Module 7: Renal and Urologic Problems

Question 1

Urinary Tract Infections (UTIs)

Answer 1

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

Question 2

UTI Etiology and Pathophysiology

Answer 2

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

Question 3

Clinical Manifestations - Lower UTIs

Answer 3

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

Question 4

Clinical Manifestation.- Upper UTIs

Answer 4

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

Question 5

UTI Diagnostic Studies

Answer 5

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

Question 6

UTI Drugs

Answer 6

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

Question 7

Acute Pyelonephritis

Answer 7

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

Question 8

Acute Pyelonephritis Diagnostic Studies

Answer 8

Urinalysis: pyuria, bacteriuria, hematuria; WBC
casts
 Urine cultures and sensitivities
 Blood cultures
 Decreased kidney function tests
 Ultrasound
 CT scan—preferred imaging study

Question 9

Acute Pyelonephritis Care

Answer 9

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

Question 10

Chronic Pyelonephritis

Answer 10

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)

Question 11

Urethritis

Answer 11

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

Question 12

Urethral Diverticula

Answer 12

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

Question 13

Interstitial Cystitis (IC)/
Painful Bladder Syndrome (PBS)

Answer 13

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

Question 14

Interstitial Cystitis (IC)/
Painful Bladder Syndrome (PBS) Treatment

Answer 14

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

Question 15

Glomerulonephritis

Answer 15

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

Question 16

Acute Poststreptococcal Glomerulonephritis

Answer 16

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

Question 17

Chronic Glomerulonephritis

Answer 17

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

Question 18

Anti-glomerular Basement
Membrane Disease

Answer 18

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

Question 19

Rapidly Progressive
Glomerulonephritis

Answer 19

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

Question 20

Nephrotic Syndrome

Answer 20

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

Question 21

Obstructive Uropathies

Answer 21

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

Question 22

Urinary Tract Calculi

Answer 22

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

Question 23

Types of Urinary Stones

Answer 23

Five categories of stones
 Calcium oxalate
 Calcium phosphate
 Cystine
 Struvite
 Uric acid

Calcium stones—most common
* May be mixed and in various locations

Question 24

Urinary Stones Clinical Manifestations

Answer 24

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

Question 25

Urinary Stone Management

Answer 25

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

Question 26

Endourologic Procedures

Answer 26

 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

Question 27

Lithotripsy

Answer 27

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

Question 28

Surgical Therapy for Stone Removal

Answer 28

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

Question 29

Nutrition Therapy for Stones

Answer 29

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

Question 30

Ureteral Strictures

Answer 30

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

Question 31

Renal Trauma

Answer 31

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

Question 32

Nephrosclerosis

Answer 32

 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

Question 33

Renal Artery Stenosis

Answer 33

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

Question 34

Renal Vein Thrombosis

Answer 34

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

Question 35

Hereditary Kidney Disease

Answer 35

Developmental abnormalities of renal
parenchyma
 Cystic in nature
 Rule out other causes and tumors

Question 36

Polycystic Kidney Disease (PKD)

Answer 36

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

Question 37

Medullary Cystic Disease

Answer 37

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

Question 38

Alport Syndrome

Answer 38

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

Question 39

Kidney Cancer

Answer 39

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

Question 40

Bladder Cancer

Answer 40

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

Question 41

Surgical Therapy for Bladder Cancer

Answer 41

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)

Question 42

Intravesical Therapy

Answer 42

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

Question 43

Urinary Incontinence

Answer 43

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

Question 44

UI Etiology and Pathophysiology

Answer 44

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

Question 45

Types of Urinary Incontinence

Answer 45

 Stress
 Urge
**Combined stress + urge = mixed incontinence
 Overflow
 Reflex
 Incontinence after trauma or surgery
 Functional incontinence
 May have more than 1 type

Question 46

UI Interprofessional Care

Answer 46

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

Question 47

Urinary Retention

Answer 47

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

Question 48

UR Etiology and Pathophysiology

Answer 48

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

Question 49

Diagnoses/Care for UR

Answer 49

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

Question 50

UR Surgical Therapy

Answer 50

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

Question 51

Acute Urinary Retention

Answer 51

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

Question 52

Chronic Urinary Retention

Answer 52

Chronic urinary retention
 Behavioral methods
* Scheduled toileting; every 3 to 4 hours
 Catheterization
 Surgery
 Drugs

Question 53

Indwelling Catheter Indications

Answer 53

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

Question 54

Intermittent Catheter Indications

Answer 54

Indications for intermittent
 Relief of urinary retention
 Diagnostic study
 Urodynamic testing
 Sterile specimen
 Medication instillation
 Measure PVR

Question 55

Unacceptable Catheter Reasons

Answer 55

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