Renal and Urologic Problems Flashcards
Urinary tract infection
Bacterial count of > 105 CFU/mL
- 102 to 103 CFU/mL can also be indicative of UTI if present with signs and symptoms
The most common pathogen – Escherichia coli (E. coli )
- also, by fungal and parasites – uncommon
Classification of uti
Upper: renal parenchyma, renal pelvis,
ureters (more risks)
Lower: bladder, urethra
Specific terms are used to delineate location of UTI or inflammation:
Pyelonephritis
Cystitis
Urethritis
Manifestations of UTI
Pain, burning, urgency, pressure in bladder area (pubic area)
Cloudy, blood in urine
In kidneys: flank pain, chills, fever,
Older adults: delirium
Dx of UTI
Nitrates, protein, leukocytes esterase – enzyme produced by WBC
Management of UTI
Health promotion (preventative)
- What instructions will you give to prevent a UTI?
Do not hold pee
Wipe front to back
Adequate amount of fluids (cranberry juice)
Avoid caffeine, alcohol, high spice foods
ion (preventative)
- full course of abx
- short term 1-3 days
- longer term 7-14 days
Patho of acute pyelonephritis
Inflammation of renal parenchyma & collecting system
Bacterial infection (most common cause)
Begins with infection of lower urinary tract
Often presence of pre-existing factor:
- vesico-ureteral reflux, or
- dysfunction of lower urinary tract infection e.g., BPH
Manifestations of acute pyelonephritis
- hematuria
- flank pain
- chills
- sick and nauseous
- tenderness of affected side (costovertebral)
Tx of Acute Pyelonephritis
- abx for 14-24 days (IV)
- NSAIDS, antipyretics
- hospitalization
- urinary analgesics
- follow up culture
Chronic Pyelonephritis
Shrunken kidney whose function is lost d/t scarring or fibrosis
Outcome of recurring infection in upper urinary tract
aka – interstitial nephritis, chronic atrophic pyelonephritis, or reflux nephropathy
Loss of functioning nephrons
Level of renal function varies depending or 1 or both kidneys are involved
Often progresses to end-stage renal disease
Urethritis
Inflammation of urethra from bacterial or viral infection
♂ = usually from sexual transmission
- Purulent discharge ⇨ gonococcal urethritis
- Clear discharge ⇨ non-gonococcal urethritis
♀ = difficult to diagnose as urethral discharge may not be present
Treatment based on identifying & treating the cause and obtaining symptomatic relief
Interstitial cystitis
A chronic, painful inflammatory disease of the bladder
Believed to be associated with autoimmune or allergic response
Ratio of women ♀ to men ♂ = 10 -12:1
2 primary clinical manifestations 1. pain 2. lower urinary tract symptoms
Diagnosis is by exclusion:
Cystitis suspected when pt experiences symptoms of a UTI despite absence of bacteriuria, pyuria, or a positive urine culture
Careful history and physical examination required
Because etiology is unknown, no single treatment
Care for Interstitial cystitis
Dietary and lifestyle alterations
- To relieve pain and ↓ voiding frequency and nocturia
- Eat low acidic foods, avoid coffee, tea, carbonated & alcoholic drinks
- OTC supplement, calcium glycerophosphate, can provide relief from
irritating effects of certain foods
Assessment focuses on characterization of the pain associated with IC
Data collection – voiding diary kept over a period of at least 3 days to
determine voiding frequency & patterns of nocturia
Glomerulo-nephritis
An immune-related inflammation of the glomeruli characterized by proteinuria, hematuria, ↓ urine production, and edema
Condition affects both kidneys equally
Tubular, interstitial, and vascular changes also occur
Glomerulo-nephritis is divided into a number of classifications which may describe:
- Extent of damage (diffuse or focal)
- Initial cause of disorder, e.g., systemic lupus erythematosus, systemic sclerosis, streptococcal infection, or
- Extent of changes (minimal or widespread)
Manifestations of Glomerulo-nephritis
Varying degrees of hematuria (microscopic to gross)
Urinary excretion of RBCs, WBCs, and casts
Proteinuria, ↑BUN, ↑creatinine
Usually, recovery from the acute illness is complete
If progressive ⇨ destruction of renal tissue and marked renal insufficiency
Acute Poststreptococcal Glomerulo-nephritis
Most common in children & young adults but all age groups can be affected
Occurs after 5-21 days of an infection of pharynx or the skin (strep sore throat, impetigo) by nephrotoxic strains of group β-hemolytic streptococci
Causes inflammation in glomeruli
Manifestations of Acute Poststreptococcal Glomerulo-nephritis
Generalized body edema (result of ↓ glomerular filtration)
Hypertension (from ↑extracellular vol.)
Oliguria
Smoky urine – indicative of bleeding in upper urinary tract
Proteinuria
Care of Acute Poststreptococcal Glomerulo-nephritis
Focus is on symptomatic relief
Rest until signs of glomerular inflammation (proteinuria, hematuria) and hypertension subside
Restrict Na+ and fluid intake & admin diuretics
May need to restrict dietary protein if evidence of ↑BUN
Treatment with Abx only if strep infection is still present
Goodpasture’s syndrome
Uncommon autoimmune disease that affects both the kidneys & lungs
Characterized by pulmonary alveolar hemorrhage and glomerulonephritis
Characterized by presence of antibodies circulating against glomerular and alveolar basement membrane – currently the term used is “anti-GBM antibody disease”
Hemoptysis, cough, dyspnea, pallor, crackles and wheezes, hepatomegaly, edema
Pulmonary hemorrhage
Chronic glomeruo-nephritis
Reflects the end stage of glomerular inflammatory disease
Characterized by proteinuria, hematuria, slow development of uremic syndrome (build up of waste products in the blood due ti inability for kidneys to excrete waste products)
does not usually follow an acute course; progresses insidiously toward renal failure over a few to 30 years
Nephrotic syndrome
The combination of nephrotic-range proteinuria with a low serum albumin level and edema
- nephrotic-range proteinuria = loss of > 3 gms protein/day in urine
Is a clinical course that can be associated with a number of diseases
Approx. 1/3 pts with nephrotic syndrome will have systematic diseases such as diabetes or systemic lupus erythematosus.
Clinical manifestations nephrotic syndrome
Peripheral edema
Massive proteinuria (↑ glomerular membrane permeability)
Dyslipidemia (↓ serum proteins stim hepatic lipoprotein synthesis)
- ↑ Cholesterol and low-density lipoproteins
Altered immune responses
- As a result, infection is a cause of morbidity & mortality
With nephrotic proteinuria → loss of clotting factors can result in hypercoagulation state
Hypercoagulability with thrombo-embolism = most serious complication of nephrotic syndrome
Management of nephrotic syndrome
Focus is symptomatic relief
Relieve edema
cure or control primary disease
Low Na+, low to moderate protein
Restriction of salt
Lipid lowering agents
Steroids in severe cases of nephrotic syndrome
Kidney cancer
Most common type ⇨ adenocarcinoma (renal cell carcinoma), which occurs
2x as often in men
The most significant risk factor for dev adenocarcinoma ⇨ cigarette smoking
Treatment of choice ⇨ radical nephrectomy (RN)
Radical RN is the surgical removal of the kidney. Adrenal gland, surrounding fascia, part of ureter, and lymph nodes
Manifestations of kidney cancer
gross hematuria
flank pain
palpable mass
Weight loss, weakness, anemia – earliest manifestations
2 types of nephrectomy
Radical nephrectomy
Partial nephrectomy
Kidney-sparing (nephron-sparing) surgery
Only removes diseased tissue from a kidney
Types of nephrectomy procedure
Laparoscopic surgery
Robot-assisted laparoscopic surgery
Open surgery
Radical nephrectomy indication
Indication:
Presence of multifocal renal masses in one kidney, and
normal contralateral kidney
Laparoscopic nephrectomy
First case on human: in1990
Candidates:
- People with a small & non-malignant kidney
Not for people who are overweight
Performed under general anesthetic
Kidney is dissected laparoscopically in the peritoneal cavity and placed in an impermeable bag.
The kidney is morcellated within the bag, which is removed via a mini incision
Post op care of nephrectomy
VS
ABCelectrolytes
Hemorrhage (highly vascular drainage) – lab values (Hgb), wound dressing, drainage output
Pain
DB and Coughing
Accurate I and O q1H – foley, nephrostomy
Complications of nephrectomy
Hemorrhage
Pneumothorax
Chest infection
Wound infection
UTI
DVT
Urinary Tract Calculi
aka kidney stone, nephrolithiasis, or urolithiasis
Hard deposits made of minerals and salts that form inside kidneys
Majority ⇨ between 20-55 years of age
Incidence higher with a family hx
Patho of urinary tract calculi
1) Often, stones form when the urine becomes concentrated, allowing minerals to crystallize and stick together.
- Crystals, when in a supersaturated concentration, can precipitate and form a stone
- Can occur at any place within the urinary tract
- Keeping urine dilute & free flowing reduces risk for recurrent formation
2) Obstruction with urinary stasis & urinary infection with bacteria
- Bacteria cause the urine to become alkaline and facilitates formation of stones
- Infected stones, when entrapped in the kidney, may assume a staghorn configuration as they enlarge
Types of urinary tract calculi
Calculus: abnormal stone formed in body tissues by accumulation of mineral salts
Lithiasis: refers to stone formation
Nephrolithiasis: formation of stones in the urinary tract
5 major categories of stones
Calcium phosphate*
Calcium oxalate*
Uric acid
Cystine
Struvite (magnesium-ammonium phosphate)
Clinical manifestations of urinary tract calculi
Pain (childbirth pain)
Pain in urine
Spasms
N and V
Care of urinary tract calculi
1) Management of acute attack
Generally, with opioids at frequent intervals
Many stones pass spontaneously but stones > 4 mm are unlikely to pass through the ureter
2) Evaluation of cause & prevention
e.g., Family hx of stone formation
Adequate hydration, Na+ restriction, dietary changes, meds to minimize urine formation
Sx of urinary tract calculi
Indications for surgery (lithotripsy, open-surgical stone removal):
Stones too large for spontaneous passage
Stones associated with infection
Stones causing impaired renal function
Persistent pain, nausea, or ileus
Inability to treat pt medically
Pt with one kidney
Cystoscopy
to remove a small stone in the bladder
Cystolitholapaxy
a procedure for large stones
Lithotrite
‘stone crusher’: an instrument to break up large stones
Endo-urological Procedure
Percutaneous nephrolithotomy
- Insertion of nephoscope through a percutaneous sinus track into the kidney pelvis
- Stones are fragmented using ultrasound, electrohydraulic, or laser lithotripsy
- Stones are removed using grasping forceps, and pelvis irrigated
- Usually a nephrostomy tube is left in place to maintain patency of ureter
- Done under x-ray vision, under general anesthetic
Lithotripsy
Use of sound waves to break renal stones into small particles that can pass down ureter
Done under X-ray or ultrasound
Different techniques:
Extracorporeal shock-wave lithotripsy
Laser lithotripsy
Percutaneous ultrasonic lithotripsy
Electrohydraulic lithotripsy
Open sx is most common
Extracorporeal shock-wave lithotripsy
‘First generation’ lithotripsy
Non-invasive, under spinal or general anesthesia
Pt placed in a water bath
Repeated shock waves administered to break up stone
Shock waves are generated by a machine, lithotripter, and focused by x-ray onto the kidneystones.
Shock wave travel into the body through skin, reaching the stone
Urinary Tract Calculi Post-lithotripsy care
Hematuria
- Common after lithotripsy
- Often, ureteral stent is placed after procedure to promote passage of fragmented stones (removed in 1-2 wks)
Pain
- As stone fragments pass down ureter
- Analgesia
Risk of infection
- Prophylactic Abx may be given as most stones are infected, and shattering can spread infection
Elimination
- Drink 2-3 L in 24hrs (unless in restriction) to flush out stone fragments
Activity
- Resume normal activity
Bladder Cancer
growth within the bladder
Bladder cancer manifestations
Gross, painless hematuria (chronic or intermittent)
Dysuria
Urinary frequency & urgency
Tx of bladder cancer
When the tumor is invasive or it involves the trigone (the area where the ureters insert into the bladder), and
Free from metastasis beyond pelvic area,
Treatment of choice:
A partial or radical cystectomy with urinary diversion
Partial cystectomy
resection of that portion of the bladder wall containing the tumor
Radical cystectomy
♂ ⇒ removal of the bladder, prostate, seminal vesicles
♀ ⇒ uterus, cervix, urethra, and ovaries
Cystectomy involves urinary diversion
Urinary diversion
Performed to treat cancer of the bladder, neurogenic bladder, congenital anomalies, strictures, trauma to the bladder, and chronic infections with deterioration of renal function
2 types of urinary diversion
1) Incontinent urinary diversion
- Ileal conduit (ileal loop)
2) Continent urinary diversion
a) Continent cutaneous reservoir
Intra-abdominal urinary reservoir that is catheterizable or has an outlet controlled by anal sphincter
b)Neobladder
Incontinent urinary diversion
Ileal conduit (ileal loop)
A 15- to 20 cm segment of the ileum is converted into a conduit for urinary drainage.
Ureters are anastomosed into one end of the conduit, and the other end of the bowel is brought out through the abdominal wall toform a stoma.
Continent urinary diversion
Reservoirs are constructed from ileum, ileocecal segment, or colon
The patient needs to self-catheterizeq4 – 6 hrs
Does not need to wear external attachments
Neobladder (aka bladder substitute)
Creation of a reservoir made of small intestine and connects it to urethra which allows urination through urethra.
Reservoir mimics the normal storage function of a urinary bladder
Reservoir inside the pelvis
Post-op care of urinary diversion
NPO
NG for 3-5 days
Mucous in urine
Paralytic ileus and obstruction possible
Stoma (red and moist)
