Exam 18 - Disorders for the Urinary System

Urinary System Disorders

• Urinary Retention: Inability to urinate despite the urge to void, can be acute or chronic.
  • Etiology/Pathophysiology: Full bladder unable to empty, leading to urinary stasis (risk of infection). Overflow incontinence occurs when bladder capacity is exceeded.
  • Acute: Inability to urinate despite a full bladder.
  • Chronic: Urge to void but inability to empty the bladder completely.
  • Causes: Obstructions, infections (UTIs, pyelonephritis), medications (Norpace, antihistamines, antispasmodics/anticholinergics like oxybutynin, tricyclic antidepressants like imipramine and amitriptyline), spinal cord injuries, strokes, post-operative complications, childbirth, or trauma.
  • Clinical Manifestations: Distended bladder palpable over the symphysis pubis, lower abdominal discomfort, anxiety, frequency, burning, urgency, nocturia, acute discomfort, voiding frequently with small amounts, episodes of incontinence, restlessness, and irritability (in diminished sensorium patients).
  • Assessment: Subjective (frequency, burning, urgency, nocturia, acute discomfort); Objective (palpable bladder, small amounts of urine voided frequently, episodes of incontinence).
  • Medical Management: Urinalysis, serum BUN, prostate-specific antigen (PSA), renal, bladder, and pelvic ultrasonography, CT of abdomen and pelvis, urinary catheters, surgical release of obstructions, urinary analgesics, and antispasmodics.
  • Nursing Interventions: Assist with return to normal voiding patterns (private, relaxed environment, bladder training, warm showers/sitz baths, warm beverages, proper voiding positioning), residual volume checks (<50mL), patient/caregiver education on recognizing and reporting symptoms.

Urinary Incontinence

• Urinary Incontinence: Involuntary urine loss from the bladder.
  • Etiology/Pathophysiology: Complete or partial incontinence, stress incontinence (leakage with coughing, sneezing), complications of other conditions (UTI, loss of sphincter control, sudden abdominal pressure changes), permanent (spinal cord injury, trauma), or temporary (pregnancy).
  • Risk Factors: Obesity, chronic lung disease, smoking, pelvic floor injury/surgery, physiologic conditions.
  • Types:
    • Stress Incontinence: Pressure or stress on the bladder sphincter (coughing, sneezing, laughing). Weakened pelvic floor muscles in women, estrogen loss during menopause.
    • Urge Incontinence: Strong urgency to void, CNS disorders (Parkinson's, Alzheimer's).
    • Overflow Incontinence: Repeated inability to completely empty the bladder, leading to unexpected leakage. Neurologic abnormalities that impair detrusor muscle contraction, or obstructions.
    • Mixed Incontinence: Combination of stress and urge incontinence.
    • Functional Incontinence: Inability to reach the toilet in time to urinate due to mental or physical impairments.
  • Clinical Manifestations/Assessment: Involuntary urine loss, subjective (factors related to incontinence, voiding patterns, behaviors), objective (difficulty controlling urine flow), gender differences (women: leakage with cough, sneezing, lifting, intercourse; men: associated with benign prostatic hypertrophy (BPH)).
  • Medical Management: Surgical repair (bladder neck), nerve stimulator, pessary (devices), self-catheterization, closed system drainage , artificial sphincter (for stress incontinence), behavior modification, pelvic floor exercises (Kegels), medications (oxybutynin (Ditropan), tolterodine (Detrol/Detrol LA), Botulinum toxin type A (Botox), estrogen), mechanical devices, surgical procedures (transvaginal tape sling).
  • Nursing Interventions: Establish a schedule (adequate fluid intake, specific voiding time), reduce fluid intake if causing bladder irritation, diet modifications (avoid alcohol, caffeine, spicy foods), bladder training exercises (Kegels), protective undergarments, meticulous skin care, emotional support.

Neurogenic Bladder

• Neurogenic Bladder: Loss of voluntary voiding control, leading to retention or incontinence.
  • Etiology/Pathophysiology: Lesion in the nervous system affecting nerve conduction to the bladder, caused by congenital anomalies (spina bifida), neurological diseases (multiple sclerosis), or trauma (spinal cord injury).
  • Types:
    • Spastic Bladder: Lesion above the voiding reflex arc (upper motor neuron), loss of sensation and motor control, bladder wall atrophy. Reflex urination with little conscious control.
    • Flaccid Bladder: Lesion in the lower motor neuron, bladder fills and distends, incomplete emptying, loss of sensation to void.
  • Clinical Manifestations/Assessment: Subjective (diaphoresis, flushing, nausea before incontinence, infrequent voiding), objective (investigate urinary status of patients at risk).
  • Diagnostic Evaluation: BUN/Cr levels, radiological studies.
  • Medical Management: Early assessment of urinary system and function, antibiotics for infections, parasympathomimetic medications (bethanechol chloride), intermittent self-catheterization, urinary collection systems, sacral nerve modulation, sacral nerve stimulation.
  • Nursing Interventions: Establish urinary elimination and prevent complications, bladder training program (spastic: self-stimulation, residual volume checks; flaccid: 2-hour voiding schedule, emotional support).

Urinary Tract Infections (UTIs)

• UTI: Generic term for infections in the urinary tract.
  • Etiology/Pathophysiology: Bacteriuria, E. coli most common pathogen, risk factors (instrumentation, diaphragm/condom use, urinary stasis/retention), more common in older adults (immobility, sensory/organ impairments), retention/reflux increase risk, chronic health states alter homeostasis, immunocompromised have difficulty recovering, ascending infections (female anatomy), Gram-negative microorganisms from the GI tract.
  • Types: Urethritis, cystitis, pyelonephritis, prostatitis infections.
  • Clinical Manifestations/Assessment: Lower UTIs (bladder), Upper UTIs (kidneys), subjective (pain, burning on urination, urgency, frequency, nocturia, malaise, abdominal/perineal/back pain), objective (bladder tenderness, cloudy/blood-tinged urine).
  • Diagnostic Tests: Urine culture & bacteriologic tests, IVP/VCUG for recurrent UTIs, prostatic fluid/tissue culture, microscopic inspection (bacteria, hematuria, pyuria).
  • Medical Management: Anti-infective medications (Bactrim, Ciprofloxacin etc.), longer therapies (Amoxicillin, Ampicillin, nitrofurantoin, levofloxacin), bladder anesthetics (Phenazopyridine, limited use to 2 days, urine turns orange), remove obstruction if present, self-catheterization (neurogenic bladder).
  • Nursing Interventions: Comfort measures (anti-infectives, analgesics, fluids), perineal care, education on complementary therapies (greenbox on page 1666), catheterization technique.

Other Urinary System Conditions

• Urethritis: Inflammation of the urethra.

  • Etiology/Pathophysiology: Gonococcal (STD, gonorrhea causing specific urethra infection), Non-gonococcal (other organisms: chlamydia, trichomonas, herpes, spermicide sensitivity).
  • Clinical Manifestations/Assessment: Pus formation, discomfort, frequency, dysuria, discharge (pus-like in gonorrhea), subjective (asymptomatic, dysuria, urethral pruritus, discharge, vaginal/vulvar irritation). objective (lower abdominal discomfort, urethral exudate, inflammation, C&S exudate)
  • Diagnostic Tests: Client history, gram stain, culture, and sensitivity.
  • Medical Management: Antibiotics, antifungals, symptom relief.
  • Nursing Interventions: Avoid sexual activity till resolved, full medication course, evaluate sexual partners.

• Cystitis: Inflammation of the bladder wall.

  • Etiology/Pathophysiology: Bacteria ascend from urethra, E. coli is most common. Ascending infections more common in women.
  • Clinical Manifestations/Assessment: Dysuria, frequency, pyuria, discomfort in bladder area, dysuria , urgency, nocturia, cloudy/strong-smelling urine, hematuria. Collected via clean-catch or catheterized urinalysis with C&S.
  • Medical Management: Anti-infective agents (Septra/Bactrim, Macrodantin), removal of obstruction, post-treatment urinalysis.
  • Nursing Interventions: Teach signs/symptoms of reinfection, adequate fluid intake, accurate I&O records.

• Interstitial Cystitis: Chronic pelvic pain disorder.

  • Etiology/Pathophysiology: Unknown, not bacterial, suspected mucosal breech, urine irritation and inflammation, spasm of detrusor muscles, hematuria, frequency, pain.
  • Clinical Manifestations/Assessment: Similar to cystitis (urinary frequency, urgency, suprapubic pain, dyspareunia, often with fibromyalgia, irritable bowel).
  • Medical Management: Rule out infection, cystoscopy, tissue biopsy, symptom management (antihistamines, antidepressants, Elmiron (pentosane polysulfate) to improve mucosal layer protection, opioids), more invasive therapies.
  • Nursing Interventions: Pain control, pelvic floor exercises, bladder diary, dietary modifications (avoid spicy, acidic foods, alcohol, citrus, chocolate, caffeine).

• Urinary Diversions: Procedures to alter urine flow pathways (ileal conduit, sigmoid conduit, continent ileal urinary reservoir (Kock pouch)).

  • Complications/Postoperative Care: Wound infection, leakage, ureteral obstruction, small bowel obstruction, stomal issues, pyelonephritis, renal calculi, respiratory compromise, signs of peritonitis, measure urinary flow and assess stoma (healthy is moist/pink).
  • Patient Teaching: Changing the urostomy bag, odor control, stoma care, altered body image, nutrition, fluid intake, modification of sexual activities, early detection of complications.

• Prostatitis: Inflammation/infection of the prostate gland.

  • Etiology/Pathophysiology: Bacterial (infectious organisms), non-bacterial (urethral occlusion), or prostatodynia (without inflammation or infection).
  • Clinical Manifestations/Assessment: Fever, chills, malaise, arthralgia, myalgia, perineal prostatic pain, urinary obstruction symptoms (frequency, urgency, dysuria, nocturia, weak stream, incomplete voiding), pain.
  • Diagnostic Tests: Prostatic fluid/tissue culture(via pre/post-prostate massage, Transabdominal U/S or MRI, U/A, C&S, blood cultures).
  • Medical Management: Acute (hospitalization, IV antibiotics; Septra, Cipro, Floxin), chronic (oral antibiotics, pain relief).
  • Nursing Interventions: Comfort measures (analgesics, sitz baths, stool softeners), medication regimen teaching, sexual activity restrictions (when acute).

• Pyelonephritis: Inflammation of the kidney structures.

  • Etiology/Pathophysiology: Generally caused by bacteria (E. coli), recurrent infections, or urinary stasis due to obstruction.
  • Clinical Manifestations/Assessment: Chills, fever, severe fatigue, flank pain, azotemia, frequency, burning urination, nausea, vomiting, headache, hypertension, stones.
  • Assessment: Subjective: acute –malaise and pain in the costovertebral angle (CVA). Chronic – unremarkable symptoms, nausea, general malaise. Objective: signs of infection, Chronic: hypertension, vomiting/diarrhea.
  • Diagnostic Tests: Urinalysis (bacteria, cloudy, hematuria, pyuria, mucus, WBCs/casts), cystoscopy, ultrasound, blood tests (leukocytosis; elevated BUN/Cr).
  • Medical Management: Symptomatic treatment (pain relief, antispasmodics, fluids), broad-spectrum antibiotics (IV initially, then PO), follow up urine culture, prolonged hospitalization (severe cases).
  • Nursing Interventions: Monitor urine color/odor, encourage fluids, encourage voiding, perineal hygiene, education on infection resolution, completing antibiotic course, follow-up.

• Obstructive Uropathy: Obstruction in urinary tract.

  • Etiology/Pathophysiology: Strictures, kinks, cysts, tumors, calculi, prostatic hypertrophy, leading to electrolyte imbalance, infection, ischemia, atrophy.
  • Clinical Manifestations/Assessment: Gradual onset (dull flank pain; difficulty urinating), acute onset (severe, colicky pain), pain characteristics, voiding patterns (frequency, hesitancy, dribbling), objective (bladder distention, palpable kidney, time/amount of voiding, hematuria).
  • Diagnostic Tests: KUB, renal ultrasound, IVP, BUN/Cr.
  • Medical Management: Establish urine drainage (catheters, ureteral stents), pain and motility control (analgesics, anticholinergics), surgical correction.
  • Nursing Interventions: Maintain adequate hydration, strict I&O, monitor for hemorrhage/infection, monitor urinary output, encourage fluids.

• Hydronephrosis: Dilation of renal pelvis/calyces.

  • Etiology/Pathophysiology: Obstruction in lower or upper urinary tract. Pressure build up, functional/anatomical damage, dilation/hypertrophy, renal fibrosis, potential kidney destruction.
  • Clinical Manifestations/Assessment: Asymptomatic if adequate function, pain (dull flank pain, acute colicky pain), voiding issues (frequency, hesitancy, dribbling, nocturia, dysuria).
  • Assessment: Subjective: Pain characteristics (location, intensity, character), voiding pattern changes, objective (urinary output, hematuria, bladder distention, kidney tenderness, nausea, vomiting, edema).
  • Diagnostic Tests: Radiologic (CT, ultrasound), urinalysis, serum BUN/creatinine, cystoscopy/retrograde pyelography, renal biopsy.
  • Medical Management: Conservative (drainage, obstruction removal, pain control), surgical (if severe), nephrectomy (severe damage).
  • Nursing Interventions: Medication administration, strict I&O, monitor electrolytes/renal function, monitor for infection/changes in urine characteristics, maintain urinary drainage, post-operative techniques/patient education.

• Urolithiasis (Kidney Stones): Urinary calculi.

  • Etiology/Pathophysiology: Immobility, obesity, genetics (family history), hyperparathyroidism, medications, recurrent UTIs, dehydration, excessive vitamin D/dairy intake, osteoporosis, specific food/nutrient/medication triggers. - Clinical Manifestations/Assessment: Pain (variable, colicky pain radiating to groin/genitalia, dull flank pain), hematuria, nausea/vomiting, tenderness, subjective: pain characteristics, more mobile stones: frequent, abrupt pain resolves once stone passed, more stationary stones: intermittent aches, symptoms of hydronephrosis/UTI. objective: Hematuria, cVA tenderness, vomiting. - Diagnostic Tests: Ultrasound, radiographic studies (KUB, IVP, CT), cystoscopy/ureteroscopy, urinalysis (hematuria, pyuria), 24-hour urine (calcium/oxalate/phosphorus/uric acid excretion), BUN/Cr, stone content analysis. - Medical Management: Anti-infectives (infection present), stone removal (cystoscopy/ureteroscopy, surgical incision (ureterolithotomy, pyelolithotomy, nephrolithotomy)), chemolysis, ESWL, urine straining. - Nursing Interventions: Encourage stone passing (increased activity, hydration, pain management), assess renal function, monitor for infection, patient education/teaching (dietary restrictions, medications, signs/symptoms).

• Bladder Cancer: Cancer of the bladder lining.

  • Etiology/Pathophysiology: Excess cell growth (potential papilloma to carcinoma), chemicals/exposure, smoking, family history, occupational exposure (paint, dyes, petroleum). More common in men.
  • Clinical Manifestations/Assessment: Asymptomatic (patients delay seeking help), intermittent hematuria, changes in voiding patterns, urinary obstruction/renal failure.
  • Diagnostic Tests: Urinalysis/culture, urine tumor markers, cytologic evaluation, bladder biopsy.
  • Medical Management: Local disease (fulguration, laser, chemotherapy instillation, radiation); surgical (partial/total cystectomy, urinary diversion).
  • Nursing Interventions: Monitor voiding patterns/urine charateristics, patient support/education (post-surgery restrictions).

• Benign Prostatic Hypertrophy (BPH): Non-cancerous prostate enlargement.

  • Etiology/Pathophysiology: Common in men over 50, unclear cause but possibly hormonal, prostate enlargement pressing on the urethra/bladder neck, preventing complete bladder emptying.
  • Clinical Manifestations/Assessment: Frequency, urgency, hesitancy, slow urine stream, nocturia, dysuria, UTI, hematuria, oliguria.
  • Diagnostic Tests: Measuring residual urine (<50mL), BUN/Cr, cystoscopy/IVP, cytology, prostate specific antigen(PSA), digital rectal exam (DRE).
  • Medical Management: Medications (alpha-adrenergic antagonists (relax smooth muscle), androgen inhibitors (inhibit prostate growth)), Surgical (TURP, TUMT, TUNA, PVP).
  • Nursing Interventions: Maintain continuous closed irrigation (CBI) if needed, Medication administration, analgesia provision, encourage ambulation, patient teaching (post-op expectations, voiding challenges, medications, follow up care.

• Urethral Strictures: Narrowing of the urethra lumen.

  • Etiology/Pathophysiology: Congenital, acquired (chronic infection, trauma, tumor).
  • Clinical Manifestations/Assessment: Dysuria, weak stream, urine stream splaying, nocturia, pain with bladder distension, fever/malaise (infection).
  • Diagnostic Tests: Voiding cystourethrogram.
  • Medical Management: Dilation, surgical release (internal urethrotomy).
  • Nursing Interventions: Adequate hydration, mild analgesics, sitz baths, urethroplasty teaching/care.

• Urinary Tract Trauma: Contusions/ruptures of urinary structures.

  • Etiology/Pathophysiology: Motor vehicle collisions, falls, penetrating trauma, abdominal surgery.
  • Clinical Manifestations/Assessment: Hematuria, abdominal/pelvic pain/tenderness, internal hemorrhage, peritonitis, urine leakage.
  • Diagnostic Tests: Urinalysis, KUB, IVP, excretory urogram, cystoscopy.
  • Medical Management: Surgical intervention to correct tears/ruptures, manage hemorrhage, prevent infection.
  • Nursing Interventions: Assess for injury, maintain adequate urine output, promote patient comfort, patient education on injury and surgical care.

Test your knowledge on urinary retention, urinary tract infections, and related nursing interventions. This quiz covers key concepts such as common clinical manifestations, diagnostic procedures, and treatment strategies for conditions affecting the urinary system. Perfect for nursing students and healthcare professionals!