The Genitourinary System

The Genitourinary System

• The kidneys and urinary system form the renal system.
• The kidneys and urinary systems are responsible for urine elimination.
• This function is critical for life and maintains homeostasis and fluid & electrolyte regulation.
• The system acts as a drainage route for urine excretion.

Importance of the Genitourinary System

• It helps manage human metabolism, toxin excretion, volume status, hormone homeostasis, and sexual and reproductive function.
• Dysfunction can cause urinary tract infections (UTIs), urinary retention (inability to void), kidney damage or failure, and reproductive health issues.
• System issues can lead to waste and toxin buildup in the blood, fluid and electrolyte imbalance, and cardiovascular problems, potentially kidney disease and failure.
• If urinary retention persists or the bladder isn't emptying completely, a straight catheter may be necessary. The catheter is removed immediately after urine flow is achieved.

Kidney Function

• Kidneys are bean-shaped and brown.
• Kidneys filter 20-25% of total cardiac output, which means total blood volume passes through kidneys about 12 times per hour (1200mL/min).
• These organs maintain body fluid balance through the glomerular Filtration Rate (GFR).
• A GFR should be above 60 for patients over 60 and is controlled by blood pressure and flow, which the kidneys regulate through constriction and dilation.
• Urine eliminates waste and toxins; the kidneys filter out harmful particles while reabsorbing appropriate fluid volumes through glomerular filtration, tubular reabsorption, and secretion.
• Kidneys adjust blood pressure by producing and releasing hormones like renin and prostaglandins.
• Renin release increases systemic blood pressure and fluid volume through angiotensin II and aldosterone.
• The system regulates acid-base balance mostly through excreting potassium and hydrogen in urine.
• Erythropoietin production occurs within the kidneys.
• Vitamin D is absorbed in the skin and activated by the kidneys, which is necessary for calcium absorption.

Organ Functions

• Kidneys help eliminate urine.
• The ureters are the tunnels that urine flows through from kidney to bladder.
• The bladder stores urine.
• The urethra is the channel through which urine travels from bladder to the toilet.

Changes with Aging

• kidneys decrease in size and weight; around 70 years old, glomeruli lose 50% of their function.
• Reduced blood volume and flow leads to decreased GFR, and older adults' ability to regulate water balance declines as they age.
• Changes in hormone levels can decrease urine concentration and change electrolyte excretion.
• Older adults should still maintain homeostasis.
• Loss of elasticity and muscle support can lead to decreased continence and increased UTIs, notably among women.
• Prostate enlargement in older men increases the risk for stream interruption which comes with hesitancy, retention, slow stream, and bladder infections.
• Constipation can affect urination.
• Normal aging processes with physiological changes can impact older adults, by increasing vulnerability to illness, a reduced functional reserve, and a high risk of chronic diseases, affecting nutrition, medication absorption, mobility, and overall safety.
• Alterations to kidney function is a significant concern. Changes or dysfunctions are common and treatable.

Assessment of the Urinary System

• Consider patient history and risk factors.
• Determine if patients are experiencing elimination problems, and review medication history.
• Ask about reproductive problems and menstruation.
• Smoking majorly increases the risk for kidney and bladder cancer.
• Exposures to chemicals and toxins can worsen the impact of smoking.
• Some countries have higher exposure rates to parasites, which increases disease risk.
• Non-localized abdominal pain is couples with confusion can lead to UTI suspicions.
• Appetite changes, weight changes, fluid intake, and energy level can indicate renal problems.
• Hypertension, diabetes, chronic disease, or traumas can damage the kidneys.
• Urinary dysfunction, BPH, kidney stones, cancer, UTIs, or bladder infections should be noted.
• Visible painless hematuria is a common bladder cancer symptom.
• Assess the patient's ability to urinate and to hold urine.
• Many meds are nephrotoxic and can damage kidney. Knowing side effects and labs is important for patients.
• Assessment questions about menstruation, discharge, and habits can be helpful in understanding the renal system.
• The patient history should include possible kidney disease, kidney stones, urologic problems (bladder, testicular, cancer, etc.), recent UTIs, BPH, hypertension, diabetes, gout, lupus, hepatitis, HIV, neurological conditions, stroke.

Family History

• Many illnesses associated with kidney and bladder problems have a genetic link.
• Patients at higher risk should have family history of a type of GU problem include kidney stones, cancer, and polycystic kidney disease.

Medication History

• Note types of prescriptions, OTC meds, herbal supplements, or essential oils.
• Note if medications are nephrotoxic.
• Medications can change urine like diuretics that alter quantity, quality, concentration, and electrolytes
• Pyridium can change the color of the urine to orange.
• Macrodantin (nitrofurantoin) changes color of urine to dark yellow or brown; anticoagulants cause hematuria.
• Antidepressants, CCBs, antihistamines, and Musculoskeletal disorder medications can affect bladder and sphincter function.
• Antibiotics like cephalosporins cause nephrotoxin.
• Antihypertensive Captopril and stomach acid inhibitor Cimetidine are medications that can cause nephrotoxicity.
• Cisplatin (for testicular cancer) and methotrexate are chemo drugs to watch out for.
• Cocaine, cyclosporine, heroin, lithium, NSAIDs, quinine, rifampin, and salicylates can cause issues.

Reproductive Disorder Questions

• Ask about types of discharge.
• For females: age menstruation started, pain experienced during menses, regularity and length of period.
• Menopause? Use of birth control? Date and results of the last Pap smear? All can be significant for kidney and urinary assessment.

History of Present Illness

• Consider health management, nutrition, metabolism, eliminations, activity and exercise, sleep and rest, cognition and perception, , self perception, role and relationship, sexuality and reproduction, coping, and values.
• Ask about general health and energy level.
• Changes in weight, appetite, thirst, fluid retention, headache, pruritus, blurred vision, and fatigue can indicate issues.
• Abdominal pain, disorientation, falls, or confusion can indicate UTI.
• Smoking is a risk factor for bladder and kidney cancer.
• Chemical exposure can increase cancer risk.
• Higher mineral content in water and in soil can lead to incidents from urinary stones (southeast US) or parasites in the middle east and Africa, may lead to cancer and infections.
• ask if patients have a smoking history or exposure to secondhand smoke; ask about painless hematuria.

Nutritional and Metabolic Health

• Types and quantities of fluid intake are important.
• Dehydration can cause UTI, stone formation, and kidney failure.
• Dairy and high-protein foods can contribute to stones.
• Asparagus and beets change the smell or color of urine.
• Caffeine, alcohol, carbonated beverages, some artificial sweeteners and spicy foods can affect urinary health.
• Some herbal teas can cause diuresis.
• Weight gain can lead to fluid retention, and altered fluid status can be caused by anorexia, nausea, or vomiting.
• Low protein diets help manage kidney disease by limiting specific nutrients.

Elimination History

• Evaluate the patient's ability to manage urination, typical habits, and factors that change due to alteration.
• Inability to sit through a 2-hour car ride or meeting is an example of alteration and may cause further life impacts.
• Normal urinary habits include how frequently an individual urinates during the day or night.
• More than one instance to be urinating at night can be a underlying condition.
• Pelvic organ prolapse can result in added pressure, frequency, and incontinence through urinary retention, and can also increase infection.
• One must note if there are changes in urine color.
• Evaluate the involuntary passing of urine which may be caused by stress or urge based incontinence.
• Bowel function can cause neurological issues or bladder incontinence.
• Constipation/impaction can cause pressure and obstruction and can impede full bladder emptying.
• Check signs of UTI like burning during urination, odorous urine, and sudden urination frequency.

Active Lifestyle

• Sedentary lifestyles lead to stasis and bone problems, which can lead to kidney stones.
• Active people may face worsened strain on their bladder like unintentional leaking during running.
• Nocturia is waking up to pass urine. It is linked to problems such as urinary incontinence, urinary retention, interstitial cystitis, polyuria (kidney disease), poorly controlled diabetes, alcohol use, intake of excess fluid.
• Determine if the patient experience pain and what level of fluid is ingested before bed.

Self-Perception

• Be careful and concerned with the embarrassing subject for patients. Assess mobility, visual acuity, and self-care ability.
• Pain assessment must be completed during evaluation. In the absence of pain for patients is a red flag as cancers are painless during early states.
• Ask details pertaining to how your urinary problem makes you feel. Problems can affect the relationship with friends or family. The issue could be caused by a change in one's work.
• Sexual satisfaction and concerns may be altered the more stress related.

Physical Assessment

• Inspect for pallor, yellow skin, changes in turgor, bruising, dry skin, stomatitis, and ammonia odors.
• Check extremities for edema, abdominal symmetry, and weight changes.
• Check general state of health looking for fatigue, lethargy, and consciousness.
• Kidneys are near the last rib and near the spinal column. Palpate for the kidneys and anatomical landmarks
• Percussion and palpation may not be as honest but be knowledgeable if you can assess.
• Lower back is assessed for pain in the flanks. Bladder evaluation should be soft and not be painful unless full.
• Auscultate for bowel sounds to influence urinary system.

Diagnostic Studies

• UA may point to abnormalities for additional studies with GU tract disorders.
• BUN/Creatinine measures kidney function and kidneys capacity to clear and secrete.
• GFR Rate is ideal at >60 rate for filtration. If high there will be dysfunction. Electrolytes can be excreted through urine.
• 3.5 -5.0 mmol is normal for potassium, less than 3.5 is hypokalemia, more than 5.0 can be hyperkalemia (greater than 6.5 is not safe.)
• The UA may show a lot of abnormalities.
• A normal level of WBC's in the system is 0-5 hpf, 5-10 hpf indicates pyuria and 20-26 can result to inflammation causing kidney failure
• Allergies for shellfish will impact what actions can be taken, because of the use of iodine
• Iodine could be harmful to the kidneys if contrast media would be used
• What can be done for a patient? Hydration can increase kidney clearance.
• Visualize inside of bladder removing stone, taking a biopsy
• Tumors can be detected, using contrast can always use iodine.
• KUB can show size and foreign bodies.
• Evaluate the kidney with blood to see if this is the right tissue.