Lower Urinary System & Reproductive Disorders PDF

Lower Urinary System Male/Female Urinary & Reproductive Disorders C. KARVAS, MSN , RN , APRN-C 1 Ureters  Carry urine from kidneys to renal pelvis  to the bladder  Ureteral lumens are narrow 2 ...

Lower Urinary System Male/Female Urinary & Reproductive Disorders C. KARVAS, MSN , RN , APRN-C 1 Ureters  Carry urine from kidneys to renal pelvis  to the bladder  Ureteral lumens are narrow 2  URINAR Y SYSTEMS MALE FEMALE Mayo Clinic St. Luke’s Health system 3 Urethra 8 – 10 inches 1 – 2 inches Bladder  Reservoir for urine  Capacity 600-1000 ml  Bladder muscle (detrusor)  Urination, micturition, voiding  Detrusor muscle: found in the wall of the bladder and is supposed to stay relaxed to fill with urine and contract when urinating  Problems with this muscle more common in males  Urine is made in the kidneys and leaves through the urethra(meatus) 5  How does Urine Flow? Protective mechanisms  Flows downward to prevent urine back flowing to kidneys  Ureters connect to bladder = ureterovesical valves (one-way valves)  Muscles of bladder  Pressure created by urine in bladder  Urine itself is sterile-antiseptic properties that help keep bacteria from sticking to the inside of the bladder  pH of urine is acidic  Prostate gland-secrete antimicrobial fluid that kills bacteria  Normal flora of vagina-lactobacilli friendly bacteria helps fight off bad organisms 6  Maintaining a healthy bladder  Use the bathroom often and when needed. ◦ Should void every 3-4 hours  Wipe from front to back after toileting/E.coli can get up into the vagina and urethra if you do not wipe this way  Urinate after intercourse- to clean things afterwards  Do pelvic floor muscle exercises (Kegels) contract or squeeze muscles around rectum and vagina at the same time  Wear cotton underwear  Limit alcohol, caffeine – smoking cessation  Drink lots of fluids  Exercise and weight management  You want to let things breath 7 Urinary Incontinence  Involuntary or uncontrolled loss of urine in any amount  Types of incontinence  Stress  Urge (overactive bladder)  Functional  Medications and Surgeries can be done to help with incontinence 8 Stress Incontinence  When physical movement or activity – coughing, laughing, sneezing, running, heavy lifting puts pressure (stress) on bladder, causing leakage of urine  Causes- pelvic floor muscle & urinary sphincter might weaken ◦ Childbirth in women ◦ Prostate surgery in men  Devices ◦ vaginal pessary(pushes upward to support bladder), urethral inserts(kind of like tampon put in the urethra)  Surgery ◦ Vaginal sling, injectable bulking agents, inflatable artificial sphincter ◦ TREATMENT THATS BEST ARE KEGEL EXERCISES 9 SLING PROCEDURE 10 Urge Incontinence  Other names ◦ overactive bladder ◦ bladder spasms ◦ irritable bladder ◦ detrusor instability  Involuntary urination with little or no warning  Frequent urination or nocturia(often occur at night)  Enuresis ◦ Bed wetting ◦ The first thing people do that have this locate the bathroom BEST TREATMENT: BLADDER RETRAINING- MAKE YOUR SELF GO TO THE BATHROOM AT CERTAIN TIMES/ MAKING A SCHEDULE FOR URINATING 11 Functional Incontinence  Inability to get to or use the toilet in time to urinate  Usually due to physical(person who has trouble walking or maybe have something in their walking path that they might trip on) or cognitive impairment(people with dementia, Alzheimer’s, etc. deal with this) ◦ Inability to walk well ◦ Furniture in way  Treatment aimed at manipulating environment ◦ Easy access to toilet ◦ Scheduled times for toileting ◦ Wearing clothes easy to remove ◦ When helping these patients to the bathroom this is a good opportunity for ambulation 12 Anticholinergics(used in the GU world)  Treat urinary incontinence (more for urge and stress) ◦ Can’t see, can’t pee, can’t spit, can’t sh…, poop  Oxybutynin (Ditropan) ◦ Decreases urgency, frequency and nocturia in overactive bladder(urgent type of incontinence) ◦ Causes urinary retention/often pts experience dry mouth and blurry vision and constipation with this med class/ Ditropan good for men and women ◦ DO NOT use anticholinergics on a patient with BPH(enlarged prostate) ◦ BPH IS THE LEADING CAUSE FOR MALE URINE RETENTION ◦ Do not give with decongestants (claritin, benadryl, sudafed)(don’t take often)  will cause hypertension  Causes for us to NOT sweat properly and sweating regulates body temp  Be careful with exercise, hot baths/showers, hot weather 13 Treatment  Kegel exercises  Scheduled toileting times  Botox injections  Nerve stimulator  Medications – anticholinergics ◦ tolterodine (Detrol) ◦ oxybutynin (Ditropan) 14 Urinary Retention  Inability to empty bladder all the way ◦ Benign Prostate Hypertrophy - # 1 cause/ONLY MEN ◦ Obstruction – kidney stone main cause for WOMEN ◦ Narrowing - urethral some women have to get things dilated because of a structural defect ◦ Tumors ◦ Certain medications – anticholinergics, opioids ◦ Being dehydrated ◦ Constipation/ can also slow down urination ◦ Urethra not contracting and relaxing properly can influence this 15 16 Urinary Retention (cont.) ◦ Acute  Sudden & often painful inability to urinate at all despite bladder fullness  Requires intervention ◦ Chronic  Gradual inability to empty the bladder; painless retention associated with increased volume of residual urine(looking at this when told to insert a catheder) 17 Chronic Urinary Retention(mixture of the types of incontinence)  Straining to pass urine or a weaker flow of urine  Feeling like bladder is still full after passing urine  Overflow incontinence – leaking urine without being able to control it  Difficulty holding in urine while coughing, laughing  Periodically have to go into get their bladder emptied 18 Nursing Management  Acute(more common for these patients to come to ER for painful sensation of not being able to urinate) ◦ bladder scan(no order needed) ◦ palpate height(right around the pelvic bone is where you’d feel fullness) ◦ ask about their normal voiding history is for them as an individual ◦ needs indwelling urinary catheter ◦ drink small amounts of fluids ◦ Avoid alcohol, caffeine, acidic fruits/anything acidic…… ◦ sitting in tub of warm water or warm shower ◦ Draining the bladder must be done/you must document the amount of urine(do this for acute and chronic)  Chronic ◦ intermittent or indwelling urinary catheter ◦ schedule toileting time 19 Bladder Cancer 4th most common cancer in men 8th most common cancer in women Smoking is the most important risk factor(heavy smokers) People exposed to a lot of dye Bladder CA-Like to go to liver bone etc 20  Clinical Manifestations & Diagnosis  Painless hematuria – gross or microscopic  Bladder irritability – dysuria, frequency & urgency  Urine cytology  Lab for tumor markers  Cystoscopy  Imaging  If a girl in childbearing years, ask if they are on their period 21 Urinary diversions – ileal conduit & Neobladder (permanent)  Most common after complete removal of bladder for bladder cancer ◦ Urostomy – ileal conduit – portion of ileum is resected & one end of segment is closed; ureters are attached to closed end of ileum and open end of ileum is brought through abdomen to form a stoma; a bag is placed over stoma(opening through the abdomen) ◦ Get some routine urinary questions that you should ask ◦ Duodenum, jejunum, ileum(finish the point) 22 23 NEOBLADDER 24 Nursing Management: Urinary Diversions  Preoperative ◦ involve family in teaching about the diversion ◦ address psychosocial aspect of stoma, stoma care & pouch application ◦ encourage patient to talk about feelings related to stoma creation ◦ enterostomal therapist consult to visit with patient 25 Neurogenic Bladder  Nerves between spinal cord and brain don’t work ◦ Parkinsons, Multiple Sclerosis, stroke, diabetes  Nursing interventions ◦ Provide routine voiding measures ◦ Avoid caffeine and alcohol ◦ Kegel exercises ◦ Catheter care when indicated, catheterize prn ◦ Medication – tamsulosin (Flomax) improves bladder storage and emptying ◦ FIND OUT THE REASON FOR CATHEDER PLACEMENT 26 Diagnostic Studies for Urinary System  Urinalysis ◦ Measurement of color, pH, specific gravity ◦ Determination of present of glucose, protein, blood, & ketones ◦ Microscopic exam for crystals, bacteria  first morning void  examine urine within 1 hour 27 Diagnostic Studies cont.  Urine studies ◦ Urine culture and sensitivity ◦ Creatinine clearance  Collect 24-hour urine specimen  Creatinine clearance closely approximates GFR (glomerular filtration rate)  Might change antibiotic  Get cultures before antibiotic treatment if already on antibiotics you will use another type of culture bottles/tubes 28 Diagnostic studies (cont.)  Serum creatinine – greater than 1.2 mg/dl is abnormal for women & men 1.4 mg/dl  Blood urea nitrogen (BUN) 7-20 mg/dl ◦ A high BUN with normal creatinine = dehydration  Creatinine clearance ◦ Glomerular Filtration Rate (GFR ) probably most accurate measurement of kidney function ◦ Chronic renal failure or urine insufficiency 29 Creatinine Clearance Keep on ice  Discard first urine  Collect for 24 hours in large collection container placed on ice (or refrigerator if testing at home)  Empty bladder initially; record time; save all urine after first urine specimen discarded  Collect for 24 hours  Have patient urinate at end of 24 hour & add specimen collection  Put on door when urine collection starts 30 Interstitial Cystitis  Painful bladder syndrome  Difficult to diagnose  Mistaken for urinary tract infection but urine culture shows no bacteria 31 Clinical Manifestations  Pain in perineum  Persistent urgent need to void  Painful intercourse  Frequent urination (up to 60 times per day)  Pain while bladder fills and relief after urinating  May have autoimmune component  Phenazopyridine(peridium) or Azo for treatment-turns urine orange and can stain things  Symptomatic after treatment get a urine test 32  Urinary Tract Infection Teaching  Hormones  Fluids – avoid alcohol, caffeine;  Antibiotics drink water, cranberry juice, green  Renal stones, scarring tea  Food – avoid acidic (lemons)  Diabetes artificial sweeteners, spicy foods  Toiletries(tampons)  Eat – high fiber (whole grains,  Obstructive prostate beans, bananas)  Vesicoureter reflux(one way valve/  Void q 3-4 hours; wear cotton-lined structural defect or kidney stone underwear  Overextended bladder-not voiding when  Exercise needing to  Indwelling catheter  Decreased immunity ◦ Structural deviations 33  Pathophysiology ◦ Bacteria enters the sterile bladder causing inflammation  May be caused by a variety of disorders ◦ Bacterial infection most common  Escherichia coli (E. coli) most common pathogen ◦ Fungal and parasitic infections may cause UTIs ◦ Cysto=bladder ◦ Pylonephritis =kidney 34 Catheter-associated urinary tract infection (CAUTI)  Most common hospital acquired infection  #1 cause = prolonged use of urinary catheter  Common bacteria ◦ E. coli ◦ Pseudomonas ◦ Proteus marabilis  Risk Factors ◦ Pediatric & female population, congenital defects, urinary retention, pregnancy, menopause, multiple partners (refer to HardToVoid slide 33) (menopause/pregnancy/multiple partners) ◦ PRACTICE STERILITY 35 36 Signs & Symptoms of a UTI  Hesitancy, frequency, urgency  Dysuria(painful urination)  Suprapubic pain ◦ Diagnose with  UA/urine culture(10ml is ideal for a urine test)TNTC?  +RBC (gross hematuria)  Cloudy  + WBC  +Nitrites(IF positive will treat for UTI) 37 Elderly/geriatric manifestations(UTI)  Geriatric –  Sudden change in LOC/confused disoriented/INFECTION ,MEDICATION/RUN CBC/RESPRIATOR Y DISTRESS/Stroke/sepsis  falls  tachypnea  Anorexia(poor appetite)  low grade fever or no fever (VS appear normal) 38 Urine Culture 39 Nursing Management  Urinalysis & urine culture – clean catch/midstream  Medication ◦ antibiotics ◦ analgesic for pain  Prevention of CAUTI  Prevention of Urosepsis-infection that has come from the urinary tract system 40 Clean Catch Urine (Midstream)  Wash hands  Clean urinary opening with towelette front to back  Void into toilet a few seconds & stop  Place sterile container into path of stream  Restart urine and collect midstream of urine ◦ Do not touch inside of sterile cup ◦ Do not hold cup tightly to perineum 41 CDC Guidelines – Indications for Indwelling Urinary Catheter  Acute urinary retention or bladder outlet obstruction  Need for accurate I&O(hourly monitoring)  Assist in healing of open sacral or perineal wounds  Prior to certain surgical procedures  Patient requires prolonged immobilization  To improve comfort for end-of-life care 42 Urosepsis – caused by infection from UTI  Untreated UTI spreads to kidneys  Risk factors ◦ Urinary catheters ◦ advanced age ◦ compromised immune system ◦ diabetes ◦ female gender-short urthera ◦ surgical procedures involving urinary tract 43 Clinical manifestations  Initially UTI symptoms ◦ Abnormal WBC count (either too high or too low) ◦ urgency, frequency, foul smelling urine, dysuria, lower abdominal pain  More serious signs symptoms (pyelonephritis) ◦ Nausea, vomiting, fever, chills, pain in lower spine (CVA tenderness)costovertebral angle tenderness)  Sepsis symptoms – (MEWS tool) ◦ Respiratory rate 22 or higher ◦ Systolic pressure ≤ 100 mm HG ◦ WBC too high or too low (4500 – 10,000 per microliter) 44 45 Severe sepsis/septic shock  Organ failure, such as kidney (low urine output)  Low platelet count  Change in mental status  High levels of lactic acid in blood (cells aren’t utilizing oxygen in the right way) 46 Management  Early goal-directed therapy (EGDT)  Broad spectrum antibiotics  Control pain  IV fluids to maintain blood pressure support  Oxygen therapy  Strict hourly I & 0 )  Removal of any catheters or devices that may be infected  Supportive care – stabilizing lungs and flow of blood 47 Suprapubic Catheter  Flexible tube inserted into the bladder through the abdomen a few inches below umbilicus  Used for ◦ Urethral trauma ◦ Some gynecological surgeries (prolapsed uterus or bladder) ◦ People who require long-term catheterization & are sexually active 48 Suprapubic catheter 49 Male Reproductive System 50 Disorders in the male population  Peyronies  Prostatitis  BPH/TURP  Priapism  Prostate cancer  Phimosis  Testicular cancer  Hypospadius  Testicular torsion  Diphalia  Erectile Dysfunction (ED)  PRE 51  Peyronies Scar tissues forms under skin of penis; plaque pulls on surrounding tissue & causes penis to curve or bend during an erection 52 Priapism Prolonged painful erection without sexual desire Can lead to impaired circulation & inability to urinate Causes: neurological & vascular disorders Medication, Injury Phimosis Inability to retract the foreskin covering the head of the penis 53 Hypospadius Birth defect in which opening of the urethra is located at the tip of the penis, along the shaft, or where penis & scrotum meet Diphalia Genetic condition present at birth in which a person has 2 penises 54 Penile Ring Entrapment (PRE) Penile ring works by reducing outflow of blood, sustaining a longer erection If left for extended period can lead to swelling of shaft, strangulation, gangrene and even complete loss of distal penis 55 Prostate Gland  Male organ that produces semen & transports sperm during ejaculation  Enlarged prostate can put pressure on urethra causing difficulty urinating  Medical term for enlarged prostate is benign prostatic hypertrophy (BPH)  Testicles make the sperm 56 Prostatitis Acute bacterial prostatitis, a bacterial infection of the prostate usually with sudden, severe symptoms Chronic bacterial prostatitis, ongoing or recurring bacterial infection usually with less severe symptoms Chronic prostatitis/chronic pelvic pain syndrome, ongoing or recurring pelvic pain and urinary tract symptoms with no evidence of infection Symptoms Flu-like Pain in abdomen, groin, or back dysuria Pain with ejaculation NOT EASY TO GET WELL/ongoing problem 57 Prostatitis (cont.)  Treatment ◦ acute bacterial – antibiotics 4 - 6 weeks ◦ chronic bacterial – antibiotics 8-12 weeks  Teaching ◦ Safe sex ◦ Weight loss ◦ Avoid spicy or acidic foods ◦ Avoid alcohol and caffeine ◦ Eat more fresh/unprocessed foods & less sugar ◦ Water, water, water!! 58 Benign prostatic hyperplasia (BPH) enlarged prostate  Prostate gland enlarges disrupting outflow of urine from pressure on the urethra  Main cause of urinary retention in men  Risk factors ◦ age, obesity, high protein diet, alcohol & smoking ◦ family history in first degree relative ◦ Restricts the urethra 59 BPH & Prostate Gland Irritative nocturia, frequency, urgency Obstructive weak stream, difficulty starting & stopping stream, dribbling Signs/symptoms 60 Diagnostic Studies (BPH)  History & Physical  Digital Rectal exam (DRE)  Prostatic specific antigen (PSA)  Transrectal ultrasound  Normal for prostate to produce PSA but high level of this can cause prostate CA 61 Medications (BPH)  2 main classes ◦ adrenergic receptor blockers (most end in osin)/often used in BPH pt.  tamsulosin (Flomax) Tamsulosin will help you lose urine; also used to help pass renal calculi/newest med.  Doxazosin (Cardura)  Terazosin (Hytrin) change positions slowly /oldest med.  Side effect: orthostatic hypotension  DO NOT TAKE WITH ERECTILE DYSFUNCTION DRUGS:VIAGRA  DO NOT GIVE WITH ANTI-ACIDS but can take with grapefruit juice  Mode of action ◦ Antagonize alpha 1 receptors, relaxing smooth muscles of the prostate which helps to improve urine flow ◦ Also causes vasodilation NOTE: side effect is hypotension; change positions slowly 62 Medications (BPH) cont. 2 main classes ◦ 5a reductase inhibitors (end in ride)  finasteride (Proscar) also helps with male propecia  dutasteride (Avodart)  Mode of action ◦ 5a reductase inhibitor is the enzyme that prevents conversion of testosterone ◦ Reduces the size of the prostate ◦ NOTE: side effects – erectile dysfunction, gynecomastia(enlarged man boobs); pregnant women should not handle finasteride 63 Complications of BPH  Hydronephrosis is swelling of kidney/s due to build up of urine causing swelling/can be mild to moderate to severe  Urine cannot drain out from kidney to bladder  Causes ◦ blockage of outflow of urine or reflux of urine from bladder to kidney  BPH  Renal stones  Narrowing of ureters  Tumors (bladder, colon, prostate)  Vesicoureteral reflux/ureteral obstruction  Treatment – may need stent(like straw to keep the ureter open) in ureter & nephrostomy tube if severe 64 Transurethral Resection of Prostate (TURP) for BPH  Surgery to remove parts of prostate tissue through the penis (for BPH)  Post procedure 3 way indwelling urinary catheter inserted to provide hemostasis & urinary drainage ◦ Continuous 3-way bladder irrigation (murphy drip) to prevent obstruction of the catheter after surgery ◦ Not removing all of it only a part of the prostate tissue  Intermittent irrigation ◦ Manual irrigation for bladder spasms, clots decreasing outflow Use sterile saline 65  3-way catheter Bladder irrigation helps keep the Urinary catheter from obstructing 66 Patient with Bladder Irrigation  Assess for bleeding & clots ◦ titrate the saline irrigation by increasing or decreasing flow  Monitor inflow and outflow  Manually irrigate catheter for bladder spasms or if decreased outflow occurs  Antispasmodics & analgesics as needed  Monitor for increase in gross hematuria a sign of hemorrhaging 67 Nursing Management  For patient going home teach ◦ kegel exercises ◦ no heavy lifting ◦ s/s of infection(high fever, drainage, warmth, redness, swelling, WBC elevated etc.) ◦ stool softeners to prevent straining ◦ fluid intake 2-3 L per day ◦ avoid caffeine & alcohol ◦ Remind pt to be patient  incontinence is common for several weeks after surgery 68 Prostate cancer  2nd leading cause of cancer death in men  Good prognosis diagnosed early  Age, obesity, alcohol, family history (risk factors)  Increased risk after age 50  No symptoms in early stages  Diagnosed often with PSA & biopsy and DRE  TNM system, Gleason score, & PSA (to stage tumor)  Early recognition & treatment to prevent metastasis ◦ Treatment depends on age and gleason score ◦ Prostate CA likes to go to the bones might not remove prostate if spread to the bones ◦ TURP PT WILL HAVE THE LARGER CATHEDER(TAKES ABOUT 30 mls to inflate) 69 Radical prostatectomy  Removal of prostate, seminal vesicles, & part of bladder  Large indwelling catheter with 20-30 mL balloon is placed (pt goes home with catheter)  Adverse outcomes ◦ erectile dysfunction ◦ urinary incontinence ◦ Educate pt and family to not let the catheter come out ◦ Having a big prostate does not always mean prostate CA 70 Testicular Cancer  More common in young males (15-20s, sometimes in 40s)  Cryptorchidism(testicle does not come down at birth) or family history of testicular cancer  Very curable caught early  tumor marker blood test for diagnosis  Radical inguinal orchidectomy  Staging 0-3  Risk for infertility ◦ Cryopreservation of sperm prior to removal ◦ Do not have children for two years if you have had this 71 Testicular self-exam  Recommended to do self-exam monthly  Examine testicles right after a hot bath or shower  Examine while standing ◦ Roll the testicle between the thumbs and forefingers ◦ Feel for lumps, swelling, hardness or other changes 72 Signs & Symptoms of Testicular Cancer Most found in early stage Lump or swelling on testicle Feeling of heaviness in scrotum Dull ache in lower belly or groin Usually painless in early stages 73 Testicular torsion  Testicle rotates, twisting the spermatic cord that brings blood to the scrotum  Occurs more on left  Reduced blood flow causes sudden and severe pain on one side of the scrotum  MEDICAL EMERGENCY – blood flow must be restored withing 6 hours or testicle will atrophy ◦ No surgery within 6 hours testicle may be removed ◦ No testicular torsion can fix itself ◦ Men in childbearing years and men who lift a lot/sports 74 Causes of Torsion  Occurs in about 1 in 4000 males under age 25 ◦ Vigorous activity ◦ Minor injury to testicles ◦ While sleeping ◦ Undescended testicle ◦ Bell clapper deformity: Born with no tissue holding testes to scrotum allowing testes to swing inside the scrotum 75 Erectile Dysfunction (ED)  Inability to attain or maintain an erection  Increases with age (40 to 70)  Priapism ◦ erection lasting longer than 4 hours  Penile injections  Erectile devices  Erectogenic Drugs- causes vasodilation ◦ sildenafil (Viagra) do not take if on a nitrate ◦ tadalafil (Cialis) do not take if on a nitrate 76 Medications for ED  Erectogenic Drugs (phosphodiesterase type 5 inhibitors) ◦ sildenafil (Viagra) will help you ”fill” out the penis ◦ tadalafil (Cialis)  Mode of Action ◦ increases blood flow to the penis and vasodilation of the pulmonary vasculature ◦ DO NOT take these medications with any nitrates  Nitroglycerin  Side effects ◦ Priapism, increased risk for heart attack 77 Penile implant with pump Corpus cavernosum injection Penile implant with Semi-erection Vacuum device 78 Words to know  Dysuria  Oliguria  Anuria  polyuria 79