Chapter 26

Urine formation by the kidney: 1. Glomerular filtration, renal blood flow and their control

Function of the Kidneys:

 Excretion of metabolic waste products and foreign chemicals
 Regulation of water and electrolyte balances
 Regulation of body fluid osmolality and electrolyte concentrations
 Regulation of arterial pressure
 Regulation of acid-base balance
 Secretion, metabolism and excretion of hormones
 gluconeogenesis

Excretion of metabolic waste products, foreign chemicals, drugs and hormone metabolites

- The kidneys eliminate waste products of metabolism that are no longer needed
- Products of waste are: urea, creatinine, end products of haemoglobin
(breakdown and metabolites of various hormones)
- Waste products are eliminated as rapidly as they’re produced

Regulation of water and electrolyte balances

- Excretion of water and electrolytes need to match intake to maintain

homeostasis
- Intake of water and electrolytes is influenced by a persons eating and drinking
habits

Regulation of arterial pressure

- The kidneys play a role in long-term regulating arterial pressure by excreting

varied amounts of sodium and water
- Kidneys also regulate short-term by secreting hormones or vasoactive substances

Regulation of acid-base balance

- The kidneys excrete acids and regulate the body fluid buffer stones
- The kidneys eliminate sulfuric acid and phosphoric acid

Regulation of erythrocyte production

- Kidneys secrete erythropoietin which stimulates the production of RBCs by

hematopoietic stem cells in the bone marrow
- Hypoxia is a stimulus for erythropoietin secretion
Regulation of 1,25-Dihydroxyvitamin D3 production

- Kidneys produce an active form of vitamin D = 1,23-dihydroxyvitamin D3

(calcitriol)
- Calcitriol is essential for normal calcium deposition in bone and calcium
reabsorption by the GI tract

Glucose synthesis

- Kidneys synthesise glucose from amino acids and other precursors during
prolonged fasting = gluconeogenesis

Micturition

The process by which the urinary bladder empties when it becomes filled

- First the bladder fills until the tension in its walls rises above a threshold level –
this elicits the 2nd step
- Second step: micturition reflex (nervous reflex) that empties the bladder or
causes a conscious desire to urinate
- Micturition reflex= autonomic spinal cord reflex

Physiologic anatomy of bladder

- Urinary bladder is a smooth muscle chamber composed of 2 main parts:

1. the body= major where urine collects
2. the neck= funnel-shaped extension from body

- Lower part of bladder AKA posterior urethra

- The smooth muscle of the bladder is called the detrusor muscle
- Detrusor muscle fibres extend in all directions and contract which increase the
pressure in the bladder from 40 to 60 mm Hg
- Contraction of the detrusor muscle is a major step in emptying the bladder
- Smooth muscle cells of the detrusor muscle fuse together so low-resistance
electrical pathways exist from one cell to another therefore an action potential
can spread through the muscle

- On posterior wall of bladder, immediately above the bladder neck is the trigone

- The trigone can be identified because its mucosa is smooth in contrast to the rest
of the bladder which is folded into rugae

- The bladder neck (posterior urethra) is 2-3cm long and its wall is made up of
detrusor muscle and elastic tissue
 - The internal sphincter is located here and prevents emptying of the bladder until
the pressure in the main part of the bladder reaches the threshold

- Urethra passes through the urogenital diaphragm which contains the external
sphincter

- External sphincter is voluntary skeletal muscle and can be used to consciously

prevent urination

Transportation of urine from the kidney through the ureters and into the bladder

- There is no significant changes in the composition of urine as it flows through the

renal calyces and ureters to the bladder

- Urine flowing from the collecting ducts into the renal calyces stretches the
calyces and increases their pacemaker activity

- This initiates peristaltic contractions that spread to the renal pelvis to the bladder

- In adults the ureters are 25-35cm long

- Walls of the ureters contain smooth muscle and are innervated by sympathetic
and parasympathetic nerves and an intramural plexus

- Ureters enter the bladder through the detrusor muscle in the trigone region

- Ureters enter obliquely for several cm through the bladder wall

- Normally, the detrusor muscle compresses the ureter and prevents backflow of
urine from the bladder when there’s a pressure build up during micturition or
bladder compression

- Each peristaltic wave along the ureter increases pressure within the ureter, so
the region passing through the bladder wall opens and allows urine to flow into
the bladder

- Ureters are well supplied with pain fibres

- Pain impulses send a sympathetic reflex back to the kidney which causes the
renal arterioles to constrict and decrease urine output = this is the ureterorenal
reflex

Micturition Reflex
 - The reflex results from a stretch reflex initiated by sensory stretch receptors in
the bladder wall (especially receptors in the posterior urethra when it begins to
fill with urine at high pressures)

- Bladder partially filled= micturition contractions relax, detrusor muscle stops

contracting and pressure falls to baseline
- Bladder continues to fill= micturition reflexes becomes more common and
detrusor muscle contracts more greatly

- Micturition reflexes are self-regenerative:

1. Initial contraction of the bladder activates stretch receptors which cause an

increase in sensory impulses from the bladder and posterior urethra
2. These sensory impulses cause a further increase in reflex contraction of the
bladder
3. This cycle is repeated until the bladder has reached a strong degree of
contraction
4. After a few seconds to a minute the self-regenerative reflex begins to fatigue
and the cycle stops which causes the bladder to relax

- The micturition reflex is a single cycle of:

1. Progressive and rapid pressure increase
2. A period of sustained pressure
3. Return of pressure to basal tone of the bladder

- When a micturition reflex does not successfully empty the bladder, the nervous
elements of the reflex are inhibited for a few minutes to an hour before another
reflex occurs
- Bladder becomes more filled= micturition reflexes occure more frequently and
more powerfully

- When the micturition reflex is powerful enough it causes another reflex, which
passed through the pudendal nerves to the external sphincter to inhibit it. If the
reflex has a stronger effect on the brain than the voluntary constrictor signals to
the external sphincter = urination occurs

Facilitation or inhibition of micturition by the brain

- Micturition reflex is an autonomic spinal cord reflex that can be inhibited by 2

centres of the brain:
1. Strong facilitative and inhibitory centres in the brain stem, located in the
pons
2. Several centres located in cerebral cortex (mainly inhibitory)

- These centres exert final control of the micturition reflex by:

1. They keep the reflex partially inhibited, except when micturition is desired
 2. They can prevent micturition by tonic contraction of the external bladder
sphincter

3. When it is time to urinate, the cortical centres can facilitate the sacral
micturition centres to help initiate a micturition reflex and at the same time
inhibit the external urinary sphincter so that urination can occur

- Voluntary urination happens by:

1. A person voluntarily contracts their abdominal muscles
2. This increases pressure in the bladder and allows extra urine to enter the
bladder neck and posterior urethra under pressure
3. This stretches the bladder and posterior urethra walls
4. This stimulates stretch receptors, which excites the micturition reflex and at
the same time inhibits the external urethral sphincter

Abnormalities of micturition

Atonic bladder and incontinence caused by destruction of sensory nerve fibres

- Micturition reflex can’t occur if sensory nerve fibres from the bladder to the
spinal cord are destroyed
- This stops the transmission of stretch signals from the bladder
- When this happens, a person loses bladder control even though efferent fibres
from the cord to the bladder a neurogenic connections within the brain are intact
- Instead of emptying from time to time, the bladder overflows and only a few
drops of urine come through the urethra at a time
- This is called overflow incontinence

- Atonic bladder can be caused by a crush injury to the spinal cord or sacral region

- Some diseases can cause damage to nerve fibres: syphilis can cause constrictive
fibrosis around the dorsal root nerve fibres, destroying them. This condition is
called tabes dorsalis, and the resulting bladder condition is called tabetic bladder