Chapter 46: Renal/Urologic

Question 1

CULTURAL & ETHNIC HEALTH DISPARITIES

Answer 1

• Urinary tract calculi are more common among whites than African Americans.
• Uric acid stones are more common in Jewish men.
• Bladder cancer has a higher incidence among white men than African American men.
• In all ethnic groups, bladder cancer affects men about three times more often than women.
• Urinary incontinence is underreported because culturally it is seen as a social hygiene problem causing patient embarrassment.

Question 2

Escherichia coli is the most common pathogen causing a UTI

Answer 2

and is primarily seen in women. Bacterial counts
of 105 colony-forming units per milliliter (CFU/mL) or higher typically indicate a clinically significant UTI. However, counts as low as 102 to 103 CFU/mL in a person with signs and symptoms
are indicative of UTI.

Question 3

Specific terms

are used to further delineate the location of a UTI. For example

Answer 3

pyelonephritis implies inflammation (usually caused by infection) of the renal parenchyma and collecting system, cystitis indicates inflammation of the bladder, and urethritis means inflammation of the urethra. Urosepsis is a UTI that has spreadsystemically and is a life-threatening condition requiring emergency
treatment

Question 4

Lower urinary tract symptoms (LUTS) are experienced in
patients who have UTIs of the upper urinary tract, as well as those confined to the lower tract. Symptoms are related to either bladder storage or bladder emptying.

Answer 4

dysuria, frequent urination (more than every 2 hours), urgency, and suprapubic discomfort or pressure. The urine may contain grossly visible blood (hematuria)
or sediment, giving it a cloudy appearance. Flank pain,
chills, and fever indicate an infection involving the upperurinary tract (pyelonephritis)

Question 5

UTI, initially obtain a dipstick urinalysis to identify the presence of nitrites (indicating bacteriuria), white blood cells (WBCs), and leukocyte esterase (an enzyme present in WBCs indicating pyuria). These findings can be confirmed by microscopic urinalysis.

Answer 5

After confirmation of bacteriuria and pyuria, a urine culture may be obtained. A urine culture is indicated in complicated or HAI UTIs, persistent bacteriuria, or frequently recurring UTIs (more than two or three episodes per year). Urine may also be cultured when the
infection is unresponsive to empiric therapy or the diagnosis is questionable

Question 6

First-choice drugs to empirically treat uncomplicated or

initial UTIs are

Answer 6

trimethoprim/sulfamethoxazole (TMP/SMX)
(Bactrim, Septra), nitrofurantoin (Macrodantin), and fosfomycin (Monurol). TMP/SMX has the advantages of being relatively inexpensive and being taken twice daily.

Question 7

treat complicated UTIs.

Answer 7

These drugs include ciprofloxacin (Cipro), levofloxacin (Levaquin), norfloxacin (Noroxin), ofloxacin (Floxin), and gatifloxacin (Tequin). In patients with UTIs secondary to fungi, amphotericin or fluconazole (Diflucan) is the preferred therapy.

Question 8

DRUG ALERT: Nitrofurantoin (Furadantin, Macrodantin)

Answer 8

• Avoid sunlight. Use sunscreen, and wear protective clothing.
• Notify health care provider immediately if fever, chills, cough,
chest pain, dyspnea, rash, or numbness or tingling of fingers or toes
develops.

Question 9

Nursing diagnoses for the patient with a UTI may include, but are not limited to, the following: pg 1067

Answer 9

• Impaired urinary elimination related to the effects of UTI

* Readiness for enhanced self-health management

Question 10

Health promotion activities include teaching preventive measures such as

Answer 10

(1) emptying the bladder regularly and completely, (2) evacuating th bowel regularly, (3) wiping the perineal area from front to back after urination and defecation, and (4) drinking an adequate amount of liquid each day.

Question 11

It is important to recognize individuals

who are at risk for a UTI. These people include

Answer 11

debilitated persons, older adults, patients who are immunocompromised (e.g., cancer, human immunodeficiency virus [HIV], diabetes mellitus), and patients treated with immunosuppressive drugs
or corticosteroids.

Question 12

Teach patients to promptly report any of the following to their health care provider:

Answer 12

(1) persistence of bothersome LUTS beyond the antibiotic

treatment course, (2) onset of flank pain, or (3) fever

Question 13

Pyelonephritis usually begins with colonization and infection of the lower urinary tract via the ascending urethral route.
Bacteria normally found in the intestinal tract, such as E. coli or Proteus, Klebsiella, or Enterobacter species, frequently cause pyelonephritis.

Answer 13

A preexisting factor is often present such as
vesicoureteral reflux (retrograde, or backward, movement of urine from lower to upper urinary tract) or dysfunction of the lower urinary tract (e.g., obstruction from benign prostatic hyperplasia [BPH], a stricture, a urinary stone).

Question 14

Ultrasonography of the urinary system may be performed

to identify anatomic abnormalities,

Answer 14

hydronephrosis, renal abscesses, or an obstructing stone.

CT urograms are also used to assess for signs of infection in the kidney and complications of yelonephritis, such as impaired renal function, scarring,
chronic pyelonephritis, or abscesses.

Question 15

The overall goals are that the patient with pyelonephritis will have

Answer 15

(1) normal renal function, (2) normal body temperature,

(3) no complications, (4) relief of pain, and (5) no recurrence of symptoms.

Question 16

In chronic pyelonephritis the kidneys become small, atrophic, and shrunken and lose function due to fibrosis (scarring).

Answer 16

Radiologic imaging and a biopsy, rather than clinical features, are used to confirm the diagnosis of chronic pyelonephritis. Imaging studies reveal a small, fibrotic kidney. The collecting system may be small or hydronephrotic. Biopsy results indicate the loss of functioning nephrons, infiltration of the parenchyma
with inflammatory cells, and fibrosis.

Question 17

Urethritis is an inflammation of the urethra. Causes of urethritis include

Answer 17

a bacterial or viral infection, Trichomonas and
monilial infection (especially in women), chlamydial infection, and gonorrhea (especially in men).

Question 18

Urethral diverticula are localized outpouchings of the urethra.

Answer 18

Most often they result from enlargement of obstructed periurethral glands.

Question 19

Interstitial cystitis (IC) is a chronic, painful inflammatory
disease of the bladder characterized by symptoms of urgency, frequency, and pain in the bladder and/or pelvis.

Answer 19

Painful bladder syndrome (PBS) is suprapubic pain related to bladder filling.
The term IC/PBS refers to cases of urinary pain that cannot be attributed to other causes such as infection or urinary calculi.

Question 20

Because the etiology of IC/PBS is unknown, no single treatment consistently reverses or relieves symptoms. Various therapies have been effective, including nutritional and drug therapy.18,19 Surgical therapy is rarely indicated.

Answer 20

Elimination of foods and beverages that are likely to irritate the bladder may provide some relief from symptoms. Typical bladder irritants include caffeine; alcohol; citrus products; aged cheeses; nuts; foods containing vinegar, curries, or hot peppers; and foods or beverages, including fruits (cranberries), likely to
lower urinary pH.

Question 21

The clinical manifestations of APSGN include

Acute poststreptococcal glomerulonephritis (APSGN)

Answer 21

generalized body edema, hypertension, oliguria, hematuria with a smoky or rusty appearance, and proteinuria.

Question 22

The diagnosis of APSGN is based on a complete history and physical examination.

Answer 22

Dipstick urinalysis and urine sediment microscopy reveal
erythrocytes in significant numbers. Erythrocyte casts are
highly suggestive of APSGN. Proteinuria may range from mild to severe. Blood tests include blood urea nitrogen (BUN) and serum creatinine to assess the extent of renal impairment.

Question 23

One of the most important ways to prevent APSGN is to
encourage early diagnosis and treatment of sore throats and
skin lesions.

Answer 23

If streptococci are found in the culture, treatment
with appropriate antibiotic therapy (usually penicillin) is essential. Encourage the patient to take the full course of antibiotics to ensure that the bacteria have been eradicated. Good personal hygiene is an important factor in preventing the spread of cutaneous streptococcal infections

Question 24

Goodpasture syndrome is an autoimmune disease characterized by circulating antibodies against glomerular and alveolar basement membrane.

Answer 24

Damage to the kidneys and lungs results when binding of the antibody causes an inflammatory reaction mediated by complement activation

Question 25

Goodpasture syndrome is a rare disease that is mostly found in young male smokers. The clinical manifestations include

Answer 25

flulike symptoms with pulmonary symptoms such as cough, mild shortness of breath, hemoptysis, crackles, rhonchi, and pulmonary insufficiency. Renal involvement causes hematuria, weakness, pallor, anemia, and renal failure. Pulmonary hemorrhage usually occurs and may precede glomerular abnormalities by weeks or months.

Question 26

RPGN can occur in a variety of situations:

Answer 26

(1) as a complication of inflammatory or infectious disease (e.g., APSGN), (2) as a complication of a systemic disease (e.g., systemic lupus erythematosus), (3) as an idiopathic disease, or (4) with the use of certain drugs (e.g., penicillamine).

Question 27

Nephrotic syndrome results when the glomerulus is excessively permeable to plasma protein, causing proteinuria that leads to low plasma albumin and tissue edema.

Answer 27

Immune responses, both humoral and cellular, are altered in nephrotic syndrome. As a result, infection is a primary cause of morbidity and mortality. Calcium and skeletal abnormalities may occur, including hypocalcemia, blunted calcium response to parathyroid hormone, hyperparathyroidism, and osteomalacia.

Question 28

Crystals, when in a supersaturated concentration, can precipitate and unite to form a stone.

Answer 28

A mucoprotein is formed in the kidneys as a matrix for the stone. Urinary pH, solute load, and inhibitors in the urine affect the formation of stones. The higher the pH (alkaline), the less soluble are calcium and phosphate. The lower the pH (acidic), the less soluble are uric acid and cystine. When a substance is not very soluble in fluid, it is more likely to precipitate out of solution

Question 29

The term calculus refers to the stone, and lithiasis refers to stone formation. The five major categories of stones are

Answer 29

(1) calcium phosphate, (2) calcium oxalate, (3) uric acid, (4) cystine, and (5) struvite (magnesium ammonium phosphate)

Question 30

Renal colic is the term used for the sharp, severe pain, which results from the stretching, dilation, and spasm of the ureter in response to the obstructing stone. Nausea and vomiting may occur due to the severe pain

Answer 30

Urinary stones cause clinical manifestations when they obstruct urinary flow. Common sites of obstruction are at the UPJ (where the renal pelvis narrows into the ureter) and at the ureterovesical junction (UVJ).

Question 31

Indications for endourologic, lithotripsy, or open surgical | stone removal include the following:

Answer 31

(1) stones too large for spontaneous passage (usually greater than 7 mm); (2) stones associated with bacteriuria or symptomatic infection; (3) stones causing impaired renal function; (4) stones causing persistent pain, nausea, or paralytic ileus; (5) inability of patient to be treated medically; and (6) patient with only one kidney.

Question 32

Purine* uric acid is by product

Answer 32

High: Sardines, herring, mussels, liver, kidney, goose, venison, meat soups, sweetbreads Moderate: Chicken, salmon, crab, veal, mutton, bacon, pork, beef, ham

Question 33

Calcium

Answer 33

High: Milk, cheese, ice cream, yogurt, sauces containing milk; all beans (except green beans), lentils; fish with fine bones (e.g., sardines, kippers, herring, salmon); dried fruits, nuts; Ovaltine, chocolate, cocoa

Question 34

Oxalate

Answer 34

High: Dark roughage, spinach, rhubarb, asparagus, cabbage, tomatoes, beets, nuts, celery, parsley, runner beans; chocolate, cocoa, instant coffee, Ovaltine, tea; Worcestershire sauce

Question 35

Nursing diagnoses for the patient with urinary tract calculi | include, but are not limited to, the following: pg 1080

Answer 35

• Impaired urinary elimination related to trauma or obstruction of ureters or urethra • Acute pain related to effects of stones and inadequate pain control or comfort measures • Deficient knowledge related to unfamiliarity with information resources and lack of experience with urinary stones

Question 36

A stricture is a narrowing of the lumen of the ureter or | urethra.

Answer 36

Ureteral strictures can affect the entire length of the ureter, from the UPJ to the UVJ. These strictures are usually an unintended result of surgical intervention or secondary to adhesions or scar formation, or they may be due to extrinsic factors such as large tumors in the peritoneal cavity.

Question 37

A urethral stricture is the result of fibrosis or inflammation of the urethral lumen.

Answer 37

Causes of urethral strictures include trauma, urethritis (particularly after gonococcal infection), surgical intervention or repeated catheterizations (iatrogenic), or a congenital defect of the urethra.

Question 38

Nursing interventions depend on the type of renal trauma | and the extent of any associated injuries. Interventions related to renal trauma include the following:

Answer 38

(1) assess the cardiovascular status and monitor for shock, especially in a penetrating injury; (2) ensure adequate fluid intake and monitor intake and output; (3) provide for pain relief and comfort measures; and (4) assess for hematuria and myoglobinuria.

Question 39

Vascular problems involving the kidney include

Answer 39

(1) nephrosclerosis, | (2) renal artery stenosis, and (3) renal vein thrombosis.

Question 40

Polycystic kidney disease (PKD) is the most common lifethreatening genetic disease in the world, affecting 600,00 people in the United States. PKD accounts for 10% to 15% of chronic kidney disease.26

Answer 40

PKD has two hereditary forms: it may be manifested in childhood or adulthood. The childhood form of PKD is a rare autosomal recessive disorder that is often rapidly progressive (see the Genetics in Clinical Practice box). The adult form of PKD is an autosomal dominant disorder

Question 41

Alport syndrome, also known as chronic hereditary nephritis, has two forms:

Answer 41

(1) classic Alport syndrome, which is inherited as a sex-linked disorder with hematuria, sensorineural deafness, and deformities of the anterior surface of the lens; and (2) nonclassic Alport syndrome, which is inherited as an autosomal disorder that causes hematuria but not deafness or lens deformities.

Question 42

Renal cell carcinoma (adenocarcinoma) is the most common type of kidney cancer

Answer 42

smoking and to asbestos, cadmium, and gasoline. Risk for kidney cancer is also increased in individuals who have acquired cystic disease of the kidney associated with ESKD

Question 43

The following is a simple | description of staging of bladder cancer:

Answer 43

Stage I: Cancer is in the inner lining of the bladder but has not invaded the bladder muscle wall. Stage II: Cancer has invaded the bladder wall but is still confined to bladder. Stage III: Cancer has spread through the bladder wall to surrounding tissue. It may also have spread to the prostate in men or the uterus or vagina in women. Stage IV: Cancer has spread to the lymph nodes and other organs, such as lungs, bones, or liver.

Question 44

The following is a simple description of staging of | kidney cancer:

Answer 44

Stage I: The tumor can be up to 7 cm in diameter but is confined to the kidney. Stage II: The tumor is larger than a stage I tumor, but is still confined to the kidney. Stage III: The tumor extends beyond the kidney to the surrounding tissue and may also have spread to a nearby lymph node. Stage IV: Cancer spreads outside the kidney to multiple lymph nodes or to distant parts of the body, such as bones, brain, liver, or lung.

Question 45

urinary incontinence..... Using the acronym DRIP, the causes | can include

Answer 45

D: delirium, dehydration, depression; R: restricted | mobility, rectal impaction; I: infection, inflammation, impaction; and P: polyuria, polypharmacy.

Question 46

Measure postvoid residual (PVR) urine in the patient undergoing evaluation for UI.

Answer 46

The PVR volume is obtained by asking the patient to urinate, followed by catheterization or use of a bladder ultrasound within a relatively brief period (preferably 10 to 20 minutes).

Question 47

An estimated 80% of incontinence can be cured or significantly improved

Answer 47

therapies...Pelvic floor muscle training (Kegel exercises) is used to manage stress, urge, or mixed UI Biofeedback is used to help the patient identify, isolate, contract, and relax the pelvic muscles drug therapy SURGERY

Question 48

Stress Incontinence*

Answer 48

Pelvic floor muscle exercises (e.g., Kegel exercises), weight loss if patient is obese, cessation of smoking, topical estrogen products, external condom catheters or penile clamp in men, surgery Urethral inserts, patches, or bladder neck support devices (e.g., incontinence pessary) to correct underlying problem

Question 49

Urge Incontinence*

Answer 49

Treatment of underlying cause Biobehavioral interventions, including bladder retraining with urge suppression, decrease in dietary irritants, bowel regularity, and pelvic floor muscle exercises Anticholinergic drugs (e.g., oxybutynin [Ditropan XL, Oxytrol], tolterodine [Detrol, Detrol LA], trospium chloride [Sanctura], solifenacin [VESIcare], and darifenacin [Enablex]); imipramine (Tofranil) at bedtime; calcium channel blockers Containment devices (e.g., external condom catheters) Vaginal estrogen creams Absorbent products

Question 50

Overflow Incontinence

Answer 50

Urinary catheterization to decompress bladder Implementation of Credé or Valsalva maneuver α-Adrenergic blocker (doxazosin [Cardura], terazosin [Hytrin], tamsulosin [Flomax], alfuzosin [Uroxatral]) 5α-Reductase inhibitors (e.g., finasteride [Proscar]) to decrease outlet resistance bethanechol (Urecholine) to enhance bladder contractions Intravaginal device such as a pessary to support prolapse Intermittent catheterization Surgery to correct underlying problem

Question 51

Reflex Incontinence

Answer 51

``` Treatment of underlying cause Bladder decompression to prevent ureteral reflux and hydronephrosis Intermittent self-catheterization diazepam (Valium) or baclofen (Lioresal) to relax external sphincter Prophylactic antibiotics Surgical sphincterotomy ```

Question 52

Incontinence After Trauma or Surgery

Answer 52

Surgery to correct fistula Urinary diversion surgery to bypass urethra and bladder External condom catheter Penile clamp Placement of artificial implantable sphincter

Question 53

Functional Incontinence

Answer 53

Modifications of environment or care plan that facilitates regular, easy access to toilet and promotes patient safety (e.g., better lighting, removal of scatter rugs, ambulatory assistance equipment, clothing alterations, timed voiding, different toileting equipment

Question 54

DRUG ALERT: Tolterodine (Detrol)

Answer 54

* Overdosage can result in severe anticholinergic effects. | * These effects include GI cramping, diaphoresis, blurred vision, and urinary urgency

Question 55

It is important to recognize both the physical and the emotional problems associated with UI. Maintain and enhance the patient’s dignity, privacy, and feelings of self-worth. This is a two-step approach:

Answer 55

``` (1) containment devices to manage existing urinary leakage and (2) a definitive plan to reduce or resolve the factors leading to UI. ```

Question 56

Timed voiding

Answer 56

Toileting on a fixed schedule (typically every 2-3 hr during waking hours).Toileting on a fixed schedule (typically every 2-3 hr during waking hours).

Question 57

Habit retraining

Answer 57

Scheduled toileting with adjustments of voiding intervals (longer or shorter) based on the individual’s voiding pattern.

Question 58

Prompted voiding

Answer 58

Scheduled toileting that requires prompts to void from a caregiver (typically every 3 hr). Used in conjunction with operant conditioning techniques to reward individuals for maintaining continence and appropriate toileting

Question 59

Bladder retraining and urgesuppression strategies

Answer 59

Scheduled toileting with progressive voiding intervals. Includes teaching of urge-control strategies using relaxation and distraction techniques, self-monitoring, reinforcement techniques, and other strategies such as conscious contraction of pelvic floor muscles.

Question 60

``` Intravaginal support devices (pessaries and bladder neck support prostheses) ```

Answer 60

Devices support bladder neck, relieve minor pelvic organ prolapse, and change pressure transmission to the urethra

Question 61

Intraurethral occlusive device (urethral plug)

Answer 61

Single-use device that is worn in the urethra to provide mechanical obstruction to prevent urine leakage. Removed for voiding.

Question 62

Penile compression device

Answer 62

Mechanical fixed compression applied to the penis to prevent any flow or leakage via the urethra. Must be released hourly to void.

Question 63

Urinary retention is caused by two different dysfunctions of | the urinary system:

Answer 63

bladder outlet obstruction and deficient | detrusor (bladder muscle) contraction strength.

Question 64

Role of Registered Nurse (RN)

Answer 64

• Assess for risk factors for incontinence or urinary retention. • Determine type of incontinence that patient is experiencing. • Develop plan of care to decrease incontinence. • Teach patient ways to decrease incontinence such as pelvic floor muscle (Kegel) exercises. • Assist patient in choosing appropriate products to contain urine.

Question 65

Role of Licensed Practical/Vocational Nurse (LPN/LVN)

Answer 65

* Use bladder scanner to estimate the postvoid residual volume (PVR). * Catheterize patient and measure PVR. * Administer medications to decrease incontinence or urinary retention.

Question 66

Role of Unlicensed Assistive Personnel (UAP)

Answer 66

• Assist incontinent patient to commode or bedpan at regular intervals. • Clean patient and provide skin care. • Notify RN about new-onset incontinence in a previously continent patient.

Question 67

Muscarinic Receptor Antagonists and Anticholinergics oxybutynin (Ditropan IR, Ditropan

Answer 67

Reduce overactive bladder contractions in urge urinary incontinence and overactive bladder

Question 68

α-Adrenergic Antagonists tamsulosin (Flomax)

Answer 68

Reduce urethral sphincter | resistance to urinary outflow

Question 69

5α-Reductase Inhibitors finasteride (Proscar) dutasteride (Avodart)

Answer 69

Androgen suppression that results in epithelial atrophy and a decrease in total prostate size

Question 70

α-Adrenergic Agonists phenylpropanolamine pseudoephedrine

Answer 70

Increase urethral resistance

Question 71

β3-Adrenergic Agonist mirabegron (Myrbetriq)

Answer 71

Improves the bladder’s storage capacity by relaxing the bladder muscle during filling

Question 72

Tricyclic Antidepressants imipramine (Tofranil) amitriptyline (Elavil)

Answer 72

``` Reduce sensory urgency and burning pain of interstitial cystitis Reduce overactive bladder contractions ```

Question 73

Calcium Channel Blockers nifedipine (Adalat) diltiazem (Cardizem) verapamil (Calan, Isoptin)

Answer 73

Reduce smooth muscle contraction strength May reduce burning pain of interstitial cystitis

Question 74

Hormone Therapy estrogen cream (Premarin, Estrace) estrogen vaginal ring (Estring) estrogen vaginal tablets (Vagifem)

Answer 74

Local application reduces urethral irritation and increases host defenses against UTI

Question 75

Indwelling Catheter

Answer 75

• Relief of urinary retention caused by lower urinary tract obstruction, paralysis, or inability to void • Bladder decompression preoperatively and operatively for lower abdominal or pelvic surgery • Facilitation of surgical repair of urethra and surrounding structures • Splinting of ureters or urethra to facilitate healing after surgery or other trauma in area • Accurate measurement of urine output in critically ill patient • Contamination of stage III or IV pressure ulcers with urine that has impeded healing, despite appropriate personal care for the incontinence • Terminal illness or severe impairment, which makes positioning or clothing changes uncomfortable, or which is associated with intractable pain

Question 76

Intermittent (Straight, In and Out) Catheter

Answer 76

• Study of anatomic structures of urinary system • Urodynamic testing • Collection of sterile urine sample in selected situations • Instillation of medications into bladder • Measurement of residual urine after urination (postvoid residual [PVR]) if portable ultrasound not available

Question 77

Complications that are seen more frequently with long-term | use (more than 30 days) of indwelling catheters include

Answer 77

HAIs, bladder spasms, periurethral abscess, pain, urosepsis, UTIs, urethral trauma or erosion, fistula or stricture formation, and stones.

Question 78

Role of Registered Nurse (RN)

Answer 78

• Determine need for catheterization. • Choose appropriate type and size of catheter. • Insert catheter in patient with urethral trauma, pain, or obstruction. • Develop plan of care to decrease risk for infection in patient with indwelling catheter.

Question 79

Role of Licensed Practical/Vocational Nurse (LPN/LVN)

Answer 79

• Insert intermittent or indwelling catheter for uncomplicated patients. • Irrigate the catheter if obstruction is suspected in stable patients (e.g., in long-term care).

Question 80

Role of Unlicensed Assistive Personnel (UAP)

Answer 80

• Provide perineal care around the catheter with soap and water. • Anchor the catheter in place (upper thigh in women and lower abdomen in men). • Notify RN about changes in skin condition, especially around meatus.

Question 81

Catheters are sized according to the French scale

Answer 81

The size used varies with the patient’s size and the purpose of catheterization. In women, urethral catheter sizes 14F to 16F are the most common. In men, sizes 14F to 18F are used. Balloon sizes are either 5 or 30 mL.

Question 82

Urethral catheterization, the most common route of catheterization, involves the insertion of a catheter through the external meatus into the urethra, past the internal sphincter, and into the bladder. different then......

Answer 82

The ureteral catheter is placed through the ureters into the renal pelvis. The catheter is inserted either (1) by being threaded up the urethra and bladder to the ureters under cystoscopic observation or (2) by surgical insertion through the abdominal wall into the ureters.