WEEK 2: Resource Session: Urinary Tract Pathology

Question 1

Glomerular diseases constitute some of the major problems in nephrology.

Chronic glomerulonephritis is one of the most common causes of chronic renal failure.

State the causes of Primary glomerulonephritis/ glomerulopathy and Secondary glomerulopathy.

Answer 1

*Primary glomerulonephritis/ glomerulopathy
Primary glomerulopathies refer to conditions where the kidney itself is the main target of the disease, and there is no underlying systemic disorder causing the kidney damage.

*Secondary glomerulopathy: systemic lupus erythematosus (SLE), vascular disorders such as hypertension, metabolic diseases such as diabetes mellitus and amyloidosis have glomerulopathy

Question 2

Describe the following primary glomerulopathies.
1. IgA Nephropathy (Berger’s Disease):
2. Minimal Change Disease:
3. Focal Segmental Glomerulosclerosis (FSGS):
4. Membranous Nephropathy:
5. Membranoproliferative Glomerulonephritis (MPGN):
6. Crescentic Glomerulonephritis:

Answer 2

IgA Nephropathy (Berger’s Disease):
Characterized by the deposition of immunoglobulin A (IgA) in the glomeruli.
It is one of the most common types of glomerulonephritis worldwide.

Minimal Change Disease:
Characterized by minimal changes visible under a microscope.
Common in children and often presents with nephrotic syndrome (proteinuria, hypoalbuminemia, edema).

Focal Segmental Glomerulosclerosis (FSGS):
Involves scarring (sclerosis) of some of the glomeruli.
Can lead to nephrotic syndrome and progressive kidney damage.

Membranous Nephropathy:
Characterized by thickening of the glomerular basement membrane.
Often associated with autoimmune conditions, infections, or certain medications.

Membranoproliferative Glomerulonephritis (MPGN):
Involves both inflammatory and proliferative changes in the glomeruli.
Classified into type I, type II, and type III based on different mechanisms.

Crescentic Glomerulonephritis:
Characterized by the formation of crescent-shaped lesions in the Bowman’s capsule.
Rapidly progressive and can lead to acute kidney injury.

Question 3

Describe the Pathogenesis of glomerular injury.

Answer 3

It is clear that immune mechanisms underlie most forms of primary glomerulopathy and many of the secondary glomerular disorders.

Deposits of immunoglobulins, often with components of complement, are found in the majority of individuals with glomerulonephritis.

IgA nephropathy has been found to be themost commoncause of glomerulonephritis worldwide.

Cell-mediated immune reactions also may play a role

Question 4

Clinical manifestations.

Name 4 systemic conditions that have to be considered in any patient with manifestations of glomerular disease.

Answer 4

SLE, HTN, DM and amyloidosis.

Question 5

The clinical manifestations of glomerular disease are clustered into the five major glomerular syndromes.

Both the primary glomerulopathies and the systemic diseases affecting the glomerulus can result in these syndromes.

Outline them along with their clinical manifestations.

Answer 5

1. Nephrotic Syndrome:

Definition: Nephrotic syndrome is a condition characterized by a group of symptoms that indicate kidney damage.

These symptoms include proteinuria (excessive protein in the urine), hypoalbuminemia (low levels of albumin in the blood), edema (swelling), and hyperlipidemia (elevated levels of fats in the blood).

Underlying Causes: Nephrotic syndrome can be caused by various primary kidney diseases, such as minimal change disease, focal segmental glomerulosclerosis (FSGS), membranous nephropathy, and others.

Clinical Features:
*Massive proteinuria: The kidneys lose large amounts of protein in the urine.
*Edema: Swelling, often around the eyes and in the legs.
*Hyperlipidemia: Elevated levels of cholesterol and triglycerides in the blood.
*Hypoalbuminemia: Reduced levels of albumin in the blood.

2. Nephritic Syndrome:

Definition: Nephritic syndrome is a condition characterized by inflammation of the kidneys, particularly the glomeruli (the filtering units of the kidneys).

It is associated with hematuria (blood in the urine), hypertension (high blood pressure), and decreased urine output.

Underlying Causes: Nephritic syndrome can be caused by various conditions, including poststreptococcal glomerulonephritis, IgA nephropathy, rapidly progressive glomerulonephritis, and others.

Clinical Features:
*Hematuria: Presence of blood in the urine.
*Mild proteinuria
*Hypertension: Elevated blood pressure.
*Decreased urine output: The kidneys may not effectively filter and excrete urine. Low GFR.
*Tea coloured urine
*

3. Rapidly progressing nephritis= acute nephritis, proteinuria, acute and chronic renal failure.
   4.Chronic renal failure= Azotemia
   5.Isolated urinary abnormalities= hematuria, proteinuria

Question 6

What are Tubulointerstitial Diseases?

Tubulointerstitial Diseases are of two types.

Answer 6

Tubulointerstitial diseases refer to a group of kidney disorders that primarily affect the renal tubules and interstitium, which are the structures between the kidney tubules. These diseases can result in inflammation, fibrosis, and damage to the tubules and interstitium, leading to impaired kidney function.

There are various causes and types of tubulointerstitial diseases, but they are generally categorized into two main types:

*Acute tubulointerstitial nephritis (ATIN)
*Chronic tubulointerstitial nephritis (CTIN).

Two major injuries are considered here.
(1) ischemic or toxic tubular injury, leading to acute kidney injury (AKI) and acute renal failure

(2) inflammatory reactions of the tubules and interstitium (tubulointerstitial nephritis).

Question 7

Define Acute kidney injury (AKI) (Acute tubular necrosis, ATN)

Answer 7

*A clinicopathologic entity characterized clinically by acute diminution of renal function.

It is the most common cause of acute renal failure which signifies rapid reduction of renal function and urine flow, falling within 24 hours to less than 400 mL per day.
Retention of nitrogenous waste and creatinine

Question 8

Name the Part of the kidney that is mainly affected by tubular interstitial disease.

Answer 8

Renal tubules and the interstitium surrounding it.

Question 9

Pyelonephritis and Urinary Tract Infection.

What is Pyelonephritis?

Answer 9

Pyelonephritis is a renal disorder affecting the tubules, interstitium, and renal pelvis
one of the most common diseases of the kidney.

Acute pyelonephritis is caused by bacterial infection and is the renal lesion associated with urinary tract infection.

Chronic is a more complex disorder; bacterial infection plays a dominant role, but other factors (vesicoureteral reflux, obstruction) are involved in its pathogenesis.

Question 10

State the Etiology of pyelonephritis

Answer 10

85% of cases of urinary tract infection, are the gram-negative bacilli that are normal inhabitants of the intestinal tract.

By far the most common is Escherichia coli
followed by Proteus, Klebsiella, and Enterobacter.
Streptococcus faecalis, also of enteric origin
staphylococci
fungal

Immunocompromised persons, particularly those with transplanted organs, viruses such as Polyomavirus, cytomegalovirus, and adenovirus

Question 11

Describe the Pathogenesis of Pyelonephritis.

Answer 11

most patients with urinary tract infection, the infecting organisms are derived from the patient’s own fecal flora.

Two routes by which bacteria can reach the kidneys.
(1) through the bloodstream (hematogenous infection) and
(2) from the lower urinary tract (ascending infection).

The hematogenous route is the less common.
Non enteric organisms, such as staphylococci and certain fungi and viruses are the common offenders.

Question 12

State the Clinical feature of pyelonephritis.

Answer 12

pain at the costovertebral angle

systemic evidence of infection, such as fever and malaise.

indications of bladder and urethral irritation, such as dysuria, frequency, and urgency.

The urine contains many leukocytes (pyuria) derived from the inflammatory infiltrate, but pyuria does not differentiate upper from lower urinary tract infection.

The finding of leukocyte casts, typically rich in neutrophils (pus casts), indicates renal involvement, because casts are formed only in tubules.

The diagnosis of infection is established by quantitative urine culture.

Question 13

Describe Chronic pyelonephritis.

Answer 13

Chronic pyelonephritis is a disorder in which chronic tubulointerstitial inflammation and renal scarring are associated with pathologic involvement of the calyces and pelvis.

The kidneys usually are irregularly scarred if bilateral, the involvement is asymmetric.

The hallmarks of chronic pyelonephritis are coarse, discrete, corticomedullary scars overlying dilated, blunted, or deformed calyces, and flattening of the papillae.

Question 14

Unrelieved obstruction almost always leads to permanent renal atrophy, termed hydronephrosis or obstructive uropathy.

State the causes of Urinary Tract Obstruction (Obstructive Uropathy)

Answer 14

Causes:
posterior urethral valves and
urethral strictures,
meatal stenosis
bladder neck obstruction; ureteropelvic junction narrowing or obstruction
severe vesicoureteral reflux.

Question 15

What is Hydronephrosis?

Answer 15

Hydronephrosis is the term used to describe dilation of the renal pelvis and calyces associated with progressive atrophy of the kidney due to obstruction to the outflow of urine.

The kidney may be slightly to massively enlarged, depending on the degree and the duration of the obstruction.

Question 16

State the Clinical Features of urinary Tract obstruction

Answer 16

*Unilateral complete or partial hydronephrosis may remain silent for long periods.

*Bilateral partial obstruction the earliest manifestation is inability to concentrate the urine, reflected by polyuria and nocturia.

*Hypertension is common in such patients

*Complete bilateral obstruction results in oliguria or anuria and is incompatible with survival unless the obstruction is relieved

*Distension of renal capsule of renal capsule may cause pain.

Question 17

What is Urolithiasis (Renal Calculi, Stones)

Answer 17

Urolithiasis refers to the formation of urinary stones or calculi within the urinary system, which includes the kidneys, ureters, bladder, and urethra.

These stones are composed of crystalline substances, such as calcium, oxalate, phosphate, and uric acid, that can precipitate out of the urine and form solid structures.

Stones may form at any level in the urinary tract, but most arise in the kidney.

Urolithiasis is a frequent clinical problem, affecting 5% to 10% of Americans in their lifetime.

Men are affected more often than women, and the peak age at onset is between 20 and 30 years.

Familial and hereditary predisposition to stone formation has long been known.

Question 18

Cause and Pathogenesis Urolithiasis.

State the four main types of calculi.

Answer 18

There are four main types of calculi

(1) calcium stones (about 70%), composed largely of calcium oxalate or calcium oxalate mixed with calcium phosphate

(2) another 15% are so-called triple stones or struvite stones, composed of magnesium ammonium phosphate

(3) 5% to 10% are uric acid stones; and

(4) 1% to 2% are made up of cystine.

Question 19

Describe the Pathogenesis of Urolithiasis.

Answer 19

An organic mucoprotein matrix nucleate stone
increased urinary concentration of the stones’ constituents, such that it exceeds their solubility (supersaturation).

The majority of these patients have hypercalciuria (with or without hypercalcemia).

A low urine volume in some metabolically normal patients may also favor supersaturation.

Magnesium ammonium phosphate stones are formed largely after infections by bacteria (e.g., Proteus and some staphylococci)

Question 20

State the Clinical Features of Urolithiasis.

Answer 20

Stones are of importance when they obstruct urinary flow or produce ulceration and bleeding.

Stone passing into ureters, producing colic, one of the most intense forms of pain, and ureteral obstruction.

larger stones first manifest themselves by hematuria.

Smaller stones by renal colic

Stones also predispose to superimposed infection, both by their obstructive nature and by the trauma they produce.

Question 21

Describe the Tumors of the Kidney under the following.

1.Most common age of occurrence
2. Biologic behavior
3. Most common microscopic feature
4. Clinical manifestation

Answer 21

1. Renal cell carcinoma
   -Adult tumor
   -Malignant
   -Clear cell carcinomas
   -Usually silent/metastasizes
2. Urothelial Carcinomas of the Renal Pelvis
   -Adult tumor
   -Malignant
   -transitional cell) carcinomas
   -Hematuria
3. Nephroblastoma/ Wilms tumors
   -Children
   -Malignant
   -embryonic renal blastema
   -Abdominal mass.

Question 22

What is cystitis?

State the common etiologic agents of cystitis.

Answer 22

Infection
Calculus
Tumors
Infections of the Urinary bladder mucosa: cystitis

Cystitis: inflammation of bladder mucosa

The common etiologic agents of cystitis are the coliforms: Escherichia coli, followed by Proteus, Klebsiella, and Enterobacter

Women are more likely to develop cystitis as a result of their shorter urethras.

Schistosomiasis (Schistosoma haematobium) is common in certain Middle Eastern countries, notably Egypt.

Question 23

State the Predisposing factors for cystitis.

Answer 23

Include bladder calculi, urinary obstruction, diabetes mellitus, instrumentation, and immune deficiency.
Most cases of cystitis take the form of nonspecific acute or chronic inflammation of the bladder.

Question 24

URINARY BLADDER NEOPLASMS

Answer 24

About 95% of bladder tumors are of epithelial origin, the remainder being mesenchymal tumors.

Most epithelial tumors are composed of urothelial (transitional cell) type and are thus interchangeably called urothelial or transitional tumors.

Urothelial tumors can be benign like papilloma and aggressive cancers associated with a high risk of death.

Many of these tumors are multifocal at presentation.

There are two distinct precursor lesions to invasive urothelial carcinoma.
*non-invasive papillary tumors, and flat non-invasive urothelial carcinoma

Question 25

State the Diseases of the prostate

Answer 25

Prostatitis
Hyperplasia
Carcinoma

Question 26

What is prostatitis?

State the clinical presentation of prostatitis.

Answer 26

PROSTATITIS
Acute bacterial prostatitis typically results from bacteria similar to those that cause urinary tract infections.
Thus, most cases are caused by various strains of E. coli, other gram-negative rods, enterococci, and staphylococci.
Nonspecific inflammation

Clinically, acute bacterial prostatitis is associated with fever, chills, and dysuria.
On rectal examination the prostate is exquisitely tender and boggy.
The diagnosis can be established by urine culture and clinical features.

Question 27

Describe BPH

Outline irs clinical manifestations.

Answer 27

Benign prostatic hypertrophy or hyperplasia, “BPH”
happens to most intact men over about age 50

The normal prostate weighs around 20 gm

Old men’s prostates enlarge to 60-200+ gm
nodular overgrowth of periurethral glands and stroma.

causes many problems (collectively called “prostatism”),

*Increased urinary frequency
*Incontinence (dribbling), dysuria (painful urination)
*hernias (from straining)
*acute urinary retention (emergency).
*Nocturia
Residual urine accumulates in an enlarged bladder behind the prostate gland
Hematuria (due to stretching of veins),

an enlarged prostate can obstruct urinary outflow from the bladder and lead to an obstructive uropathy
A normal prostate gland is about 3 to 4 cm in diameter.
The above prostate on the right side is enlarged due to prostatic hyperplasia, which appears nodular.
Thus, this condition is termed either BPH (benign prostatic hyperplasia) or nodular prostatic hyperplasia.

Question 28

Discuss prostate cancer.

Answer 28

Adenocarcinoma of the subcapsular glands

Prostate cancer is the commonest cancer in men, and the second leading cancer killer of men.

*Latent prostate cancer: found only at autopsy
*Incidental prostate cancer: found on prostatic chips
*Occult prostate cancer might pop up in bone marrow or lymph node prior to becoming symptomatic.

Symptomatic cancer
Prostate cancer is mostly a disease of men over age 50

Prostate cancers supposedly arise in the posterior lobe.
Androgens play some role.

Cancer of the prostate presents as a painless lump in the gland
prostatic acid phosphatase and/or prostate-specific antigen – both are highly sensitive and specific for prostatic origin.

Prognosis
Gleason I-V system
Staging TNM system

Question 29

Define CRYPTORCHIDISM.

What are the complications of CRYPTORCHIDISM?

Answer 29

CRYPTORCHIDISM: Incomplete descent of the testis into the scrotal

Cryptorchid testes may be found abdomen, inguinal canal, prepubic.

Complications:
*Atrophy and fibrosis
*Increased risk of torsion of the spermatic cord and gangrene of the testis
*Increased risk of germ cell cancer (usually seminoma)

Question 30

Define EPIDIDYMITIS AND ORCHITIS.

Answer 30

Epididymoorchitis
Epididymitis is the inflammation of the epididymis.

-Gonorrhea
-Chlamydia
-Tuberculous

Orchitis
-Orchitis is the inflammation of the testicle itself.
-Mumps
-Gummatous Syphilis

Question 31

Discuss TORSION OF SPERMATIC CORD (“torsion of the testis”):

Answer 31

TORSION OF SPERMATIC CORD (“torsion of the testis”):
Twisting of the spermatic cord is likely to result in venous infarction and gangrene in a few hours.
This is quite common, especially in children and adolescents.
In later life this may lead to infertility.

Question 32

Discuss Hydrocele of the testis

Answer 32

fairly common.
Clear fluid accumulates in a sac of tunica vaginalis lined by a serosa with a variety of inflammatory and neoplastic conditions.

A hydrocele must be distinguished from a true testicular mass, and transillumination may help, because the hydrocele will transilluminate but a testicular mass will be opaque.

Question 33

Discuss tumors of the testis.

Answer 33

Over 95% of tumors of the testis are malignant germ cell tumors.

These tumors are among the commonest solid tumors of young men.

The most common germ cell tumor is seminoma.
Lymphoma
solid tumors of lymphoid tumors
Paratesticular sarcomas
Rhabdomyoma
Rhabdomyosarcoma