Urinary System & Disorders

Micturition

• Complex neural response allowing the bladder to contract, the urethral sphincter to relax, and urine to leave the body.

Voiding Reflex

• Voluntary control over bladder emptying develops as a child matures.
• Adults typically feel the first urge to void when the bladder is half full.

Common Alterations in Urinary Elimination

• Urinary tract infections (UTIs): Involuntary leakage of urine.
• Urinary incontinence: An accumulation of urine due to the bladder's inability to empty.
• Nocturia: Waking in the night to urinate.
• Urinary retention: Commonly result from catheterization (CAUTI), may also be caused by hygiene.
• Urinary diversions: Diversion of urine to an external source.

Common Symptoms of Urinary Alterations

• Incontinence: Involuntary loss of urine
• Urgency: Sudden, compelling desire to urinate difficult to defer.
• Dysuria: Pain, burning, or discomfort during urination.
• Frequency: Voiding more than eight times in 24 hours.
• Hesitancy: Delay in initiating urination
• Polyuria: Notably larger urine excretion volume.
• Oliguria: Diminished urinary output relative to intake.
• Nocturia: Number of times urine is passed during the main sleep period.
• Dribbling: Leakage of urine despite voluntary control.
• Hematuria: Passage of visible blood mixed with urine
• Elevated postvoid residual urine: Volume of urine in bladder after emptying.

Urinary Tract Infections (UTIs)

• UTI involves the lower urinary tract causing cystitis, urethritis, and prostatitis in male patients.
• Patients with female genitalia are more susceptible to infection due to the short urethra
• Causes: obstruction of the urinary tract (e.g., benign prostatic hyperplasia, pelvic organ prolapse), incomplete bladder emptying, and abnormal anatomy.
• Risk factors: older adults, antibiotic use, progressive underlying disease, and decreased immunity.
• UTI can spread to the upper tract, causing kidney infection (pyelonephritis) and potentially long-term kidney damage.
• Bacteria can spread to the bloodstream (bacteremia) resulting in urosepsis
• Symptoms of lower UTIs: pain/burning sensation during urination (dysuria), fever, chills, nausea, vomiting, and malaise.
• Symptoms of upper UTIs: inflammation of the bladder causing a frequent/urgent need to void, incontinence, and confusion

Clinical Manifestations of UTIs

• Irritation to the bladder and urethral mucosa resulting in blood-tinged urine (hematuria).
• Cloudy, foul-smelling urine or a change in urine colour, in the absence of other symptoms, does not indicate infection.
• If the infection spreads to the upper urinary tract (i.e., the kidneys), rapid onset of flank or lower back pain, tenderness, fever, and chills can occur.
• Catheter-associated UTIs (CAUTIs): results in increased length of hospital stay, morbidity, and mortality for patients.
• Reduce unnecessary use of in-dwelling catheters and remove them as soon as clinically indicated; good perineal care is recommended.

Indications for Urinary Catheterization

• Post-operative or acute urinary retention
• Bladder outlet obstruction (e.g., gross hematuria, BPH, pelvic organ prolapse, urethral strictures)
• Need for accurate measurements of I&O
• Prolonged immobilization
• Continuous bladder irrigation (CBI)
• Administration of medications into the bladder (cancer)
• Improving comfort at the end of life
• Perioperative in selected surgical procedures.

Contraindications for Urinary Catheterization

• Perceived comfort in patients with urinary or fecal incontinence.
• Using a catheter to obtain urine for tests when patients can void voluntarily.
• Prolonged postoperative use without appropriate indications.

Urinary Incontinence

• Defined as a complaint of involuntary loss of urine.
• Often occurs with other lower urinary tract symptoms. (e.g., daytime frequency, nocturia, urgency, intermittent or slow stream, hesitancy, postmicturition symptoms)
• Psychosocial impact ranges from lifestyle changes to stigma, embarrassment, and self-imposed social isolation.
• Types include transient, urgency, stress, mixed, UI associated with chronic retention, functional, neurogenic

Nocturia

• Bothersome symptom defined as the need to get up at night on a regular basis to urinate.
• Prevalence increases with age.
• Possible causes: overactive bladder, prostate enlargement (men), excess urine production at night (nocturnal polyuria), heart failure, obstructive sleep apnea, loss of vasopressin.
• Associated with metabolic imbalances (hyperglycemia, hypercalcemia).

Urinary Retention

• Accumulation of urine in the bladder due to the bladder's inability to empty.
• Micturition reflex is impaired
• The build-up of urine causes pressure, discomfort, tenderness, restlessness, and diaphoresis.
• Possible causes: Post-partum, urogenital surgery, medication adverse effects (anticholinergic), fecal impaction, Post-operative urinary retention (POUR), Chronic urinary retention.

Safety Alert: Autonomic Dysreflexia

• Bladder distention can trigger autonomic dysreflexia in individuals with spinal cord injury above the T6 level.
• Dysregulation of the autonomic nervous system leads to uncoordinated autonomic response (potentially life-threatening hypertension).
• Immediate recognition and correction (e.g. irrigating or changing the Foley catheter) is critical.

Urinary Diversion

• A urinary stoma to divert urine flow from the kidneys to the abdominal surface.
• Reasons for diversion include: bladder cancer, trauma, radiation injuries, fistulas, and chronic cystitis.
• Temporary or permanent.
• Patients require an ostomy appliance.
• Local irritation and skin breakdown are possible due to urine contact with skin.

GU Fistula

• Abnormal connection between the urinary and genital tracts.

Urinary Diversion Methods

• Ileal Conduit: Loop of ileum separated with intact blood supply where ureters are implanted; remaining ileum reconnected

• Orthotopic Neobladder: Internal pouch formed from the ileum and reconnected to the urethra

• Indiana Pouch: Creates a continent internal pouch from the ileum; a portion is connected to the abdominal wall

• Ideal urinary stoma are symmetrical, do not have skin breakdown and protrude about 1.5cm

Nursing Considerations: Urinary Elimination

• Infection control and hygiene: sterile urinary tract
• Catheter duration is most important risk factor for UTIs
• Medical and surgical asepsis during catheterization
• Growth and development: changes in kidney and bladder function with aging, less effective emptying, increased susceptibility to UTIs, and elevated postvoid residual volume.
• Psychological considerations: urinary problems can impact sexuality and self-concept, embarrassment, and self-isolation
• Cultural considerations: cultural needs around urinary function.

Assessment of Urine

• Color: Pale straw to amber (depending on concentration); dark red/bright red (kidney/bladder/urethra bleed); dark amber (bilirubin)
• Clarity: Transparent at voiding; cloudy if left standing/high protein/bacteria
• Odor: Characteristic; stronger with concentration; ammonia with stagnant urine; sweet/fruity (diabetes, starvation)

Urine Testing Collection Techniques:

• Clean-Catch Midstream: Patient cleans urethral area; begins urinating and collects midstream in sterile container.
• 24-hour urine collection: Urine collected over 24 hours, discarding first void, collecting remaining urine in provided container.
• Catheterized sample: Collected by healthcare professional directly from catheter.

Urinalysis

• Color, Clarity, Odor: Normal values. Changes in these can indicate problems
• pH (Acidity): Normal range (4.5-8). High pH may suggest infection or high-protein diet; low pH indicates high-protein diet or certain medications
• Protein: Normally absent or in small amounts. Proteinuria can indicate kidney disease or infection.
• Glucose: Absent. Glycosuria suggests high blood sugar levels (uncontrolled diabetes)
• Ketones: Absent. Ketonuria can indicate uncontrolled diabetes, starvation, or a low-carbohydrate diet.
• Leukocyte Esterase & Nitrites: Indicate infection
• Blood: Absent. Hematuria can indicate infection, trauma, or kidney stones
• Bilirubin & Urobilinogen: Absent. Bilirubin suggests liver or gallbladder disease

Diagnostic Examinations

• Noninvasive examination
• Invasive examination

Common Post-Procedure Interventions

• Assessing intake and output
• Observing characteristics of the urine, including color, clarity, and presence of blood

Health Promotion

• Promoting regular micturition: Use sensory stimuli to stimulate voiding reflex
• Maintaining elimination habits, adequate fluid intake promoting complete bladder emptying: double voiding/intermittent catheterization, bladder scanning
• Preventing infection: good perineal hygiene, hand washing, fluid intake, good quality perineal products.
• Use of urinary catheter requires prescript
• Incontinence alone is not reason to insert catheter

Class Learning Outcomes

• Compare common alterations in urinary elimination.
• Describe nursing implications of common diagnostic tests.
• Discuss nursing measures to prevent episodes of incontinence.
• Describe nursing and collaborative care for clients with chronic renal failure and chronic kidney disease.
• Describe indications for peritoneal and hemodialysis.
• Describe nursing care for clients undergoing peritoneal and hemodialysis.

Chronic Kidney Disease (CKD)

• Progressive, irreversible loss of kidney function.

• Chronic renal failure

• Kidney damage: pathological abnormalities (nephron destruction), markers of damage (blood, urine, imaging tests)

• Glomerular filtration rate (GFR) decline (<60 mL/minute/1.73 m²) for 3+ months.

• 80% GFR loss without significant body response

• Compensatory mechanism: remaining nephrons increase in size (hypertrophy)

• Leading causes of end-stage renal disease include diabetes mellitus, hypertension, renal vascular disease (affecting blood flow), renal artery stenosis/thrombosis, renal vein thrombosis.