Lower Urinary System Flashcards
Ureters
Carry urine from renal pelvis to the bladder
Ureteral lumens are
Narrow
Male vs female urethra length
Male: 8 to 10 inches
Female: 1 to 2 inches
Females are more prone to
UTI because of short urethra
UTI bacteria
E. Coli
Bladder
Reservoir for urine
Bladder capacity
600-1000 mL
Bladder muscle
Detrusor
Other names for urinating
Urination, micturition, voiding
detrusor muscle
Remains relaxed when bladder is empty, contracts when full (mostly) and pushes urine out
How does urine flow?
Flows downwards to prevent urine back flowing into kidneys
Ureters connect to bladder=
Ureterovesical valves (one-way valves)
Urine is
Sterile
Once it hits air, it is no longer sterile
pH of urine is
Acidic
Prostate gland is in
Men
Maintaining a healthy bladder
-should void every 3-4 hours
-wipe from front to back
-urinate after intercourse
-do kegels
-cotton underwear
-limit alcohol/smoking
-drink lots of fluids
Kegels are good for
Stress incontinence
Kegels
Pelvic floor muscle exercises
-contract/squeeze muscles around rectum and vagina at the same time
Urinary incontinence
Involuntary or uncontrolled loss of urine in any amount
Stress incontinence
When physical movement or activity (coughing, laughing, sneezing, running, heavy lifting) puts pressure (stress) on bladder, causes leakage of urine
Stress incontinence causes
Pelvic floor muscle and urinary sphincter weaken
-childbirth in women
-prostate surgery in men
Stress incontinence devices
Vaginal pessary, urethral inserts
Stress incontinence surgery
Vaginal sling, injectable bulking agents, artificial sphincter
Urge incontinence
Involuntary urination with little or no warning
(Overactive bladder, bladder spasms, irritable bladder, Detrusor instability)
What occurs with urge incontinence?
Frequent urination or nocturia
Enuresis (bed wetting!)
Urge incontinence treatment
Bladder training
Functional incontinence
Inability to get to or use the toilet in time to urinate
-usually due to physical or cognitive impairment (inability to walk well, furniture in the way)
Functional incontinence treatment
Aimed at manipulating environment
-easy access to toilet
-scheduled times for toileting
-wearing clothes easy to remove
Anticholinergics
Treat urinary incontinence (more for urge and stress)
-can’t see, can’t pee, can’t spit, can’t shit
Oxybutynin (Ditropan)
Decreases urgency, frequency, and nocturia
-causes urinary retention!
Do not use Oxybutyin (Ditropan) or anticholinergics
With patients with BPH (large prostate)
With decongestants (Claritin, Benadryl, Sudafed) — WILL CAUSE HTN
Avoid what when taking anticholinergics
Hot baths, hot tubs, and use caution when exercising or in hot weather
Treatment of urinary incontinence
Kegel exercises
Scheduled toileting times
Botox injections
Nerve stimulator
Medications for urinary incontinence
Tolterodine (detrol)
Oxybutynin (Ditropan)
Urinary retention
Inability to empty bladder all the way
Causes of urinary retention
BPH — #1 cause!
Obstruction (kidney stone)
Narrowing - urethral
Tumors
Certain meds (anticholinergics, OPIOIDS!!)
Being dehydrated
Constipation
Acute urinary retention
Sudden and often painful inability to urinate at all despite bladder fullness
-requires intervention
Chronic urinary retention
Gradual inability to empty the bladder; painless retention associated with increased volume of residual urine
Chronic urinary retention s/s
Straining to pass urine/weaker flow
Feels like bladder is still full after voiding
Overflow incontinence
Difficulty holding in urine when coughing, laughing etc
Nocturia/enuresis
Swelling/mild pain in abdomen
Overflow incontinence
Leaking urine without being able to control it
Acute urinary retention
Nursing management
Bladder scan
Voiding history
Needs indwelling urinary catheter
Drink small amounts of fluid
Chronic urinary retention
Nursing management
Intermittent or indwelling urinary cath
Schedule toileting time
What is the most important risk factor for bladder cancer?
Smoking
Clinical manifestations
Bladder cancer
Painless hematuria
Bladder irritability (dysuria, frequency & urgency)
Urinary diversions
ileal conduit and neobladder
-most common after complete removal of bladder for bladder cancer
ileal conduit
Portion of ileum is resected and one end of segment is closed; ureters are attached to closed end of ileum and open end of ileum is brought through abdomen to form a stoma; a bag is placed over the stoma
Neobladder
Piece of small intestine formed into a pouch and positioned in same position of original bladder, urine comes out urethra
Neurogenic bladder
Nerves between spinal cord and brain don’t work
(Parkinson’s, multiple sclerosis, stroke, diabetes)
Neurogenic bladder nursing interventions
Avoid caffeine and alcohol
Kegels
Catheter prn
Meds — tamsulosin (FLOmax) improves bladder storage and emptying
Urinalysis
-Measurement of color, pH, specific gravity
-determination of presence of glucose, protein, blood, and ketones
-microscopic exam for crystals, bacteria (first morning void, examine urine within 1 hour)
Urine studies
-urine culture and sensitivity
-creatinine clearance
-collect 24 hour urine specimen
- closely approximates GFR (Glomerular filtration rate)
GFR
Glomerular filtration rate
-most accurate measure of kidney function!!!!!
Serum creatinine
Greater than 1.2 mg/dl is abnormal for women
Greater than 1.4 mg/dl is abnormal for men
BUN
7-20 mg/dl
High BUN with normal creatinine =
Dehydration
Interstitial cystitis
Painful bladder syndrome
Difficult to diagnose
Mistaken for UTI!! But urine culture shows no bacteria
Clinical manifestations
Interstitial cystitis
-pain in perineum
-persistent, urgent need to void
-painful intercourse
-frequent urination (up to 60x per day!)
-pain while bladder fills and relief after urinating
-may have AUTOIMMUNE component
Urinary tract infection causes
(HARD TO VOID!)
Hormones
Antibiotics
Renal stones, scarring
Diabetes —> high risk for uti
Toiletries
Obstructive prostate
Vesicoureter reflux
Overextended bladder
Indwelling catheter
Decreased immunity (structural deviations)
UTI teaching
Fluids- avoid alcohol and caffeine, drink water, cranberry juice, green tea
Foods- avoid acidic, spicy, artificial sweeteners
Eat- high fiber (whole grains, beans, bananas)
Void- every 2-4 hours, cotton lines underwear
Exercise
Patho of UTI
Bacteria enters sterile bladder causing inflammation
Bacterial infection most common
Fungal and parasitic infections may also cause utis
most common pathogen for UTI
E. coli
The 4 units of the lower GU tract
Bladder, kidney, urethra, ureter
Kidney infections
Pyelolonephritis
Bacteria are easier to get into blood stream = sepsis
Bladder infection
Cystitis
Urethra infection
Urethritis
Ureter infection
Ureteritis
CAUTI
Catheter associated urinary tract infection
CAUTI #1 cause
Prolonged use of urinary catheter (goal is to keep urinary cath OUT)
-most common hospital acquired infection
CAUTI common bacteria
E. Coli
Pseudomonas
Proteus marabilis
CAUTI risk factors
-pedi and females
-urinary retention
-pregnancy
-menopause
-multiple partners
CAUTI routes of infection
Meatal junction
Outlet device
Catheter tubing connection
S/S of CAUTI
-hesitancy, frequency, urgency
-dysuria
-suprapubic pain
Diagnose CAUTI with
+ RBC (gross hematuria)
Cloudy
+ WBC
+ Nitrates
Elderly/geriatric manifestations (CAUTI)
-sudden change in LOC
-falls
-tachypnea
-anorexia
-low grade fever or no fever (VS appear normal)
Nursing management
CAUTI
Urinalysis and urine culture (clean catch)
Meds (antibiotics, analgesic for pain)
Prevention of CAUTI
Prevention of urosepsis
Clean catch urine (midstream)
Clean urinary opening with towelette front to back
Void into toilet a few seconds then stop
Place sterile container into path of stream
Restart urine and collect
Indications for indwelling urinary catheter
Acute urinary retention or bladder obstruction
Need for accurate I&O (hourly monitoring, should be at least 30mL)
Assist in healing of open sacral or perineal wounds
Prior to certain surgeries
Pt requires prolonged immobilization
To improve comfort for end of life care
Urosepsis
Caused by infection from UTI that moves to kidneys
Urosepsis risk factors
Urinary catheters
Advanced age
Diabetes
Female
Compromised immune system
Surgical procedures involving urinary tract
Clinical manifestations of Urosepsis
-initially uti symptoms
-more serious s/s (pyelonephritis)
-N/V, fever, chills, pain in lower spine
Sepsis symptoms
MEWS tool!!!!
-respiratory rate 22 or higher
-systolic pressure < 100 mmHg
-WBC too high or too low (4500-10,000)
Severe sepsis/septic shock
Organ failure, such as kidney (low urine output)
Low platelet count
Change in mental status
High levels of lactic acid in blood (cells aren’t utilizing oxygen in the right way)
Urosepsis management
Early goal-directed therapy (EGDT)
Antibiotics
Strict I&O
Removal of any catheters or devices that may be infected
Suprapubic catheter
Flexible catheter tube inserted into bladder through the abdomen a few inches below umbilicus
Suprapubic catheters are used for
-urethral trauma
-some gynecological surgeries (prolapsed uterus or bladder)
-people who require long-term catheterization & are sexually active
Priapism
Prolonged painful erection without sexual desire (usually longer than 4 hours)
Priapism can lead to
Impaired circulation and inability to urinate
Priapism causes
Neurological and vascular disorders
Phimosis
Inability to retract the foreskin covering the head of the penis
Hypospadius
Birth defect in which opening of urethra is located at the tip of the penis, along shaft, or where penis and scrotum meet
Diphalia
Genetic condition present at birth in which a person has 2 penises
Penile ring entrapment (PRE)
Works by reducing outflow of blood, sustaining a longer erection
-IF LEFT for an extended period of tie can lead to swelling of the shaft, strangulation, gangrene, and even complete loss of distal penis
Prostate gland
-male organ that produces semen and transports sperm during ejaculation
Enlarged prostate
Benign prostatic hypertrophy (BPH)
-can put pressure on urethra causing difficulty urinating
Acute bacterial prostatitis
Bacterial infection of the prostate, usually with less severe symptoms
Chronic bacterial prostatitis
Ongoing/recurring bacterial infection usually with less severe symptoms
Chronic prostatitis/chronic pelvic pain syndrome
Ongoing/recurring pelvic pain and uti symptoms with no evidence of infection
Chronic prostatitis/chronic pelvic pain syndrome symptoms
Flu-like
Pain in abdomen, groin, or back
Dysuria
Pain with ejaculation
Can prostatitis be prevented?
No
Prostatitis treatment
Acute bacterial- antibiotics 4-6 weeks
Chronic bacterial- antibiotics 8-12 weeks
Prostatitis teaching
-safe sex!!!!
-weight loss
-avoid spicy/acidic foods
-avoid alcohol/caffeine
-unprocessed/less sugar
-water!!
Benign prostatic hyperplasia (BPH) enlarged prostate
Prostate gland enlarges, disrupting outflow of urine from pressure on the urethra
-main cause of urinary retention in men
Irritative BPH
Nocturia, frequency, urgency
Obstructive BPH
Weak stream, difficulty starting and stopping stream, dribbling
Diagnostic studies (BPH)
-history and physical
-digital rectal exam (DRE)
-prostatic specific antigen (PSA)
-transrectal ultrasound
Adrenergic receptor blockers
Most end in “osin”
Tamsulosin (FLOmax) - will help you lose urine; helps urine FLOW
Doxazosin (cardura)
Terazosin (Hytrin) change positions slowly!!
Adrenergic receptor blockers
Mode of action
Antagonize alpha 1 receptors, relaxing smooth muscles of the prostate, which helps improve urine flow
-also causes VASODILATION
Do not take Adrenergic receptor blockers with
Antiacids or viagra! These can further cause hypotension!!
5a reductase inhibitors
End in “ride”
Finasteride (proscar) helps with male propecia
Dutasteride (avodart)
5a reductase inhibitor is the enzyme that
-prevents conversion of testosterone
-reduces size of prostate!
Side effects of 5a reductase inhibitors
Erectile dysfunction, gynecomastia
Pregnant women should not handle
Finasteride
Complications of BPH
Hydronephrosis is swelling of kidneys due to build up of urine causing swelling
Urine cannot drain out from kidney to bladder = urinary retention!
Hydronephrosis causes
-Blockage of outflow of urine or reflux of urine from bladder to kidney
-renal stones
-narrowing of ureter
-tumors
-vesicoureteral reflux/ureteral obstruction
Transurethral resection of prostate (TURP) for BPH
Surgery to remove parts of prostate tissue through the penis
Usually __________ after TURP
Bleeding
Post TURP procedure
3 way indwelling catheter inserted to provide hemostasis and urinary drainage
What is used to prevent obstruction of the catheter after TURP?
Continuous 3 way bladder irrigation (Murphy drip)
Intermittent irrigation for bladder
Manual irrigation for bladder spasms, clots decreasing outflow
Sudden gross hematuria =
Possible bleed
Patient with bladder irrigation
-assess for bleeding & clots
-monitor inflow and outflow
-monitor for increase in gross hematuria (hemorrhage)
Nursing management
Bladder irrigation
-kegels
-no heavy lifting
-s/s of infection
-stool softeners
-patience
Prostate cancer is diagnosed with
PSA and biopsy
Radical prostatectomy
Removal of prostate, seminal vesicles, and part of the bladder
What is placed with prostatectomy?
Large indwelling catheter with 20-30mL balloon (pt goes home with catheter)
radical prostatectomy adverse reactions
Erectile dysfunction
Urinary incontinence
Testicular cancer is more common in
Young males (15-44)
Testicular cancer
-very curable if caught early
-risk for infertility
-tumor marker blood test
-recommended to do self-exam monthly
S/S of testicular cancer
-lump/swelling on testicle
-feeling of heaviness in scrotum
-dull ache in lower belly or groin
-usually painless in early stages
Testicular torsion
Testicle rotates, twisting the spermatic cord that brings blood to the scrotum
Testicular torsion occurs more on the
Left
Testicular torsion results in
Reduced blood flow that causes sudden and severe pain on one side of the scrotum
Testicular torsion medical emergency =
Blood flow must be restored within 6 hrs or testicle will atrophy
Causes of testicular torsion
-vigorous activity
-minor injury to testicles
-while sleeping
Erectile dysfunction
Inability to attain or maintain an erection
Erectile dysfunction increases with
Age (40 to 70)
Erectile devices and drugs
Sildenafil (viagra)
Tadalafil (cialis)
** do not take if on a nitrate!!
Erectogenic drugs (phosphodiesterase type 5 inhibitors) mode of action
Increases blood flow to penis and vasodilation of the pulmonary vasculature
Side effects of erectogenic drugs
Priapism, increased risk for heart attack
Oliguria
Urine output abnormally low
Anuria
A sense of urine production
Polyuria
Excessive urination
