U r inary S y s tem

- M i c r o s c o p i c a s p e c t -

Departemen Anatomi-Histologi FKUB

Sistem Ginjal dan Saluran Kemih

1 Nyeri pinggang 4 Tidak bisa menahan/ urgensi kencing

2 Peningkatan atau penurunan frekuensi buang air kecil (BAK)

5 Nyeri saat BAK

3 Berkurangnya jumlah air kencing 6 BAK mengejan

7 BAK tidak puas 13 Air kencing campur udara

8 Akhir kencing menetes 14 Air kencing campur tinja

9 Pancaran kencing menurun 15 Keluar darah dari saluran kencing

10 Kencing bercabang 16 Darah keluar bersama produk ejakulat

11 Waktu kencing preputium melembung

17 Air kencing seperti the

12 Air kencing merah 18 Duh (discharge) dari saluran kencing

DAFTAR MASALAH SKDI 2012

1 Urinary tract infection 4

2 Gonorrhea 4

3 Uncomplicated Pyelonephritis 4

4 Paraphimosis 4

5 Acute glomerulonephritis 3A

6 Chronic glomerulonephritis 3A

7 Renal colic 3A

8 Urinary stone diseases or urinary calculi without colic 3A

9 Phimosis 3A

10 Prostatitis 3A

11 Torsion of testis 3B

12 Ruptur uretra 3B

13 Ruptur kandung kencing 3B

14 Ruptur ginjal 3B

15 Benign prostatic hyperplasia 3A

16 Striktura uretra 3B

17 Priapismus 3B

18 Chancroid 3A

Daftar penyakit, SKDI level 3-4

Contents:

1. Functions

2. Kidneys (ren)

– Positions

– Renal blood vessels

– Renal structures

3. Ureters

4. Urinary bladder (Vesica urinaria/VU)

5. Urethrae

Case 1

– A 6-year-old male developed an upper respiratory tract infection followed by facial edema with dark-colored urine after 2 weeks. Upon examination, his blood pressure was at 140/85 mmHg. Urinalysis reveals too numerous to count RBCs/hpf, 8-10 WBCs/hpf and 4+ protein.

Clinical Corelation

• Summary :A 6 years old,Upper resp tract infection, edema, hypertension, hematuri, proteinuri

• Diagnosis : Acute Glomerulonefritis

• What is the most likely diagnosis?

• What is the likely anatomical mechanism

for this disorder?

• From the sign and symptomps, what

structure is likely affected?

3 Functions of the Urinary System

1. Excretion: – removal of organic wastes from body fluids

2. Elimination: – discharge of waste products

3. Homeostatic regulation: – of blood plasma volume and solute

concentration

Components

• Kidneys. consist of nephrons and a system of collecting

ducts; filter blood and produce urine

• Ureters. Muscular tubes that collect urine output from

the kidney and carry it to the urinary bladder

• Urinary bladder. Hollow muscular organ that stores

urine

• Urethra. Tube that drains urine from urinary bladder to

the exterior

General Structure.

• Kidneys are paired bean-shaped organs enveloped by a thin capsule of connective tissue.

• Each kidney is divided into an outer cortex and an inner medulla.

• The renal hilum is a concavity on the medial border of the kidney. It houses arteries, veins, lymphatic vessels, nerves, and the renal pelvis.

• Each kidney contains about 2 million nephrons. A nephron and the collecting tubule into which it drains form a uriniferous tubule.

REN : Cortex-medulla

• The renal pelvis is a funnel-shaped expansion of the upper end of the ureter.

• It is continuous with the major renal calyces, which in turn have several small branches, the minor calyces.

• Apex of each renal pyramid renal papilla

It has a perforated tip (area cribrosa) that projects into the lumen of a minor calyx.

Extrarenal passageways

• Renal (medullary) pyramids are conical or pyramidal structures whose bases are adjacent to the cortex the renal medulla.

• Each kidney contains 10 to 18 renal pyramids.

• each pyramid consists primarily of the thin limbs of loops of Henle, blood vessels, and collecting tubules.

• sends extensions into the cortex = (medullary rays)

• Renal columns. Extensions of cortical tissue between renal pyramids

• apex of each renal pyramid. renal papilla

The renal medulla, Deep to cortex

It consists primarily of renal

corpuscles and convoluted

tubules.

Medullary rays

= Medullary tissue located in

the cortex

= tubules that extend from

the base of each renal

(medullary) pyramid into the

cortex

The renal cortex the superficial layer

Renal lobulations

Renal lobe. consists of a renal pyramid and its closely associated cortical tissue Renal lobule. A central medullary ray and the adjacent cortical labyrinth extending to the interlobular vessels nephrons drain into the collecting tubules of the medullary ray.

Renal lobe

Renal lobule.

interlobular vessels

The Nephron

consist of :

• a renal corpuscle,

• proximal convoluted tubule

(TCP),

• loop of Henle,

• distal convoluted tubule

(TCD)

Classification of Nephrons

(depending upon the location of the renal corpuscle)

• cortical • juxtamedullary, :

possess longer loops of Henle

1. A renal corpuscle consists of

– glomerulus

– Bowman capsule, as location of blood filtration

– Podocytes

– Renal filtration barrier

The Nephron renal corpuscle, TCP

loop of Henle, TCD

renal corpuscle, TCP

loop of Henle, TCD

• Glomerulus.

A tuft of fenestrated capillaries,

formed by an afferent arteriole,

leaves the glomerulus via the

efferent arteriole.

(1) Glomerular endothelial cells

(2) The basal lamina

(3) The mesangium : Mesangial

cells and mesangial matrix

glomerulus Bowman capsule Podocytes Renal filtration barrier

whose pores lack diaphragms.

• Glomerulus.

(1) Glomerular endothelial cells : = inner layer of the

capillary walls. Have large fenestrae (60–90 nm in diameter)

but lack the thin diaphragms

(2) The basal lamina is between the podocytes and the

glomerular endothelial cells :by both cell populations.

Contains three distinct zones: (a) The lamina rara externa, adjacent to the podocyte epithelium

(b) The lamina densa, a thicker, intermediate zone, Collagen, type IV

(c) The lamina rara interna, adjacent to the capillary endothelium

(3) The mesangium : the interstitial tissue between

glomerular capillaries. It is composed of mesangial cells and

an amorphous extracellular matrix

glomerulus Bowman capsule Podocytes Renal filtration barrier

renal corpuscle, TCP

loop of Henle, TCD

whose pores lack diaphragms.

Mesangial cells :

• phagocytose

• can contract, decreasing the surface area available for

filtration.

• possess receptors for angiotensin II and atrial natriuretic

peptide.

The mesangial matrix

helps support glomerular capillaries.

glomerulus Bowman capsule Podocytes Renal filtration barrier

renal corpuscle, TCP

loop of Henle, TCD

• Bowman’s capsule.

Double-walled, epithelial capsule with central space called

Bowman’s space; surrounds the glomerulus and receives the

fluid filtered from the blood

– Parietal layer. Outer layer, simple squamous epithelium

– Visceral layer; Inner layer surrounding the glomerulus.

Consists of a single layer of modified epithelial cells

called podocytes.

glomerulus Bowman capsule, Podocytes Renal filtration barrier

renal corpuscle, TCP

loop of Henle, TCD

Poles of the glomerulus Vascular pole. Where afferent and efferent arterioles

enter and leave the renal corpuscle, Urinary pole. Where the parietal layer of Bowman’s

capsule is continuous with TCP

• Podocytes

Have several primary

processes that give rise

to many secondary

processes called

pedicels

Pedicels of adjacent

podocytes interdigitate

and surround the

glomerular capillaries.

The slits (filtration slits)

between the pedicels

are bridged by slit

diaphragms (a layer of

filamentous material)

glomerulus Bowman capsule,

Podocytes Renal filtration barrier

renal corpuscle, TCP

loop of Henle, TCD

= highly modified epithelial cells that form the visceral layer of the Bowman capsule.

• The renal filtration barrier

– Fenestrated endothelium of glomerular capillary

– Thick, fused basal laminae of the podocytes and the glomeru-ar endothelial cells

– Slit diaphragms between pedicels of visceral layer of epithelium

renal corpuscle, TCP

loop of Henle, TCD

glomerulus Bowman capsule, Podocytes

Renal filtration barrier

Proximal convoluted tubule

lined by a single layer of irregularly shaped (cuboidal to

columnar) epithelial cells that have microvilli brush border.

These cells exhibit the following structures:

(1) Apical canaliculi, vesicles, and vacuoles (endocytic complex),

which function in protein absorption

(2) Prominent interdigitations along their lateral borders, which

interlock adjacent cells with one another

(3) Numerous mitochondria compartmentalized in the basal

region by extensive infoldings of the basal plasma membrane,

which supply energy for the active transport of Na+ out of the

tubule

renal corpuscle,

TCP loop of Henle,

TCD

renal corpuscle, TCP

loop of Henle, TCD

thick

descending

limb of loop of

Henle (thick ascending limb of Henle’sloop),

renal corpuscle, TCP

loop of Henle, TCD

Loop of Henle.

Located in medullary tissue (medullary ray & medulla)

• Proximal tubule, straight portion. Located either in medullary ray

(in cortex) or in medulla. Histology is identical to that of TCP

• Thin segment, Found in medulla.

– Composed of a simple squamous epithelium

– Actively pumps out chloride, with sodium following passively, to

produce a hypertonic urine

• Distal tubule, straight portion. Located in medulla or in medullary

ray (in cortex)

– Composed of a simple cuboidal epithelium with inconsistent

microvilli. The basal plasma membrane is extensively infolded

with numerous mitochondria between the folds.

Distal convoluted tubule

• Located in the labyrinth portion of cortex; highly convoluted

• lacks a brush border, Histology is identical with the distal straight tubule

• Returns to a glomerulus to form part of the juxtaglomerular apparatus

• Major site of salt and water control in the body

renal corpuscle, TCP

loop of Henle,

TCD

The JG apparatus is located at the vascular pole of the renal corpuscle.

It helps to maintain blood pressure

1. JG cells : primarily in the wall of the afferent arteriole, as modified smooth muscle cells

= protein-secreting cells. synthesize renin and store it in secretory granules.

2. Macula densa cells : tall, narrow, closely packed epithelial cells of the distal tubule. appear as a dense spot (macula densa)

3. Extraglomerular mesangial cells/ = polkissen (pole cushion)/lacis cells. Lie between the afferent and efferent glomerular arterioles.

JG apparatus

Function.

• (if there) A decrease in extracellular fluid volume (perhaps

detected by the macula densa) stimulates JG cells to

release renin into the bloodstream.

• Renin acts on angiotensinogen in the plasma, converting it

to angiotensin I. In capillaries of the lung and elsewhere,

angiotensin I is converted by angiotensin-converting

enzyme (ACE) to angiotensin II, a potent vasoconstrictor

that stimulates release of aldosterone in the adrenal cortex.

• Aldosterone stimulates the epithelial cells of the distal

convoluted tubule to remove Na+ and Cl Water follows

the ions, thereby increasing the fluid volume in the

extracellular compartment, which leads to an increase in

blood pressure.

The connecting tubule

is a short segment between TCD and the collecting tubule.

It is lined by two types of epithelial cells:

a. Principal cells have many infoldings of the basal plasma membrane. These cells remove Na from the filtrate and secrete K into it.

b. Intercalated cells have many apical vesicles and mitochondria. These cells remove K from the filtrate and secrete H into it.

Excretory Tubules and Ducts and Extrarenal Passages

Collecting tubule

• Composed of simple cuboidal to simple columnar cells;

usually displays distinct lateral boundaries between cells

• Drains urine from the distal convoluted tubule

• enters the medullary ray in the cortex and descends into

the medulla

• Joins with other collecting tubules to form the papillary

ducts (of Bellini)

• helps in concentrating the urine

1. Cortical collecting tubules are located primarily within medullary rays, They are lined by a simple epithelium containing two types of cuboidal cells.

Principal (light) cells AND Intercalated (dark) cells

2. Medullary collecting tubules. Similar in structure to cortical collecting tubules and contain both principal and intercalated cells in their lining epithelium.

3. Papillary collecting tubules (ducts of Bellini) are large collecting tubules (200–300 μm in diameter), formed from converging smaller tubules. They are lined by a simple columnar cells that have a single central cilium. They empty at the area cribrosa, a region at the apex of each renal pyramid that has 10 to 25 openings into a minor calyx.

• Minor and major calyces. Transport urine to the renal

pelvis and into the ureter; lined by transitional epithelium

• Renal pelvis. lined by transitional epithelium; formed by

the union of major calyces

• Ureter. Muscular tube connecting the renal pelvis and the

urinarybladder, lined by transitional epithelium; two

layers of smooth muscle in the upper two-thirds, inner

longitudinal and outer circular, with the addition of a third

outer longitudinal layer in the lower one-third

Extrarenal passageways

Cont.; of passageways • Urinary bladder. Lined by a transitional epithelium,

specialized to provide for distension of the organ; a thick muscular wall contains three interlacing layers of smooth muscle

• Urethra

– The urethra conveys urine from the bladder outside the body. In males, the urethra also carries semen during ejaculation.

– It has a two-layer muscularis consisting of an inner longitudinal and an outer circular layer of smooth muscle.

– It is surrounded at some point by an external sphincter of skeletal muscle, which pemits its voluntary closure.

• Male urethra

– 20 cm long and is divided into prostatic, membranous, and cavernous portions.

– It is lined by transitional epithelium in the prostatic portion and by pseudostratified or stratified columnar epithelium in the other two portions.

– The fossa navicularis, located at the distal end of the cavernous urethra, is lined by stratified squamous epithelium.

– contains mucus-secreting glands of Littre in the lamina propria.

• Female urethra

– shorter (4–5 cm long)

– It is lined primarily by stratified squamous epithelium, although patches of pseudostratified columnar epithelium are present.

– It may contain glands of Littre in the lamina propria.

RESUME

RESUME

Case recall

A 6-year-old male developed an upper respiratory tract infection followed by facial edema with dark-colored urine after 2 weeks. Upon examination, his blood pressure was at 140/85 mmHg. Urinalysis reveals too numerous to count RBCs/hpf, 8-10 WBCs/hpf and 4+ protein.

GNA

• Acute glomerulonephritis is a disease characterized by the sudden appearance of edema, hematuria, proteinuria, and hypertension.

• Pathogenesis : inflammation of the glomerulus is manifested by proliferation of cellular elements secondary to an immunologic mechanism.

• Inflamation mesangial cells (phagocytic) ↗ narrowed capilary lumen NaCl concentration at the macula densa↙ renal arteriolar resistance>> glomerular hypertension sistemik HT

• Fusion processus of podocyte penetration slit >> hematuri

• Base membrane damage, ELECTRICAL CHANGES protein loss hipoalbuminemia edema

Suggested homework

SKDI

- Struktur yang terganggu - Patofisiologi - Gejala - Target Penatalaksnaan

Suggested homework Region Epithelium Major Functions Summary

etc

Suggested reading

• Basic Histology, Juncquiera

• Human Anatomy Martini

• PRINCIPLES OF ANATOMY AND PHYSIOLOGY Tortora

• Essential Pathophysiology , Porth

Selamat belajar….