Management of Patients

With Urinary Disorders

Dr. Lubna Dwerij
INFECTIONS OF THE URINARY TRACT
 Urinary tract infections (UTIs) are caused by pathogenic
microorganisms in the urinary tract (the normal urinary
tract is sterile above the urethra).
 Lower UTIs include:
 Bacterial cystitis (inflammation of the urinary bladder).
 Bacterial prostatitis (inflammation of the prostate gland).
 Bacterial urethritis (inflammation of the urethra).
 There can be acute or chronic nonbacterial causes of
inflammation in any of these areas that can be
misdiagnosed as bacterial infections.
INFECTIONS OF THE URINARY TRACT
 Upper UTIs are much less common and include acute or
chronic pyelonephritis (inflammation of the renal pelvis),
interstitial nephritis (inflammation of the kidney), and
renal abscesses.
 Depending on whether the UTI is recurrent and the
duration of the infection; Upper and lower UTIs are
further classified as uncomplicated or complicated.
INFECTIONS OF THE URINARY TRACT
 Most uncomplicated UTIs are community acquired.
 Complicated UTIs usually occur in people with urologic
abnormalities or recent catheterization and are often
acquired during hospitalization.
 A UTI is the second most common infection in the body,
most cases occur in women.
 The urinary tract is the most common site of nosocomial
infection.
 In most of these hospital-acquired UTIs, instrumentation
of the urinary tract or catheterization is the precipitating
cause.
Pathophysiology
 Several mechanisms maintain the sterility of the bladder
(urine flow) Abnormalities or dysfunctions of these
mechanisms are contributing risk factors for lower UTIs.
 For infection to occur, bacteria must gain access to the
bladder, attach to and colonize the epithelium of the
urinary tract, and initiate inflammation.
 Many UTIs result from fecal organisms ascending from the
perineum to the urethra and the bladder and then
adhering to the mucosal surfaces.
Pathophysiology
 Bacterial Invasion of the Urinary Tract
 Reflux
 An obstruction to free-flowing urine is a
condition known as urethrovesical reflux, which
is the reflux (backward flow) of urine from the
urethra into the bladder.
 With coughing, sneezing, or straining, the
bladder pressure increases, which may force
urine from the bladder into the urethra. When
the pressure returns to normal, the urine flows
back into the bladder, bringing into the bladder
bacteria from the anterior portions of the
urethra.
Pathophysiology
 Reflux
 Urethrovesical reflux is also caused by
dysfunction of the bladder neck or urethra.
 Ureterovesical or vesicoureteral reflux refers
to the backward flow of urine from the bladder
into one or both ureters.
 Normally, the ureterovesical junction prevents
urine from traveling back into the ureter.
 When the ureterovesical valve is impaired by
congenital causes or ureteral abnormalities,
the bacteria may reach the kidneys and
eventually destroy them.
Pathophysiology
 Uropathogenic Bacteria
 Bacteriuria is generally defined as more than 105 colonies
of bacteria per milliliter of urine.
 Bacterial count exceeding 105 colonies/mL of clean-catch
midstream urine is the measure that distinguishes true
bacteriuria from contamination in female.
 In men, contamination of the collected urine sample
occurs less frequently; hence, bacteriuria is defined as
104 colonies/mL urine.
 The organisms most frequently responsible for UTIs are
those normally found in the lower gastrointestinal (GI)
tract, usually E. coli.
Pathophysiology
 Routes of Infection
 Bacteria enter the urinary tract in three ways:
 By the transurethral route (ascending infection).
 Through the bloodstream (hematogenous spread).
 By means of a fistula from the intestine (direct extension).
 The most common route of infection is transurethral, in
which bacteria (often from fecal contamination) colonize
the periurethral area and subsequently enter the bladder by
means of the urethra.
 In women, the short urethra offers little resistance to the
movement of uropathogenic bacteria.
Clinical Manifestations
 A variety of signs and symptoms are associated with UTI.
 About half of all patients with bacteriuria have no
symptoms.
 Signs and symptoms of an uncomplicated lower UTI
(cystitis) include:
 Burning on urination.
 Frequency (voiding more than every 3 hours).
 Urgency, nocturia (awakening at night to urinate),
incontinence, and suprapubic or pelvic pain.
 Hematuria and back pain may also be present. In older
people, these symptoms are less common
Clinical Manifestations

 In patients with complicated UTIs, manifestations can

range from asymptomatic bacteriuria to gram-negative
sepsis with shock.
 Complicated UTIs often are caused by a broader spectrum
of organisms, have a lower response rate to treatment,
and tend to recur.
 Many patients with catheter-associated UTIs are
asymptomatic; however, any patient with a catheter who
suddenly develops signs and symptoms of septic shock
should be evaluated for urosepsis (sepsis resulting from
infected urine).
Assessment and Diagnostic Findings
 Results of various tests, such as bacterial colony counts,
cellular studies, and urine cultures, help confirm the
diagnosis of UTI.
 In an uncomplicated UTI, the strain of bacteria determines
the antibiotic of choice.
Assessment and Diagnostic Findings
 Urine Cultures
 Urine cultures are useful for documenting a UTI and
identifying the specific organism present.
 UTI is diagnosed by bacteria in the urine culture. A colony
count of at least 10ˆ5 colony-forming units (CFU) per
milliliter of urine on a clean-catch midstream or
catheterized specimen is a major criterion for infection.
 However, UTI and subsequent sepsis have occurred with
lower bacterial colony counts.
Assessment and Diagnostic Findings
 The following groups of patients should have urine cultures
obtained when bacteriuria is present:
 All men (because of the likelihood of structural or
functional abnormalities).
 All children
 Women with a history of compromised immune function or
renal problems.
 Patients with diabetes mellitus
 Patients who have been recently hospitalized or who live in
long-term care facilities.
Assessment and Diagnostic Findings
 Patients with prolonged or persistent symptoms
 Patients with three or more UTIs in the previous year
 Pregnant women.
 Postmenopausal women
Assessment and Diagnostic Findings
 Cellular Studies
 Microscopic hematuria is present in about half of patients
with an acute UTI.
 Pyuria (greater than 4 white blood cells [WBCs] per high-
power field) occurs in all patients with UTI; however, it is
not specific for bacterial infection.
 Pyuria can also be seen with kidney stones, interstitial
nephritis, and renal tuberculosis.
Assessment and Diagnostic Findings
 Other Studies
 A multiple-test dipstick often includes testing for WBCs,
known as the leukocyte esterase test, and nitrite testing.
 Diagnostic studies such as computed tomography (CT) and
ultrasonography are useful diagnostic tools.
 A CT scan may detect pyelonephritis or abscesses, and
ultrasonography is extremely sensitive for detecting
obstruction, abscesses, tumors, and cysts.
Medical Management
 Management of UTIs typically involves pharmacologic
therapy and patient education.
 The nurse teaches the patient about prescribed
medication regimens and infection prevention measures.
 Acute Pharmacologic Therapy
 The ideal medication for treatment of UTI is an
antibacterial agent that eradicates bacteria from the
urinary tract with minimal effects on fecal and vaginal
flora, thereby minimizing the incidence of vaginal yeast
infections.
Medical Management
 Acute Pharmacologic Therapy
 Various treatment regimens have been successful in
treating uncomplicated lower UTIs in women: single- dose
administration, short-course (3 to 4 days) regimens, or 7-
to 10-day regimens.
 The trend is toward a shortened course of antibiotic
therapy for uncomplicated UTIs, because most cases are
cured after 3 days of treatment.
 Regardless of the regimen prescribed, the patient is
instructed to take all the doses prescribed, even if relief
of symptoms occurs promptly.
Medical Management
 Long-Term Pharmacologic Therapy
 Although brief pharmacologic treatment of UTIs for 3 days
is usually adequate in women, infection recurs in about
20% of women treated for uncomplicated UTIs.
 Relapses suggest that:
 The source of bacteriuria may be the upper urinary tract
 Initial treatment was inadequate or administered for too
short a time.
 Reinfection with new bacteria is the reason for more than
90% of recurrent UTIs in women.
Medical Management
 Long-Term Pharmacologic Therapy
 If infection recurs after completing antimicrobial therapy,
another short course (3 to 4 days) of full-dose
antimicrobial therapy followed by a regular bedtime dose
of an antimicrobial agent may be prescribed.
 If there is no recurrence, medication is taken every other
night for 6 to 7 months.
 Long-term use of antimicrobial agents decreases the risk
of reinfection and may be indicated in patients with
recurrent infections.
Assignment
 Discuss the nursing process for PATIENT WITH A LOWER URINARY
TRACT INFECTION (Page. 1363- 1364)
 Assessment
 Diagnosis
 Planning and goals
 Nursing interventions
 Evaluation
 PATIENT EDUCATION Preventing Recurrent Urinary Tract Infections
(CHART 45-4)
Upper Urinary Tract Infections
 Pyelonephritis is a bacterial infection of the renal pelvis,
tubules, and interstitial tissue of one or both kidneys.
 Causes involve either the upward spread of bacteria from
the bladder or spread from systemic sources reaching the
kidney via the bloodstream.
 An incompetent ureterovesical valve or obstruction
occurring in the urinary tract increases the susceptibility of
the kidneys to infection, because static urine provides a
good medium for bacterial growth.
Upper Urinary Tract Infections
 Bladder tumors, strictures, benign prostatic hyperplasia,
and urinary stones are some potential causes of
obstruction that can lead to infections.
 Systemic infections (such as tuberculosis) can spread to
the kidneys and result in abscesses.
 Pyelonephritis may be acute or chronic.
ACUTE PYELONEPHRITIS
 Clinical Manifestations
 The patient with acute pyelonephritis is acutely ill with
chills, fever, leukocytosis, bacteriuria, and pyuria.
 Low back pain, flank pain, nausea and vomiting,
headache, malaise, and painful urination are common
findings.
 Physical examination reveals pain and tenderness in the
area of the costovertebral angle.
 In addition, symptoms of lower urinary tract involvement,
such as urgency and frequency, are common.
ACUTE PYELONEPHRITIS

 Assessment and Diagnostic Findings

 An ultrasound study or a CT scan may be performed to
locate any obstruction in the urinary tract. Relief of
obstruction is essential to prevent the complications and
eventual kidney damage.
 Urine culture and sensitivity tests are performed to
determine the causative organism so that appropriate
antimicrobial agents can be prescribed.
ACUTE PYELONEPHRITIS
 Medical Management
 Patients with acute uncomplicated pyelonephritis are
most often treated on an outpatient basis if they are not
exhibiting dehydration, nausea or vomiting, or symptoms
of sepsis.
 For outpatients a 2-week course of antibiotics is
recommended because renal parenchymal disease is more
difficult to eradicate than mucosal bladder infections.
 Commonly prescribed agents include some of the same
medications prescribed for the treatment of UTIs.
ACUTE PYELONEPHRITIS
 A follow-up urine culture is obtained 2 weeks after
completion of antibiotic therapy to document clearing of
the infection.
 Hydration with oral or parenteral fluids is essential in all
patients with UTIs when there is adequate kidney
function.
 Hydration helps facilitate “flushing” of the urinary tract
and reduces pain and discomfort.
CHRONIC PYELONEPHRITIS
 Repeated bouts of acute pyelonephritis may lead to
chronic pyelonephritis.
 Clinical Manifestations
 Noticeable signs and symptoms may include fatigue,
headache, poor appetite, polyuria, excessive thirst, and
weight loss.
 Persistent and recurring infection may produce progressive
scarring of the kidney, resulting in renal failure.
Assessment and Diagnostic Findings
 The extent of the disease is assessed by an IV urogram and
measurements of creatinine clearance, blood urea
nitrogen, and creatinine levels.
 Bacteria, if detected in the urine, are eradicated if
possible.
 Complications of chronic pyelonephritis include
 End-stage renal disease.
 Hypertension.
 Formation of kidney stones (from chronic infection with
urea-splitting organisms).
Medical Management
 Medical Management
 Long-term use of prophylactic antimicrobial therapy may
help limit recurrence of infections and renal scarring.
 Impaired renal function alters the excretion of
antimicrobial agents and necessitates careful monitoring
of renal function, especially if the medications are
potentially toxic to the kidneys.
Nursing Management
 The patient may require hospitalization or may be treated
as an outpatient.
 When the patient requires hospitalization, fluid intake and
output are carefully measured and recorded. Unless
contraindicated, 3 to 4 L of fluids per day is encouraged to
dilute the urine, decrease burning on urination, and prevent
dehydration.
 The nurse assesses the patient’s temperature every 4 hours
and administers antipyretic and antibiotic agents as
prescribed.
Nursing Management
 Symptomatic patients are often more comfortable on bed
rest.
 Patient teaching focuses on prevention of further infection
by:
 Consuming adequate fluids.
 Emptying the bladder regularly.
 Performing recommended perineal hygiene.
 The importance of taking antimicrobial medications
exactly as prescribed is stressed, as is the need for
keeping follow-up appointments.
ADULT VOIDING DYSFUNCTION
 Both neurogenic and non-neurogenic disorders can cause
adult voiding dysfunction.
 The micturition (voiding or urination) process involves
several highly coordinated neurologic responses that
mediate bladder function.
 A functional urinary system allows for appropriate bladder
filling and complete bladder emptying.
 If voiding dysfunction goes undetected and untreated, the
upper urinary system may be compromised.
Urinary Incontinence
 Involuntary loss of urine from the bladder
 Although urinary incontinence is commonly regarded as a
condition that occurs in older multiparous women, it can
occur in young nulliparous women, especially during
vigorous high-impact activity.
 Age, gender, and number of vaginal deliveries are
established risk factors that explain, in part, the increased
incidence in women.
Urinary Incontinence
 Types of Urinary Incontinence
 Stress incontinence is the involuntary loss of urine
through an intact urethra as a result of sneezing,
coughing, or changing position.
 It predominantly affects women who have had vaginal
deliveries and is thought to be the result of decreasing
ligament and pelvic floor support of the urethra and
decreasing or absent estrogen levels
 Urge incontinence is the involuntary loss of urine
associated with a strong urge to void that cannot be
suppressed.
Urinary Incontinence
 An uninhibited detrusor contraction is the precipitating
factor. This can occur in a patient with neurologic
dysfunction that impairs inhibition of bladder contraction
or in a patient without overt neurologic dysfunction.
 Functional incontinence refers to those instances in
which lower urinary tract function is intact but other
factors, such as severe cognitive impairment (eg,
Alzheimer’s dementia), make it difficult for the patient
to identify the need to void or physical impairments
make it difficult or impossible for the patient to reach
the toilet in time for voiding
Urinary Incontinence
 Iatrogenic incontinence refers to the involuntary loss of
urine due to extrinsic medical factors, predominantly
medications.
 One such example is the use of alpha-adrenergic agents.
In some people with an intact urinary system, these
agents adversely affect the alpha receptors responsible
for bladder neck closing pressure; the bladder neck
relaxes to the point of incontinence.
 As soon as the medication is discontinued, the apparent
incontinence resolves.
Urinary Incontinence
 Mixed urinary incontinence, which encompasses several
types of urinary incontinence, is involuntary leakage
associated with urgency and also with exertion, effort,
sneezing, or coughing.
Assessment and Diagnostic Findings
 Once incontinence is recognized, a thorough history is
necessary. This includes a detailed description of the problem
and a history of medication use.
 The patient’s voiding history, a diary of fluid intake and
output, and bedside tests (eg, residual urine, stress
maneuvers) may be used to help determine the type of urinary
incontinence involved.
 Urinalysis and urine culture are performed to identify
infection.
 Urinary incontinence may be transient or reversible if the
underlying cause is successfully treated and the voiding
pattern reverts to normal.
Medical Management
 Management depends on the type of urinary incontinence
and its causes.
 Management of urinary incontinence may be behavioral,
pharmacologic, or surgical.
 Behavioral Therapy
 Behavioral therapies are the first choice to decrease or
eliminate urinary incontinence
 In using these techniques, health care professionals help
patients avoid potential adverse effects of pharmacologic
or surgical interventions.
Medical Management
 Behavioral Therapy
 Pelvic floor muscle exercises (sometimes called Kegel
exercises) represent the cornerstone of behavioral
intervention for addressing symptoms of stress, urge, and
mixed incontinence.
 Other behavioral treatments include:
 Fluid Management
 Standardized Voiding Frequency
 use of a voiding diary
Medical Management

 Pharmacologic Therapy
 Pharmacologic therapy works best when used as an
adjunct to behavioral interventions.
 Anticholinergic agents inhibit bladder contraction and are
considered first-line medications for urge incontinence.
 Several tricyclic antidepressant medications can also
decrease bladder contractions as well as increase bladder
neck resistance.
Medical Management
 Pharmacologic Therapy
 Hormone therapy (eg, estrogen) taken orally,
transdermally, or topically was once the treatment of
choice for urinary incontinence in postmenopausal
women because it restores the mucosal, vascular, and
muscular integrity of the urethra.
Medical Management
 Surgical Management
 Surgical correction may be indicated in patients who have
not achieved continence using behavioral and
pharmacologic therapy.
 Most procedures involve lifting and stabilizing the bladder
or urethra to restore the normal urethrovesical angle or to
lengthen the urethra.
Nursing Management
 For behavioral therapy to be effective, the nurse must
provide support and encouragement, because it is easy for
the patient to become discouraged if therapy does not
quickly improve the level of continence.
 Patient teaching is important and should be provided
verbally and in writing
Nursing Management
UROLITHIASIS AND NEPHROLITHIASIS
 Urolithiasis and nephrolithiasis refer to stones (calculi) in
the urinary tract and kidney, respectively.
 The occurrence of urinary stones occurs predominantly in
the third to fifth decades of life and affects men more
than women.
 About half of patients with a single renal stone have
another episode within 5 years.
Pathophysiology
 Stones are formed in the urinary tract when urinary
concentrations of substances such as calcium oxalate,
calcium phosphate, and uric acid increase.
 Stones may be found anywhere from the kidney to the
bladder and may vary in size from minute granular
deposits, called sand or gravel, to bladder stones as
large as an orange.
 Stone formation is not clearly understood, and there
are a number of theories about their causes.
 One theory is that there is a deficiency of substances
that normally prevent crystallization in the urine, such
as citrate, magnesium, and uropontin
Pathophysiology
 Another theory relates to fluid volume status of the
patient (stones tend to occur more often in dehydrated
patients).
 Certain factors favor the formation of stones, including
infection, urinary stasis, and periods of immobility, all of
which slow renal drainage and alter calcium metabolism.
 In addition, increased calcium concentrations in the blood
and urine promote precipitation of calcium and formation
of stones.
Pathophysiology
 Causes of hypercalcemia (high serum calcium) and
hypercalciuria (high urine calcium) may include the
following:
 Hyperparathyroidism
 Renal tubular acidosis
 Cancers
 Granulomatous diseases
 Excessive intake of milk and alkali
 Myeloproliferative diseases (leukemia, polycythemia vera,
multiple myeloma)
Pathophysiology
 Urinary stone formation can occur in patients with
inflammatory bowel disease and in those with an
ileostomy or bowel resection because these patients
absorb more oxalate.
 Medications known to cause stones in some patients
include antacids, acetazolamide (Diamox), vitamin D,
laxatives, and high doses of aspirin.
 However, in many patients, no cause may be found.
Clinical Manifestations
 Signs and symptoms of stones in the urinary system
depend on the presence of obstruction, infection, and
edema.
 Some stones cause few, if any, symptoms while slowly
destroying the functional units (nephrons) of the kidney;
others cause excruciating pain and discomfort.
 Stones in the renal pelvis may be associated with an
intense, deep ache in the costovertebral region.
 Hematuria is often present; pyuria may also be noted.
Clinical Manifestations
 If the pain suddenly becomes acute, with tenderness over
the costovertebral area, and nausea and vomiting appear,
the patient is having an episode of renal colic.
 Diarrhea and abdominal discomfort may occur.
 These GI symptoms are due to renointestinal reflexes and
the anatomic proximity of the kidneys to the stomach,
pancreas, and large intestine
Clinical Manifestations
 Stones lodged in the ureter (ureteral obstruction) cause
acute, excruciating, colicky, wavelike pain, radiating down
the thigh and to the genitalia.
 Often, the patient has a desire to void, but little urine is
passed, and it usually contains blood because of the abrasive
action of the stone.
 This group of symptoms is called ureteral colic.
 In general, the patient spontaneously passes stones 0.5 to 1
cm in diameter.
Clinical Manifestations
 Stones lodged in the bladder usually produce symptoms of
irritation and may be associated with UTI and hematuria.
 If the stone obstructs the bladder neck, urinary retention
occurs.
 If infection is associated with a stone, the condition is far
more serious, with urosepsis threatening the patient’s life.
Assessment and Diagnostic Findings
 The diagnosis is confirmed by x-rays of the kidneys,
ureters, and bladder (KUB) or by ultrasonography, IV
urography, or retrograde pyelography.
 Blood chemistries and a 24-hour urine test for
measurement of calcium, uric acid, creatinine, sodium,
pH, and total volume are part of the diagnostic workup.
 Dietary and medication histories and family history of
renal stones are obtained to identify factors predisposing
the patient to the formation of stones.
Assessment and Diagnostic Findings
 Stone analysis can provide a clear indication of the
underlying disorder.
 For example, calcium oxalate or calcium phosphate stones
usually indicate disorders of oxalate or calcium
metabolism, whereas urate stones suggest a disturbance
in uric acid metabolism.
Medical Management
 The goals of management are to:
 Eradicate the stone.
 Determine the stone type.
 Prevent nephron destruction.
 Control infection.
 Relieve any obstruction that may be present.
 The immediate objective of treatment of renal or ureteral
colic is to relieve the pain until its cause can be
eliminated.
Medical Management
 Opioid analgesic agents are administered to prevent shock
and syncope that may result from the excruciating pain.
 Nonsteroidal anti-inflammatory drugs (NSAIDs) are
effective in treating renal stone pain.
 Generally once the stone has passed, the pain is relieved.
 Unless the patient is vomiting or has heart failure or any
other condition requiring fluid restriction, fluids are
encouraged.
 A high, around-the-clock fluid intake reduces the
concentration of urinary crystalloids, dilutes the urine,
and ensures a high urine output.
Medical Management
 Nutritional Therapy
 Nutritional therapy plays an important role in preventing
renal stones.
 Fluid intake is the mainstay of most medical therapy for
renal stones.
 Calcium Stones
 Historically, patients with calcium-based renal stones
were advised to restrict calcium in their diet.
 Liberal fluid intake is encouraged along with dietary
restriction of protein and sodium; however, dietary
changes cannot be recommended with confidence because
of insufficient evidence.
Medical Management
 Uric Acid Stones
 For uric acid stones, the patient is placed on a low-purine
diet to reduce the excretion of uric acid in the urine.
 Foods high in purine (shellfish, anchovies, asparagus,
mushrooms, and organ meats) are avoided, and other
proteins may be limited.
 Allopurinol (Zyloprim) may be prescribed to reduce serum
uric acid levels and urinary uric acid excretion.
 Cystine Stones
 A low-protein diet is prescribed, the urine is alkalinized,
and fluid intake is increased.
Medical Management
 Oxalate Stones
 A dilute urine is maintained and the intake of oxalate is
limited.
 Many foods contain oxalate; however, only certain foods
increase the urinary excretion of oxalate.
 These include spinach, strawberries, chocolate, tea,
peanuts, and wheat bran.
Medical Management
 Interventional Procedures
 If the stone does not pass spontaneously or if
complications occur, common interventions include
endoscopic or other procedures.
 For example, ureteroscopy, extracorporeal shock wave
lithotripsy (ESWL), or endourologic (percutaneous) stone
removal may be necessary.
Medical Management

 During a cystoscopy, which is used for removing small

stones located in the ureter close to the bladder, a
ureteroscope is inserted into the ureter to visualize the
stone. The stone is then fragmented or captured and
removed
Medical Management
 Extracorporeal shock water lithotripsy (ESWL) is used for
most symptomatic, non passable upper urinary stones.
Electromagnetically generated shock waves are focused
over the area of the renal stone. The high-energy dry
shock waves pass through the skin and fragment the stone.
Medical Management

 Percutaneous nephrolithotomy is used to treat larger

stones. A percutaneous tract is formed and a nephroscope
is inserted through it. Then the stone is extracted or
pulverized.
Assignment
 Discuses the nursing process for PATIENT WITH KIDNEY STONES
(page. 1379- 1380)
 Assessment
 Diagnosis
 Planning
 Intervention
 Evaluation
Discus Behavioral Interventions for Urinary Incontinence (chart 45-8,
page 1369)
Reference
 Hinkle, J. L., & Cheever, K. H. (2014). Brunner & Suddarth's textbook of
medical-surgical nursing (Edition 13.). Wolters Kluwer Health/Lippincott
Williams & Wilkins.