Module 7: Renal and Urologic Problems Flashcards
Urinary Tract Infections (UTIs)
Most common outpatient infection
Causes
Most common pathogen: Escherichia coli (E. coli)
* 75% cases; 65% complicated UTIs
Fungal and parasitic
* Immunosuppressed
* Diabetic or kidney problems
* Received multiple courses of antibiotics
* Live in or have traveled to certain developing countries
Classification of UTI
By location - upper or lower
Pyelonephritis – renal parenchyma and collecting
system
Cystitis – bladder
Urethritis – urethra
Urosepsis – systemic
* Life threatening
* Emergency treatment
Complicated or uncomplicated
Uncomplicated
* Occur in otherwise normal urinary tract in the bladder
Complicated
* Occur in people with underlying disease or other
structural, functional problem
Antibiotic resistance
Immunocompromised
Pregnant
Recurrent infection
* At risk for pyelonephritis, urosepsis, renal damage
UTI Etiology and Pathophysiology
Urinary tract above urethra normally sterile
Defense mechanisms help prevent UTIs
Complete emptying with void
Ureterovesical junction competence
Ureteral peristalsis propels urine towards bladder
Acidic pH of urine (6.0-7.5))
Abundant antimicrobial proteins and peptides
interfere with bacterial growth
Organisms from perineum ascend urethra
GI tract: gram-negative bacilli
Contributing factors: urologic instrumentation and
sexual intercourse
Hematogenous transmission
UTIs - most common health-care associated infection
(HAI)
Catheter-associated urinary tract infections (CAUTIs)
—E.coli or Pseudomonas
Increased length of stay, costs, mortality
Clinical Manifestations - Lower UTIs
Lower urinary tract symptoms (LUTS)
Emptying symptoms
* Hesitancy, intermittency, post void dribbling, urinary retention or incomplete emptying, dysuria
Storage symptoms
* Urinary frequency, urgency, incontinence, nocturia, nocturnal enuresis
Hematuria and/or cloudy appearance
Many problems produce LUTS; often confused with UT
Clinical Manifestation.- Upper UTIs
Upper urinary tract symptoms:
Flank pain, chills, fever
Other: fatigue, anorexia, or asymptomatic
Older adults: classic manifestations absent
Nonlocalized abdominal discomfort, cognitive impairment, or generalized deterioration; often afebrile
Asymptomatic bacteriuria—colonization of bacteria in
bladder; screen and treat with pregnancy
UTI Diagnostic Studies
Initial: dipstick for nitrates, WBCs, and leukocyte
esterase
Urine culture/sensitivity
Clean-catch urine sample
History
Recurring UTIs (more than 2 to 3/yr)
Complicated UTIs
CAUTIs or HAI UTIs
UTI unresponsive to empiric therapy
Imaging: ultrasound or CT scan
UTI Drugs
Drug therapy
Uncomplicated or initial UTIs
* Trimethoprim/sulfamethoxazole (TMP-SMX)
* Nitrofurantoin Cephalexin
* Fosfomycin
* Other: ampicillin, amoxicillin, or cephalosporins
Complicated: fluoroquinolones
Fungal: fluconazole
Urinary analgesic: phenazopyridine (azo dye
Acute Pyelonephritis
Etiology and pathophysiology
Inflammation of renal parenchyma and collecting
system
* Most common: bacteria (E.coli, Proteus, Klebisella, or
Enterobacter from intestinal tract)
* Other: fungi, protozoa, or viruses
Urosepsis—systemic infection from urologic source
Pyelonephritis—initial colonization and infection
of lower urinary tract from urethra
Preexisting factor—vesicoureteral reflux (urine
moves from lower to upper urinary tract) or
dysfunction of lower urinary tract (obstruction,
stricture, or stones)
CAUTI—long-term care residents
Pregnancy-induced changes
Starts in renal medulla, spreads to cortex
Clinical Manifestations
Classic: fever/chills, nausea/vomiting, malaise,
flank pain
Other: dysuria, urgency, frequency
Costovertebral angle (CVA) tenderness
Acute Pyelonephritis Diagnostic Studies
Urinalysis: pyuria, bacteriuria, hematuria; WBC
casts
Urine cultures and sensitivities
Blood cultures
Decreased kidney function tests
Ultrasound
CT scan—preferred imaging study
Acute Pyelonephritis Care
Mild symptoms (outpatient or short inpatient)
Fluids, NSAIDs, follow-up cultures and imaging
Antibiotics: oral 5 to 14 days; IV to oral 14 to 21 days
* Sensitivity guided
Severe symptoms (as above except)
IV fluids until oral tolerated
Combination parenteral antibiotics
Relapses—6 weeks antibiotics
Recurrent—prophylactic antibiotics
Urosepsis—monitor for and treat for septic
shock to prevent irreversible damage or death
Health promotion and maintenance
Similar to UTIs
Early treatment of UTIs to prevent ascending infection
Regular medical care with structural abnormalities
Patient teaching
Disease process
Take medications as prescribed
Follow-up care
Signs and symptoms of relapse or recurrence
Adequate fluid intake (8 glasses/day)
Rest
Chronic Pyelonephritis
Kidneys inflamed cause scarring leading to loss of
renal function
Result from anatomic abnormalities or recurrent
infections of upper urinary tract
Diagnosis: radiologic imaging and biopsy
Treatment: treat infection and underlying
contributing factors
Prevent progression to end-stage renal disease
(ESRD)
Urethritis
Inflammation of the urethra due to bacterial or viral
infection
Trichomonas or monilia, chlamydia, or gonorrhea
Males—sexually transmitted; see discharge, dysuria,
urgency, and frequency
Females—diagnosis difficult; see LUTS
Treatment: antimicrobials, sitz baths
Patient teaching: avoid vaginal sprays, perineal
hygiene, no sex for 7 days, and contact partners
Urethral Diverticula
Localized outpouchings of urethra from enlarged
periurethral glands
Incidence: women more than men
Urethral: trauma, instrumentation, or dilation;
vaginal delivery, or frequent infections
Symptoms: dysuria, post void dribbling,
frequency, urgency, suprapubic discomfort,
incomplete bladder emptying, incontinence, or
asymptomatic (women); hematuria, cloudy urine,
vaginal wall mass with purulent discharge
Diagnosis
Ultrasound and MRI
Voiding cystourethrography (VCUG)
Urethroscopy
Treatment (surgical)
Transvaginal diverticulectomy
Marsupialization (Spence procedure)
Urethroscopic surgical excision
Complications
Incontinence, infection, bleeding, fistula
Interstitial Cystitis (IC)/
Painful Bladder Syndrome (PBS)
IC—chronic, painful, inflammatory disease of the
bladder; IC causes PBS
Urgency, frequency, bladder/pelvic pain
Urinary pain not attributed to other causes
Etiology: unknown
Possible factors:
* Neurogenic hypersensitivity
* Mast cell changes in muscle or mucosal layer
* Infection (unusual organism)
* Toxic substance in urine
Clinical Manifestations
and Diagnostic Studies
Primary clinical manifestations: pain and
bothersome LUTS
Severe: void more than 60 times/day-night
Pain: usually suprapubic but may involve perineum
Increased pain with bladder filling, postponed
urination, physical exertion, suprapubic pressure,
certain foods, emotional distress
Decreased pain with voiding (temporary)
Often misdiagnosed as chronic or recurring UTI or
chronic prostatitis; diagnosis of exclusion
Remissions and exacerbations
Interstitial Cystitis (IC)/
Painful Bladder Syndrome (PBS) Treatment
Treatments
Nutrition and drug therapies
* Reduce intake of bladder irritants
* Calcium glycerophosphate—reduces irritation
Stress management strategies
Tricyclic antidepressants, analgesics, antihistamines
Physical therapy and bladder hypodistention
Botox; cyclosporine A
Surgery—with debilitating pain
Glomerulonephritis
Inflammation of the glomeruli
Also see tubular and interstitial changes, vascular
scarring and hardening (glomerulosclerosis);
affects both kidneys
3rd leading cause of ESRD in United States
Associated conditions: kidney infections,
nephrotoxic drugs, immune disorders, systemic
diseases
Acute: sudden symptoms; temporary or reversible
Chronic: slow, progressive; irreversible renal
failure
Acute Poststreptococcal Glomerulonephritis
Common type of acute glomerulonephritis
Common in children, young adults, and adults
more than 60 years old
Develops 1 to 2 weeks after an infection of
tonsils, pharynx, or skin by nephrotoxic strains of
group A -hemolytic streptococci; form antibodies
to streptococcal antigen
Exact mechanism unknown
Clinical Manifestations
Generalized edema, hypertension, oliguria, hematuria,
varying degrees of proteinuria, fluid retention
Periorbital edema first then progresses to total body
including ascites and peripheral edema
Smoky urine—bleeding in upper urinary tract
Proteinuria—varies with glomerulonephropathy
HTN—increased ECF volume
Abdominal or flank pain
May be asymptomatic; found on routine urinalysis
Diagnosis
H & P
Antistreptolysin-O (ASO) titers
Decreased complement components
Renal biopsy—confirmation
Dipstick urinalysis and urine sediment microscopy
* Erythrocytes/casts
* Protein
BUN and serum creatinine—renal impairment
95% recover completely or improve with
conservative treatment; important to recognize
or can progress to chronic glomerulonephritis
Management—symptom relief
Rest—decreased inflammation and HTN
Restrict Na+ & fluids/ administer diuretics—
decreased edema
Restrict protein—decreased BUN
Antibiotics—if streptococcal infection present
Prevention
Early diagnosis and treatment of sore throats and skin
lesions
Positive streptococci culture—antibiotics
* Patient teaching: take entire prescription
Personal hygiene with skin infections
Chronic Glomerulonephritis
Syndrome of permanent and progressive renal
fibrosis can progress to ESRD
No history of kidney disease
Alport syndrome—inherited
Symptoms develop slowly; unaware
Found coincidentally with abnormal UA, increased
BP, or increased serum creatinine
Decreased renal function causes ESRD (over
several years)
Manifestations
Hematuria, proteinuria, urinary excretion of formed
elements (RBCs, WBCs, casts)
Increased BUN and creatinine
Diagnosis
H&P, exposure to drugs (NSAIDs), microbial infections,
and viral infections
Evaluate for immune disorders
Ultrasound and CT scan; renal biopsy
Treatment: depends on cause
Symptomatic and supportive care
Anti-glomerular Basement
Membrane Disease
Formerly called Goodpasture syndrome
Autoimmune disease—antibodies attack glomerular
and basement membranes
Kidney and lung damage from antibody binding
causes inflammatory reaction and complement
activation
Rare disease; occurs age 30’s to 60’s
Clinical manifestations
Flu-like and pulmonary symptoms
Renal involvement
Management
Corticosteroids
Immunosuppressive drugs
Plasmapheresis
Rituximab
Dialysis
Renal transplant
Nursing
Smoking cessation
Critical care: as for AKI and respiratory distress
Maybe fatal from hemorrhage and respiratory failur
Rapidly Progressive
Glomerulonephritis
Glomerular disease with glomerular crescent formations; loss of renal function in days to months
3 types
* Anti-GBM disease
* Due to immune complex disease
* Due to pauci-immune disease
Manifestations
* HTN, edema, proteinuria, hematuria, RBC casts
Treatments: correct fluid overload, HTN, uremia, and injury to kidney
* Corticosteroids, cyclophosphamide, plasmapheresis
* Dialysis and transplant
Nephrotic Syndrome
Glomerulus permeable to plasma protein causing
proteinuria leading to low albumin and edema
Etiology and clinical manifestations
Minimal change disease most common cause in children
1/3 of adults have systemic disease
Peripheral edema, massive proteinuria, HTN,
hyperlipidemia, hypoalbuminemia, foamy urine
* Decreased albumin; ascites and anasarca when severe
hypoalbuminemia is present
* Immune response altered results in infection
* Hypocalcemia and skeletal abnormalities
* Hypercoagulability
Treatment depends on cause
Goals - cure or control primary disease and relieve
symptoms
* Corticosteroids and cyclophosphamide
* Manage diabetes
* ACE inhibitor, ARB, diuretics
* Antihyperlipidemic drugs
* Anticoagulants
* Low-sodium, moderate protein diet; small, frequent meals
Nursing - manage edema; provide support
* Daily weights, accurate I & O, measure abdomen/extremities
* Avoid infection
Obstructive Uropathies
Urinary obstruction—anatomic or functional
condition that blocks or impedes the flow of urine
Congenital or acquired
Damage occurs above level of obstruction
* Severity depends on location, duration, amount of
pressure or dilation, presence of urinary stasis or
infection
* May affect only one kidney and the other kidney may
compensate
Bladder neck or prostate
Detrusor muscle hypertrophy
Eventual large, residual urine
Bladder outlet
Increased pressure with filling or storage
Vesicoureteral reflux, hydroureter, and
hydronephrosis
Chronic pyelonephritis and renal atrophy
Partial obstruction of ureter or ureteropelvic junction
(UPJ)
Low to moderate pressure—kidney dilates without
noticeable loss of functions
Urinary stasis and reflux—increases risk of pyelonephritis
Both kidneys or only 1 functioning kidney involved—
changes in renal function occur and BUN and creatinine
increase
Progressive obstruction can lead to renal failure
Treatment—find and relieve blockage
Insertion of tube, surgery, or urinary diversion
Urinary Tract Calculi
Nephrolithasis—kidney stone disease
In United States 13% of men and 7% women
Middle-aged; risk increases with age
More frequent in:
* Whites than blacks, Hispanics, and Asians
* Those with family history
* Southeast United States; followed by Southwest, and
Midwest
* Summer (hot climate and dehydration)
* Uric acid stones in Jewish men
Risk factors for kidney stones
Metabolic
Climate
Diet
Genetic
Lifestyle
Concentration of supersaturated crystals precipitate
and form stone
Reduce risk by keeping urine dilute and free flowing
Stone formation—influencing factors
Urinary pH
* Higher pH—calcium and phosphate less soluble
* Lower pH—uric acid and cysteine less soluble
Solute load
Inhibitors in urine
Obstruction with urinary stasis
Infection with urea-splitting bacteria (struvite)
Infected stones—staghorn configuration
* Renal infection, hydronephrosis, loss of kidney function
Types of Urinary Stones
Five categories of stones
Calcium oxalate
Calcium phosphate
Cystine
Struvite
Uric acid
Calcium stones—most common
* May be mixed and in various locations
Urinary Stones Clinical Manifestations
First symptom—sudden, severe pain (renal colic)
Flank area, back, or lower abdomen
Ureter stretches, dilates, and spasms
May see nausea and vomiting; “kidney stone dance;”
dysuria, fever, chills; moist, cool skin
Common sites of obstruction
Ureteropelvic junction (UPJ)
* Dull costovertebral flank pain or renal colic
Ureterovesical junction (UVJ)
* Lower abdominal pain; testicular or labial pain
How to Diagnose
Noncontrast helical (spiral) CT scan
Ultrasound
Urinalysis
24-hour urine
Retrieval and analysis of stones—important to
determine problem contributing to stone
formation
Urinary Stone Management
2 concurrent approaches:
1. Manage acute attack
* Pain, infection, and/or obstruction
Opioids, NSAIDS, -adrenergic blockers
2. Evaluate cause of stone formation and prevent further development
* Family history; geographic residence; nutrition assessment; fluid intake; vitamins A, C, and D; activity pattern
* History of prolonged illness, GI or GU disease or surgery, previous stones, prescribed and OTC meds, diet supplements
Treatment and patient teaching
Adequate hydration
Sodium restriction
Diet changes
Drugs
* Alter pH of urine, prevent excess urinary secretion of a
substance, or correct primary disease
Struvite stones: antibiotics and acetohydroxamic acid;
surgery
Stones of 4 mm or less may pass spontaneously (may
take weeks)
Endourologic, lithotripsy, or open surgical stone removal may be considered if stones
Are too large (more than 7 mm) to pass spontaneously
Are associated with bacteriuria or symptomatic infection
Impair renal function
Cause persistent pain, nausea, or paralytic ileus
Or if:
The patient can’t be treated medically or only has one
kidney
Endourologic Procedures
Cystoscopy—remove stone in bladder
Cystolitholapaxy—large stones broken up with
lithotrite (stone crusher)
Cystoscopic lithotripsy—ultrasonic waves break
stones
Complications of above procedures:
Hemorrhage, retained stone fragments, and infection
Ultrasonic, laser or electrohydraulic lithotripsy—used to
break stones during:
Flexible ureteroscopes—remove stones from renal pelvis and upper urinary tract
Percutaneous nephrolithotomy—nephroscope inserted through skin into pelvis of kidney; stone fragmented and removed, followed by irrigation. May place nephrostomy tube.
* Complications: bleeding, injury to adjacent structures, and infection
Lithotripsy
Procedure to eliminate stones from urinary tract:
Laser lithotripsy
Extracorporeal shock-wave lithotripsy (ESWL)
Percutaneous ultrasonic lithotripsy
Electrohydraulic lithotripsy
* Ureteral stent placed to facilitate passage of sand;
removed in 2 weeks
* Postprocedure: hematuria; prophylactic antibiotics
Encourage fluids to dilute urine and reduce pain
* Complications (rare): hemorrhage, infection,
obstruction
Surgical Therapy for Stone Removal
Primary indications for surgery:
Pain, infection, and obstruction
Type of surgery depends on location of stone
Nephrolithotomy—kidney
Pyelolithotomy—renal pelvis
Ureterolithotomy—ureter
Cystotomy—bladder
Postop complication: hemorrhage
Nutrition Therapy for Stones
Obstructing stone
Adequate fluids to avoid dehydration
* Forcing fluids not recommended; increased pain
After urolithiasis
High intake (~3 L/day) to produce 2.5 L urine/day
Water is best!
Prevents supersaturation of minerals
Reduce risk of dehydration
Limit colas, coffee, and tea—increased stone formation
Low-sodium diet
Diet restrictions according to type of stone
* Purine, calcium, oxalate
Prevention of recurrence
Lifestyle changes
Diet changes
* Adequate fluid intake (3 L/day) if no CV or renal
compromise; produce 2.5 L urine/day; increase if
very active
* Diet restrictions
Immobile/bed rest patients
Medications; patient teaching
Ureteral Strictures
Can affect entire length of ureter from UPJ to UVJ and
alter kidney function
Causes: congenital, adhesions or scar formation, or large tumor in peritoneal cavity
Clinical Manifestations: mild to moderate colic, flank pain, and CVAT
Treatments:
* Bypass with stent or nephrostomy tube placement; balloon or catheter dilation
* Surgery: endoureterotomy, ureteroureterostomy, or
ureteroneocystostomy
Fibrosis or inflammation of urethral lumen leads
to narrowing and compromised opening and
closing with bladder filling and voiding
Causes: trauma, urethritis, surgical intervention
or repeated catheterizations, congenital defect,
idiopathic
Manifestations
Straining to void
Urine stream: diminished, sprayed, or split
Postvoid dribbling
Incomplete bladder emptying, frequency, and nocturia
Severe obstruction—urinary retention
Diagnostic studies
Retrograde urethrography (RUG), ultrasound
urethrography, cystourethrogram, and VCUG
Treatment
Dilation with metal instruments or stents of increasing size; stenosis may occur
Self-catheterization every few days
Endoscopic or surgical procedure
* Urethroplasty
* Resection and re-anastomosis or urethra
Renal Trauma
Blunt—most common
Causes: abdominal, flank, or back injury; sports
injuries, MVAs, and falls
Penetrating—violence (e.g., gunshot, stabbing)
Clinical manifestation: Hematuria
Diagnostic studies: urinalysis, ultrasound, CT,
MRI, renal arteriogram
Treatments—depend on severity
Bed rest, fluids, analgesia
Exploratory surgery and repair
Nephrectomy
Nursing care
Assess CV status; monitor for shock
Adequate intake; monitor I & O
Pain management
Monitor for hematuria and myoglobinuria
Nephrosclerosis
Sclerosis of small arteries and arterioles of the
kidney causes reduced blood flow, ischemia,
interstitial fibrosis, and necrosis
Benign nephrosclerosis—age-related (more than 60
years old) changes due to HTN and atherosclerosis
Accelerated (malignant) nephrosclerosis—medical
emergency due to severe HTN
SBP greater than or equal to 180 mm Hg and/or DBP
greater than or equal to 120 mm Hg
Treatment: antihypertensive drugs
Renal Artery Stenosis
Partial occlusion of one or both renal arteries and major
branches
Causes: atherosclerosis or fibromuscular hyperplasia
Manifestations: sudden HTN
* Ages less than 30 and more than 50 years
Diagnostic studies: renal duplex Doppler ultrasound, CT or MRI angiography, and renal arteriogram
Treatment goals
Control BP and restore renal perfusion
Treatments
Percutaneous transluminal renal angioplasty
Surgical revascularization
Nephrectomy (if one kidney involved
Renal Vein Thrombosis
May be unilateral or bilateral
Causes: trauma, extrinsic compression, renal cell
cancer, pregnancy, contraceptive use, and nephrotic
syndrome
Manifestations: flank pain, hematuria, or nephrotic
syndrome
Treatments
Anticoagulation
Corticosteroids
Surgical thrombectomy
Hereditary Kidney Disease
Developmental abnormalities of renal
parenchyma
Cystic in nature
Rule out other causes and tumors
Polycystic Kidney Disease (PKD)
One of the most common life-threatening genetic
diseases in the world
In United States 600,000 people
Fourth leading cause of ESRD
Genetic link: 2 hereditary forms
Adult—autosomal dominant (90% of cases)
Child—autosomal recessive
Adult PKD
Affects both kidneys in men and women
Cortex and medulla filled with thin-walled cysts that
destroy surrounding tissue by compression
Cysts are filled with fluid; may have blood or pus
Signs and symptoms develop at 30 to 40 years of age
Clinical manifestations (initial): HTN; hematuria; pain
or heavy feeling in back, side or abdomen; UTI or
urinary stones; may be asymptomatic
Most common problem: chronic, severe pain
Kidneys are enlarged; may be palpable
Affects other structures: liver, heart, blood vessels, intestines,
and brain
Diagnostic studies: ultrasound or CT scan
Also consider: clinical findings and family history
Treatment: no cure
Prevent or treat UTI
Nephrectomy
Dialysis and kidney transplant
Nursing: management for ESRD; genetic counseling
Medullary Cystic Disease
Hereditary disorder of older adults
Kidneys with cysts in medulla are asymmetric and
scarred; unable to concentrate urine
Clinical manifestations: polyuria, HTN, progressive
renal failure, severe anemia, and metabolic acidosis
Treatment: as with ESRD
Genetic counseling
Alport Syndrome
Chronic hereditary nephritis
Males earlier and more severe than females
Gene mutation for collagen resulting in altered synthesis of glomerular basement membrane
3 genetic types
Sex-linked (most common)
* See: hematuria, progressive hearing loss, and deformities in lens
Autosomal recessive—hematuria
Autosomal dominant—hematuria
Treatment: management of ESRD is kidney transplant
Kidney Cancer
In United States 63,340 new cases/year; 14,970
die
Renal cell carcinoma (adenocarcinoma)—most
common (Fig. 50.8 in the textbook)
Males more than females; average age 64 years
old
Risk factors: cigarette smoking, ACKD, obesity,
HTN, exposure to asbestos, cadmium, and
gasoline
Increased incidence—First-degree relatives
Early stage: asymptomatic; often incidental finding for
unrelated condition
25% have metastasis when diagnosed
* Renal vein, vena cava, lungs, liver, and long bones
Common manifestations: hematuria, flank pain, palpable mass in flank or abdomen
Other: weight loss, fever, HTN, anemia
Diagnostic Studies: CT scan, ultrasound, angiography,
biopsy, MRI; radionuclide isotope scan
Bladder Cancer
Most common urinary system cancer
81,900 new cases/year; 17,240 deaths/year
Older adults more than 55 = 90% cases
Men more than women; whites > blacks or Hispanics
Transitional cell cancer—most frequent
Most are papillomatous growths
Risk factors: cigarette smoking
Other: industrial exposure to dyes; cervical cancer treated with radiation or chemotherapy; prolonged indwelling catheters, chronic, recurrent urinary tract stones, and chronic UTIs
Clinical Manifestations/Studies
Most common manifestation: microscopic or gross,
painless hematuria
Other: dysuria, frequency, and urgency
Diagnostic studies
Urine specimens for cancer or atypical cells, and
bladder tumor antigens
CT scan, ultrasound, or MRI
Cystoscopy and biopsy—confirm cancer
Cancer is graded and staged (I to V) before
treatment; most diagnosed early
Staging determined by depth of invasion of bladder
and surrounding tissue
Treatments include:
Surgery
Radiation
Chemotherapy
Intravesical therapy
Surgical Therapy for Bladder Cancer
Transurethral resection of the bladder tumor
(TURBT)—superficial lesions removed with
cystoscope
Fulguration (burns base of the tumor) or high energy
laser (kills cancer cells)
Used to control bleeding in high risk patients or with
advanced tumors
Disadvantage: re-occurrence, scarring, or inability to
hold urine (repeated TURBTs
Segmental (partial) cystectomy—remove large
tumors in 1 area of bladder wall and margin of
normal tissue
Radical cystectomy—invasive tumors or trigone
area but no metastasis beyond pelvic area; must
have urinary diversion
Men—bladder, prostate, and seminal vesicles
Women—bladder, uterus, cervix, urethra, anterior
vagina, and ovaries
Post Op Care
Postoperative care
Drink large volume of fluid for 1 week
Patient teaching:
Monitor color and consistency of urine
Pink for several days; not bright red or with clots
May have dark red or rust-colored flecks for 7 to 10
days
Opioid analgesics and stool softeners; coping; and
follow-up care (regular cystoscopies)
Intravesical Therapy
Local instillation of immunotherapy or chemotherapy
by urethral catheter
Retained for 2 hours; change position every 15
minutes
Weekly intervals for 6 to 12 weeks
Induction and maintenance therapy
Post procedure: irritative voiding and hemorrhagic
cystitis—increased fluids
Urinary Incontinence
Involuntary leakage of urine
More prevalent with older adults (women more than
men) but not a natural consequence of aging
Gender differences
* Men—common with BPH or prostate cancer; overflow
incontinence from urinary retention
* Women—stress and urge incontinence
UI Etiology and Pathophysiology
Bladder pressure greater than urethral closure
pressure
Interference with bladder or sphincter control
DRIP
D: delirium, dehydration, depression
R: restricted mobility, rectal impaction
I: infection, inflammation, impaction
P: polyuria, polypharmacy
Types of Urinary Incontinence
Stress
Urge
**Combined stress + urge = mixed incontinence
Overflow
Reflex
Incontinence after trauma or surgery
Functional incontinence
May have more than 1 type
UI Interprofessional Care
Many can be cured or improved
Treat transient, reversible factors first
Interventions depend on type
Individualized to patient preference, type and severity,
and anatomic defects
* Lifestyle modifications
* Scheduled voiding regimens
* Pelvic floor muscle rehabilitation
* Antiincontinence devices
* Containment devices
Drug therapy
Surgical therapy
-Depends of type of UI
* Urinary structural support/repositioning
* Increased urethral resistance of internal sphincter and
intraabdominal pressure reception
* Retropubic colposuspension and pubovaginal sling
* Suburethral sling
* Bulking agent injection
* Artificial sphincter surgery
Urinary Retention
Inability to empty bladder with voiding or the accumulation of urine because of inability to void
May be associated with leakage or post void dribbling—overflow UI
Acute urinary retention—inability to pass urine; medical emergency
Chronic urinary retention—incomplete emptying despite urination
Post void residual (PVR)—normal 50 to 75 mL
* More than 100 mL—repeat or further evaluation with UTIs
* More than 200 mL—further evaluation
UR Etiology and Pathophysiology
Bladder outlet obstruction—bladder can’t empty
due to severe blockage
Men—enlarged prostate
Deficient detrusor contraction—muscle can’t
contract with enough force or time to empty
bladder
Neurologic diseases involving sacral 2, 3, and 4;
diabetes; overdistention; chronic alcohol use; and
anticholinergic drugs
Diagnoses/Care for UR
Diagnostic studies (Same as UI)
Urinalysis, post void residual, urodynamic studies,
ultrasound
Interprofessional care
Behavioral therapies (as with UI)
Scheduled toileting and double voiding
Catheterization: intermittent or indwelling
Drug therapy
UR Surgical Therapy
Surgical therapy—obstruction
Transurethral or open techniques for:
* Prostate enlargement or cancer
* Bladder neck contracture
* Urethral strictures
* Dyssynergia of bladder neck
Abdominal or transvaginal approach for:
* Pelvic organ prolapse
Surgical therapy—deficient detrusor contraction
* Sacral neuromodulation
* Intraurethral valve pump
Acute Urinary Retention
Acute urinary retention—emergency
Insert catheter —consider indwelling
Patient teaching to minimize risk:
* Drink small amounts throughout the day
* Be warm when trying to void
* Avoid excess alcohol
Patient teaching if unable to void:
* Drink caffeinated coffee or tea to increase urgency
* Warm bath/shower
* Seek medical care
Chronic Urinary Retention
Chronic urinary retention
Behavioral methods
* Scheduled toileting; every 3 to 4 hours
Catheterization
Surgery
Drugs
Indwelling Catheter Indications
Indications for indwelling
Relief of urinary retention
Bladder decompression preop or postop
Facilitate surgery
Facilitate healing
Accurate I & O—critical care
Stage III or IV pressure ulcer
Terminal illness—comfort
Intermittent Catheter Indications
Indications for intermittent
Relief of urinary retention
Diagnostic study
Urodynamic testing
Sterile specimen
Medication instillation
Measure PVR
Unacceptable Catheter Reasons
Unacceptable reasons for catheterization
Routine urine specimen
Convenience for nurse or patient’s family
Complications of long-term use (more than 30 days)
CAUTI—most common HAI
Other: bladder spasms, periurethral abscess, chronic
pyelonephritis, urosepsis, urethral trauma or erosion,
fistula or stricture formation, and stones
Complications of long-term use (more than 30 days)
CAUTI—most common HAI
Other: bladder spasms, periurethral abscess, chronic
pyelonephritis, urosepsis, urethral trauma or erosion,
fistula or stricture formation, and stones
