• KIDNEY

• PARTS OF KIDNEY

• NEPHRON

• PARTS OF NEPHRON

• RENAL TUBULES

• SUBSTANCES REABSORBED IN DIFFERENT

PARTS OF RENAL TUBULES
Anatomy & location of kidney
Structure of a nephron
Functions of kidney
 Renal blood flow
• In 70kg adult combined blood flow in both
kidneys is about 1100ml/min (22% of total
CO).

• Blood flow to kidney is very high.

 Peculiarities of renal blood
flow with its important
1. High pressure blood flow Filtration.
2. High glomerular & low peri-tubular capillary
hydrostatic pressure Filtration and
reabsorption.
3. Blood flow is not homogenous. High blood
flow to renal cortex & reduced blood flow in
renal medulla formation &
excretion of dilute & concentrated urine.
4. Two sets of capillary.

5. Portal arterial system

6. Auto-regulation of blood flow

7. O2 consumption by renal blood is more and

O2 extraction is low.
Renal blood flow & O2 consumption

• On weight basis kidney consume more

oxygen than brain due to high blood flow.

• Renal oxygen consumption varies in

proportion with renal tubular reabsorption
of Na+ & GFR.
O2 consumption by kidneys
Juxtaglomerular apparatus
 Functions of JGA

1. Secrets renin & prostaglandin.

2. Extraglomerular cells or Lacis cells secret

cytokines IL2 and tumor necrosis factor.

3. Macula densa cells secret thromboxane

A2.
 MECHANISM OF URINE FORMATION

• Basic mechanisms-

i) Glomerular filtration
ii) Tubular reabsorption
iii) Tubular secretion.
 Glomerular filtration

• Glomerular filtration: the process by

which blood passes through the glomerular
capillaries and filtrated through the flirtation
membrane.

• Composition of glomerular filtrate

• Filtration membrane-
1. Glomerular capillary membrane
2. Basement membrane
3. Visceral layer of Bowmen’s capsule

• Glomerular capillary membrane-

i) Capillary endothelial layer,
ii) Basement
iii) Epithelial layer (podocytes)
Structure of glomerular capillary
Glomerular Filtration Rate
• The total quantity of glomerular filtration
formed by all the functional nephrons of
both kidneys.

• Normally it is 125ml/min or 180L/day.

Pressures determining the
filtration
 Determinants of GFR
• GFR= Kf X Net filtration pressure

• Kf (Filtration co-efficient)= it is the measure of

hydraulic conductivity & surface area of the
glomerular capillaries.

• Kf= GFR / Net filtration pressure

= (125ml/min) / 10mmHg
= 12.5 ml/min/mmHg
 Factors affecting GFR
1. Kf α GFR
2. Renal blood flow α GFR
3. Glomerular capillary hydrostatic pressure α GFR
4. Glomerular cap.colloid osmotic pressure/ α GFR
5. Bowmans’ capsule hydrostatic pressure / α GFR
6. Constriction of afferent & efferent arterioles
7. Systemic arterial pressure
8. Strong Sympathetic stimulation / α GFR
Afferent & efferent arteriolar constriction
Regulation of GFR & Blood flow
• To maintain a constant GFR
• 10% increase in the rate of GFR can
increase 30 folds of urine output.

• Two theories-
1.Macula densa feedback mechanism
2.Myogenic autoregulation
Formation of urine

• Mechanism of urine formation

• Structure of renal tubules
• Substances reabsorbed or
secreted in renal tubules
Mechanism of urine formation
•Substances reabsorbed or
secreted by renal tubules

• Complete reabsorption- glucose, amino acids,

vitamin

• Substances actively reabsorbed in PCT- glucose,

amino acids, vitamins, Na+, K+, HCO3-, Ca++

• Passively reabsorbed- water, Cl-, urea

• Substances Secreted- K+, H+ NH3, Creatinine,

PAH
 TUBULAR REABSORPTION
• Filtration=GFR X Plasma concentration
Example- for glucose-
180L/day (GFR) x 1gm/L= 180gm/day.

None of the filtrated glucose excreted in urine.

• Glomerular filtration & tubular reabsorption is

quantitatively larger than urinary excretion.
 Tubular reabsorption is selective.

• Some substances are completely reabsorbed

(glucose, AA).

• Some are highly reabsorbed but excreted

according to need of the body (Na+, K+).

• Poorly reabsorbed (waste products).

 Route of reabsorption-
1. Transcellular route- transport of water &
other solutes through the apical (luminal)
surface of cell membrane.
2. Paracellular route- the substance move
through the junctional space between the
cells-

A. through the tight junction between the cells

B. transport from interstitial fluid into capillary.
 Mechanism of reabsorption
• Two basic mechanism-
1. Active transport
2. Passive transport

• Substances which are actively reabsorbed-

Na+,K+,HCO3-,PO4-,Ca++,SO4---, Glucose,
amino acids, uric acid, ketone bodies.

• Passive reabsorption- water, urea & Cl-.

 REABSORPTION OF SODIUM

• From GFR 99% of sodium is reabsorbed.

• Two-thirds of sodium reabsorbed in PCT

remaining one third in other segments &
collecting duct.
Reabsorption of sodium
Reabsorption of Sodium
 REABSORPTION OF GLUCOSE

• Glucose is completely reabsorb in PCT.

• Glucose is transported with sodium by sodium-

dependent glucose transporter (SGLUT2 &
SGLUT1) in the brush borders of PCT.

• Basolateral part to interstitium by GLUT2 on S1

segment & by GLUT1 in latter part of S3 segment.
Types of glucose transporter
Reabsorption of amino acids & glucose
Reabsorption of Cl- & K+
 Tubular secretion

• It is the process by which substances are

transported from blood into renal tubules.
It is also called ‘tubular excretion’.
 Substances secreted from different
segments of renal tubules
1. Active secretion of potassium & reabsorption of
sodium occurs by Na+-K+ pump in principal
cells.
2. Hydrogen ion is secreted by two mechanism-
a. Na+-H+ counter transport - early tubular segment
b. Primary active secretion of H+ in the Intercalated
cells (I cells) of late distal & collecting tubule .

3. NH3 secreted from PCT.

 Secretion of H+ & reabsorption of
HCO3- in the renal tubules
• Active secretion of H+ occurs in PCT
(secondary active transport) whereas in DCT
& CT (primary active secretion).
• Urine pH: 6 to 6.8 (8).
• When H+ secretion increases the urinary pH
can be decrease to 4.5 which is known as
rate limiting pH or lower most pH achieved
by kidneys.
Secretion of H+
 Reabsorption of HCO3- in the renal
tubules

• About 80 to 90% HCO3- reabsorption

occurs in PCT.

• Remainder 10% occurs in DCT & CD.

Secretion & reabsorption in late DCT
Secretion of K+
 Reabsorption of water

• PCT, DCT & in collecting duct.

• Reabsorption of water in proximal
convoluted tubules or obligatory
reabsorption of water
• Proximal convoluted tubule is highly permeable
to water.
• Ascending limb of LOH completely impermeable
to water.

• This concentration gradient causes osmosis of

water towards renal interstitium.
Water reabsorption
Reabsorption of water from distal
convoluted tubules & collecting duct –
facultative reabsorption
• The distal convoluted tubules & collecting duct
normally are impermeable to water.
• By the presence of ADH these segments become
permeable to water.
• ADH combines with V2 receptor in the tubular
epithelial cells.

• Presence of aquaporins (AQP) which act as water

channels
Passive reabsorption of urea
& chloride

1. Solvent drag
(PCT)
2. Reabsorption of
Cl- by Passive &
secondary active
transport.
3. Urea- passive
reabsorption
PCT
LOH
Transport of Na+, K+, Cl-
DCT
Mechanism of Na+-K+
transport in DCT
Medullary collecting duct
 Regulation of tubular
reabsorption-

• To maintain precise balance between

glomerular filtration & tubular reabsorption.

1. Glomerulotubular balance
2. Hormonal factors
3. Nervous factor
1. Glomerulotubular balance
•Increased reabsorption rate in response to increased
the rate of tubular load.

•Maintains 65% rate of GFR even in increased

filtration rate.

•Importance-
1.It helps to prevent overloading in the distal tubular
segment when increased GFR.
2.Act as line of defense to buffer the effects of
spontaneous changes in GFR on urine output.
 2. Hormones regulating tubular reabsorption

Hormones Action

Aldosterone NaCl,H20 reabsorption, K

secretion
Angiotensin II NaCl,H20 reabsorption, in
PCT, ALLH (thick), CD
ADH Increase water reabsorption in
DCT & CD
ANP (Atrial Natro Uretic decrease sodium chloride
peptide) reabsorption

Parathormone Increase reabsorption of Ca++

& decrease phosphate
reabsorption
 3. Nervous factor (Sympathetic
stimulation)

• Stimulation of sympathetic system on

renal tubules-Increase sodium & water
reabsorption thus decrease their
excretion.

• Also causes secretion of renin from

juxtaglomerular cells which cause
formation of angiotensin II.
 TRANSPORT MAXIMUM OR
Tm value
• The substances which are actively
reabsorbed or secreted has a maximum
rate to transport in the renal tubules.
• For glucose it is 375mg/min in adult male &
300mg/min in adult female.
• TmG 375mg/min, When all the nephrons
of both kidneys reached the maximum
capacity to reabsorb glucose
Tm of substances actively secreted

• Creatinine= 16mg/min
• Para-aminohippuric acid= 80mg/min

• Substances that are actively

transported but do not exhibit
Transport maximum exhibits - gradient-
time transport
• RENAL THRESHOLD-
It is the critical concentration of a
substance above which it appears in
the urine but below which it does not
appear in urine.

* For glucose it is 200mg/dl

 • Plasma load-

• it is the total amount of a substance present in

the plasma that passes through the kidneys in
each minute.
• Example- Glucose= 70-100mg/dl

Plasma load= plasma flow X plasma conc. Of that substance

650ml/minX 1mg/1ml = 650mg/min.
Filtrated load or tubular load-
• it is the total amount of a substance
entering the tubules by filtration per
minute.

Filtrated load= GFR X plasma concentration

For glucose= 180L/day X 1gm/L.
= 180gm/day.
Mechanism of urine
formation
Dilute urine formation
Concentrated urine formation
 Control of urine
concentration & volume-

1. Water content of the body

2. Anti diuretic hormone (ADH).

 Formation of dilute urine
Increase water content of the body

Decrease body fluid Osmolarity

Inhibits ADH secretion from the posterior

pituitary

No reabsorption of water in the distal renal

tubules

Excretion of large volume of water (dilute

urine)
• Tubular fluid is isosmotic in the Proximal
convoluted tubules
• Tubular fluid is diluted in the ALLH
• Tubular fluid in the Distal convoluted &
collecting tubules become further diluted in
the absence of ADH

• Normal urine output is about 1.5L/day.

• Range (1 to 2L/day)
• When there is large excess of water in the
body kidney can excrete 20L/day of dilute
urine the concentration of which is 50mosm/L.
The kidney conserves water by
producing concentrated urine

• The human kidney can produce a

maximal urine concentration of 1200 to
1400mosm/L.
 Obligatory urine volume`
• It is the minimum volume of urine which kidney
must be excreted.
• Urine concentration must be 1200mosm/L.

A normal 70 kg adult can excrete about

600mosm of solute per day.
So his obligatory urine volume=

600mosm/day = 0.5L/day.
1200mosm/L
Renal Mechanism of concentrated urine
formation
1. High level of ADH.
2. Hyper osmotic renal medullary interstitium.
3. Renal blood flow
4. Recycling of urea

# The process by which the renal medullary

interstitium becomes hyper osmotic –

‘‘Counter Current Mechanism’.

 High ADH level
• The renal medullary interstitium is
hyperosmotic.
• Decrease water intake increases the ADH
secretion.
• In the presence of high ADH level - there is
increase reabsorption of water.
• Production of concentrated urine.
Role of ADH in concentrated urine formation
 Counter current mechanism-
• It is the mechanism where two fluids are
flowing through two parallel tubes in close
proximity & in counter direction, which is
connected by a hair pin manner at the tip &
the concentration may be multiplied along the
length of the tubules.

• Consist of two parts-

a) Countercurrent multiplier &
b) Counter current exchanger.
• Countercurrent multiplier:
occurs in the Loop of Henle along the renal
tubules.
Function- produces hyperosmotic renal medullary
interstitium.

• Countercurrent exchanger:
Occurs in the vasa recta.
Function-it maintains hyperosmolarity in the renal
medulla.
Counter current mechanism produces a
hyperosmotic renal medullary interstitium

1. Active transport of Na+ & co-transport of

K+& Cl- to medullary interstitium.
2. Active transport of ions from collecting
ducts into medullary interstitium.
3. Facilatated diffusion of urea into the
medullary interstitium.
4. Diffusion of small amount of water from
medullary tubules into medullary interstitium.
Counter current multiplier mechanism
 Countercurrent exchanger
• Function- maintenance of hyper osmotic renal
medullary interstitium.
• Site- vasa recta.
Mechanism-

1. Low medullary blood flow. It helps to

decrease loss of solute in the Medullary
interstitium.

2. Minimize wash of solutes from Medullary

interstitium.
 Mechanism of vasarecta-
Blood enters & leaves medulla by Vasarecta

Vasarecta highly permeable to solutes in blood except for plasma

protein.

Blood descends into medulla toward papillae & become more

concentrated

At the tip of Vasarecta its conc. Is 1200mOsm/L

As ascends toward cortex it becomes progressively less conc.

Because solute moves back into medullary interstitium, as
water moves into vasarecta.
 Recirculation of urea
• In PCT 40-50% of filtrated urea is reabsorbed.
• The ALLOH, DCT, CT all are impermeable to
urea.
• ADH causes reabsorption of water, urea
remains in the tubular fluid & passively diffuse
into medullary interstitium.
• Some urea diffuse from medulla in to thin limb
of LOH so that it again passes through the
renal tubules.
Recirculation of urea
• In PCT 40-50% of filtrated urea
is reabsorbed.
• The ALLOH, DCT, CT all are
impermeable to urea.
• ADH causes reabsorption of
water, urea remains in the
tubular fluid & passively diffuse
into medullary interstitium.
• Some urea diffuse from
medulla in to thin limb of LOH
so that it again passes through
the renal tubules.
 Renal control of acid base balance
• kidney control acid base balance by
excreting acidic or basic urine.

Basic mechanism:
* If secretion of H+ is more than HCO3-
filtration then let loss of acid.

* Excess filtration of HCO3- than H+ then

there is net loss of base.
• Kidney filters about 4320mEq/day of HCO3-.
• To reabsorb this amount kidney must secret
equal amount of H+.

• Body produces 80mEq of non volatile acid from

protein metabolism.

• Additional 80mEq H+ must be secreted.

• For a total 4400mEq/day H+ secreted in the

tubular fluid.
 Acidification of urine
• It is the ability of the renal tubules to
produce acidic urine by increase H+
secretion, reabsorption of HCO3- and
generation of new HCO3- by
combination of Phosphate & Ammonia
buffer.
Mechanism-
A. Secretion of H+ - from cells of PCT,
ALLOH & DCT by Na+ -H+ counter
transport.
Renal Tubular cells Tubular
interstitial fluid lumen
Na++ HCO3-
Na+

K+ H+
HCO3- + H+

H2CO3
H2CO3

H2O
+
CO2 CO2 CO2+ H2O
 B. Reabsorption of HCO3-

1. To reabsorb HCO3- combines with H+ to

form H2CO3 then dissociates into H2O &
CO2.

2. Thus each time a H+ is formed in the

epithelial cells, a HCO3- is also formed &
released back into the blood.
 -
3. Titration of HCO3 against H+
in renal tubules
• Tubular H+ secretion is about 4400mEq/day
& rate of HCO3- filtration is about
4320mEq/day.
• But titration process not accurate, as slight
excess H+ (80mEq/day) in tubules is
excreted in urine.

• These H+ is not freely excreted. It is

excreted in combination with NH4+ & PO4-
buffer.
 \
• Renal Tubular cells Tubular
Interstitial fluid lumen

Cl Cl- Cl-

HCO3 + H+ H+
H2CO3

H 2O
+
CO2 CO2
C. Generation of new bicarbonate
ion

I. The Phosphate buffer system carries

excess H+ in the urine & generates
new bicarbonate ions .
Renal Tubular cells Tubular
interstitial fluid lumen
Na+ +NaHPO4-
Na+

K+ H+ + NaHPO4
HCO3- + H+
H2CO3

H2CO3

H2O NaH2PO4
+
CO2
CO2
II. Role of Ammonia buffer in
excretion of H+ in the urine &
generation new bicarbonate
ions
Renal Proximal Tubular lumen
interstitial fluid tubular cells

Glutamine Glutamine
Glutamine

2HCO3- NH4+

NH4+ NH4+ +Cl-

Na+ Na+
Renal Collecting Tubular cells Tubular
interstitial fluid lumen

NH3 NH3
Na+
K+
HCO3- + H+ H+ Cl-

H2CO3 H2CO3
NH4+ + Cl-

H2O
+
CO2
CO2
 Renal regulation of acid base
balance
• Acidosis
• Alkalosis

• Renal correction of acidosis- increase excretion

of H+ & addition of HCO3- in the ECF.

• Renal correction of alkalosis-decrease tubular

secretion of HCO3- & increased excretion of
HCO3-.
•Diueresis
•Water Diuresis & osmolar
diuresis
•Osmolar clearance
•Free water clearance
 Osmolar clearance (Cosm)

it is the virtual volume of plasma that contains

total amount of osmotically active substance
that is excreted out through the urine per
minute.
Cosm= UosmX V
Posm
U osm= osmolarity in urine
P osm= osmolarity in plasma
V= urine volume/min
 Free water clearance( CH20)
• it is the total vol. of plasma that contains
excess amount of water which is excreted
out through the urine per minute.
CH2O=Vol. of urine/min Cosm
CH2O= 0, if urine isotonic to plasma.
CH2O= +ve, dilute urine.
CH2O=-ve, in Conc. urine.
Renal Tubular cells Tubular lumen
Interstitial fluid

Na+ Na+
Na+ + HCO3
ATP
K+
H+ H+ + HCO3

HCO3-
-
HCO3 + H+

H2CO3 H2CO3
H2O

+
CO2 CO2 + H2O
CO2
Renal inter I cells (DCT&CD) Tubular lumen
Stitial fluid

Cl- Cl- Cl-

HCO3
- ATP
HCO3 + H+ H+

H2CO3

H2O
+
CO2
CO2
 Composition of normal urine

Water- 1.2 L
solids excreted in urine

Organic substance inorganic substances

Urea Na+
Uric acid K+
Creatinine Ca++
Ammonia Cl-
PO4---
SO4—
 Properties of urine

Volume- 100-1500ml/day
Reaction- slightly acidic (pH- 6 to 6.8)
Specific gravity- 1.01-1.035
Color-normally straw
Odor- first urine aromatic but odor becomes
stronger due to bacterial decomposition.
Appearance- transparent.
 Renal function tests
A. Examination of urine
B. Examination of Blood
C. Examination of blood & urine or renal clearance test
D. Radio & imaging tests
 A. Examination of urine
Urine analysis

I. Physical examination
II. Microscopic examination
III. Chemical analysis
 I. Physical examination
1. Volume- increase in chronic renal failure, Diabetes
insipidus, Glycosuria etc.
2. Color- abnormal color in jaundice (yellow),
hematuria (red), medications.
3. Appearance- normally clear but turbid incase of
presence of protein, bacteria, crystals or yeast.
4. Specific gravity- it is low in diabetes insipidus &
high in diabetes mellitus.
5. pH & reaction- depends upon pathological
conditions like renal acidosis (CRF) or alkalosis or
even diet.
 II. Microscopic examination
1. Red blood cell- glomerular disease, UTI.
2. WBC- increase in acute glomerulonephritis, urinary
tract or vaginal infection.
3. Epithelial cells- nephrotic syndrome or renal tubular
disease.
4. Casts- Hyaline casts in protinuria, cellular casts-
(RBC) tubular necrosis (WBC) pyelonephritis.
5. Crystals- calcium, ammonium, magnesium
6. Bacteria- increase in number in UTI.
 III. Chemical analysis
1. Glucose- appears when blood glucose >180mg/dl.
2. Protein- proteinuria- nephrotic syndrome,
glomerulonephritis.
3. Ketone bodies- pregnancy, fever, DM, prolong
starvation etc.
4. Bilirubin- appears in hepatic & post hepatic jaundice.
5. Bile salt- jaundice
6. Blood- glomerulonephritis, stone, infection or
malignancy of renal tract.
7. Urobilinogen- hemolytic jaundice.
 B. Examination of blood
1. Estimation of Plasma proteins- normal values
total protein = 6.4-8.3m/dl
serum albumin=4.7gm/dl
serum globulin= 2.3gm/dl
fibrinogen= 0.3gm/dl
The level of plasma protein altered in renal failure.

2. Estimation of Creatinine, urea, uric acid-

normal values
Urea= 25-40 mg/dl
Creatinine=0.5-1.5mg/dl
Uric acid=2.5mg/dl
C. Renal Clearance test
(blood & Urine)
 C. Examination of blood & urine
1. Plasma clearance or renal clearance-
it is the virtual volume of plasma that is completely
cleared of the substance by the kidneys per unit of time
when excreted through urine.

Clearance rate (Cs)= Us X Vml/min

Ps
Us= conc. of substance in urine
V= volume of urine flow
Ps= conc. of substance in plasma
• If plasma osmolarity is 300mosm/L & urine
osmolarity is 600mosm/L then- U X V / P
600mosm/LX 0.001L/min
300mosm/L

= 0.002L/min or 2ml/min of plasma is cleared of

solutes.
2. Measurement of glomerular filtration
rate (GFR)= substances which are completely
filtered neither reabsorbed or secreted are used to
measure GFR.
For example- inulin, Creatinine, radioactive
iothalamate.

Amount filtrated = Amount excreted

GFR X P inulin = U inulin X Vml/min

P inulin
Clearance of inulin= U inulin X Vml/min
P inulin

= 125mg/ml X 1ml/min
1 mg/ml

= 125ml/min
• Measuring GFR in compare to inulin
clearance
1.If clearance rate of substance is equal to that of
inulin clearance that substance is filtered
only not reabsorbed or secreted.
2.If clearance rate of substance is less to that of
inulin clearance that substance is reabsorbed
by renal tubules..
3.If clearance rate of substance is greater than
that of inulin clearance that substance must
have been secreted by renal tubules..
3. Measurement of Renal Plasma Flow (RPF)

• to measure plasma flow – Para-aminohipporic acid

(PAH).
- PAH clearance indicates the amount of plasma
passes through the kidneys.

Renal plasma flow= U PAH x V

P PAH
5.85 mg/ml X 1ml/min
0.01 mg/ml
= 585ml/min.
if excretion ratio 90% then
RPF = 585/0.9= 650ml/min.
• Filtration Fraction (FF) – it is the fraction of
plasma that filters through the glomerular
membrane.

FF= GFR / Renal Plasma flow

= 125ml/min/650ml/min
= 0.19
4. Measurement of renal blood flow- to determine it
requires- i. Renal plasma flow (RPF)
ii. Percentage of plasma volume in the blood
i. Renal plasma flow
It is measured by using PAH clearance (650ml/min).
ii. Percentage of plasma volume: determined by PCV.

If PCV=0.45(45%) & RPF = 650ml/min, then renal

blood flow (RBF)= RPF/(1-hematocrit)
= 650/(1-0.45)
= 650/0.55 or 1182ml/min.
• Osmolar clearance- it is the vol. of
plasma that contains total amount of
osmotically active substances that is
cleared out through urine per minute.

Cosm= Uosm X V
Posm
• Free water clearance- it is the total vol. of
plasma that contains excess amount of
water which is excreted out through the urine
per minute.

CH2O= Vol.of urine ml/min Cosm

CH2O= 0, if urine isotonic to plasma.
CH2O= +ve, dilute urine.
CH2O=-ve, in Conc. urine.
 D. Radio & imaging test

1. X-Ray KUB region

2. USG Abdomen
3. Intra Venous Urography (IVU)
4. CT scan
5. Renal biopsy
 Micturition

• Step 1- the bladder fills progressively until the

tension in the wall rises above the threshold
level.
• This elicits the second step

• Step 2- a nervous reflex called ‘micturition

reflex’ that empties the bladder.
* Although it is an automatic spinal cord
reflex but it can be inhibited or facilitated
by the centers of cerebral cortex or brain
stem.

• Physiologic anatomy & nervous

connections of urinary bladder
 Innervations of urinary bladder

• Pelvic nerve (S2 & S3)- carries both sensory

& motor nerve fibers.
• Sensory fibers detect the degree of stretch in
the bladder wall.
• The motor nerves mainly parasympathetic
fibers.
• pudendal nerve (skeletal motor nerve fiber)
supplying the external bladder sphincter are
somatic nerve fibers that have voluntary
controls.

• Sympathetic innervations from sympathetic

chain through hypogastric nerves (L2)
stimulate mainly the blood vessels & has little
effect on bladder contraction.
 Transport of urine from
kidney through ureter
into bladder
• Vesico-ureteral reflux

• Uretero-renal reflex
 Micturition reflex
Filling of the urinary bladder
Stimulation of stretch receptors of bladder wall
Afferent impulse passes via the pelvic nerve from the bladder

Efferent impulse return back via the pelvic nerve to the bladder
Contraction of detrusor muscle & relaxation of internal sphincter

Flow of urine into urethra & Stimulation of stretch receptor

Afferent impulse pass via pelvic nerve Inhibition of the

pudendal nerve Relaxation of external sphincter
voiding urine
• Once the micturition reflex begins it is
self regenerative.

• The cycle continues repeatedly until the

force of contraction of the bladder
reaches the maximum & the urine is
voided completely.
 Facilitation or inhibition of
micturition by the brain
• Spinal centers for micturition are present
in sacral & lumber segments.
• Strong Facilitator & inhibitory center :
mainly in the pons, brain stem
• Inhibitory center located in the cerebral
cortex but they can become excitatory.
• Higher center keeps micturition reflex
partially inhibited
1. until desire for micturition.

2. Can prevent until convenient time & place.

3. At the time of urinate the cortical center can

facilitate the sacral center to initiate
micturition and inhibit external sphinkter.
 Voluntary micturition
Person voluntarily contracts his/her abdominal muscles

Increase pr. in the bladder which allows extra urine to

enter into the bladder neck & post urethra under pr.

Stretching of the bladder wall elicits micturition reflex

Emptying of all the urine from urinary bladder

** rarely more than 5 to 10 ml of urine left in bladder.

 Effects of interference of
nervous control of bladder
• Section of sympathetic supply- relaxation of
ureteric orifices, trigon & internal sphincter.
• Injury to sacral nerve supply- complete loss
of voluntary control. Bladder response to small
volume of urine. Residual urine may left in
bladder.
• Injury to afferent nerve supply- dribbling of
urine.
• Injury to cortical control- efferent control is
disturbed.

• Acute transection of the cord- abolished

voluntary micturition. “ retention with
overflow”.
• Cystitis or acute urinary tract infection may
occur.
• It is the clinical condition when urinary bladder
loses its micturition reflex contraction due to
destruction of sensory nerve fibers from the
bladder to spinal cord (afferent fiber).
• In this condition the person loses
bladder control.

• ‘overflow incontinence’.
 Causes
1. most commonly crush injury to the sacral
region of spinal cord.
2. Certain diseases which can cause damage of
the dorsal root nerve fibers.
Syphilis- causes damage by constrictive
fibrosis.
This condition is called ‘tabes dorsalis’ & the
resulting bladder condition is called ‘tabetic
bladder’.
 AUTOMATIC BLADDER

• In this condition there is no longer voluntary

bladder control by the brain.

• Caused by damage of the spinal cord above

the sacral region ( a typical micturition reflex still
remain).
• After spinal shock period the micturition reflex
returns however voluntary control is absent
from higher centers.

• The condition can be improved by periodic

bladder emptying by catheterization.
 UNINHIBITED NEUROGENIC
BLADDER

• This condition derives from partial damage of

the spinal cord or brain stem that interrupts
most of the inhibitory signals resulting into
frequent & uncontrolled micturation.
 NOCTURNAL MICTURATION
• Involuntary voiding of urine at night. Also known as
‘enuresis’ or bed wetting.

• Occurs due to loss of voluntary control of micturition.

• Normally present in infants & <3yrs aged child.

• Occurs due to incomplete myelination of motor

nerve fibers to the bladder.

• When myelination complete voluntary control

develops.
 Body fluid
• Total body water is 60% of body weight or
42L incase of 70Kg adult.

• Body fluid compartments

• Intracellular fluid constitute about 40% of

total body weight.
• Rest 20% is ECF.
• Difference between ECF & ICF
 Daily water input-output chart (ml/day)

• Daily input- • Daily output

Fluid ingested-2100ml Insensible- skin: 350ml
From metablism-200ml Insensible lungs: 350ml
Total intake= 2300ml Sweat 100ml
Feces 100ml
Urine 1400ml
Total output= 2300ml
Body fluid compartments

Total body fluid

42L

Extra cellular fluid Intracellular fluid

14L 28L

Plasma Interstitial fluid

3L 11L

Trans cellular fluid

 Measurement of body fluid
volume
• Indicator dilution method
• Formula: V= M/c
V= volume of fluid compartment
M= mass or total quantity of marker injected
C= conc. Of marker in sample fluid
 Marker used
• Total body water= Deuterium
Oxide(D2O)
tritium oxide(T2O), antipyrine
ECF= Ra Na+, Cl-, SO4-, Inuline, mannitol,
sucrose

Plasma= Ra Iodine (131 I),

Ivan’s blue (T-1824)
 Example of measurements
• ECF= Mass(mg)- amount loss in urine(mg)
Conc.of sucrose in plasma mg/ml
• Interstitial fluid volume
ECF-plasma volume
• ICF= total fluid volume- ECF volume
• Plasma volume=
amount of dye injected- amount excreted
Avg. concentration of dye in plasma
Measurement of fluid volume
in the different body fluid
compartment-the indicator-
dilution principle
 Edema
• Excess fluid in the body tissues.
• Most cases involve ECF compartments
but may also occur ICF.

• Intracellular edema-
1. Depression of metabolic system of body
tissues
2. Lack of nutrition
 ECF edema
I. Increased capillary pressure
A. Excessive kidney retention salt & water
1. Acute or chronic kidney disease
2. Excess minerelocorticoids
B. High venous pressure
1. Heart failure
2. Venous obstruction
3. Failure of venous pumps
C. Decreased arteriolar resistance
1. Excessive body heat
2. Vasodilatorors

II. Decreased plasma proteins

A. Loss of protein (Nephrotic syndrome)
B. Loss of protein from skin
1. Burn
2. Wounds
C. Failure to produce protien
1. Liver disease
2. Protein malnutrition

III. Increased capillary permeability

A. Relase of histamin
B. Toxins
C. Vitamin deficiency
D. Bacterial infection
E. Burn
IV. Blockage of lymph return
1. Cancer
2. Infection (fileria)
3. Surgery
4. Congenital absence of lymph vessels
 Important terms to be known
• Isosthenuria: inability of the kidney to
form concentrated or diluted urine.
• Uremia: high concentration of urea in
blood.
• Azetoemia: the non protein nitrogenous
substance include urea, uric acid,
creatinine & other compounds.
• Protenuria
• Hematuria
• Glycosuria