Overview of the genitourinary system

The genitourinary system in both males and females contains the kidneys and associated renal arteries
and veins, the ureters, the bladder, and the urethra running through the genitalia.

The urinary system provides many function that help the body:

To maintain homeostasis, or balance of the organ systems.

For instance, the urinary system

1. Removes wastes and toxins such as ammonia, uric acid, and some medications from the blood
2. Regulates osmotic pressures in the blood and interstitial fluid
3. Regulates concentration levels of calcium, sodium, potassium, magnesium, and phosphorus
4. Controls the acid-base balance by making necessary adjustments
5. Regulates blood pressure
6. Activates vitamin D in order to maintain calcium levels
7. Regulates oxygen level through stimulation of erythropoietin- the hormone responsible for
increased red blood cell production in the bone marrow.

The kidneys form urine through a process of filtration, reabsorption, and secretion with constant
homeostasis maintained throughout the process.

Under usual living conditions the kidneys can be maintained on as little as 30% capacity, but under
stressful conditions such as high temperatures kidney reserves are needed to maintain proper
functioning.

Urinary structural changes with age

The kidneys

With age the kidneys shrink in length and weight.

30 years of age, the average kidney weighs 150 to 200 g.

By age 90, it weight has declined to between 110 and 150 g.

The number of glomeruli decreases by as much as 30% to 40% by age 90 due to glomerulosclerosis.

 Glomerulosclerosis is scarring of the filtering part of the kidneys (glomerulus). This

causes a loss of protein into the urine. These proteins help fluid stay within the blood
vessels. Without them, fluid leaks into the nearby tissue causing swelling.

Remaining glomeruli decrease in size but increase in basement membrane thickness.

The size and number of nephrons, the combination of the Bowman’s capsule and renal tubule with
glomerulus, also decrease with age.

On average, renal blood flow declines 10% per decade beginning as early as 20 years of age.

Young adults (20 years) average a renal blood flow of 600 ml/min whereas average blood flow in older
adults (80 years) average only 300 ml/min.
Changes in blood flow and glomerular filtration rate (gfr) account for a majority of functional disability in
the kidneys with age.

This decline is measure by creatinine or insulin clearance and usually begins in the third decade (30) as a
result of changes in glomeruli, clustering of capillaries, and renal blood flow rate.

Renal tubules also show age-related changes, including decreased number and length.

There is also evidence of age-related interstitial fibrosis and thickening of renal tubule basement
membranes. Which can affect in reabsorption and excretion.

Despite age-related structural changes, the kidneys contain a large reserve capacity, and functional
abilities remain relatively stable unless stressed.

The Bladder

Is a hollow organ lined with a mucous membrane, contains smooth muscle including the detrusor
muscle and consists of two components, the bladder body and the base.

With age, the bladder decreases in size and develops fibrous matter in the bladder wall, changing its
overall stretching capacity and contractibility.

The filling capacity of the bladder also declines along with the ability to withhold voiding.

The ability of the detrusor to contract declines in both aging men and women, and these is an increase
in incidence of detrusor over activation.

In around 50% of men with benign prostatic hyperplasia (BPH), the enlargement of the prostate causes
obstruction of the bladder outlet and results in urinary dysfunction.

In response to bladder outlet obstruction, the bladder walls become thicker and stronger in order to
recompense for declining function.

Overall, the bladder goes through few variable structural changes with age, but these changes can
impact a person physically.

Ureters and the urethra

The urinary system contains two ureters that connect to each kidney to the bladder, but ureters do not
demonstrate any age-specific changes.

The urethra – forms the canal that leads from the bladder out of the body, and also functions in
response to excitatory or inhibitory stimuli.

In the male, the sphincter elevates from the prostate encompassing the urethra.

In the female, the urethra extends about 3 to 4 cm.

Males have longer urethras: this is due to the urethra’s anatomical location in the penis.

With age, and striated muscle that controls sphincters also thin and weakens.

In men, the prostate gland surrounds the urethra directly below the bladder, and prostate enlargement
around the bladder and urethra can cause urinary dysfunction.

Urinary functional changes with age

Urination

Involves both the central and peripheral nervous systems and requires that bladder contraction and
urethral relaxation occur simultaneously.

The amount of urine expelled from the body decreases with age correlating with increases of around 50-
100 ml in postvoid residual (PVR) with age.

Renal changes affect the ability to concentrate and dilute the urine, causing electrolyte imbalance.

Urine osmolality in the older adult reaches about half of that in a younger adult, leading to increased
water loss in the aged.

Older individuals also experience an increase in nocturia or an increased number of fluid voids occurring
at night, which can disturb sleep patterns.

Prostate volume increases in aging males, and it is possible that, with longevity, every male will
experience benign prostatic hyperplasia (BPH).

BPH can lead to prostatic changes that influence lower urinary tract function as well as erectile and
ejaculatory disorders.
More specifically, in BPH the prostate enlarges enough to encroach on the urethra and bladder causing
urinary retention, difficulty voiding, urinary tract infections, and in advanced stages, renal failure.

Nerve stimulations to the smooth muscle of the prostate, bladder, and urethra occur in BPH, causing
voiding difficulty.

However, blocking the stimulus allows the muscle to relax, improving voiding abilities in BPH.

Glomeruli Filtration Rate

The glomeruli filtration rate (GFR), usually measured by creatinine clearance, declines in older
individuals, but there is no resultant increase in blood creatinine concentration.

Creatinine clearance is measured by the Cockcroft-Gault equation (1976):

140−age ( years ) × IBW (ideal body weight)( kg)

mg
72× serum creatinine ( )
dl
 Note : Multiply by 0.85 for females

Measuring creatinine does not yield an accurate concentration rate because:

1. The creatinine production rate is variable

2. The tubules also secrete creatinine
3. Elders have decreased muscle mass

Inaccuracy in measurement generally results in an overestimation of creatinine level of about 20% to

30%.

The Cockcroft-Gault equation can be used to predict renal disease but may not reflect the usual aging
process.

As a result, use of the equation can lead to medication underdosing in healthy older adults and
overdosing in compromised older adults.

A closer estimation of actual GFR comes from inulin clearance or non-radio-labeled iothalamate.

Adverse drug reactions occur approximately 3 to 10 times more often in the older population as
compared to younger cohorts.

Adverse drug reactions in the older population occur as a result of changes in the kidneys, more
specifically changes in GFR and renal clearance.

Adverse drug reactions can also occur due to changes in tubular filtration.

Estimates of GFR among older adults correlate with aging tubular filtration and are often used to
determine the amount of drug to use in the older population.
The key phrase in geriatric pharmacy remains ‘’ start low and go slow’’ because of renal changes that
affect pharmacokinetics and pharmacodynamics with age.

Furthermore, polypharmacy and medication compliance are also associated with increased adverse
events in the older population.

Homeostasis Changes

Overall, the aging kidneys function relatively well in maintaining fluid levels and electrolyte
concentration balance; however, age-related changes are more readily observed under conditions of
stress such as dehydration and high temperatures.

Age-related structural changes in the kidneys lead to some functional declines such as deterioration in
the ability to regulate sodium concentrations under usual conditions.

In addition, there is a decline in the ability to maintain sodium and potassium homeostasis and to
conserve water during times of stress.

The inability to properly regulate sodium can be attributed to malfunctioning of the ascending loop of
Henle In addition to increases in prostaglandin levels and tubular unresponsiveness to aldosterone.

A decline in overall potassium level in the body also occur with age due to low potassium secretion
resulting from the decline in tubular reaction to aldosterone.

Older adults also experience changes in the ability to reabsorb water and, in conjunction with decreased
thirst in older adults, the body can become dehydrated more quickly.

Acid-base homeostasis appears to be relatively stable (pH 6.9 to 7.7) in older adults under usual
conditions, however; under conditions of acid overload older adults cannot excrete acid as quickly as
younger adults.

The nephron functionally serves the kidneys by balancing sodium and water and eliminating waste from
the bloodstream.

With age, nephrons shrink in size and decrease in number. This is partly due to decreased blood flow in
the glomeruli, which causes an increase in solute levels and eventually renders the nephron
nonfunctional.

Changes in homeostasis can negatively impact both the structural and functional capacity of the renal
system.

Hormone Changes

Plasma renin and aldosterone concentration levels gradually decline with age, beginning around 40
years of age.

With age, the renin-angiotensin system undergoes a decline in its ability to maintain salt levels following
salt deprivation.
In addition, the renin-angiotensin-aldosterone axis falls to adequately respond to hormone volume
changes in healthy older adults without deprivation; therefore, maximum sodium levels cannot be
attained.

During normal renal functioning, antidiuretic hormone release is responsible for reabsorption of fluid in
the tubules and production of a concentrated urine to maintain blood osmolality.

Studies concerning changes in the basal levels of antidiuretic hormone in the elderly have been
inconclusive.

Several studies, however, have indicated that changes in reabsorption are related to loss of
responsiveness of antidiuretic hormone receptors in the tubule, leading to nocturnal polyuria with
frequent nighttime voiding.

Aging changes also occur in the calcium-parathormone-vitamin D3 axis, as exhibited by decreased serum
calcium levels, increased parathyroid hormone levels resulting from GFR decline, and declines in vitamin
D metabolism by the aging kidneys.

Due to decline in vitamin D metabolism by the kidneys, vitamin D supplementation is usually

recommended in the older population.

Age-related changes in the genitourinary system lead to alterations in genital structures, voiding
behaviors, toxin and medication clearance, hormone levels, and overall physiologic homeostasis of the
body.

Overall structural and functional changes can vary with age, but these changes can impact a person
physically, emotionally, psychologically, and socially, especially when urinary function declines and
becomes abnormal, as seen with incontinence.

Although aging changes in the kidneys can vary among older adults, as seen with GFR, as a whole these
changes are quite common and should be considered when evaluating and treating an older population.