Overview
What Is It?
As you age, the structure of your kidneys can change, reducing their ability to remove wastes. Illness and injury can also affect the filtering ability of the kidneys or block urine's passage.
Your urinary system works with other organs to get rid of wastes and keep chemicals and water in the body balanced. As an adult woman, you eliminate about a quart and a half of urine each day, but the amount can vary depending on the amount of fluid and food you've consumed and how much you lose through sweating and breathing. Some medications can affect the quantity of urine your body eliminates.
When your body uses proteins derived from the foods you eat, it creates a waste product called urea that is carried in the bloodstream to the kidneys, two bean-shaped organs approximately the size of fists. They are located just below the rib cage near the middle of the back. Each kidney has about a million tiny filtering units called nephrons, which remove urea from the blood.
A ball of small blood capillaries (a glomerulus) and a small tube called a renal tubule comprise a nephron. The kidneys remove or return chemicals such as phosphorus, potassium and sodium in quantities needed to maintain optimal blood levels of these substances. Urea, water and other waste products create urine as the substances move through the nephrons and down the kidney's renal tubules.
The kidney also releases three vital hormones: erythropoietin which stimulates production of red blood cells in bones; renin, a blood-pressure regulator; and the active form of vitamin D, which maintains calcium levels in bone.
Urine exits the kidneys through two thin tubes about eight to 10 inches long called ureters, which carry the fluid to the bladder, a hollow muscular organ that stores urine. Ureter muscles tighten and relax to pump urine downward and away from the kidneys. The process is more or less continuous, with minute quantities of urine emptying into the bladder about every 10 to 15 seconds. If the urine gets stuck in the ureters or backs up, a kidney infection can result.
Shaped like a balloon, the bladder sits in the pelvis and stores urine until you are ready to urinate. As it becomes fuller, it swells into a round shape and then shrinks when it is emptied. A healthy urinary system can hold up to 16 ounces of urine for two to five hours. Bladder nerves send signals to let you know when to urinate; the signals grow steadily more urgent as the bladder fills.
To keep urine from leaking, circular muscles called sphincters close tightly around the opening of the bladder. When you decide to urinate, bladder muscles tighten and sphincter muscles relax, and the urine is pushed down the urethra.
As you age, the structure of your kidneys can change, reducing their ability to remove wastes. Illness and injury can also affect the filtering ability of the kidneys or block urine's passage. Urinary system muscles also tend to weaken as you grow older, leading to increased incidence of urinary tract infections and incontinence.
Urinary system disorders are widespread. According to the National Kidney Foundation, approximately 26 million Americans have chronic kidney disease, and most do not know it. Millions more are at risk. Incontinence and overactive bladder are two of the most common health problems among women. And 85,790 Americans died of end-stage renal disease in 2005.
Major Urinary System Disorders
Health care professionals often use the term "renal function" when talking about the kidneys; if both kidneys are healthy, you have 100 percent renal function. If one becomes nonfunctional or is donated for a transplant operation, you will still be healthy, even with only 50 percent of renal function. However, if function slips below 20 percent, serious health problems arise because the kidneys can no longer perform their function of regulating water and chemicals and removing waste. Levels below 10 to 15 percent necessitate dialysis or transplantation.
Renal function levels below 10 to 15 percent necessitate dialysis or transplantation. Unfortunately, symptoms of chronic renal failure (a gradual loss of function) may go undetected for several years and often do not become noticeable before kidney function falls to 25 percent or less.
Acute renal failure denotes a sudden onset of renal failure, such as that caused by an accident, certain drugs or poison. The kidneys may recover or the damage may be permanent. If the kidneys stop working entirely, the result is a condition called uremia, in which the body fills with extra water and waste products, leading to swelling in the hands or feet, fatigue and weakness. End-stage renal disease (ESRD) refers to when the kidneys have lost all or nearly all function.
Specific kidney conditions include:
Analgesic Nephropathy
Improper use of over-the-counter painkillers, or analgesics, can lead to kidney failure. These products include aspirin, acetaminophen, ibuprofen and naproxen sodium, all of which are safe for most people when taken at the recommended dosages. However, combining these drugs or taking them when you have certain conditions boosts your risk of kidney disease. You should avoid these medications if you have an autoimmune disease such as lupus, advanced age, chronic kidney conditions or have recently binged on alcohol.
If you have any of these conditions, make sure your health care professional and pharmacist are consulted before you risk taking an analgesic, since short-term use can cause acute (temporary) kidney failure.
Taking one or more of these products daily for several years can cause analgesic nephropathy, chronic kidney disease leading gradually to end-stage renal disease (ESRD). Combination painkillers (such as aspirin and acetaminophen) are especially dangerous. If you find you need painkillers often, talk to a health care professional about the best options for protecting your kidneys.
Cystocele
A cystocele, occurs when the pelvic floor muscles, which form the wall between the bladder and vagina, weaken, allowing the bladder to drop into the vagina. The consequences are discomfort and voiding difficulties, such as urine leakage or incomplete bladder emptying.
There are three grades of cystocele:
- Grade 1: the bladder drops a short way into the vagina
- Grade 2: the bladder sinks to the opening of the vagina
- Grade 3: the bladder bulges through the vaginal opening
Interstitial Cystitis (IC)
Interstitial cystitis (IC) may also be called painful bladder syndrome, urethral syndrome and frequency-urgency syndrome. It is an inflammatory condition of the lining of the bladder.
The inflammation associated with this chronic bladder disorder can cause diminished bladder capacity or size, glomerulations (pinpoint bleeding) and (rarely) ulcers in the bladder lining. Rarely, in severe cases, scarring and stiffening of the bladder can occur. Although the cause of this disorder is unknown, research shows that it may be associated with other diseases such as vulvodynia (vulvar or vaginal pain), fibromyalgia, irritable bowel syndrome (IBS) and endometriosis. Interstitial cystitis affects an estimated 1.3 million Americans, more than 1 million of whom are women.
Typical IC-associated sensations include discomfort, pressure, tenderness or intense pain in the bladder and surrounding pelvic area. The intensity of pain may shift as the bladder fills or empties. Other symptoms include pain associated with intercourse and frequent and/or urgent need to urinate (women with severe IC may urinate as many as 60 times a day). Symptoms often get worse before or during menstruation and after sexual activity.
No one knows for sure what causes IC; theories point to an autoimmune disease, abnormality in the urine, hereditary condition, infection or allergic condition.
Glomerular diseases
Diseases that damage the glomeruli—the kidney's filtering units—can lead to kidney failure. Two major categories of glomerular diseases are:
- glomerulonephritis, inflammation of the membrane tissue in the kidney that filters wastes and extra fluid from the blood
- glomerulosclerosis, scarring or hardening of tiny blood vessels in the kidney
When the glomeruli are damaged, protein and blood can seep into the urine, and waste products can accumulate in the blood. If too much of the protein albumin is lost, the blood is less able to absorb extra fluid.
Glomerular diseases are indicated by:
- proteinuria
- hematuria
- reduced glomerular filtration rate (inefficient waste filtering)
- hypoproteinemia (low levels of protein in the blood)
- swelling, or edema
The diseases have many causes, including:
- Autoimmune diseases, such as lupus. Autoimmune diseases are conditions that develop as a result of the immune system attacking healthy tissue instead of combating invading bacteria or viruses.
- Hereditary nephritis, also called Alport syndrome. A family history of chronic glomerular disease or impaired vision may stem from this syndrome, and men are more likely to progress to chronic renal failure and/or vision loss.
- Infection-related glomerular disease, such as strep throat, heart infection (bacterial endocarditis), HIV or skin infection (impetigo). The kidneys usually recover from infection-related damage, but sometimes damage is permanent and ESRD results.
Hematuria
Hematuria is a term used for the presence of red blood cells in the urine. Sometimes hematuria is visible, but in many cases the urine appears normal. Hematuria is not a disease in itself, but a sign of some other condition.
The cause may be a serious one, such as bladder or kidney cancer, but more often the cause is relatively benign. Exercise can cause episodic hematuria, for example. Obvious blood in the urine is often associated with bladder infections or kidney stones. Still, you should check with a health care professional any time you see blood in your urine or follow up if a urinalysis shows red blood cells in your urine.
To identify the cause of hematuria, your doctor may order various tests, such as urinalysis, blood tests, ultrasound, intravenous pyelogram or CT urogram, or may examine your bladder with a cystoscope. If white blood cells are present in the urine, a urinary tract infection or kidney disease may be the cause.
Treatment is tailored to the cause of the hematuria. If it is not caused by a serious condition, no treatment is necessary.
End-Stage Renal Disease (ESDR) and Kidney Failure
The early stages of kidney disease may not cause noticeable symptoms. However, symptoms may include frequent headaches, fatigue or an all-over itch. Worsening disease can cause urination patterns to change (becoming more or less frequent), appetite loss, nausea and vomiting, swelling or numbness in the hands or feet, drowsiness, difficulty concentrating, skin darkening and muscle cramps. Treatment generally requires dialysis or transplant, described in the treatment section.
Diabetes is the leading cause of ESRD.
When diabetes is undiagnosed or poorly controlled, excess sugar circulates in the blood, leading to higher blood flow into the kidney and glomerular scarring. Diabetic nephropathy is the term used for such damage, which can be delayed or prevented by maintaining healthy blood sugar levels. If you have diabetes, high blood pressure or a genetic condition called polycystic kidney disease, your health care team will monitor your condition to prevent or limit the damage to the kidneys. Such damage may lead to renal failure and ESRD.
Bladder Cancer and Kidney Cancer
Signs and symptoms of bladder cancer include blood in the urine (which may be bright red or rusty in appearance or only seen under the microscope), painful or frequent urination or feeling the urge to urinate even though the bladder is empty.
Renal cell cancer is the most common form of kidney cancer. As the cancer grows, it may spread to nearby organs, such as the liver, colon or pancreas, or may disperse (metastasize) to other parts of the body. Cancer cells often spread to lymph nodes, bean-shaped organs that produce infection-fighting cells. Signs and symptoms of renal cell cancer include blood in the urine, back or abdominal pain, or a mass on the kidney. Many kidney cancers are diagnosed by ultrasound or CT examination performed for other medical reasons.
Kidney or Ureter Stones
Stones, or calculi, are usually formed in the kidneys but may be found anywhere in the urinary system. Stones are among the most painful and most common urinary tract disorders—an estimated five to 10 percent of Americans will have a kidney stone at some point in their lives. Men are afflicted with kidney stones more often than women, and Caucasians are more susceptible than African Americans. Stones are most likely to occur between the ages of 20 and 50 in women (later in men) and are more likely to occur in people who have previously had stones.
Kidney stones vary widely in size and in the amount of pain they cause. Most are passed from the body without assistance, but there are a variety of strategies to treat stones that linger.
A kidney stone forms from crystals that separate from urine and accumulate on the kidney's inner surfaces. Urine contains chemicals that prevent crystal formation, but in some people the process doesn't work well and they develop stones. If the stones are small enough, they travel through the urinary tract and leave the body without causing symptoms.
Most stones contain calcium and either oxalate or phosphate—all three are part of a healthy diet. Less common are struvite or infection stones, caused by urinary tract infections. Terms used to describe stones include nephrolithiasis (kidney stones), urolithiasis (urinary tract stones) and ureterolithiasis (ureter stones).
Risk for kidney stones is higher in those with family histories of stones; those who have urinary tract infections, kidney disorders and metabolic disorders such as hyperparathyroidism, cystinuria (too much of an amino acid called cystine) or hyperoxaluria (excess production of oxalate salt); and those with a disease called renal tubular acidosis. High levels of urinary calcium lead to crystals of calcium oxalate or calcium phosphate, which can grow into painful stones.
Other risk factors include:
- hyperuricosuria—a disorder of uric acid metabolism
- gout
- excess intake of vitamin D
- blockage of the urinary tract
- use of diuretics or calcium-based antacids
- chronic bowel inflammation, intestinal bypass surgery or ostomy surgery
The initial symptom is usually sudden, intense pain, provoked by the movement of a stone in the urinary tract. The feeling is usually a sharp, very severe, cramping pain in the back and side in the kidney or lower abdominal region. Nausea and vomiting may occur, and the pain may spread to the groin. A stone too large to pass easily causes continuing pain in the muscles in the ureter as they try to squeeze the stone into the bladder. As the stone approaches the bladder, you may feel compelled to urinate more frequently or feel a burning pain when you urinate.
Note: Fever and chills suggest an infection that warrants a health care professional's immediate attention.
Kidney stones are usually diagnosed via x-ray or sonogram. Urinalysis often shows blood cells. A health care professional may order blood and urine tests to detect abnormal substances that may be stimulating stone production. A type of x-ray called an intravenous pyelogram (IVP) or spiral CT scan may be used to scan the urinary system as well. In addition, to help determine what's causing your kidney stones and, therefore, to plan appropriate prevention measures, your health care professional may ask you to urinate through a strainer designed to catch any stones you pass so the stones can be analyzed for their makeup.
Neurogenic Bladder
The smooth functioning of the urinary system depends on muscles and nerves working properly to store urine in the bladder and release it at the appropriate time. Nerves running between the bladder and the brain tell the brain when the bladder is full and tell the bladder when it's OK to relax and release the urine. When the nerves that carry these messages malfunction, a condition called neurogenic bladder results.
Some possible causes of neurogenic bladder include:
- diabetes
- accidents that cause trauma to the brain or spinal cord
- nerve problems such as multiple sclerosis, strokes, or Parkinsonism
- congenital nerve problems such as spina bifida
Primary effects of neurogenic bladder are:
- urine leakage, when muscles holding the urine do not get the message to stay tight to retain the urine
- urine retention, when the muscles holding in the urine do not get the message that they should let go
- damage to the tiny blood vessels in the kidneys that results when the bladder gets too full. This prevents good drainage, causing back pressure.
- bladder infection or infection of the kidneys
Polycystic Kidney Disease (PKD)
This genetic disorder causes multiple cysts to grow in the kidneys and gradually displace functioning parts of the kidney. PKD symptoms sometimes show up in childhood, including frequent headaches and back or side pain. Other symptoms include high blood pressure, urinary tract infections and kidney stones, as well as blood or protein in urine. The disease, however, may exhibit no symptoms for years. There are two forms of PKD :
- Autosomal Dominant Polycystic Kidney Disease (ADPKD) is the most common, affecting one in 400 to one in 1,000 adults. Symptoms include high blood pressure, and the condition can lead to renal failure.
- Autosomal Recessive Polycystic Kidney Disease (ARPKD), also known as infantile PKD , is far less common, affecting only one in 10,000 to one in 20,000 at a far younger age, including newborns, infants and children. It can be detected during pregnancy through amniocentesis or chorionic villus sampling.
Proteinuria
Proteinuria denotes high levels of protein in the urine. When kidneys are healthy, filtering units called glomeruli remove waste products but leave behind nutrients the body needs, such as proteins, which are usually too large to pass through kidney filters unless the kidneys are damaged. When albumin, a small protein, seeps into the urine, blood vessels lose their capacity to reabsorb fluid from the tissues. The fluid then builds up in hands, feet or ankles, causing swelling.
Symptoms of proteinuria include foamy-appearing urine and swelling in the hands, feet, abdomen or face. But the condition can also be invisible, producing no symptoms. Laboratory testing is the only way to measure proteinuria.
One basic test uses a chemically treated strip of paper to detect protein levels. The paper changes color if dipped in urine with high levels of protein. A more sensitive test, which can detect microalbuminuria, requires urine collection over 24 hours. You may also have to provide a blood sample for creatinine and urea nitrogen testing (see kidney disease and renal failure). If blood levels of these two substances are high, kidney function is impaired.
Proteinuria is a sign of glomerulonephritis, also called nephritis (inflammation of the kidney). Diabetes, hypertension and various kidney diseases can cause the inflammation, which can lead to renal failure and, ultimately, end-stage renal disease (ESRD).
The severity of damage correlates with the level of proteinuria and whether the protein content is entirely albumin or includes other proteins (the more kinds of proteins, the greater the damage).
If you have diabetes, you should be regularly checked for proteinuria. The National Kidney Foundation also recommends that all routine checkups include proteinuria testing, especially for those at high risk.
Small amounts of albumin in the urine—microalbuminuria—is the first sign of declining kidney function in people with diabetes (the leading cause of ESRD). As function continues to slide, the level of albumin rises and the condition becomes proteinuria.
The second most common cause of ESRD is high blood pressure. Proteinuria and high blood pressure together indicate deteriorating kidney function. Medication for hypertension must be started, or renal failure will result. African Americans are at higher risk for high blood pressure and the resulting kidney problems than Caucasians.
Proteinuria also strikes more frequently in Native Americans, Hispanic Americans, Pacific Islanders, older people and overweight people. If you have a family history of kidney disease, you should have your urine tested regularly.
Urinary Incontinence
Many factors can cause urinary incontinence, or a loss of bladder control resulting in the involuntary release of urine. Incontinence is a problem for millions of American women, particularly those aged 65 and older. It is especially common in women who are pregnant or have recently delivered a baby and in elderly women. Incontinence can also affect men.
Bladder control, or continence, is the result of a system of nerves and muscles working together correctly. If the muscles at the bladder neck or in the pelvic floor are weak, laughter, sneezing or heavy lifting can cause leakage.
A condition called urge incontinence arises when the bladder muscle is overactive and contracts involuntarily. Since the occurrence of urge incontinence is unpredictable, it is more devastating to one's quality of life. Overactive bladder (OAB) occurs when you void more than eight times in the day and twice at night, have a strong urge to void, and/or urge incontinence. It affects millions of Americans, both men and women.
Overflow incontinence occurs when your bladder is overly full and leaks urine. You may feel as though you need to empty your bladder but cannot.
Urinary Tract Infection (UTI)
Urinary tract infections are usually caused by bacteria from the bowel that live on the skin near the rectum or near the vagina. Because the openings of the bowel, vagina and urethra are close together, it's easy for the bacteria to spread from the bowel to the urethra and travel up the urinary tract into the bladder, sometimes into the kidneys.
Normal urine is sterile, containing fluid, salts and waste products, but not bacteria. Infections can come from a variety of bacteria that normally live in the digestive system, but infections can also be caused by sexually transmitted microorganisms such as chlamydia and mycoplasma.
Infection can occur when the bacteria cling to the opening of the urethra and multiply, producing an infection of the urethra, called urethritis. Infection can also occur when the bacteria get into the bladder, causing cystitis, or a bladder infection. If the problem is not treated, the infection can continue spreading up the urinary tract, causing infection in the kidneys, called pyelonephritis. A kidney infection that is not treated can result in the kidneys being unable to drain urine, permitting the bacteria to enter the bloodstream, which can cause a life-threatening infection.
The first sign of a UTI is usually a strong urge to urinate. As you release urine, you feel a painful burning sensation, and little urine is eliminated. The urge to urinate returns quickly, and urination may be hard to control. You may have urine leakage during sleep. You may also have soreness in your lower abdomen, in your back, or in the sides of your body. Your urine may look cloudy or have a reddish tinge from blood. It may smell foul or strong. You also may feel tired, shaky and washed out. If the infection has spread to the kidneys, you may have fever, chills, nausea, vomiting and back pain, in addition to the frequent urge to urinate and painful urination.
Vesicoureteral Reflux (VUR)
When urine flows backward from the bladder into the ureters, the condition is called vesicoureteral reflux (VUR). It is most often diagnosed in childhood. If your child develops a urinary tract infection, he or she should be evaluated for VUR because the condition is found in about one-third of children with a UTI .
Primary VUR arises when a child is born with an impaired valve where the ureter joins the bladder. The valve fails to close fully, causing urine to back up from the bladder into the ureters and kidneys. The condition may improve over time as the ureter grows and valve function improves.
Secondary VUR arises due to a blockage in the urinary tract, often the result of an infection that causes the ureter to swell. Again, the result is a backflow of urine into the kidneys.
The leading symptom of VUR is infection. Other symptoms may arise as a child gets older, including high blood pressure, proteinuria and kidney failure.
Diagnosing VUR may involve a voiding cystourethrogram, a test that provides an image of the urinary system to determine if a defect in the urinary tract is causing VUR and infection. Other tests may include a kidney and bladder ultrasound; an intravenous pyelogram (IVP), which involves injecting a liquid that can be seen on x-rays to highlight any obstructions in the kidney or bladder; or nuclear scans, tests that use radioactive material injected into a vein to reveal how well the kidneys and bladder are functioning.
The goal of VUR treatment is to prevent kidney damage. An infection should be treated immediately with antibiotics to prevent it from moving into the kidneys. Antibiotics can also help correct reflux caused by an infection. Sometimes surgery is necessary to repair a physical defect that causes VUR.
Urinary Retention
Sometimes the bladder fails to empty fully, leading to retained urine. Acute urinary retention results in a sudden inability to urinate, accompanied by pain and discomfort. The condition may be caused by a urinary tract obstruction from the prostate gland in men or from pelvic masses in women (fibroid tumors are the most common); stress or neurological factors; infection; and certain medications. Relaxation of the pelvic floor structures resulting in a large bulging cystocele may also result in kinking of the urethra and urinary retention. The cause determines the treatment.
Urinary retention is a relatively common problem after surgery. It occurs as a result of the anesthetic, drugs used for pain control or the type of surgery performed. Chronic urinary retention, by contrast, refers to a persistent condition of urine remaining in the bladder and incomplete emptying. Chronic urinary retention can lead to urinary tract infections.
Evaluation for urinary retention includes a medical history and physical examination (including a prostate examination in men) to find the source of the problem. If an acute nerve problem is suspected, your doctor may order a CT scan or MRI . A urogynecologist or urologist may perform advanced urodynamic testing to help determine the cause of the voiding dysfunction. He or she may also perform a cystoscopic examination.
Diagnosis
If you are having urinary system symptoms, you may be asked to undergo various tests. Some of the most common are:
Blood tests. Tests for kidney disease include:
- Serum creatinine. Measures blood levels of a substance called creatinine that is generated when the body breaks down protein and uses it.
- Creatinine clearance. Measures how effectively your kidneys remove creatinine.
- Blood urea nitrogen (BUN). A nitrogen-containing substance called urea is a normal byproduct resulting when the body breaks down protein and uses it. Healthy kidneys remove urea from the blood for excretion in urine. Excess urea in the blood is a sign the kidneys are not functioning well. BUN can also be transiently elevated with dehydration.
Dipstick test for proteinuria. When the kidneys are not functioning well, protein may be present in urine. Foamy urine is a strong sign of protein, but usually there are no visible symptoms. The test for proteinuria uses a dipstick that changes color in the presence of protein.
Renal biopsy. In this procedure a health care professional obtains a sample of kidney tissue to examine under a microscope. A needle is inserted through the skin into the back of the kidney to retrieve a tissue sample.
Renal imaging. If blood and urine testing suggests impaired kidney function, your health care professional may recommend renal imaging, a procedure that captures an image of the kidneys using ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI).
Urinalysis. For this test, you urinate into a special container and leave the sample with a nurse or lab technician. The urine is then analyzed for signs of infection, blood cells and abnormal substances such as proteins, glucose or white blood cells and bacteria.
Urine culture. A urine culture is a laboratory test that tests for infection in your urine by allowing any bacteria in the urine sample to grow and multiply. The bacteria are then identified and tested to see which antibiotic will work best to kill the bacteria. Your urine is sent for a culture if infection is suspected on urinalysis.
Urine cytology. A urine cytology involves a check of your urine for cancer cells.
Ultrasound. Lubricating jelly is rubbed on your abdomen and pelvis, and a wand passes over your kidneys and bladder to check for abnormalities in your urinary tract or genitals, as well as residual or leftover urine in your bladder.
Intravenous pyelogram (IVP). This test x-rays the urinary tract to identify a malformation, tumor, kidney or bladder stone or other blockage preventing normal urine flow. A dye containing iodine is administered via a needle into a vein; the dye is then incorporated into the urine, making the urinary tract easier to see on x-rays.
Cystoscopic examination. During this test, a health care professional inserts an instrument called a cystoscope through the urethra and into the bladder. The cystoscope is pencil thin and has a light at the tip to allow a look inside the tract. A cystoscope may have an additional instrument attached to perform a treatment procedure, such as a biopsy. Cystoscopy may be recommended in a variety of circumstances, including frequent urinary tract infections, blood in the urine, incontinence or overactive bladder, presence of unusual cells in the bladder, need for a catheter, chronic pain or interstitial cystitis, urinary tract blockage, kidney stone or an unusual growth. A ureteroscope, which is an even smaller tube, can be inserted into a ureter.
Urodynamic test. This is a series of tests of bladder function. Bladder pressure is measured as the bladder fills, stores and empties urine—in other words, in each phase of bladder activity. For this test, a small tube called a catheter is inserted through the urethra into your bladder. The bladder is then filled with either water or an x-ray dye. Another small tube is inserted into the vagina or rectum to measure abdominal pressure when you strain or cough; if a dye is used, an x-ray is taken. Your doctor may suggest this series of tests if your symptoms suggest muscle or nerve problems in the lower urinary system (bladder, urethra and sphincter muscles).
Treatment
A primary care health care professional can treat many urinary disorders, but some conditions may require consultation with a urologist, a surgeon who specializes in the treatment of urinary system disorders and conditions affecting the reproductive system. A urogynecologist is a gynecologist who is trained to treat bladder and pelvic floor disorders in women. For kidney disorders, particularly kidney failure, a nephrologist (a medical specialist in kidney diseases) may be needed.
Treatment for cystocele
A grade 1 or 2 cystocele may require no treatment, except avoidance of heavy lifting or straining. For moderately bothersome cystoceles, a pessary (a plastic or rubber device that fits into your vagina to help support your uterus, vagina, bladder or rectum) may be fitted to the vagina to hold the bladder in place. A pessary must be removed and cleaned regularly to prevent infection and ulcers.
A large cystocele may require surgery to reposition the bladder. The surgery requires a hospital stay of one to several days and four to six weeks for a full recovery.
Treatment for kidney stones
Surgery is usually not necessary to remove kidney stones. Drinking plenty of water—two to three quarts per day––and taking drugs which can relax the ureter may allow for the stone to pass down the tract. A health care professional may recommend that you stay home, drink plenty of fluids and take pain medicine as needed. You may be asked to save the passed stone for tests.
Shockwave lithotripsy. The most common method for removing stones is shockwave lithotripsy (SWL), in which shockwaves initiated outside the body travel through skin and body tissues until they hit the stones. The stones disintegrate into sand-like particles and are passed through the urinary tract. The procedure may be done in a hospital or on an outpatient basis; you typically resume your normal activities within a few days, but it may take months for you to pass all the pieces.
Complications may include blood in the urine for a few days, bruising and discomfort of the back or abdomen. To minimize risk of problems after the treatment, you should avoid medications that reduce blood clotting (such as aspirin) for one to two weeks before treatment.
The stone particles may cause pain as they pass through the urinary tract. Your health care professional may insert a small tube called a stent through the bladder into the ureter to help the fragments pass. Some people may need two or more SWL treatments.
Surgery is generally an option when the stone:
- does not pass after a reasonable time and causes constant pain
- is too large to pass on its own or is caught in a difficult place
- blocks urine flow
- causes continuing urinary tract infection
- harms kidney tissue or provokes incessant bleeding
- is growing (as shown on x-rays)
The two most common surgical techniques for removing stones are:
- Urethroscopic stone removal. This procedure is used for stones lodged in the ureter or for kidney stones. A small fiber-optic instrument called a ureteroscope is passed through the urethra and bladder and into the ureter or kidney. When the stone is found, the surgeon either removes it or shatters it with an instrument that breaks the stone.
- Percutaneous nephrolithotomy. This surgical procedure usually requires a hospital stay and is used for large stones or stones in locations not conducive to SWL. The surgeon makes a small incision in the back, creates a tunnel to the kidney and uses a nephroscope to find and remove the stone. A nephrostomy tube may stay in the kidney during the healing process. Large stones may require use of an ultrasound, electrohydraulic energy probe or laser to break up the stone. One advantage over SWL is that percutaneous nephrolithotomy removes the stone particles rather than leaving them to pass through the kidney and out the ureters.
- Parathyroid gland surgery. In some cases, calcium stones are caused by a small benign tumor in one of the parathyroid glands, four glands located just below your Adam's apple. If this is the case, you may have surgery to remove the tumor or one or more of the parathyroid glands.
Treatment for bladder cancer
Treatment for bladder cancer depends on the size and staging of the tumor. For early-stage tumors, the usual treatment is transurethral resection of the bladder tumor, a procedure during which a lighted tube is inserted through the urethra and into the bladder to remove the cancer for biopsy and to cut or burn away any remaining cancer cells. Chemotherapy and immunotherapy may also be used to prevent cancer recurrence. In extreme cases, a cystectomy, or removal of the bladder, may be performed.
Treatment for interstitial cystitis (IC)
Behavioral therapy. Make sure you get enough water, ideally about two quarts a day. Although no scientific evidence points to dietary factors as the cause of IC, avoiding potential bladder irritants, including coffee, chocolate, carbonated beverages, acidic foods or drinks, may help ease symptoms. Controlling stress can also help.
Medications. Medications are the primary treatment for IC. The only drug specifically approved for IC is pentosan (Elmiron). Pentosan helps restore the normal bladder lining but may take up to six months to work. Several other medications not specifically indicated for IC may also help reduce symptoms, including nonsteroidal anti-inflammatory drugs (NSAIDs), antihistamines and antidepressants, particularly amitriptyline (Elavil) or imipramine (Tofranil). You may require more than one medication.
Bladder instillation. Also called a bladder wash or bath, the bladder is filled with a drug cocktail containing one of several substances including heparin, pentosan, or dimethyl sulfoxide (DMSO, RIMSO-50), which must be held for a specified period of time—usually 10 to 20 minutes––before urinating. This treatment is performed every week or two for six to eight weeks and repeated as needed.
Because DMSO passes into the bladder wall, it reaches tissue more effectively to reduce inflammation and pain. It also appears to prevent the muscle spasms that cause pain and urgent/frequent need to urinate.
Side effects of DMSO include a garlic taste and odor that may last up to three days following treatment. Bladder symptoms may get temporarily worse for a day or so after initial treatments. Blood tests, including a complete blood count and kidney and liver function tests, should be conducted twice a year. Other medications may be added, such as a local anesthetic, to make a DMSO "cocktail."
In addition, a newer approach to bladder instillation involves using a mixture of heparin, lidocaine and sodium bicarbonate. When instilled directly into the bladder, this combination of drugs significantly relieved urinary pain and urgency in the majority of people participating in a clinical trial.
Bladder distention. This treatment arose from the observation that some patients felt better after undergoing cystoscopy, during which the bladder is filled to capacity with liquid. Symptoms often get worse a day or two after distension but return to pre-procedure levels or improve after two to four weeks. No one knows exactly why this treatment is effective, but one theory is that distension increases bladder capacity by interfering with the bladder's transmission of pain signals. This is not an ideal treatment, however. It only helps small numbers of patients and requires anesthesia.
Surgery. All surgical treatments for IC have unpredictable results and most health care professionals turn to surgery only as a last resort. Surgical procedures include:
- Fulguration, a process in which a cystoscope is inserted through the urethra, and Hunner's ulcers (star-shaped lesions found on the bladder walls of some people with IC) are coagulated with electricity or a laser.
- Neuromodulation or sacral nerve root stimulation is a newer treatment option that involves stimulating the sacral nerve to help alleviate frequency, urgency and pain. A small electrode is placed under the skin next to the third sacral nerve root in the back. If a test stimulation is effective, a permanent battery is placed under the skin for regular stimulations. Although this can be very helpful in some patients, the results are not always sustained.
- Augmentation is a surgical procedure that enlarges the bladder by removing damaged and inflamed sections of the bladder and rebuilding it with bowel (small or large intestine) tissue. The effect on pain varies, and IC may recur on the bowel tissue used to enlarge the bladder.
The bladder can also be removed entirely in a procedure called cystectomy. The ureters are then attached to a segment of bowel that opens onto the skin of the abdomen. Urine empties through the opening, called a stoma, into a bag outside the body.
Bear in mind that even a cystectomy does not guarantee the end of IC symptoms; some women experience phantom pain. So make sure you explore other options first.
Treatment for urinary tract infections
Luckily, most infections are not serious and can be easily treated with antibiotic medications. However, a urinary tract infection can be stubborn and sometimes recurs a few weeks after treatment.
Nearly 20 percent of women who have a urinary tract infection will have another, and 30 percent of those who have had two will have a third. About 80 percent of those who have had three will have a fourth. If left untreated, urinary tract infections can lead to other more complicated health problems so they should not be ignored. Prevention includes drinking plenty of liquids, frequent urination and taking vitamin C. Cranberry prevents bacteria from adhering to the bladder wall and may be an effective deterrent to bladder infections. Women who experience recurrent bladder infections often have the bacteria introduced during sexual activity. Treatment prophylactically with a single antibiotic tablet taken just after sex can prevent additional bladder infections.
Treatment for urinary retention
Treatment for urinary retention may include the insertion of a Foley catheter through the urethra into the bladder to relieve urinary retention. Various urethral dilators may be used to open the channel wide enough to pass a catheter through. If a catheter cannot reach your bladder because of an obstruction in the urethra, a suprapubic tube may be placed through the skin, over the pubic bone and through the lower abdominal wall directly into the bladder. The tube provides temporary drainage until the situation can be managed via a cytoscopic procedure.
Treatment for proteinuria
Treatment for proteinuria starts with controlling hypertension and/or diabetes. Those with diabetes should measure blood sugar levels frequently, eat a balanced diet to appropriately manage diabetes, exercise and take prescribed medicines. Those with high blood pressure are usually prescribed ACE (angiotensin-converting enzyme) inhibitors or a similar class of drugs called angiotensin receptor blockers (ARBs) to control the condition. These drugs protect the kidneys more than other blood pressure medicines. People with reduced kidney function and high blood pressure should try to keep their blood pressure below 130/80 mm Hg.
The National Kidney Foundation also recommends limiting salt and protein intake. A consultation with a dietitian may help you develop a kidney-healthy dietary plan.
Treatments for incontinence
A variety of treatments are available to treat incontinence, including:
- Exercises: Pelvic floor exercises known as Kegel exercises can strengthen the muscles you use to stop urinating so you can hold urine in your bladder longer. To do Kegels, squeeze the muscles you use to stop urinating for a few seconds and then relax. Your health care professional can tell you specifically how often and for how long you should do Kegels.
- Medications: A variety of drugs can be used to help control incontinence. Some of them relax bladder muscles, helping your bladder to empty more completely, some help prevent bladder contractions and others tighten the muscles in the bladder and urethra to reduce leakage.
- Biofeedback techniques: These techniques can help you become more aware of signals from your body so you can gain more control over the muscles in your bladder and urethra.
- Pessary: A vaginal insert that holds up the bladder neck. It may also pinch the urethra closed to help retain urine in the bladder. It is usually not necessary to remove the pessary to urinate. Normal bladder contractions can usually force urine out through the pinched-off urethra.
- Surgery: Surgery can improve incontinence if the condition is caused by a physical problem such as a change in the bladder position. Common surgery for incontinence involves placing a sling beneath the urethra to help close it during episodes of increased pressure or reducing a bulging bladder or urethra and securing it. Surgery is usually not recommended until you are finished having children because both pregnancy and childbirth can cause damage.
Other Treatments for Kidney Conditions
Hemodialysis is the most common treatment for advanced or permanent kidney failure. In this procedure your blood is circulated out of your body, the wastes filtered out in a machine and the clean blood returned to the body. Removing harmful wastes and extra salt and fluids helps control your blood pressure and maintain proper chemical balance in the body. Treatments are given in a clinic, often called a dialysis center, usually three times a week for three to five hours per visit. The annual survival rate for people on dialysis is about 80 percent.
Peritoneal dialysis allows you to give yourself treatments at home for advanced and permanent kidney failure, but it is important that you work closely with your health team. As with hemodialysis, the treatment filters your blood and returns it to circulate in your body. For this procedure, a soft tube (catheter) is surgically placed in your abdomen and then is used to fill your abdomen with a cleansing liquid. Your body's waste products and extra fluid transfer from your blood into the dialysis solution and then are drained out of the body. The process of actually putting the solution in and out of your abdomen takes about 30 to 40 minutes, but the solution stays in your abdomen for four to six hours. This process is typically done four times a day. There are two forms of peritoneal dialysis: Continuous ambulatory peritoneal dialysis (CAPD) doesn't require a machine and you can walk around with the solution in your abdomen. Continuous cycler-assisted peritoneal dialysis (CCPD), also called automated peritoneal dialysis, uses a machine to fill and drain your abdomen, usually while you sleep.
Infection is the most common problem with peritoneal dialysis. You must understand and follow all instructions from your health team. Keep a close watch for any signs of infection and report them immediately. These include:
- Fever
- Nausea or vomiting
- Redness or pain near the catheter
- Unusual color or cloudiness in your used dialysis solution
- A catheter cuff that is out of place
Transplants. For some with kidney failure, transplantation is an option. If the donated kidney is not a close match for your body, your immune system will react against it as if it were a virus or bacteria. Drugs that suppress the immune system are used to help the body accept the transplant. Transplant is more effective than dialysis, with a one-year survival rate of 95 percent and 80 percent at five years for people receiving living-donor kidneys. (Survival rates are slightly lower for people receiving deceased-donor kidneys.)
Prevention
Drinking adequate amounts of water is key to a healthy urinary system. The urinary system regulates concentrations of substances such as potassium and sodium. When you don't drink enough water, your body responds by retaining water to maintain the proper concentration.
A good rule of thumb is to drink enough water and other fluids (at least eight glasses a day) to keep the urine clear or straw colored. The fluids also help clear bacteria from the urinary tract. Cranberry juice may help prevent repeat urinary tract infections, but you may want to avoid the beverage during an infection since it contains acid that can exacerbate the painful urination associated with the condition.
Limit your intake of soda because carbonated drinks can make some kidney conditions worse. High levels of calcium and oxalate (a substance found in chocolate, black tea, peanuts, sweet potatoes and leafy green vegetables) can contribute to kidney stones in susceptible people.
Carbonated drinks, coffee and spicy or acidic foods or drinks can cause bladder irritation for some people. Avoiding such foods and drinks can improve bladder symptoms.
Medications, poisons and trauma-related blood loss can also harm the kidneys. In particular, combining over-the-counter painkillers such as aspirin, acetaminophen and ibuprofen can be toxic. Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen, can also damage the kidneys. Ask your health care professional or pharmacist about adverse effects of any medications you are taking, including over-the-counter drugs.
High blood pressure can lead to kidney dysfunction. Smoking also elevates bladder cancer risk, and chronic coughing associated with the habit can worsen incontinence.
Preventing kidney stones
If you have had more than one kidney stone, your risk of developing another is high. Fortunately, there are strategies for preventing the recurrence of stones. A good place to start is a medical assessment to determine if you have a known stone-forming condition. Blood and urine tests may be required, and you may be asked to provide urine samples after the initiation of treatment to assess whether the treatment is working.
Medications may also be used to prevent stones, including:
- Allopurinol (Lupurin, Zyloprim) for some cases of uric acid stones.
- Diuretics such as hydrochlorothiazide (Esidrix, HydroDIURIL) to control hypercalciuria by reducing levels of urinary calcium.
- Sodium cellulose phosphate (Calcibind) for severe hypercalciuria associated with recurrent calcium stones. It works by binding to calcium in the intestines and keeping it out of the urine .
- Tiopronin (Thiola), which reduces the amount of cystine in the urine.
- Potassium citrate (Urocit-K), which helps make the urine less acidic, reducing formation of uric acid kidney stones.
- Acetohydroxamic acid (Lithostat) for infection stones (struvite stones) that cannot be removed. Acetohydroxamic acid is used with long-term antibiotic drugs to prevent the infection that provokes stone growth.
You can also make lifestyle changes to reduce your risk:
- Drink more liquids, especially water. Your total daily urine output should be two to three quarts.
- Eat foods high in calcium. In the past, susceptible people were told to avoid such foods, but new studies show that high-calcium foods actually help prevent stones. Calcium supplements, however, may increase the risk of stones, so try to get your daily intake from food sources.
- Based on the results of lab tests, you may be advised to avoid foods with added vitamin D as well as antacids with a calcium base. If your urine is highly acidic, you may be advised to lower your intake of meat, fish and poultry (all of which boost urinary acid concentration).
- If you tend to form calcium oxalate stones, you may be asked to cut back on the following foods: beets, chocolate, coffee, cola, nuts, rhubarb, spinach, strawberries, tea and wheat bran.
Facts to Know
- Approximately 26 million Americans have kidney disease and millions more are at risk, according to the National Kidney Foundation.
- Incontinence and overactive bladder are among the most common health problems in women.
- Drinking plenty of water is key to urinary system health. A good rule of thumb is to drink enough water and other fluids (at least eight glasses a day) to keep the urine clear or straw colored.
- Combining over-the-counter painkillers such as aspirin, acetaminophen, naproxen sodium and ibuprofen can be toxic to your kidneys. Long-term use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen can also damage the kidneys.
- Kidney stones are among the most painful and most common urinary tract disorders—about 5 to 10 percent of Americans will have a kidney stone at some point in their lives. Stones are most likely to occur between the ages of 20 and 50 in women and are more likely to occur in people who have previously had stones.
- Diabetes accounts for most cases of end-stage renal disease (ESRD). Diabetes-related ESRD can be delayed or prevented by keeping blood sugar levels down.
- African Americans are at greater risk than Caucasians for high blood pressure and the resulting kidney problems. African Americans age 25 to 44 are more likely than Caucasians to develop kidney failure related to hypertension.
- "Renal function" refers to how well your kidneys are functioning. If both kidneys are healthy, you have 100 percent renal function. If one becomes non-functional or is donated for a transplant, you will still be healthy, even with only 50 percent of renal function. However, if function slips below 20 percent, serious health problems arise, and below 10 to 15 percent dialysis or a transplant may be required.
- End-stage renal disease (ESRD) refers to permanent total or nearly total kidney failure, requiring dialysis or transplantation. If untreated, ESRD can cause seizures, coma and death. In the United States , 85,790 died of ESRD in 2005.
- The annual survival rate for people on kidney dialysis is about 80 percent. Transplant is more effective than dialysis, with a one-year survival rate of 95 percent and 80 percent at five years for people receiving living-donor kidneys.
Questions to Ask
Review the following Questions to Ask about urinary tract conditions so you're prepared to discuss this important health issue with your health care professional.
- What possible conditions do my symptoms suggest?
- What is involved in the test you want me to take? Will I be uncomfortable?
- What are my test results? Please explain them to me. Can I have a copy of those results?
- How will my kidneys and the rest of my urinary system be affected?
- How might medications I am currently taking affect my urinary system?
- What steps can I take to improve the health of my urinary system? Are there foods or drinks I should avoid or seek out?
- What are the treatment options available for my condition? Why are you recommending this particular treatment?
- What would you estimate my current renal function to be?
- How will I know if my treatment is working? Will further tests be needed? When?
- Since kidney disease does not produce noticeable symptoms until late in the disease process, how can we monitor the health of my kidneys?
Key Q&A
What could cause blood in my urine?
The cause may be a serious one, such as bladder or kidney cancer, but more often the cause is relatively benign. For example, urinary tract infections or exercise can cause episodes of hematuria—the medical term for blood in the urine. Still, you should check with a health care professional any time you see blood in your urine.
Why am I having repeated incidences of kidney stones?
A variety of factors can make a person susceptible to stones in the urinary tract. Risk for stones is higher in those with family histories of stones; those who have urinary tract infections, kidney disorders and metabolic disorders such as hyperparathyroidism, cystinuria (too much of an amino acid called cystine) and hyperoxaluria (excess production an oxalate salt); and those with a disease called renal tubular acidosis. Another risk factor is absorptive hypercalciuria, in which the body absorbs too much calcium from food and dumps the excess into the urine. High levels of urinary calcium lead to crystals of calcium oxalate or calcium phosphate, which can grow into painful stones.Various laboratory tests and a family history should allow your health care professional to determine a likely cause. You can then make dietary changes to prevent future stones.
My health care professional is concerned because I have protein in my urine, but I feel fine. Should I worry?
Yes. Proteinuria is a sign of glomerulonephritis (inflammation of the glomeruli; see below), also called nephritis (inflammation of the kidney). Diabetes, hypertension and various kidney diseases can cause the inflammation, which can lead to renal failure and, ultimately, end-stage renal disease (ESRD).
What is the connection between diabetes and kidney disease?
Diabetes is the number one cause of end-stage renal disease. If diabetes is undiagnosed or poorly controlled, excess sugar will circulate in the blood, leading to higher blood flow into the kidney and glomerular scarring. Diabetic nephropathy is the term used for such damage, which can be delayed or prevented by keeping blood sugar levels down.What is the connection between high blood pressure and kidney disease?
The number two cause of ESRD is high blood pressure. Long-term control of blood pressure is critical to preserving kidney function. ACE (angiotensin-converting enzyme) inhibitors and a similar class of drugs called angiotensin receptor blockers (ARBs) are the best medications for controlling the condition and preventing kidney damage. These drugs protect the kidneys more than other blood pressure medicines. People with reduced kidney function and high blood pressure should try to keep their blood pressure below 130/80 mm Hg.
How can I protect my kidneys if I have diabetes?
- Have your glycohemoglobin (hbA1c) checked regularly; the test measures your average blood sugar for the previous two to three months.
- Adhere to your diabetes control regimen, including insulin injections and other medications, diet, exercise and blood sugar monitoring.
- Have your blood pressure checked several times a year (at every visit to your health care professional) and follow any recommendations for reducing it. Ask your health care professional about ACE inhibitors and ARBs.
- Have your urine checked yearly for protein and microalbumin (a protein component).
- Ask your health care professional whether you need to lower your protein intake.
How can I prevent recurrence of a cystocele?
Avoidance of straining from chronic constipation, avoidance of heavy lifting and learning to contract the pelvic floor muscles to "splint" the pelvic floor during coughing, sneezing and lifting will help to prevent recurrent cystocele. In addition, weight loss in obese women may be helpful. Seeking medical attention to prevent chronic cough is also beneficial.
Is surgery the best option for a painful case of interstitial cystitis (IC)?
No, the results of the various types of IC surgeries are unpredictable—new ulcers may form after old ones are removed, and IC may afflict bowel tissue used to augment or rebuild the bladder. Even a cystectomy—removal of the bladder—does not guarantee the end of IC symptoms; some patients experience phantom pain. Be sure to explore other options first. Health care professionals should only turn to surgery as a last resort.What other treatment options are available for IC?
Sometimes eliminating irritating food and beverages from the diet—such as tomatoes, coffee, spices and acidic foods—reduces symptoms of IC. Nonmedicinal approaches to relief include gentle stretching exercises and bladder training. Bladder training involves working with a health care professional to plan specific times at which to urinate and then using relaxation techniques and distractions to stick to the schedule. Patients keep a diary and over time try to extend the time between scheduled urinations.Transcutaneous electrical nerve stimulation (TENS) is a relatively inexpensive treatment that uses mild electrical pulses to relieve pain and reduce frequency of urination. The pulses are administered through wires on the lower back or above the pubic area, although some devices are inserted into the vagina or rectum (in men). Scientists believe TENS works to relieve IC by increasing blood flow to the bladder and triggering pain-relieving substances.
What tests can I expect if I am having urinary system symptoms?
Urinalysis and blood testing are standard. Depending on your particular symptoms and history, your health care professional may perform a cystoscopy, in which a tiny telescope is inserted through the urethra into the bladder; a biopsy, in which tissue is removed for evaluation; an intravenous pyelogram or a CT urogram, in which an x-ray is taken of the urinary tract enhanced with a radioactive dye; a urodynamic test, in which the bladder is filled with liquid and then emptied to measure function; or imaging using magnetic resonance imaging or computed tomography techniques.Organizations and Support
For information and support on Urinary Tract Conditions, please see the recommended organizations, books and Spanish-language resources listed below.
American Urogynecologic Society
Website: https://www.augs.org
Address: 2025 M Street NW, Suite 800
Washington, DC 20036
Phone: 202-367-1167
Email: info@augs.org
American Urological Association
Website: https://www.auanet.org
Address: 1000 Corporate Blvd.
Linthicum, MD 21090
Hotline: 1-800-RING-AUA (1-866-746-4282)
Phone: 410-689-3700
Email: aua@auanet.org
Interstitial Cystitis Association (ICA)
Website: https://www.ichelp.org
Address: 100 Park Avenue, Suite 108A
Rockville, MD 20850
Hotline: 1-800-HELP-ICA (1-800-435-7422)
Phone: 301-610-5300
Email: icamail@ichelp.org
National Kidney and Urologic Diseases Information Clearinghouse
Website: https://www.niddk.nih.gov/
Address: 3 Information Way
Bethesda, MD 20892
Hotline: 1-800-891-5390
Email: nkudic@info.niddk.nih.gov
Society of Urologic Nurses and Associates
Website: https://www.suna.org
Address: East Holly Avenue, Box 56
Pittman, NJ 08071
Hotline: 1-888-827-7862
Email: suna@ajj.com
Books
A Seat on the Aisle, Please! The Essential Guide to Urinary Tract Problems in Women
by Elizabeth Kavaler
Spanish-language resources
Medline Plus: Urine and Urination
Website: https://www.nlm.nih.gov/medlineplus/spanish/urineandurination.html
Address: US National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
Email: custserv@nlm.nih.gov
Kids Health from Nemours Foundation
Website: https://kidshealth.org/parent/en_espanol/general/kidneys_urinary_esp.html
Email: https://secure02.kidshealth.org/teen/kh_misc/send_...
