Review of Anatomy and Physiology of the Genito-Urinary System

Kidneys

Bean-shaped and highly vascular. Consist of the renal cortex, central renal medulla, internal calyces, and renal pelvis
as well as the nephron, which serves as the kidney’s functional unit.
○ Filtration: The nephron, the functional unit of the kidney, sits within the cortex. It's responsible for
filtering blood plasma, removing waste products and excess fluid, while retaining essential
components like water, electrolytes, and proteins.
○ Reabsorption: In the proximal tubule, the body selectively reabsorbs valuable substances like water,
electrolytes, glucose, and amino acids back into the bloodstream.
○ Secretion: The nephron also secretes waste products and excess hydrogen ions into the urine from
the blood through the distal tubule and collecting duct.
○ Excretion: Filtered urine then flows into the minor calyces, then the major calyces, then the renal
pelvis, which is the funnel-shaped reservoir of the kidney.

Overall, kidneys are responsible for the following functions:

● Removal of waste products
● Removal of drugs and medications
● Balance the body’s fluids
● Release of hormones to regulate blood pressure
● Produce an active form of vitamin D
● Assist in the production of red blood cells

Ureters ● The ureters, one from each kidney, are tubes that carry urine from the
kidney to the urinary bladder.
● About 10 to 12 inches long
● Have muscular walls that contract and relax to push urine downward.
● They are responsible for taking urine that has been filtered and
reabsorbed in the kidneys to the bladder for storage and excretion.
● upper half = located in the abdomen
● lower half = located in the pelvic area

Urinary Bladder

● A hollow, spherical, muscular organ in the pelvis.

● The bladder wall has three main layers:
○ Mucosa: The inner layer, which lines the bladder and is responsible for trapping and storing urine.
 ○ Muscularis: The middle layer, made of smooth muscle, allows the bladder to expand and contract to
store and expel urine.
○ Adventitia: The outer layer, which connects the bladder to surrounding tissues.

The bladder functions are:

● Storage: The bladder stores urine produced by the kidneys. The bladder can store up to 2 cups of urine before
it needs to be emptied.
● Emptying: The bladder empties urine through the urethra, a tube that connects the bladder to the outside of
the body.
● Continence: The bladder muscles and sphincters work together to maintain continence, preventing
involuntary urine leakage. The internal urethral sphincter is a muscle ring that stays closed unless the bladder
is full and contracts to initiate urination.

Urethra: ● A hollow tube that connects the urinary bladder to the urinary meatus.
● It allows urine to be excreted from the body.
● It is lined by stratified columnar epithelium, which is protected from
the corrosive urine by mucus secreting glands.
● The length of the urethra differs in human females and males.
● Females
○ The urethra is about 1.5 inches (3 to 4 centimeters) long.
○ It opens to the outside of the body between the vagina and the
clitoris.
● Males
○ The urethra is about 8 to 9 inches long (about 20 centimeters).
○ It passes through the prostate gland, the urogenital diaphragm,
and the penis. In these regions, the urethra is called the
prostatic urethra, membranous urethra, and spongy (penile)
urethra, respectively.
● In both males and females, a skeletal muscle, the external urethral
sphincter, surrounds the urethra as it passes through the urogenital
diaphragm.
● Urination happens when the bladder is filled (around 200-300 mL),
triggering a reflex. The spinal cord sends a signal to relax the internal
urethral sphincter and contract the detrusor muscle.
● The internal urethral sphincter is involuntary. The external urethral
sphincter is voluntary. It is the external urethral sphincter that we
learned to control when going through the potty training phase of life.

Clients with Inflammatory Disorders of the GUT

 UTI (Upper and Lower tract)

Definition: ​Urinary tract infections (UTIs) are caused by pathogenic Assessment:

microorganisms
in the urinary tract. ● Patient history of pertinent signs
and symptoms
A UTI is the second most common infection in the body. Most cases occur ● Urine Assessment
in women; one out of every five women in the United States will develop a ● Urine cultures- Urine cultures are
UTI during her lifetime. useful for documenting a UTI and
identifying the specific organism
Urinary tract infections (UTIs) are classified by location: the lower present.
urinary tract (which includes the bladder and structures below the ● Cellular studies- microscopic
bladder) or the upper urinary tract (which includes the kidneys and hematuria is present in about
ureters). They can also be classified as uncomplicated or complicated half of patients with an acute UTI.
UTIs. ● Multiple-test dipstick- often
includes testing for WBCs, known
LOWER UTI as the leukocyte esterase test,
● Lower UTIs include bacterial cystitis (inflammation of the urinary and nitrite testing.
bladder), bacterial prostatitis (inflammation of the prostate gland), ● Tests for sexually transmitted
and bacterial urethritis (inflammation of the urethra). infections may be performed
● Signs and symptoms of an uncomplicated lower UTI include because acute urethritis caused
burning on urination, urinary frequency (voiding more than every by sexually transmitted
3 hours), urgency, nocturia, incontinence, and suprapubic or pelvic organisms or acute vaginitis
pain. Hematuria and back pain may also be present. infections may be responsible for
● In patients with complicated UTIs, manifestations can range from symptoms similar to those of
asymptomatic bacteriuria to gram-negative sepsis with shock. UTIs.

UPPER UTI
● Upper UTIs are much less common and include acute or chronic
pyelonephritis (inflammation of the renal pelvis), interstitial
nephritis (inflammation of the kidney), and kidney abscesses.
Early symptoms of UTI in older adults include burning, urgency, and fever.

Pathophysiology:
Pharmacologic and Medical Care: Diagnostic and Laboratory:

● Trimethoprim-sulfamethoxazole (TMP-SMX): TMP-SMX is a ● Complete Blood Count (CBC)-

combination of two antibiotics that is effective against a wide To evaluate a patient for sepsis, a
range of bacteria. It is a common first-line treatment for severe reaction to infection.
uncomplicated UTIs. (Bactrim, Septra) ● Blood Culture- To assess if a UTI
● Nitrofurantoin: Nitrofurantoin is another common first-line has spread to your blood.
treatment for uncomplicated UTIs. It is available in both oral and ● Urodynamic testing- Tests how
topical formulations. It has a low potential for antibiotic resistance well your bladder, sphincters,
and holds an 83 to 93 percent cure rate. This drug is frequently and urethra are storing and
used to treat UTIs in pregnant women. (Macrodantin, Macrobid) releasing urine.
● Fosfomycin: Fosfomycin is a single-dose antibiotic that is effective ● Ultrasonography and kidney
against a wide range of bacteria. It is often used for uncomplicated scans are extremely sensitive for
UTIs that do not respond to other antibiotics. (Monurol) detecting obstruction, abscesses,
● Fluoroquinolones: Fluoroquinolones are a class of antibiotics tumors, and cysts.
that are effective against a wide range of bacteria, including some ● Urinalysis- A urinalysis is a
that are resistant to other antibiotics. However, they should be group of physical, chemical, and
used as a last resort due to the risk of side effects. microscopic tests on a sample of
urine. These tests look for
evidence of infection, such as
bacteria and white blood cells.

Nursing Management:

​Patient Education
● Educate the patient about UTIs, including the causes, symptoms, and treatment.
● Encourage the patient to drink plenty of fluids to help flush out bacteria from the urinary tract.
● Advise the patient to urinate frequently to prevent bacteria from building up in the bladder.
● Instruct the patient on proper perineal hygiene to help prevent the spread of bacteria to the urethra.
● Counsel the patient on the importance of taking antibiotics as prescribed to prevent recurrence of the UTI.
Fluid Management
● Encourage the patient to drink plenty of fluids, at least 2-3 liters per day, unless contraindicated.
● Monitor the patient's fluid intake and output to ensure adequate hydration.
● If the patient is unable to drink enough fluids orally, intravenous fluids may be ordered.
Pain Management
● Assess the patient's pain level and provide appropriate pain medication as ordered.
● Apply a warm compress to the patient's lower abdomen to help relieve pain.
● Encourage the patient to take sitz baths to help soothe the pain and inflammation.
Prevention of Recurrence
● Counsel the patient on the importance of practicing good hygiene habits to prevent the spread of bacteria to
the urethra.
● Encourage the patient to wear loose-fitting, cotton underwear to help keep the area around the urethra dry.
● Advise the patient to shower rather than bathe to prevent the spread of bacteria.
● If the patient is sexually active, encourage them to use a diaphragm or condom to reduce the risk of UTI.
Additional Nursing Interventions
● Monitor the patient's vital signs, including temperature, blood pressure, and pulse, for signs of infection.
● Monitor the patient's urine output and appearance for any changes.
● Collect urine specimens for laboratory testing as needed.
● Provide emotional support and reassurance to the patient.
Discharge Planning
● Review the patient's discharge instructions with them before they leave the hospital.
● Make sure the patient understands the importance of taking antibiotics as prescribed.
● Provide the patient with written instructions on how to prevent UTIs.
 Pyelonephritis

Definition: Also known as pyelitis or nephropyelitis Pyelonephritis Assessment:

refers to the inflammation of the functional kidney tissue, also known
as the renal pelvis and parenchyma. Common signs and symptoms associated with
It is an infection caused by bacteria in one or both kidneys that affects pyelonephritis include:
the renal pelvis, tubules, and interstitial tissue.
● Back, side, and groin pain
● Acute pyelonephritis is a bacterial infection of the kidney. Chronic ● Urgency and frequency of urination
pyelonephritis, on the other hand, is caused by non bacterial ● Pain with urination
infections and inflammatory processes that may be metabolic, ● Fever
chemical, or immunologic in origin. ● Nausea and vomiting
● The urine is usually cloudy, containing
● It can be secondary to ureterovesical reflux or the backflow of urine
mucus and blood
from the bladder into the ureters, this is when urine cannot drain
from the pelvis of the kidney because of an obstruction blocking the Additional signs and symptoms include chills,
kidney or ureter such as stones, strictures, or tumors tachycardia, tachypnea, nocturia, generalized
malaise, and fatigue

Pathophysiology: Pharmacologic and Medical Care:

● Pyelonephritis is generally treated

with sulfonamides, such as
trimethoprim-sulfamethoxazole(TMP-
SMX,Bactrim)or the antimicrobial
ciprofloxacin hydrochloride (Cipro).
● Antipyretics are used to reduce fever.
● Analgesics are also used to manage
pain.
● Treatment often is started before
urine culture results are obtained,
because these drugs are effective
against the usual organisms.
Compliance is better with a 3-day
course of treatment; however, it is not
used for clients with recurrent
infections or acute pyelonephritis.
● Acute pyelonephritis usually requires
10 to 21 days of antibiotic therapy.
Intravenous antibiotics may be
necessary if the infection is severe or
nausea and vomiting are present

Diagnostic and Laboratory: Nursing Management: It is important to

● Urinalysis closely monitor the patients during their
● KUB x-ray/CT scan treatment to ensure that the medications are
● CBC working correctly and that the patient is
● Voiding cystourethrography responding positively to the treatment plan.
● Cystoscopy Regular physical exams, urinalysis, and other
tests should be conducted to assess the
effectiveness of the interventions.
 Clients with Vascular Disorders of the GUT

Renal Artery stenosis

Definition: Assessment:

Renal artery stenosis (RAS) is a narrowing of the Symptoms of RAS can vary depending on the severity of the
arteries that carry blood to the kidneys. narrowing and the amount of kidney damage that has
occurred. Some common symptoms include:
RAS can be caused by a number of factors, including:
● Atherosclerosis: This is a buildup of plaque in ● High blood pressure
the arteries, which can narrow them. ● Headache
● Fibromuscular dysplasia: This is a condition ● Fatigue
that causes the walls of the arteries to thicken ● Shortness of breath
and narrow. ● Back pain or flank pain
● Takayasu arteritis: This is a rare autoimmune ● Blood in the urine
disease that can cause inflammation of the ● Reduced urine output
arteries. ● Enlarged kidneys

Pathophysiology:

Diagnostic and Laboratory: Pharmacologic and Medical Care:

Treatment options for RAS include:
● Blood tests ● Medications
● Urine tests ○ Angiotensin-converting enzyme (ACE)
● Renal angiography inhibitors
● Renography ○ Angiotensin II receptor blockers (ARBs)
● renal duplex Doppler ultrasonography: ○ Statins
○ Anticoagulants
○ Diuretics
● Procedures
○ Renal angioplasty
○ Stent placement
○ Renal artery bypass surgery
○ Renal endarterectomy
○ Surgical revascularization
Nursing Management:

● Assess the patient's symptoms, risk factors, vital signs, weight, laboratory findings, and imaging findings.
● Monitor the patient's fluid intake and output and weigh the patient daily
● Assess the patient's overall health and well-being, including their nutritional status, mental health, and social
support system.
● Administer medications as prescribed by the doctor and monitor the patient's response to medications.

Nephrosclerosis

Definition:
Nephrosclerosis (hardening of the renal
arteries) is most often due to prolonged
hypertension and diabetes.,
Nephrosclerosis is a major cause of CKD
(chronic kidney disease) and ESKD
(end-stage kidney disease) secondary to
many disorders.
There are two types of nephrosclerosis:
benign and malignant. Benign is more
common and progresses slowly, while
malignant is rare and rapidly worsens.
Assessment:
● Inquire the patient’s medical history, including any pre-existing
conditions such as hypertension, diabetes, or chronic kidney
disease.
● Perform a thorough physical examination, paying attention to
signs of kidney disease, including: edema, hypertension, renal
artery bruits, and tenderness or masses related to the kidneys.
Signs and symptoms
● Unhealthy levels of blood pressure
● Swelling in the feet, ankles, or legs.
● Fluid retention
● Changes in urine output and color.
● Fatigue and weakness
● Decreased appetite
● Generalized itching of the skin.
● Nausea and vomiting.

Pathophysiology:

Diagnostic and Laboratory: Pharmacologic and Medical Care:

 ● Urine Testing Medications
● Ultrasonography
● Kidney biopsy
● Blood tests
○ Serum Creatinine and
Blood Urea Nitrogen
(BUN)
○ Electrolyte Levels (e.g.,
Sodium, Potassium)
● Angiotensin converting enzyme (ACE) inhibitors: to reduce
blood pressure and improve kidney function by increasing the
amount of urine produced and decreasing fluid retention in the
body.
● Angiotensin II receptor blockers (ARBs):a type of medication
used to treat nephrosclerosis. Commonly prescribed ARBs for
nephrosclerosis include Losartan, Candesartan, Valsartan, and
Olmesartan.
● Diuretics: commonly prescribed for nephrosclerosis are thiazide
diuretics: hydrochlorothiazide and indapamide. Used to help
reduce fluid retention and pressure on the vascular walls.
● Calcium channel blockers: to help decrease blood pressure and
reduce the risk of kidney damage from nephrosclerosis.

Therapy
● Dialysis
● Lifestyle Changes

Surgical Management
● Kidney Transplant

Nursing Management:
● Monitor blood pressure regularly.
● Administer antihypertensive medications as prescribed.
● Monitor blood glucose levels regularly.
● Administer insulin or oral hypoglycemic medications as prescribed.
● Monitor fluid intake and output.
● Implement restrictions on fluid and sodium intake as necessary.
● Monitor renal function through regular assessments of serum creatinine, blood urea nitrogen (BUN), and
glomerular filtration rate (GFR).
● Report any significant changes in renal function promptly.
● Administer pain medications as prescribed.
● Collaborate with a dietitian to develop a renal-friendly diet plan.
● Monitor for signs of fluid overload, electrolyte imbalances, and infections.
● Patient Education:
○ Provide information on the importance of medication adherence.
○ Educate the patient on the significance of regular follow-up appointments.
○ Teach self-monitoring techniques for blood pressure and blood glucose levels.
● Collaborate with physicians, nephrologists, dietitians, and other healthcare professionals.

Clients with Obstructive Disorder of GUT

Renal Calculi

Definition: Assessment:

Renal calculi, also known as kidney stones, are
hard deposits that form inside the kidneys.
They are made up of minerals and salts that
crystallize in the urine.
Kidney stones can form anywhere in the
urinary tract, which includes the kidneys,
● Assess for signs and symptoms such as pain, hematuria,
dysuria, nausea, vomiting, and fever.
● Assess for risk factors for kidney stones, such as
dehydration, diet, family history, and medical conditions
such as obesity, diabetes, and hyperparathyroidism.
● Inspect and palpate the abdomen for tenderness or
distention.
ureters, bladder, and urethra. ● Inspect the genitalia for signs of infection or irritation

Urolithiasis and nephrolithiasis: Clinical Manifestations:

Urolithiasis - refers to the formation of stones Signs and symptoms of stones in the urinary system depend on the
anywhere in the urinary tract, including the presence of obstruction, infection, and edema.
kidneys, ureters, bladder, and urethra.
Nephrolithiasis - kidney stones that form in the Obstruction:
kidneys. ● Increase in hydrostatic pressure
● Distention of the renal pelvis and proximal ureter
Infection:
There are four main types of kidney stones: ● Chills
● Fever
● Calcium oxalate stones: They are made ● Frequency
up of calcium and oxalate, a substance ● Pyelonephritis
that is found in many foods. ● UTI
● Uric acid stones: These stones are made Renal stones:
up of uric acid, a waste product that is ● Pain
produced by the body when it breaks ● Hematuria
down purines, substances that are ● Pyuria
found in some foods. ● Intense, deep ache in the costovertebral region
● Struvite stones: These stones are made ● Radiation of pain anteriorly and downward toward the
up of magnesium, ammonium, and bladder in the female and toward the testes in the male
phosphate. Ureteral stones:
● Cystine stones: These stones are made ● Acute, excruciating, colicky, wavelike pain that radiates
up of cystine, an amino acid. down the thigh and to the genitalia
● Desire to void, but little urine is passed
● Blood in the urine
Bladder stones:
● Symptoms of irritation
● UTI
● Hematuria
● Urinary retention if the stone obstructs the bladder neck

Pathophysiology: Diagnostic and Laboratory:

● Blood test
● Urinalysis
● noncontrast CT Scan
● Chemical and stone analysis

Pharmacologic and Medical Care:

Medical Management:
● Opioid analgesics
 ○ Morphine sulfate
● NSAIDs
○ Ketorolac
● Spasmolytic drugs
○ Oxybutynin chloride
● Antibiotics
○ Gentamicin, cephalexin
● Increase fluid consumption to aid in the passage of the stone, unless the patient is vomiting.
● Heat therapy: Hot baths or moist heat to the flank area may also be helpful.

Specific medications may be used to treat kidney stones depending on the type of stone.
● Calcium stones
○ Ammonium chloride
○ Thiazide diuretics
○ Orthophosphates
○ Sodium cellulose phosphate
● Uric acid stones may be treated with allopurinol.
○ Allopurinol (Zyloprim)
○ Potassium
○ sodium citrate
○ sodium bicarbonate
● Cystine stones may be treated with a low-protein diet, urine alkalinization, and increased fluid intake.
○ Alpha mercaptopropionylglycine (AMPG)
○ Captopril (Capoten)

Interventional Procedures:
● Ureteroscopy Surgical Management:
● Extracorporeal shock wave lithotripsy ● Nephrolithotomy
(ESWL) ● Nephrectomy
● Endourologic (percutaneous) stone ● Pyelolithotomy
removal ● Ureterolithotomy
● Chemolysis ● Retrograde ureteroscopy
● Stenting
● Cystotomy
● Cystolitholapaxy

Nursing Management:

● Assess the patient's pain level regularly and administer pain medications as prescribed.
● Encourage the patient to drink plenty of fluids.
● Strain the patient's urine to collect any stones that are passed.
● Monitor the patient's vital signs and fluid intake and output.
● Inspect the patient's urine for blood and signs of infection.
● Teach the patient about renal calculi, including the causes, symptoms, treatment options, and prevention
strategies. This includes instructing the patient to:
○ Avoid protein intake to decrease urinary excretion of calcium and uric acid.
○ Limit sodium intake to 3–4 g/day.
○ Be aware that low-calcium diets are not generally recommended, except for true absorptive
hypercalciuria.
○ Avoid intake of oxalate-containing foods.
■ Spinach, black tea, rhubarb, cocoa, beets, pecans, peanuts, okra, chocolate, wheat germ, lime
peel, and Swiss chard
○ Drink fluids (ideally water and one glass of cranberry juice per day) every 1–2 hours during the day.
○ Drink two glasses of water at bedtime and an additional glass at each nighttime awakening.
○ Avoid activities leading to sudden increases in environmental temperatures that may cause excessive
sweating and dehydration.
○ Contact the primary provider at the first sign of a urinary tract infection.

Definition: A urethral stricture Assessment:
involves scarring that narrows the
tube that carries urine out of the body,
called the urethra. As a result of a
stricture, less urine comes out of the
bladder. This can cause problems in
the urinary tract, such as infection.
Diagnostic and Laboratory:
● Urine tests
● Urinary flow test
● Urethral ultrasound
● Pelvic ultrasound
● Pelvic MRI scan
● Retrograde urethrogram
● Cystoscopy
Urinary strictures
● Obtain a detailed medical history, including the onset and duration of
symptoms.
● Inquire about any history of urethral trauma, infections, or previous
urethral surgeries.
● Perform a thorough physical examination.
Signs and symptoms
● Weak urine stream
● Urethral discharge
● Penile swelling and pain
● Presence of blood in the semen or urine
● Darkening of the urine
● Sudden, frequent urges to urinate
● Painful urination (dysuria)
● Urinary tract infection (UTI)
● Urinary retention
● Frequent starting and stopping urinary stream
● Pain or burning during urination
● Pain in the pelvic or lower abdominal area
Pathophysiology:
Pharmacologic and Medical Care:
● Currently no drug treatments for this disease
Nonsurgical Procedures
● Urethral dilation: done under general anesthesia, a metal tube
(dilator) is inserted into the urethra in order to stretch the area of the
stricture.
● Permanent urethral stents: small mesh tubes inserted inside the
 urethra to keep it open. They integrate with the urethral wall over
time and are suitable for patients unable to undergo urethral
reconstruction due to other medical conditions.

Surgical Procedures
● Open urethroplasty: scarred part of the urethra is removed and then
either the healthy part of the urethra is reconnected or the urethra is
reconnected using a graft.
● Urine flow diversion: in severe cases, a complete urinary diversion
procedure may be necessary.

Nursing Management:
● Monitor urinary patterns, including frequency, urgency, and any signs of obstruction.
● Monitor fluid intake and output to ensure an adequate urinary flow.
● Encourage sufficient hydration to prevent urinary tract infections (UTIs) and facilitate urine passage.
● Administer pain medications as prescribed.
● If a catheter is in place, ensure proper placement and functioning.
● Monitor for signs of catheter-related complications, such as infection or blockage.
● Implement strict aseptic techniques during catheter care and any urinary procedures.
● Monitor for signs of UTIs, such as fever, dysuria, and cloudy urine.
● Assist with finding comfortable positions and encourage mobility.
● Collaborate with urologists and other healthcare professionals.

Benign Prostatic Hyperplasia (BPH)

Definition: Benign prostatic hyperplasia (BPH) is a Assessment:

noncancerous enlargement or hypertrophy of the
prostate, and is one of the most common diseases in
aging men. It can cause bothersome lower urinary
tract symptoms that affect quality of life by interfering
with normal daily activities and sleep patterns.
BPH typically occurs in men older than 40 years. By
the time they reach 60 years, 50% of men have BPH. It
affects as many as 90% of men by 85 years of age. BPH
is the second most common cause of surgical
intervention in men older than 60 years.
The health history focuses on the urinary tract, previous
surgical procedures, general health issues, family history of
prostate disease, and
fitness for possible surgery.
Obstructive and irritative symptoms may include:
● Urinary frequency and urgency
● Nocturia
● Hesitancy in starting urination
● Decreased and intermittent force of stream and the
sensation of incomplete bladder emptying
● abdominal straining with urination
● a decrease in the volume and force of the urinary
stream

Pathophysiology:
Diagnostic and Laboratory:
● PSA (Prostate-Specific Antigen) Test: PSA is
a protein produced by the prostate gland.
Elevated PSA levels may indicate BPH, prostate
cancer, or prostatitis. However, PSA testing is
not definitive for BPH diagnosis.
● Urinalysis: A urinalysis checks for the
presence of blood, white blood cells, or
bacteria in the urine, which could indicate
infection or other urinary tract abnormalities.
● Urine Flowmetry: This test measures the
strength and duration of the urinary stream to Medical Therapy
assess urinary flow dynamics.
Minimally Invasive Procedures
● Post-Void Residual (PVR) Volume: This test
measures the amount of urine remaining in the
bladder after urination. An elevated PVR may
indicate incomplete bladder emptying due to
BPH.
● dribbling (urine dribbles out after urination)
● complications of acute urinary retention and
recurrent UTIs.
Generalized symptoms may also be noted, including:
● fatigue
● anorexia
● nausea
● vomiting
● pelvic discomfort
Pharmacologic and Medical Care:
● Alpha-blockers: Alpha-blockers relax the muscles in
the prostate and bladder neck, making it easier to
urinate. Examples of alpha-blockers include
tamsulosin (Flomax), alfuzosin (Uroxatral),
doxazosin (Cardura), and terazosin (Hytrin).
● 5-alpha reductase inhibitors: 5-alpha reductase
inhibitors reduce the production of
dihydrotestosterone (DHT), a hormone that causes
the prostate gland to grow. Examples of 5-alpha
reductase inhibitors include finasteride (Proscar)
and dutasteride (Avodart).
● Transurethral resection of the prostate (TURP):
TURP is a procedure that uses a resectoscope to
remove enlarged prostate tissue.
 ● Transrectal Ultrasound (TRUS): TRUS uses ● Holmium laser enucleation of the prostate
ultrasound waves to visualize the prostate (HOLEP): HOLEP is a procedure that uses a laser to
gland and measure its size and shape. remove enlarged prostate tissue.
● Cystoscopy: Cystoscopy involves inserting a
thin tube with a camera into the urethra to Open Surgery
directly visualize the bladder and urethra. It is ● ​Transurethral incision of the prostate (TUIP)-
primarily used to rule out other causes of TUIP is an outpatient procedure used to treat smaller
urinary symptoms, such as bladder stones or prostates. One or two cuts are made in the prostate
urethral strictures. and prostate capsule to reduce constriction of the
urethra and decrease resistance to flow of urine out
of the bladder; no tissue is removed.

● Prostatectomy: Prostatectomy is a procedure that

removes the entire prostate gland.

Nursing Management:

Preoperative Care

● Assessment: Perform a thorough assessment of the patient's history, physical examination, and laboratory
findings to understand the extent of BPH and identify any potential complications.
● Education: Educate the patient about BPH, its symptoms, treatment options, and potential complications.
Provide clear instructions on preoperative preparation, including dietary restrictions, medication adjustments,
and bowel preparation.
● Medication Management: Review the patient's current medications and make necessary adjustments as
prescribed by the physician. Monitor for any adverse effects of medications and provide appropriate
interventions.
● Psychological Support: Offer emotional support and reassurance to the patient, addressing their concerns and
anxieties related to the upcoming surgery.

Intraoperative Care
Circulating Nurse:
● Assist the surgical team in maintaining a sterile environment and ensuring patient safety throughout the
procedure.
● Monitor the patient's vital signs, hemodynamic parameters, and fluid balance closely.
● Administer medications as ordered by the surgeon.
● Communicate with the anesthesiologist regarding the patient's condition and any potential concerns.

Scrub Nurse:
● Anticipate the surgeon's needs and prepare the necessary instruments and equipment.
● Maintain a sterile field throughout the procedure.
● Hand surgical instruments to the surgeon efficiently and safely.
● Count surgical sponges and instruments before and after the procedure to ensure none are retained in the
patient's body.

Postoperative Care
● Pain Management: Assess the patient's pain level regularly and administer pain medication as ordered.
Monitor for any adverse effects of pain medication.
● Catheter Care: If a catheter is present, provide proper care and education to the patient on catheter
management, including cleaning techniques, drainage bag maintenance, and signs of potential complications.
● Bladder Drainage: Monitor the patient's urine output and assess bladder function. Encourage fluid intake to
promote adequate urine production.
● Wound Care: Assess the surgical incision for signs of infection, bleeding, or dehiscence. Dress the wound as
needed and provide wound care education to the patient.
 ● Activity Restriction: Adhere to the physician's orders regarding activity restriction and gradually increase
activity as tolerated.
● Diet and Fluid Management: Encourage a balanced diet and adequate fluid intake to promote healing and
prevent constipation.
● Discharge Planning: Provide comprehensive discharge instructions, including medication reconciliation,
wound care instructions, follow-up appointments, and signs and symptoms to report.
● Emotional Support: Continue to provide emotional support and address any concerns or anxieties the patient
may have during the recovery period.

Additional Considerations
● Patient Education: Reinforce patient education regarding BPH, its management, and potential complications.
Encourage lifestyle modifications, such as fluid intake, bladder training, and dietary adjustments, to promote
long-term urinary health.
● Collaboration with Healthcare Team: Collaborate effectively with other members of the healthcare team,
including physicians, urologists, and physical therapists, to ensure comprehensive care for the patient with
BPH.

Client with Problems in the GUT related Structures

Phimosis and paraphimosis

Definition: Phimosis is a condition in which the foreskin Assessment:

(prepuce) cannot be retracted over the glans in
uncircumcised males. Phimosis often develops in adults Physical Examination:
as a result of inflammation, edema, and constriction
because of poor hygiene or underlying medical
conditions such as diabetes. The thickened secretions
(smegma) can become encrusted with urinary salts and
calcify, forming calculi in the prepuce and increasing the
risk of penile carcinoma.
Paraphimosis is a condition in which the foreskin, once
retracted over the glans, cannot be returned to its usual
position. Chronic inflammation under the foreskin leads
to formation of a tight ring of skin when the foreskin is
retracted behind the glans, causing venous congestion,
edema, and enlargement of the glans, which makes the
condition worse. As the condition progresses, arterial
occlusion and necrosis of the glans may occur.
● Obtain a detailed medical history, including
information about any sudden onset of genital pain,
swelling, or discomfort.
● Ask the patient if they have attempted to manually
reduce the paraphimosis.
● Respect the patient's privacy and ensure their
comfort during the examination.
● Inspect the genitalia, focusing on the appearance of
the penis and foreskin.
● Assess the presence of paraphimosis by observing
visible swelling of the glans and constriction of the
foreskin.
● Note any discoloration, changes in tissue texture, or
signs of impaired blood flow to the glans (a medical
emergency).
● Check for signs of infection, ulceration, or tissue
damage due to the constriction.
 ● Evaluate the patient's pain level and overall
discomfort.

Pathophysiology: Diagnostic and Laboratory:

● Urinalysis
● Blood tests (CBC)
● If there are signs of infection, swabs or cultures of
the affected area may be obtained to identify the
causative microorganisms and guide appropriate
antibiotic treatment.

Pharmacologic and Medical Care:

Treatment for phimosis secondary to inflammation:

● Topical Steroid Creams: For mild cases of phimosis, topical steroid creams may be prescribed. These creams
contain corticosteroids and can help reduce inflammation and soften the foreskin, making it easier to retract.
● May also be recommended to do daily stretching exercises to gradually increase the elasticity of the foreskin.
● Circumcision

Treatment for paraphimosis:

● Compressing the glans for 5 minutes to reduce the tissue edema and size and then pushing the glans back
while simultaneously moving the foreskin forward (manual reduction). The constricting skin ring may require
incision under local anesthesia. Circumcision is usually indicated after the inflammation and edema subside.
● Over-the-counter or prescribed pain relievers to alleviate discomfort during and after reduction procedures.
● Antibiotics
● Intravenous Fluids

Nursing Management for Phimosis:

● Explain the importance of maintaining proper hygiene to prevent infection and irritation.
● Educate the patient or caregiver on how to apply topical steroid cream, emphasizing the importance of
following the prescribed regimen.
● Teach the patient or caregiver how to perform foreskin stretching exercises, emphasizing the importance of
gentle and gradual stretching.

Nursing Management for Paraphimosis:

● Administer prescribed pain relievers to alleviate pain and discomfort during and after reduction procedures.
Administer prescribed antibiotics if indicated.
● Assess for signs of infection, such as redness, swelling, or discharge, and report findings promptly.
● In severe cases, administer IV fluids as directed to reduce edema and improve blood flow.
● Continuously monitor the patient's vital signs
● Observe for any complications, such as changes in tissue color, swelling, or signs of infection.
● Ensure that the patient is referred to a urologist for further evaluation and management.
 Testicular torsions

Definition: In the male reproductive system, the spermatic cord Assessment:

is the one supplying blood to the testis. In testicular torsions, the The following are signs and symptoms that may
testis rotates which causes the spermatic cord to be twisted, indicate the occurrence of testicular torsions:
impeding the arterial and venous supply to the testicles and
surrounding structure. This is a surgical emergency and may ● Sudden, severe pain in the testicle which
either occur spontaneously, the result of a trauma, or because of may develop over 1 to 2 hours, with or
anatomic abnormality. Testicular torsions most likely occur in without a predisposing event
males that are younger than 20 years old. If blood supply is still ● Nausea and lightheadedness
not restored after 6 hours, this may lead to death of the
● Testicular tenderness
testicular tissue
● Swelling of the scrotum
● A tender mass or knot above the testis
● Elevated testis
● Change in scrotum color
● Frequent urination
● Fever

Pathophysiology: Diagnostic and Laboratory:

● Physical examination
● Ultrasonography
● Urine and blood test
● Surgical Exploration

Pharmacologic and Medical Care:

● Pain Management: Although testicular torsion needs prompt surgery, pain relief medication can be given to the
client while awaiting the surgery. The physician might prescribe opioids, or NSAIDs to alleviate pain which can
help in reducing discomfort and anxiety to the client.
● Antibiotic: Administering antibiotics to the client is not a treatment for the condition but a precautionary
measure for the surgery. This is given to reduce the risk of infection to clients while in surgery.
● Manual Detorsion: If surgery is not immediately available, the healthcare provider might attempt a manual
detorsion to relieve the blood flow and salvage the testicle.
Nursing Management:

● Continuously assess and reassess the patient's pain level, making adjustments to pain management as
necessary.
● Continuously monitor the patient's vital signs, especially blood pressure and heart rate, to detect any signs
of hemodynamic instability that could result from compromised blood flow to the testicle.
● Keep the scrotal area clean and dry to minimize the risk of infection or skin irritation.
● Monitor the color of the scrotum and surrounding tissues for pallor (paleness) or cyanosis (bluish
discoloration), which can indicate impaired blood flow.
● Administer the pain relief medications, antibiotics, and other medications as ordered by the physician

Orchitis

Definition: a rare, acute Assessment:

inflammatory response of one or
both testes as a complication of History of Present Illness:
systemic infection or as an ● Onset and duration of symptoms
extension of an associated ● Character of pain: sharp, dull, aching
epididymitis caused by bacterial, ● Location of pain: unilateral or bilateral
viral, spirochetal, or parasitic ● Associated symptoms: fever, urethral discharge, dysuria
organisms. ● Past medical history: previous episodes of orchitis, STIs
● Medications: potentially causative medications
Micro-organisms may reach the
testes through the blood, Psychosocial History:
lymphatic system, or, more ● Impact of symptoms on daily activities, emotional well-being
commonly, by traveling through ● Concerns about fertility, sexual function
the urethra, vas deferens, and
epididymis; bacteria usually Vital Signs:
spread from an associated ● Temperature: evaluate for fever
epididymitis in sexually active ● Blood pressure: assess for signs of dehydration
men. ● Pulse: monitor for tachycardia

Causative organisms include Inspection:

Neisseria gonorrhoeae, Chlamydia ● Scrotum: observe for swelling, redness, bruising
trachomatis, E. coli, Klebsiella, ● Skin: check for lesions, rashes
Pseudomonas aeruginosa,
Staphylococcus species, and Palpation:
Streptococcus species. ● Testicles: gently palpate for tenderness, enlargement, irregularity
● Epididymis: feel for tenderness, enlargement
● Inguinal lymph nodes: assess for enlargement
● Neurological Assessment:
○ Sensory: assess sensation in the scrotum and testes
○ Motor: evaluate for any motor deficits

Pathophysiology:
Diagnostic and Laboratory:
● Ultrasound-to visualize
the testicles
● Blood tests-to check for
infection
● Urine tests-to rule out
STIs.
Nursing Management:
Assessment
● Thorough History: Obtain a detailed history of the patient's symptoms, including onset, duration, character,
and aggravating factors. Inquire about any history of STIs, trauma to the testicles, or autoimmune disorders.
● Physical Examination: Perform a comprehensive physical examination, focusing on the scrotum. Assess for
Signs and symptoms of orchitis include:
● Fever
● pain, which may range from mild to severe
● tenderness in one or both testicles;
● bilateral or unilateral testicular swelling
● penile discharge
● blood in the semen
● leukocytosis.
Pharmacologic and Medical Care:
For viral orchitis, treatment is typically focused on managing symptoms and
providing supportive care. This may include:
● Bed Rest: Resting the testicles can help to reduce inflammation and pain.
● Ice packs: Applying ice packs to the scrotum can help to reduce swelling
and pain.
● Pain relievers: Over-the-counter pain relievers, such as ibuprofen or
acetaminophen, can help to relieve pain.
● Scrotal support: Wearing a scrotal support can help to reduce discomfort
and protect the testicles from further injury.
Bacterial orchitis requires antibiotic treatment. The specific type of antibiotic
used will depend on the type of bacteria that is causing the infection. Antibiotic
treatment is typically given for 10-14 days.
Autoimmune Orchitis
Autoimmune orchitis is treated with corticosteroids or other
immunosuppressive medications. These medications help to suppress the
immune system and reduce inflammation.
Trauma
Treatment for orchitis caused by trauma typically involves pain management
and scrotal support. In some cases, surgery may be necessary to repair any
damage to the testicles or epididymis
 swelling, redness, tenderness, and enlargement of the testicles and epididymis. Check for inguinal lymph node
enlargement.
● Pain Assessment: Evaluate the patient's pain level using a pain scale. Assess the location, intensity, and quality
of pain. Monitor for changes in pain severity over time.

Pain Management
● Pharmacological Interventions: Administer pain medication as prescribed by the physician. This may include
analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), or opioids. Monitor for adverse effects of pain
medication.
● Non-pharmacological Interventions: Apply scrotal support to reduce pain and discomfort.
● Encourage rest and avoid strenuous activities that may aggravate pain.

Infection Control
● Hand Hygiene: Practice strict hand hygiene to prevent the spread of infection. Encourage the patient to wash
their hands frequently, especially after touching the scrotum or dressing changes.
● Dressing Changes: Perform dressing changes as needed, using sterile technique and appropriate personal
protective equipment (PPE).
● Catheter Care: If a urinary catheter is present, provide proper catheter care to prevent infection. Educate the
patient on catheter maintenance, cleaning techniques, and signs of potential complications.

Education and Support

● Patient Education: Educate the patient about orchitis, its causes, symptoms, and treatment options. Explain
the importance of rest, scrotal support, and medication adherence.
● Psychological Support: Provide emotional support and reassurance to the patient, addressing their concerns
and anxieties related to their condition.
● Activity Restriction: Adhere to the physician's orders regarding activity restriction. Gradually increase activity
as tolerated and pain permits.
● Follow-up Care: Schedule follow-up appointments to monitor the patient's progress and ensure complete
recovery.

Epididymitis

Definition: Epididymitis is an infection of the Assessment:

epididymis, which usually spreads from an
infected urethra, bladder, or prostate.
Prevalence is greatest in men 19 to 35 years of
age. Risk factors for epididymitis include recent
surgery or a procedure involving the urinary
tract, participation in high-risk sexual practices, ● Any recent sexual activity, including the use of barrier
personal history of an STI, past prostate
infections or UTIs, lack of circumcision, history
of an enlarged prostate, and the presence of a
chronic indwelling urinary catheter.
● Begin by obtaining a detailed medical history from the
patient. Ask about the following:
● Onset and duration of symptoms, including the presence
of pain, swelling, or discomfort in the scrotum.
methods or any potential exposure to sexually
transmitted infections (STIs).
● Any history of urinary tract infections (UTIs) or previous
episodes of epididymitis.
 ● Recent activities that may have contributed to trauma or
strain in the genital area.
● Any history of chronic medical conditions, surgeries, or
medications.
● Conduct a thorough physical examination of the scrotum
and genital area:
● Inspect the scrotum for redness, swelling, or signs of
inflammation.
● Palpate the scrotum gently to assess for tenderness,
warmth, or lumps.
● Examine the testicles for any changes in size, shape, or
consistency.
● Assess the patient's vital signs, including temperature, as
fever may be present.
● Assess for Systemic Symptoms:Evaluate for systemic
symptoms, such as fever, chills, or malaise, which can be
associated with epididymitis.
● Discuss the patient's sexual history in a nonjudgmental
manner to assess for potential STIs that may have led to
epididymitis.

Pathophysiology Diagnostic and Laboratory:

● Urinalysis
● Complete blood cell count,
● Gram stain of urethral drainage,
● urethral culture or deoxyribonucleic acid (DNA) probe
● Referral for syphilis and HIV testing in sexually active
patients.

Pharmacologic and Medical Care:

● Antibiotics (ciprofloxacin, levofloxacin, doxycycline, or azithromycin.): The choice of antibiotics depends on
the suspected or identified pathogen and any relevant antibiotic resistance patterns. If epididymitis is
associated with an STI, the patient’s partner should also receive antimicrobial therapy.
● The spermatic cord may be infiltrated with a local anesthetic agent to relieve pain if the patient is seen
within the first 24 hours after onset of pain.
● Supportive interventions also include reduction in physical activity, scrotal support and elevation, ice packs,
anti-inflammatory agents, analgesics (including nerve blocks), and sitz baths.
● Urethral instrumentation (e.g., catheter insertion) is avoided. The patient is observed for scrotal abscess
formation as well.
● In chronic epididymitis, a 4- to 6-week course of antibiotic therapy for bacterial pathogens is prescribed.
● An epididymectomy (excision of the epididymis from the testis) may be performed for patients who have
recurrent, refractory, incapacitating episodes of this infection.

Nursing Management:
 ● Prescribe bed rest and elevate the scrotum with a scrotal bridge or folded towel. This is to prevent traction
on the spermatic cord, promote venous drainage, and relieve pain.
● Administer antimicrobial agents as prescribed. This is to treat the underlying infection until acute
inflammation subsides.
● Apply intermittent cold compresses to the scrotum for pain relief.
● Provide local heat or sitz baths to aid in resolving inflammation.
● Administer analgesic medications as prescribed.
● Instruct the patient to avoid straining, lifting, and sexual stimulation until the infection is under control.
● Emphasize the importance of continuing prescribed analgesic agents and antibiotics.
● Encourage the use of ice packs, if needed, to alleviate discomfort.
● Inform the patient that it may take 4 weeks or longer for the inflammation to fully resolve.

Surgical Procedures

Nephrostomy

Definition: A nephrostomy is a surgical procedure that creates an opening between the kidney and the skin. This
opening allows urine to drain from the kidney using a catheter (tube) directly into a bag outside the body.
Nephrostomies are usually temporary, but they can also be permanent in some cases.

There are two main types of nephrostomy procedures:

● Percutaneous nephrostomy (PCN): This is the most common type of nephrostomy. It is performed using a
thin needle that is inserted through the skin and into the kidney under X-ray guidance. A catheter is then
placed through the needle and into the kidney to drain urine.
● Open nephrostomy: This type of nephrostomy is performed through a surgical incision in the abdomen. It is
typically only used when PCN is not possible or has failed.

Indication:
● Kidney stones: Nephrostomies can be used to relieve pain
and prevent kidney damage caused by large kidney stones
that cannot pass on their own.
● Ureteral obstruction: Nephrostomies can be used to
bypass a blockage in the ureter, which is the tube that
carries urine from the kidney to the bladder. Ureteral
obstructions can be caused by kidney stones, tumors, or
scarring.
● Bladder dysfunction: Nephrostomies can be used to drain
urine from the kidney if the bladder is unable to empty
Purpose:
● Relieving pain and preventing kidney
damage caused by large kidney stones
that cannot pass on their own.
● Bypassing a blockage in the ureter,
which is the tube that carries urine
from the kidney to the bladder. This
blockage can be caused by kidney
stones, tumors, or scarring.
● Draining urine from the kidney if the
bladder is unable to empty properly
due to conditions such as neurogenic
 properly due to conditions such as neurogenic bladder or bladder or urethral stricture.
urethral stricture.

Nursing Responsibilities:

Preoperative Care
● Assessment: Conduct a thorough patient assessment to gather information about their medical history,
current condition, and potential risk factors for complications.
● Education: Educate the patient about the nephrostomy procedure, including its purpose, risks, and benefits.
Provide clear instructions on preoperative preparation, such as dietary restrictions and bowel preparation.
● Medication Management: Review the patient's current medications and make necessary adjustments as
prescribed by the physician. Monitor for any adverse effects of medications and provide appropriate
interventions.
● Psychological Support: Offer emotional support and reassurance to the patient, addressing their concerns and
anxieties related to the upcoming surgery.

Intraoperative Care
Circulating Nurse:
● Assist the surgical team in maintaining a sterile environment and ensuring patient safety throughout the
procedure.
● Monitor the patient's vital signs, hemodynamic parameters, and fluid balance closely.
● Administer medications as ordered by the surgeon.
● Communicate with the anesthesiologist regarding the patient's condition and any potential concerns.

Scrub Nurse:
● Anticipate the surgeon's needs and prepare the necessary instruments and equipment.
● Maintain a sterile field throughout the procedure.
● Hand surgical instruments to the surgeon efficiently and safely.
● Count surgical sponges and instruments before and after the procedure to ensure none are retained in the
patient's body.

Postoperative Care
● Pain Management: Assess the patient's pain level regularly and administer pain medication as ordered.
Monitor for any adverse effects of pain medication.
● Catheter Care: Provide proper care and education to the patient on catheter management, including cleaning
techniques, drainage bag maintenance, and signs of potential complications.
● Bladder Drainage: Monitor the patient's urine output and assess bladder function. Encourage fluid intake to
promote adequate urine production.
● Wound Care: Assess the surgical incision for signs of infection, bleeding, or dehiscence. Dress the wound as
needed and provide wound care education to the patient.
● Activity Restriction: Adhere to the physician's orders regarding activity restriction and gradually increase
activity as tolerated.
● Diet and Fluid Management: Encourage a balanced diet and adequate fluid intake to promote healing and
prevent constipation.
● Discharge Planning: Provide comprehensive discharge instructions, including medication reconciliation,
wound care instructions, follow-up appointments, and signs and symptoms to report.
● Emotional Support: Continue to provide emotional support and address any concerns or anxieties the patient
may have during the recovery period.

Cystectomy

Definition: Cystectomy is a complex surgical procedure in which a surgeon removes some or all of your urinary
bladder, the organ below your kidneys and above your urethra that holds your urine before it leaves your body. The
surgery is done through a cut (incision) the doctor makes in your lower belly. Sometimes it can be done as
laparoscopic surgery.
Types:
● Radical cystectomy removes the entire bladder, nearby lymph nodes, part of the urethra and nearby organs
that may contain cancer cells.
● Partial cystectomy removes part of the bladder.
● Simple cystectomy takes out all of the bladder.

Indication: Purpose:
A radical cystectomy is
Cancers, which include: performed to treat cancer
that has invaded muscle
● Bladder cancer that invades the muscle but remains confined to the bladder tissue of the bladder or
● Other pelvic cancers, such as advanced colon, prostate or endometrial cancer recurrent noninvasive
where the bladder is removed along with other organs bladder cancer. A partial
cystectomy, although rarely
Non-cancerous conditions, which include: performed, is used to
remove a cancerous tumor
● Severe interstitial cystitis that does not respond to other treatments. in an isolated portion of the
● Developmental abnormalities of the bladder bladder. A simple
● Bladder diverticula (outpouchings within the inner wall of the bladder). cystectomy removal of only
● An abnormal connection (fistula) between the colon or the vagina and the the bladder may be a
bladder. treatment for noncancerous
● Localized endometriosis of the bladder. Endometriosis of the bladder is when (benign) conditions.
the tissue that normally lines the uterus occurs in other organs, in this case, in
the bladder
● The presence of symptoms like severe blood loss in urine due to cavernous
hemangioma or other conditions

Nursing Responsibilities:
● Monitor intake and output carefully, assessing urine output every hour for the first 24 hours, then every 4
hours or as ordered.
● Assess the color and consistency of urine.
● Assess size, color, and condition of the stoma and surrounding skin every 2 hours for the first 24 hours, then
every 4 hours for 48 to 72 hours.
● Monitor serum electrolyte values, acid-base balance, and renal function tests such as BUN and serum
creatinine.
● Teach the client and family about stoma and urinary diversion care, including odor management, skin care,
increased fluid intake, pouch application and leakage prevention, self-catheterization for clients with
continent reservoirs, and signs of infection and other complications.

Ureterostomy

Definition: It is a surgery to create a urinary diversion (changing path by which urine leaves the body). It
permanently reroutes the flow of urine through an opening in the abdominal area to a collecting pouch outside of
the body.
Indication: Purpose: The purpose of a ureterostomy is to
allow urine to drain from the body when the
Patient with: bladder cannot function properly.
● birth defect, such as spina bifida
● bladder dysfunction
● ureteral obstruction
● previous abdominal irradiation

Nursing Responsibilities:

Preoperative care:
● Assess the patient's overall health status, including their vital signs, weight, and medical history.
● Assess the patient's understanding of the procedure and their stoma care needs.
● Educate the patient about the ureterostomy procedure and aftercare. This includes teaching them about the
different types of ureterostomy appliances, how to change and empty their appliance, and how to care for
their skin around the ureterostomy.
● Monitor the patient's vital signs and fluid intake and output.

Postoperative care:
● Monitor the patient's vital signs and fluid balance closely.
● Observe the incision site for signs of infection, such as redness, swelling, and drainage.
● Educate the patient about their care, including how to change and empty their appliance, how to care for
their skin around the ureterostomy, and how to prevent complications.
● Change the appliance as needed, usually every 3-7 days.
● Teach the patient how to identify and manage common ureterostomy complications
● Monitor for moisture in bed linens or clothing as it indicates possible leakage from the appliance

Urinary diversion

Definition: Urinary diversion is a surgical procedure that reroutes the normal flow of urine out
of the body when urine flow is blocked. Urinary diversion can result in a replacement bladder (neobladder) or an
opening in the abdominal wall (stoma).

There are two categories of urinary diversion:

○ Cutaneous urinary diversion: urine drains through an opening created in the abdominal wall and skin.
⋄ Ileal conduit (ileal loop)
⋄ Cutaneous ureterostomy
○ Continent urinary diversion: a portion of the intestine is used to create a new reservoir for urine.
⋄ Continent ileal urinary diversion (formerly known as “indiana pouch”)
⋄ Ureterosigmoidostomy

Indication: Purpose:
● Bladder cancer To facilitate urine flow from a different path.
● Neurogenic bladder The procedure aims to prevent urine retention
● Irreparable loss of bladder due to injury and infection.
● Management of pelvic malignancy
● Birth defects
● Strictures
● Trauma to the ureters and urethra
● Chronic inflammation of the bladder causing several
ureteral and renal damage.

Nursing Responsibilities:
● Implementing a regular toileting schedule.
● Monitor urine output and bladder function.
 ● Monitor closely for complications.
● Practice hand hygiene and aseptic technique during care of the patient.
● Providing privacy and comfort during toileting.
● Assisting with mobility and positioning.
● Providing stoma and skin care.
● Testing urine and caring for the ostomy.
● Encouraging fluids and relieving anxiety.
● Prevention of infection and complications.
● Educate the client:
○ Avoid lifting heavy objects and doing strenuous physical activities.
○ Avoid contact sports.
○ Caring for the stoma and emptying/changing the urostomy pouch.

Transurethral Resections

Definition: Transurethral resections are minimally invasive surgical techniques used to treat various conditions
affecting the urinary tract, typically the bladder or prostate. These procedures are performed through the urethra,
eliminating the need for external incisions. The specific type of transurethral resection may vary depending on the
underlying condition:

1. Transurethral Resection of the Prostate (TURP): It is used to treat benign prostatic hyperplasia (BPH), a
non-cancerous enlargement of the prostate gland. During TURP, a portion of the prostate tissue that is
causing urinary obstruction is removed using specialized instruments inserted through the urethra. remains
the benchmark for surgical treatment for BPH. It involves the surgical removal of the inner portion of the
prostate through an endoscope inserted through the urethra; no external skin incision is made. It can be
performed with ultrasound guidance. The treated tissue either vaporizes or becomes necrotic and sloughs.
The procedure is performed in the outpatient setting and usually results in less postoperative bleeding than
a traditional surgical prostatectomy.
2. Transurethral Resection of Bladder Tumor (TURBT): TURBT is a procedure used to diagnose and treat
bladder cancer. During TURBT, a cystoscope is inserted through the urethra to remove or biopsy abnormal
bladder tissue, including tumors.
3. Transurethral Resection of Bladder Neck (TURBN): TURBN is performed to treat bladder neck contractures,
which can cause urinary flow obstruction. The procedure involves cutting or resecting the scar tissue or
constriction in the bladder neck to improve urine flow.
4. Transurethral Resection of Urethral Stricture (TURUS): TURUS is used to treat urethral strictures, which are
narrowings or blockages in the urethra. During the procedure, the strictured tissue is carefully resected to
widen the urethral passage.
5. Transurethral Resection of Bladder Diverticulum (TURBD): TURBD is used to treat bladder diverticula, which
are outpouchings or sac-like structures in the bladder wall. The procedure involves removing the diverticular
tissue to alleviate symptoms and potential complications.

Indication: Purpose:
● Benign Prostatic Hyperplasia (BPH): TURP
Transurethral Resection of the Prostate) ● Treatment of Benign Prostatic Hyperplasia
 ● Bladder Cancer: TURBT (Transurethral Resection of
Bladder Tumor)
● Bladder Neck Contractures: TURBN (Transurethral
Resection of Bladder Neck).
● Urethral Strictures: TURUS (Transurethral Resection
of Urethral Stricture)
● Bladder Diverticula: TURBD (Transurethral Resection
of Bladder Diverticulum)
● Urethral Tumors or Lesions: TUR procedures may be
indicated for the removal of urethral tumors or
suspicious lesions within the urethra.
● Urethral or Bladder Stones: TUR procedures can be
used to fragment and remove stones located within
the urethra or bladder.
(BPH): Purpose: To alleviate urinary
symptoms caused by BPH, including
difficulty urinating, urinary retention, and
recurrent urinary tract infections.
● Diagnosis and Treatment of Bladder Cancer.
● Treatment of Bladder Neck Contractures
● Management of Urethral Strictures
● Treatment of Bladder Diverticula
● Removal of Urethral Tumors or Lesions
● Management of Urethral or Bladder Stones:
To fragment and remove stones that have
formed within the urethra or bladder,
relieving urinary obstruction and
preventing stone-related complications.

Nursing Responsibilities:

Post-Operative:
● Monitor vital signs closely in order to observe any signs of shock.
● Note the color of the fluid being expelled from the three-way catheter.
● Monitor the fluid status of the patient as he gets into the 24-hour bladder irrigation.
● Assess for the patient's mental status as this is the first sign of water intoxication which can be possible
because of 24-hour fluid irrigation.
● Note the client’s reaction regarding bladder training and eventually the removal of the catheter.
● Assess for urinary retention and feeling of bloating and fullness of the patient.
● Check for the dressing and the surrounding tissues for inflammation and infection.
● The assessment of urine and blood loss must be monitored every hour especially on the first 24 hours of the
procedure. Normal findings may include red-tinged urine to pink within 24 hours.

Special Procedures

Shockwave Lithotripsy

Definition: Shock Wave Lithotripsy (SWL) is the most common treatment for kidney stones in the U.S. Shock waves
from outside the body are targeted at a kidney stone causing the stone to fragment. The stones are broken into tiny
pieces. It is sometimes called ESWL: Extracorporeal Shock Wave Lithotripsy Shock wave lithotripsy may help reduce
your symptoms (such as pain) and allow you to pass the kidney stones on your own. It may help you avoid more
invasive surgery to remove kidney stones.

Indication: Purpose: SWL describes a

Shock wave lithotripsy usually works best to treat smaller stones inside the nonsurgical technique for treating
kidney or upper part of the ureter (urine tube). stones in the kidney or ureter (the
tube going from the kidney to the
Health care Providers often use shock wave lithotripsy to treat kidney stones bladder) using high-energy shock
that: waves. Stones are broken into
"stone dust" or fragments that are
● Are too large to pass on their own (larger than 5 millimeters in diameter small enough to pass in urine. lf
about the size of a pencil eraser). large pieces remain, another
treatment can be performed
● Block urine flow.
● Are very painful.

Nursing Responsibilities:
● Monitor total urine output and patterns of voiding.
● Encourage the patient to drink enough to excrete 3,000 to 4,000 mL of urine every 24 hours.
 ● Monitor vital signs for early indications of infection; infections should be treated with the appropriate
antibiotic agent before efforts are made to dissolve the stone.

Digital rectal examination (DRE)

Definition: A digital rectal examination (DRE) is a physical medical procedure in which a physician or nurse, inserts a
lubricated, gloved finger (digit) into the patient's rectum to assess the condition of the rectal wall, as well as nearby
structures and organs in the pelvic region.

Indication: Purpose:
● Prostate Cancer Screening: One of the most common
indications for a DRE in males is prostate cancer screening. It ● Assessment of the Rectum
is often performed as part of a routine check-up, especially ● Prostate Examination
for men over the age of 50 or those with a family history of ● Assessment of Pelvic Organ
prostate cancer. ● Assessment of Fecal Impaction
● Assessment of Prostate Health
● Evaluation of Rectal Symptoms
● Assessment of Pelvic Organ Health (Females)
● Evaluation of Fecal Impaction

Nursing Responsibilities:

● Verify the patient's identity and ensure proper patient identification procedures are followed.
● Explain the purpose and procedure of the DRE to the patient to alleviate anxiety and obtain informed consent.
● Maintain the patient's privacy and dignity throughout the procedure by providing a private examination room
and offering appropriate draping or covering for modesty.
● Assist the patient into a comfortable and appropriate position for the examination, usually in the left lateral
decubitus (Sims) position with knees bent.
● Encourage the patient to relax and breathe deeply to minimize discomfort.
● Observe the patient's reaction during and after the procedure, noting any signs of discomfort, pain, or distress.
● Document the procedure in the patient's medical record, including the date, time, the healthcare provider's
findings, and the patient's response or any adverse events.
● Properly dispose of used gloves and other disposable materials, following infection control guidelines.
● Perform hand hygiene before and after assisting with the DRE to prevent the spread of infection.