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Because the cortical glomeruli and tubules are deprived of blood, the flow of urine is diminished, and in extreme cases may cease. Lymphatic filariasis Filariasis, Elephantiasis. Please note that our editors may make some formatting changes or correct spelling or grammatical errors, and may also contact you if any clarifications are needed. Explore the model using your mouse pad or touchscreen to understand more about the lymphatic system. The differentiation of T cells occurs in the cortex of the thymus.
In early stages of lymphedema, elevating the limb may reduce or eliminate the swelling. Palpation of the wrist or ankle can determine the degree of swelling; assessment includes a check of the pulses. The axillary or inguinal nodes may be enlarged due to the swelling.
Enlargement of the nodes lasting more than three weeks may indicate infection or other illnesses such as sequela from breast cancer surgery requiring further medical attention. Diagnosis or early detection of lymphedema is difficult. The first signs may be subjective observations such as a feeling of heaviness in the affected extremity. These may be symptomatic of early stage of lymphedema where accumulation of lymph is mild and not detectable by changes in volume or circumference.
As lymphedema progresses, definitive diagnosis is commonly based upon an objective measurement of differences between the affected or at-risk limb at the opposite unaffected limb, e. Bioimpedance measurement which measures the amount of fluid in a limb offers greater sensitivity than existing methods. Chronic venous stasis changes can mimic early lymphedema, but the changes in venous stasis are more often bilateral and symmetric. Lipedema can also mimic lymphedema, however lipedema characteristically spares the feet beginning abruptly at the medial malleoli ankle level.
According to the Fifth WHO Expert Committee on Filariasis   the most common method of classification of lymphedema is as follows: The same classification method can be used for both primary and secondary lymphedema The International Society of Lymphology ISL Staging System is based solely on subjective symptoms, making it prone to substantial observer bias.
Imaging modalities have been suggested as useful adjuncts to the ISL staging to clarify the diagnosis. The lymphedema expert Dr. With the assistance of medical imaging apparatus, such as MRI or CT , staging can be established by the physician, and therapeutic or medical interventions may be applied:. Lymphedema can also be categorized by its severity usually referenced to a healthy extremity: Treatment varies depending on edema severity and the degree of fibrosis.
Most people with lymphedema follow a daily regimen of treatment. The most common treatments are a combination of manual compression lymphatic massage, compression garments or bandaging.
Although a combination treatment program may be ideal, any of the treatments can be done individually. In these last years the Godoy Method brings a new concept in the treatment of lymphedema and proposes the normalization or near normalization in all clinical stages including in elephantiasis with normalization of the skin.
CDT is a primary tool in lymphedema management. The technique was pioneered by Emil Vodder in the s for the treatment of chronic sinusitis and other immune disorders. Initially, CDT involves frequent visits to a therapist.
Once the lymphedema is reduced, increased patient participation is required for ongoing care, along with the use of elastic compression garments and nonelastic directional flow foam garments. Manual manipulation of the lymphatic ducts manual lymphatic drainage or MLD consists of gentle, rhythmic massage to stimulate lymph flow and its return to the blood circulation system. The treatment is gentle.
CDT is generally effective on nonfibrotic lymphedema and less effective on more fibrotic legs, although it helps break up fibrotic tissue. Elastic compression garments are worn on the affected limb following complete decongestive therapy to maintain edema reduction. Inelastic garments provide containment and reduction.
Compression bandaging, also called wrapping, is the application of layers of padding and short-stretch bandages to the involved areas. Short-stretch bandages are preferred over long-stretch bandages such as those normally used to treat sprains , as the long-stretch bandages cannot produce the proper therapeutic tension necessary to safely reduce lymphedema and may in fact end up producing a tourniquet effect. During activity, whether exercise or daily activities, the short-stretch bandages enhance the pumping action of the lymph vessels by providing increased resistance.
This encourages lymphatic flow and helps to soften fluid-swollen areas. Intermittent pneumatic compression therapy IPC utilizes a multi-chambered pneumatic sleeve with overlapping cells to promote movement of lymph fluid. In some cases, pump therapy helps soften fibrotic tissue and therefore potentially enable more efficient lymphatic drainage. Most studies investigating the effects exercise in patients with lymphedema or at risk of developing lymphedema examined patients with breast-cancer-related lymphedema.
In these studies, resistance training did not increase swelling in patients with pre-existing lymphedema and decreases edema in some patients, in addition to other potential beneficial effects on cardiovascular health. Compression garments should be worn during exercise with the possible exception of swimming in some patients. Resistance training is not recommended in the immediate post-operative period in patients who have undergone axillary lymph node dissection for breast cancer.
Few studies examine the effects of exercise in primary lymphedema or in secondary lymphedema that is not related to breast cancer treatment. Several surgical procedures provide long-term solutions for patients who suffer from lymphedema. Prior to surgery, patients typically are treated by a physical or an occupational therapist trained in providing lymphedema treatment for initial conservative treatment of their lymphedema.
Vascularized lymph node transfers VLNT can be an effective treatment of the arm and upper extremity. Lymph nodes are harvested from the groin area or the supraclavicular area with their supporting artery and vein and moved to the axilla armpit or the wrist area. Microsurgery techniques connect the artery and vein to blood vessels in the axilla to provide support to the lymph nodes while they develop their own blood supply over the first few weeks after surgery.
The newly transferred lymph nodes then serve as a conduit or filter to remove the excess lymphatic fluid from the arm and return it to the body's natural circulation. This technique of lymph node transfer may be performed together with a DIEP flap breast reconstruction.
This allows for both the simultaneous treatment of the arm lymphedema and the creation of a breast in one surgery. The lymph node transfer removes the excess lymphatic fluid to return form and function to the arm. In selected cases, the lymph nodes may be transferred as a group with their supporting artery and vein, but without the associated abdominal tissue for breast reconstruction.
Lymph node transfers are most effective in patients whose extremity circumference reduces significantly with compression wrapping, indicating most of the edema is fluid. VLNT significantly improves the fluid component of lymphedema and decrease the amount of lymphedema therapy and compression garment use required.
Lymphaticovenous anastomosis LVA uses supermicrosurgery to connect the affected lymphatic channels directly to tiny veins located nearby. The lymphatics are tiny, typically 0.
The procedure requires the use of specialized techniques with superfine surgical suture and an adapted, high-power microscope. LVA can be an effective and long-term solution for extremity lymphedema and many patients have results that range from a moderate improvement to an almost complete resolution. LVA is most effective early in the course of the disease in patients whose extremity circumference reduces significantly with compression wrapping, indicating most of the edema is fluid.
Patients who do not respond to compression are less likely to fare well with LVA, as a greater amount of their increased extremity volume consists of fibrotic tissue, protein or fat.
Multiple studies showed LVAs to be effective. Lymphaticovenous anastomosis was introduced by B. O'Brien and colleagues for the treatment of obstructive lymphedema in the extremities. Clinical studies involving LVA indicate immediate and long-term results showed significant reductions in volume and improvement in systems that appear to be long-lasting.
Results showed a statistically significant reduction in the number of patients who went on to develop clinically significant lymphedema. Indocyanine green fluoroscopy is a safe, minimally invasive and useful tool for surgical evaluation. People whose limbs no longer adequately respond to compression therapy may be candidates for suction assisted lipectomy SAL.
This procedure has been called liposuction for lymphedema and is specifically adapted to treat this advanced condition. Like the tubules they make hairpin bends, retrace their path, and empty into arcuate veins that parallel the arcuate arteries. Normally the blood circulating in the cortex is more abundant than that in the medulla amounting to over 90 percent of the total , but in certain conditions, such as those associated with severe trauma or blood loss, cortical vessels may become constricted while the juxtamedullary circulation is preserved.
Because the cortical glomeruli and tubules are deprived of blood, the flow of urine is diminished, and in extreme cases may cease.
The renal venules small veins and veins accompany the arterioles and arteries and are referred to by similar names. The venules that lie just beneath the renal capsule , called stellate venules because of their radial arrangement, drain into interlobular venules.
In turn these combine to form the tributaries of the arcuate, interlobar, and lobar veins. Blood from the renal pyramids passes into vessels, called venae rectae, which join the arcuate veins. In the renal sinus the lobar veins unite to form veins corresponding to the main divisions of the renal arteries, and they normally fuse to constitute a single renal vein in or near the renal hilus.
Lymphatic capillaries form a network just inside the renal capsule and another, deeper network between and around the renal blood vessels. Few lymphatic capillaries appear in the actual renal substance, and those present are evidently associated with the connective tissue framework, while the glomeruli contain no lymphatics.
The lymphatic networks inside the capsule and around the renal blood vessels drain into lymphatic channels accompanying the interlobular and arcuate blood vessels. The main lymph channels run alongside the main renal arteries and veins to end in lymph nodes beside the aorta and near the sites of origin of the renal arteries.
The ureters are narrow, thick-walled ducts, about 25—30 centimetres 9. Throughout their course they lie behind the peritoneum, the lining of the abdomen and pelvis, and are attached to it by connective tissue. In both sexes the ureters enter the bladder wall about five centimetres apart, although this distance is increased when the bladder is distended with urine.
The ureters run obliquely through the muscular wall of the bladder for nearly two centimetres before opening into the bladder cavity through narrow apertures. This oblique course provides a kind of valvular mechanism; when the bladder becomes distended it presses against the part of each ureter that is in the muscular wall of the bladder, and this helps to prevent the flow of urine back into the ureters from the bladder.
The wall of the ureter has three layers, the adventitia, or outer layer; the intermediate, muscular layer; and the lining, made up of mucous membrane. The adventitia consists of fibroelastic connective tissue that merges with the connective tissue behind the peritoneum.
The muscular coat is composed of smooth involuntary muscle fibres and, in the upper two-thirds of the ureter, has two layers—an inner layer of fibres arranged longitudinally and an outer layer disposed circularly. In the lower third of the ureter an additional longitudinal layer appears on the outside of the vessel. As each ureter extends into the bladder wall its circular fibres disappear, but its longitudinal fibres extend almost as far as the mucous membrane lining the bladder.
The mucous membrane lining increases in thickness from the renal pelvis downward. Thus, in the pelvis and the calyxes of the kidney the lining is two to three cells deep; in the ureter, four to five cells thick; and in the bladder, six to eight cells.
The mucous membrane of the ureters is arranged in longitudinal folds, permitting considerable dilation of the channel. There are no true glands in the mucous membrane of the ureter or of the renal pelvis. The chief propelling force for the passage of urine from the kidney to the bladder is produced by peristaltic wavelike movements in the ureter muscles. The urinary bladder is a hollow muscular organ forming the main urinary reservoir.
It rests on the anterior part of the pelvic floor see below , behind the symphysis pubis and below the peritoneum. The symphysis pubis is the joint in the hip bones in the front midline of the body. The shape and size of the bladder vary according to the amount of urine that the organ contains. When empty it is tetrahedral and lies within the pelvis; when distended it becomes ovoid and expands into the lower abdomen.
It has a body, with a fundus, or base; a neck; an apex; and a superior upper and two inferolateral below and to the side surfaces, although these features are not clearly evident except when the bladder is empty or only slightly distended. The neck of the bladder is the area immediately surrounding the urethral opening; it is the lowest and most fixed part of the organ.
In the male it is firmly attached to the base of the prostate, a gland that encircles the urethra. The superior surface of the bladder is triangular and is covered with peritoneum. The bladder is supported on the levator ani muscles, which constitute the major part of the floor of the pelvic cavity. The bladder is covered, and to a certain extent supported, by the visceral layer of the pelvic fascia. This fascial layer is a sheet of connective tissue that sheaths the organs, blood vessels, and nerves of the pelvic cavity.
The fascia forms, in front and to the side, ligaments, called pubovesical ligaments, that act as a kind of hammock under the inferolateral surfaces and neck of the bladder. The blood supply of the bladder is derived from the superior, middle, and inferior vesical bladder arteries.
The superior vesical artery supplies the dome of the bladder, and one of its branches in males gives off the artery to the ductus deferens , a part of the passageway for sperm. The middle vesical artery supplies the base of the bladder. The inferior vesical artery supplies the inferolateral surfaces of the bladder and assists in supplying the base of the bladder, the lower end of the ureter, and other adjacent structures.
The nerves to the urinary bladder belong to the sympathetic and the parasympathetic divisions of the autonomic nervous system.
The sympathetic nerve fibres come from the hypogastric plexus of nerves that lie in front of the fifth lumbar vertebra. Sympathetic nerves carry to the central nervous system the sensations associated with distention of the bladder and are believed to be involved in relaxation of the muscular layer of the vesical wall and with contraction of sphincter mechanism that closes the opening into the urethra.
The parasympathetic nerves travel to the bladder with pelvic splanchnic nerves from the second through fifth sacral spinal segment. Parasympathetic nerves are concerned with contraction of the muscular walls of the bladder and with relaxation of its sphincter.
Consequently they are actively involved in urination and are sometimes referred to as the emptying, or detrusor, nerves. The bladder wall has a serous coat over its upper surface. This covering is a continuation of the peritoneum that lines the abdominal cavity; it is called serous because it exudes a slight amount of lubricating fluid called serum.
The other layers of the bladder wall are the fascial, muscular, submucous, and mucous coats. The fascial coat is a layer of connective tissue, such as that which covers muscles. The muscular coat consists of coarse fascicles, or bundles, of smooth involuntary muscle fibres arranged in three strata, with fibres of the outer and inner layers running lengthwise, and with fibres of the intermediate layer running circularly; there is considerable intermingling of fibres between the layers.
The smooth muscle coat constitutes the powerful detrusor muscle, which causes the bladder to empty. The circular or intermediate muscular stratum of the vesical wall is thicker than the other layers. Its fibres, although running in a generally circular direction, do interlace. The internal muscular stratum is an indefinite layer of fibres that are mostly directed longitudinally. The submucous coat consists of loose connective tissue containing many elastic fibres.
It is absent in the trigone, a triangular area whose angles are at the two openings for the ureters and the single internal urethral opening. Slim bands of muscle run between each ureteric opening and the internal urethral orifice; these are thought to maintain the oblique direction of the ureters during contraction of the bladder.
Another bundle of muscle fibres connects the two ureteric openings and produces a slightly downwardly curved fold of mucous membrane between the openings. The mucous coat, the innermost lining of the bladder, is an elastic layer impervious to urine.
Hydatid Disease Cystic, Alveolar Echinococcosis. Intestinal Roundworms Ascariasis, Ascaris Infection. Isospora Infection see Cystoisospora Infection. Kala-azar Leishmaniasis, Leishmania Infection. Leishmaniasis Kala-azar, Leishmania Infection. Liver Flukes Clonorchiasis, Opisthorchiasis, Fascioliasis. Loiasis Loa loa Infection.
Lymphatic filariasis Filariasis, Elephantiasis. Pediculosis Head or Body Lice Infestation. Pthiriasis Pubic Lice Infestation. Pseudoterranova Infection Anisakiasis, Anisakis Infection.
Taeniasis Taenia Infection, Tapeworm Infection. Tapeworm Infection Taeniasis, Taenia Infection. Trichuriasis Whipworm Infection, Trichuris Infection.