP Oblique Projections - RPO/LPO
Patient is supine
Patient rotated to 30 degrees
CR to iliac crest, 2 in. lateral to midline
Center to side up

37. AP Oblique Projections - RPO/LPO
Elevated kidney will be parallel to cassette
Kidney closest to cassette will be perpendicular
Entire KUB region must be included

38. Nephrotomography
Best method for visualizing renal parenchyma (neprons and collecting tubules)
Ability to visualize kidneys free of intestinal content superimposition

40. Retrograde Urography
What does retrograde mean?
Opposite normal flow

41. Retrograde Urography Considered an operative procedure
Pt may be under general anesthesia
Sterile technique is used
Nurse responsible for set-up of exam and pt. care

42. Retrograde Urography Requires catheterization of ureters
Contrast injected directly into pelvicaliceal system via cathethers
Provides improved opacification of renal collecting system

43. Retrograde Urography (cont’d)
Contrast does not enter blood stream
Used for patients with renal insufficiency or contrast sensitivity
Ureters, and collecting systems can be selectively imaged and sampled
Little physiologic information provided

45. Cystography

46. Cystography Radiologic exam of urinary bladder
Contrast administration usually performed retrograde (against normal flow of urine)

47. Excretory Cystogram
Retrograde Cystogram

48. Cystography Indicated for:
Vesicoureteral reflux (backward flow of urine into ureters)
Recurrent lower urinary tract infection
Neurogenic bladder: (dysfunction due to disease of central nervous system or peripheral nerves)

49. Cystography indications cont’d
Bladder trauma
Prostate enlargement
Lower urinary tract fistulae
Urethral stricture
Posterior urethral valves (obstructive congenital defect of the male urethra)

50. Cystography
Contraindications – anything related to catheterization of urethra!

51. “Retrograde” Cystography
Contrast will be drip-infused via a catheter
Bladder will be filled to capacity
Fluoro-spot and overhead films will be obtained

52. Cystography Routine Series
Scout
filled AP
both obliques
lateral
voiding
post-void

53. AP Axial Bladder CR( similar to coccyx projection)
Angled 10 to 15 degrees caudad to center of IR
Enters 2 above upper border of pubic symphysis

54. AP Axial Bladder (excretory method)

55. PA Axial Bladder (prone)CR
Angled 10 to 15 degrees cephalad
Enters about 1”distal to coccyx
Exits just above superior border of pubic symphysisPatient prone
Arms out of anatomy of interest
IR centered to CR

56. AP Oblique Bladder Pt position 40- to 60-degree
RPO or LPO depending on physician preference

57. AP Oblique Bladder CR Perpendicular to center of IR
CR 2 above upper border of pubic symphysis and 2 medial to upper ASIS
If bladder neck and proximal urethra is of interest, 10-degree caudal angle of CR will project pubic bones below them

58. Lateral Bladder Patient position Part position
Lateral recumbent, right or left side
Part position
Knees flexed
MCP aligned to midline
CR to midcoronal plane at 2 in. above symphysis pubis

59. Lateral Bladder Demonstrates anterior/posterior bladder walls
Base of bladder
Any vesicovaginal or vesicorectal fistulae

61. Cystourethrography

62. Cystourethrography Retrograde study to visualize bladder and urethra
Contrast does not enter blood stream
Sterile technique must be used
Nurse will generally perform catheterization

63. Male Cystourethrography
AP Oblique Projection - RPO/LPO
Patient is supine, rotated degrees
Urethral syringe (or Brodney clamp?) is used to introduce contrast
Cunningham Penile Clamp: device used to help control male urinary incontinence.

64. Male Cystourethrography
Images are obtained as contrast is injected
Entire urethra must be visualized
Bladder can be filled to obtain antegrade voiding study
Why is this antegrade if its injected into urethra?

65. Female Cystourethrography
Retrograde
AP Projection (maybe obliques)
Bladder can be filled and patient void for antegrade studies
Cassette should be centered as for cystography
Abduct thighs to prevent superimposition of bone or soft tissue

66. Incontinence Studies Positioning is same as retrograde cystography
On lateral films, pt. asked to strain to demonstrate any prolapse or incontinence

67. Metallic Bead Chain Cystourethrography
To evaluate stress incontinence in females only
Beaded chain inserted in Urethra
Shows anatomic changes in shape and position of anatomic floor
Valsalva tech. applied for comparison

68. Voiding Cystourethrogram
X-ray images of bladder and urethra during urination
Follows cystogram - urinary catheter removed
Pt. urinates into special radiolucent urinal as images taken .

69. Voiding Cystourethrogram cont’d
Shows size and shape of bladder under stress caused by urination
Demonstrates urethra functioning
Most commonly used for young girls with history of recurrent bladder infections

70. The End