Deck 21: The Kidneys, the Ureters, the Bladder, and the Urethra

Question 1

A 16-year-old boy received a severe kick in the right flank while playing football at school. On examination in the emergency department, his right flank was severely bruised, and his right costovertebral angle was extremely tender on palpation. A specimen of urine showed microscopic hematuria. A diagnosis of damage to the right kidney was made.

-The following statements concerning blunt trauma to the kidney are correct except which?

A) The kidney tends to be crushed between the twelfth rib and the vertebral column.
B) The kidney can be injured by fractures of the twelfth rib (right kidney) or eleventh and twelfth ribs (left kidney).
C) In most patients the kidney damage is mild and results in nothing more than microscopic hematuria, as in this patient.
D) In severe kidney lacerations, extensive hemorrhage and extravasation of blood and urine into the pararenal fat occurs.
E) In severe kidney lacerations, a mass caused by extravasated blood and urine behind the peritoneum may be palpated, especially on the right side.
F) Both kidneys lie on the posterior abdominal wall and are at the same vertebral level.

Answer 1

Both kidneys lie on the posterior abdominal wall and are at the same vertebral level.

Question 2

A 19-year-old boy was involved in a gang fight. It started as an argument but quickly worsened into a street brawl with the use of knives. He was examined in the emergency department and found to have a bleeding stab wound in his left flank. A urine specimen revealed frank blood.

-Stab wounds of the kidneys involve other abdominal organs in a high percentage of cases. Of the organs listed, which one is least likely to be damaged in this patient?

A) Stomach
B) Spleen
C) Inferior vena cava
D) Left colic flexure
E) Left suprarenal gland
F) Coils of jejunum
G) Body of the pancreas

Answer 2

Inferior vena cava

Question 3

An inebriated 40-year-old man was involved in a fight over a woman. The woman's husband gave the man a severe blow to the lower part of the anterior abdominal wall, whereupon he doubled up with pain and collapsed on the floor. On admission to the emergency department of the local hospital, the man was in a state of shock and complaining of severe pain in the lower abdominal region. He was unable to pass urine since the fight. A diagnosis of ruptured urinary bladder was made.

-The following statements concerning this patient are correct except which?

A) Rectal examination revealed a bulging backward of the rectovesical fossa.
B) Although the patient had consumed a considerable volume of liquor, dullness was not present on percussion of the anterior abdominal wall above the symphysis pubis.
C) The urine accumulated in the rectovesical pouch.
D) A full bladder is more likely to be ruptured by a blow to the anterior abdominal wall than an empty bladder.
E) In the adult, as the normal bladder fills, its superior wall extends upward into the abdomen, leaving the covering of parietal peritoneum behind.

Answer 3

In the adult, as the normal bladder fills, its superior wall extends upward into the abdomen, leaving the covering of parietal peritoneum behind.

Question 4

A 39-year-old woman was admitted to the local hospital after experiencing a gunshot wound to the lower part of her back. Radiographic examination revealed that the bullet was lodged in the vertebral canal at the level of the third lumbar vertebra. A comprehensive neurologic examination indicated that a complete lesion of the cauda equina had occurred.

-The following statements concerning this patient are likely to be true except which?

A) The cauda equina, which consists of anterior and posterior nerve roots below the level of the first lumbar segment, was sectioned at the level of the third lumbar vertebra.
B) The preganglionic sympathetic nerve fibers to the vesical sphincter that descend in the anterior roots of the fourth and fifth lumbar nerves were sectioned.
C) The preganglionic parasympathetic fibers to the detrusor muscle that descend in the anterior roots of the second, third, and fourth sacral nerves were sectioned.
D) The patient would have an autonomous bladder.
E) The bladder would fill to capacity and then overflow.
F) Micturition could be activated by powerful contraction of the abdominal muscles and manual pressure on the anterior abdominal wall in the suprapubic region.

Question 5

A 15-year-old boy was taking part in a bicycle race when, on approaching a steep hill, he stood up on the pedals to increase the speed. His right foot slipped off the pedal and he fell violently, his perineum hitting the bar of the bicycle. Several hours later he was admitted to the hospital unable to micturate. On examination, he was found to have extensive swelling of the penis and scrotum. A diagnosis of ruptured urethra was made.

-The following statements concerning this case are correct except which?

A) Rupture of the bulbous part of the urethra had taken place.
B) The urine had escaped from the urethra and extravasated into the superficial perineal pouch.
C) The urine had passed forward over the scrotum and penis to enter the anterior abdominal wall.
D) The urine had extended posteriorly into the ischiorectal fossae.
E) The urine was located beneath the membranous layer of superficial fascia.

Question 6

A 34-year-old man was suffering from postoperative retention of urine after an appendectomy. The patient's urinary tract was otherwise normal. Because the patient was in considerable discomfort, the resident decided to pass a catheter.

-The following statements concerning the catheterization of a male patient are correct except which?

A) Because the external urethral orifice is the narrowest part of the urethra, once the tip of the catheter has passed this point, further passage should be easy.
B) Near the posterior end of the fossa terminalis, a fold of mucous membrane projects from the roof and may catch the end of the catheter.
C) The membranous part of the urethra is narrow and fixed and may produce some resistance to the passage of the catheter.
D) The prostatic part of the urethra is the widest and most easily dilated part of the urethra and should cause no difficulty to the passage of the catheter.
E) The bladder neck is surrounded by the sphincter vesicae and always strongly resists the passage of the tip of the catheter.

Question 7

An explorer in the Amazon jungle was found alive after having lost contact with the outside world for 6 months. On physical examination, he was found to be in an emaciated condition. On palpation of the abdomen, a rounded, smooth swelling appeared in the right loin at the end of inspiration. On expiration, the swelling moved upward and could no longer be felt. What anatomic structure could produce such a swelling?

Question 8

An intravenous pyelogram revealed that a patient's left kidney was in its normal position, but the right kidney was situated in front of the right sacroiliac joint. Can you explain this on embryologic grounds?

Question 9

An examination of a patient revealed that she had a horseshoe kidney. What anatomic structure prevents a horseshoe kidney from ascending to a level above the umbilicus?

Question 10

An intravenous pyelogram revealed that the calyces and pelvis of a patient's right kidney were grossly dilated (a condition known as hydronephrosis). What embryologic anomaly may be responsible for this condition?

Question 11

A 55-year-old woman was found rolling on her kitchen floor, crying out from agonizing pain in her abdomen. The pain came in waves and extended from the right loin to the groin and to the front of the right thigh. An anteroposterior radiograph of the abdomen revealed a calculus in the right ureter. What causes the pain when a ureteral calculus is present? Why is the pain felt in such an extensive area? Where does one look for the course of the ureter in a radiograph? Where along the ureter is a calculus likely to be held up?

Question 12

Which congenital anomaly of the ureter is likely to present as a case of urinary incontinence?

Question 13

Renal pain is a common symptom faced by medical professionals. Describe the course taken by pain nerve fibers from the kidneys. In which regions of the body is pain commonly referred to?

Question 14

In relation to abdominal trauma, can you explain the differences between the bladder position in a child compared with that of an adult? Does the degree of filling of the adult bladder affect the signs and symptoms presented by the patient with a ruptured bladder? Can you explain how it is possible to pass an aspirating needle through the anterior abdominal wall into the full bladder in an adult without entering the peritoneal cavity?

Question 15

Why is acute cystitis more common in females than in males? In anatomic terms explain stress incontinence.
contracted diaphragm has pushed it down to its lowest level. When the diaphragm relaxes on expiration, the kidney returns to its original position.