Renal System

Chapter 55
Management of Patients with Urinary Disorders
Infections of the Urinary Tract

Hi students! My name is Dr. Miranda Bailey. You will be following me on

rounds today. I’m covering for one of the other doctors today, so we are
rounding on the urology unit.
Before we begin, I’d like to familiarize you with the infections of
the urinary tract. They may affect the upper or lower tract and
may be complicated or uncomplicated.

The first patients we’ll see today have lower urinary tract
infections. These include bacterial cystitis (inflammation of the
bladder), bacterial prostatitis (inflammation of the prostate
gland), and bacterial urethritis (inflammation of the urethra).

Most uncomplicated UTIs are community acquired. Your

complicated UTIs usually occur in people with urologic
abnormalities or were recently catheterized. Many of these
patients are hospitalized.
UTIs are the second most common infection in the body and
occur most often in women. In fact, 1 out of every 5 women in
the US will have at least one UTI in their lifetime.

UTIs are also the most common nosocomial (hospital-acquired)

infection. About 600,000 people will develop a UTI while in the
hospital every year. These are usually due to catheterization or
manipulation of the urinary tract. Of course, Grey-Sloan
Memorial does not have this problem. Our doctors and nurses
are meticulous in their patient care.
 Lower Urinary Tract Infection

Our first patient today is Carey. Carey was admitted yesterday complaining of
urinary burning and frequency, nocturia, and pelvic pain. She became alarmed
when she noticed a little blood in her urine. She has recurrent UTIs, so she was
admitted for a full workup.
“Good morning, Carey. I’m covering for Dr. Karev today. I heard
you had some questions about UTIs. The bladder is sterile.
Bacteria attaches and colonizes to the epithelium of the urinary
tract. Otherwise, your urine would wash the bacteria away. This
colonization activates the body’s dense mechanisms and
inflammation occurs. Urethral IgA, normal vaginal and urethral
flora, and glycosaminoglycan (GAG) usually keep the bacteria
from attaching.”

“A urethrovesical reflux is a backward flow of urine from the

urethra to into the bladder. This occurs when you cough, sneeze,
or strain. The reflux of urine brings bacteria from the ureter into
the sterile bladder. It can also be caused by dysfunction of the
bladder neck or urethra. This occurs in post-menopausal women
and especially very young children.”
“Another cause of UTI is urethrovesical reflux. Urine from the
bladder backflows into the ureters. Usually something called the
urethrovesical junction prevents this, but abnormalities or
congenital disorders may alter the function.”

“ We are going to check you for bacteriuria. This means that

there is bacteria in your urine. You will need to do a clean-catch
midstream urine specimen to make sure that it is not
contaminated by normal urethral bacteria. This bacteria is
usually E. coli.”

“The bacteria can enter your urinary tract through the urethra
(ascending), bloodstream (hematogenous spread), or because of
a intestinal fistula (direct extension). Women have a short
urethra, so the bacteria meet little resistance when trying to
enter the urinary tract. Sexual activity may also force bacteria
from the urethra into the bladder.”
“Carey, your signs and symptoms are consistent with an
uncomplicated UTI. You might also experience back pain. If your
UTI was complicated, you might develop septic shock. These are
harder to treat because there are more organisms responsible with
a lower response to treatment. Because you have recurrent UTIs,
you probably have a mix of complicated and uncomplicated. Left
untreated, the infection might enter the bloodstream, causing
urosepsis.”

“Carey, we have your urine specimen. We’re currently doing a

culture so we know what organism we’re dealing with and how to
treat you. Because you are showing signs of infection, the colony
count should be greater than 100,000 CFU/mL. “

“We can see the blood in your urine, so we won’t need to check
the urine for blood. Your urinalysis shows WBCs in your urine. This
is called pyuria.”
“We completed a leukocyte esterase test (checking for WBCs) and
nitrate testing. We also checked for sexually transmitted infections
since their symptoms tend to mimic UTIs. Don’t worry, you don’t have
an STI. Today you will have ultrasonography and kidney scans. These
will allow us to assess for obstruction, abscesses, tumors, and cysts.”

“We will start a short course of antibiotics. Usually UTIs clear up with
3 days of treatment. We will want you to continue these antibiotics,
even if you feel better. Students, please refer to Table 55-1 in your
textbook. You will be explaining these treatment options to Carey.”

“Carey, since you have recurring UTIs, we are considering sending you
home with antibiotics to be taken every other night for 6-7 months.
This will decrease the odds of recurrence. If we discover that your
bacteria is persistent, we will send you home with a low-dose
prophylactic therapy (trimethoprim with or without
sulfamethoxazole). You would take this at bedtime nightly.”
“Get some rest Carey and we’ll be back to check on you later. Call
the nurse if you need anything.”

“Students, what do you think would be different if Carey was an

older adult? UTIs are common in older adults. Men catch up to
women on incidence due to bladder outlet obstruction (benign
prostatic hyperplasia) and women tend to become less sexually
active. Stroke and diabetes may lead to neurogenic bladder where
the bladder does not completely empty. Post-menopause, women
are less able to fight off colonization of bacteria. The antibacterial
activity of prostatic secretions in men slows down. Chronic bacteria
prostatitis is the leading cause of UTIs in men. Cognitive impairment,
immunocompromise, and immobility may also lead to UTI. While
older adults experience the same fever, burning, and urgency as
younger patients, they may also present with incontinence and
delirium. They are treated the same way as younger patients, but
dosage may need to be adjusted. We also provide plenty of fluids.”
• “Students, it’s time to do some digging. If you have your
textbook handy, let’s look at the nursing process for lower
UTIs.”
 Urolithiasis and
Nephrolithiasis
“My next patient is Will. Will
was brought into the ED
yesterday after his wife called
911. Will was having
excruciating, colicky, wave-like
pain radiating down his thigh
and to the genitalia. There was
blood in his urine when he was
able to void. These symptoms
are known as ureteral colic. We
diagnosed Will with a stone in
his ureter. He was admitted for
pain control.
Stones develop in the urinary tract because of high levels of calcium oxalate, calcium
phosphate, and uric acid (supersaturation). The amount of the substance, its ionic
strength, and the pH of the bladder also play a role in the development of stones. Stones
occur in places other than the ureter, like Will’s. They can develop anywhere from the
kidneys to the bladder. They can be very small (sand or gravel) or as large as an orange.

Stones develop on certain factors to develop. These include infection, urinary, stasis,
immobility, and hypercalcemia. Hypercalcemia can be caused by hyperparathyroidism,
renal tubular acidosis, cancer, dehydration, granulomatous diseases, excessive intake of
vitamin D and milk, and myeloproliferative diseases. Uric acid stones may be seen in
patients with gout. Struvite stones develop in persistently alkaline, ammonia-rich urine
because of the presence of certain bacteria. Struvite stones tend to form in patients with
neurogenic bladder, foreign body presence, and recurrent UTIs.

Stones also occur in patients with anatomic issues of the kidney, inflammatory bowel
disease, and in patients with an ileostomy or bowel resection. Medications such as
acetazolamide (Diamox), vitamin D, laxatives, and high doses of ASA may also lead to
stone formation.

Will’s stone is in the ureter. Stones in the renal pelvis cause an intense, deep ache in the
costovertebral region. Hematuria and pyuria may be present. Nausea and vomiting is
caused by renal colic. Diarrhea and abdominal discomfort may also occur.
Bladder stones may be associated with UTI and hematuria. Urinary retention occurs if
the bladder neck is obstructed. Stones 0.5-1 cm may be passed spontaneously. Any stone
larger than 1 cm will usually need to be either removed or broken up with lithotripsy.

When Will came in, we did a noncontrast CT scan. We also measured his calcium, uric
acid, creatinine, sodium, and pH levels through blood work and urinalysis. We’re
currently doing a 24-hour urine to collect information not found in blood work or
urinalysis. Once Will passes his stone, we’ll do a chemical analysis to determine its
composition. That gives us a better idea of why Will developed a stone.

Our goal is to remove the stone, either spontaneously or medically, determine the stone
type, prevent nephron destruction, control infection, and relieve an obstruction. We also
need to relieve Will’s pain. We’ve been using NSAIDs to inhibit the synthesis of
prostaglandin E. This reduces inflammation and facilitates passage of the stone. Will is
receiving a bolus of normal saline and we’re encouraging him to hydrate as much as
possible. We’re also using moist heat to the flank to help with the pain. Occasionally we
need to treat the acute pain with narcotic analgesics.
Once we determine what type of stone Will has, we can look at nutritional therapy to
prevent another one from occurring. Will should drink 8-10 8 oz. glasses of water daily to
dilute the urine. We want a urine output of at least 2L/day.

If the stone is a calcium stone, we’ll recommend that Will restricts dietary calcium. We’ll
prescribe ammonia chloride. We’ll add a thiazide diuretic if the cause is increased serum
calcium in the blood and urine.

If he has a uric acid stone, Will will be placed on a low-purine diet. I’ll also prescribe
allopurinol (Zyloprim) to reduce his serum uric acid levels and urinary uric acid secretion.

Cystine stones will be treated with a low-protein diet and alkalinizing the urine. If the
stones are oxalate stones, we will keep Will’s urine diluted and restrict spinach,
strawberries, rhubarb, chocolate, tea, peanuts, and wheat bran in his diet.

Education will be provided to Will about the prevention of kidney stones. You’ll find that
information in Chart 55-12 in your textbook. You’ll need this information for Will’s
discharge education.
If Will’s stone doesn’t pass on its own, we can use ureteroscopy to visualize and destroy
it. We’ll insert a ureteroscope and laser into the ureter (we can also use an
electrohydraulic lithotripter or ultrasound device instead of a laser). We may need to
place a stent for 48 hours to keep the ureter patent.

We can also use extracorporeal shock wave lithotripsy to break the stone up so it can
pass. I know you already learned about this, so I won’t bore you with the details. I will
tell you that the patient requiring multiple shocks will have discomfort. If we use
electrohydraulic lithotripsy, stone will also be also be broken up, but Will could have
complications such as hemorrhage, infection, and urinary extravasation. With either of
these methods, Will we need to strain his urine for stone particles for examination.

Chemolysis may also be used. This requires a chemical solution to be flowed

continuously on a stone through a percutaneous nephrostomy. The stone will dissolve
because of the alkylating or acidifying agents used. We will need to closely monitor the
pressure inside the renal pelvis during the procedure.

If all else fails, we’ll need to do surgery. A nephrolithotomy (incision into the kidney to
remove the stone) or nephrectomy (kidney is removed because it is no longer functional
or has hydronephrosis). If the stone is in the bladder, we will perform a cystostomy. If in
the kidney pelvis, we’ll use a pyelolithotomy and if in the ureter, a ureterolithotomy.
We can also do a cystolitholapaxy to crush the stone within the bladder.
Your job in treating Will begins with an assessment. You will assess him for pain, nausea,
vomiting, diarrhea, and abdominal distention. You’ll want to make note of the severity
and radiation of the pain. You will also monitor Will for signs of UTI and obstruction.
Each time Will voids, check his urine for blood and strain it for stones. You also need to
monitor Will for infection and urosepsis if a UTI or pyelonephritis are present.

Your discharge teaching will include the need for Will to strain and examine his urine. He
will need to look for blood and stone particles. He will need to have ample fluids to
prevent dehydration and to make plenty of urine to get rid of stones particles. Instruct
Will to monitor his temperature because of the risk of infection. A call to his primary care
provider will be needed if he has a temperature, decreased urine volume, bloody or
cloudy urine, or pain. Make sure that Will understands dietary restrictions based on the
composition of his stone. He will also need to have urine cultures every 1-2 months for
the first year following the stone. Follow-up appointments will be made if Will has a
lithotripsy.
Genitourinary Trauma
The next patient on rounds is Zac. Zac
was hit in the lower abdomen by a
baseball bat after bragging about his 6-
pack. It’s not good to hit people with
baseball bats, but I think the guy had
enough of Zac walking around with his
shirt off. The blow caused bladder
trauma. Zac has a contusion that
presented as ecchymosis. We are
monitoring him for rupture,
hemorrhage, shock, sepsis, and
extravasation of blood into other tissues.
Other areas of trauma are the ureters and urethra. Ureteral trauma is usually caused by
motor vehicle crashes, sports injuries, falls, and assaults. Zac was lucky he didn’t
experience this too. If this had occurred, Zac would have required surgery to repair the
ureter and placement of stents to divert urine away from the anastomosis). Fistulas can
develop if urine leakage continues. If Zac had urethral trauma, we would have seen the
classic triad of blood in the urinary meatus, inability to void, and distended bladder.

Our goal of management is to control any hemorrhage, pain, or infection and to maintain
urinary drainage. We are monitoring Zac’s hemoglobin and hematocrit levels closely. A
decrease may signal hemorrhage. We are also watching him for oliguria and signs of
hemorrhagic shock or acute peritonitis.

If Zac had a urethral trauma, he would have required a suprapubic catheter. Repair can
be done either laparoscopically or through an open approach. A urinary catheter is
placed to minimize the risk of urethral disruption and to prevent complications like
stricture, incontinence, and impotence. The catheter stays in place for about a month.

You will assess Zac frequently for flank and abdominal pain, muscle spasm, and swelling
over the flank. You will instruct him about adequate fluid intake and the care of his
incision once he is discharged. Fever, hematuria, flank pain, or signs of decreasing kidney
function should be reported immediately. Zac will need to follow the set guidelines
regarding lifting, driving, and increasing activity.
Bladder Cancer
We’re going to do rounds on the
oncology unit next. Our first patient is
Humphrey. He would like you to call him
Bogie. Bogie is a long-time smoker and
has just been diagnosed with bladder
cancer. Bladder cancer is the third most
common cancer in men (11th in women)
and smoking is a leading risk factor.

Bogie sought treatment after blood in

his urine. He had no pain. He was also
getting frequent UTIs.
We did a ureteroscopy on Bogie when he was initially admitted. This is the mainstay of
diagnosis. We also did an excretory urography, CT, MRI, ultrasonography, and bimanual
examination (for this we anesthetized Bogie). Cytologic examination was done on fresh urine
and saline bladder washings to give us information about Bogie’s prognosis and tumor staging.

Treatment depends on the grade of the tumor, the stage of tumor growth, and the presence of
metastasis. Bogie’s age and physical, mental, and emotional status were also considered when
determining our treatment options.

If Bogie had a benign tumor, we might have been able to perform transurethral resection or
fulguration (cauterization). We would then instill bacilli Calmette-Guérin (BCG) into the
bladder and continued treatment for a year. Bogie’s tumor has already metastasized, so we
had to perform a radical cystectomy. We removed his bladder, prostate, seminal vesicles, and
the immediately adjacent perivesical tissues. If this had been a female patient, we would have
removed the bladder, lower ureter, uterus, fallopian tubes, ovaries, anterior vagina, and
urethra. We also removed Bogie’s pelvic lymph nodes. This surgery requires a urinary diversion
procedure, but we’ll discuss that in a bit.

Bogie is being treated with a combination of methotrexate, 5-FU, vinblastine, doxorubicin, and
cisplatin. We are also doing radiation therapy. If we were unsuccessful in removing all the
tumor, we would have delivered thiotepa, doxorubicin, mitomycin, and BCG live to the tumor
itself.

Preoperative radiation would be an option if there was no metastasis.

 Urinary Diversions
Let’s talk about the types of urinary diversions available to us. We use urinary diversions
to divert urine from the bladder to a new exit site. This is usually through an abdominal
stoma. Not only do we use urinary diversions for patients who have undergone a
cystectomy, but we use them for patients with pelvic malignancy, birth defects,
strictures, ureter or urethral trauma, neurogenic bladder, chronic infection causing
urethral and kidney damage, and intractable interstitial cystitis). We may also use it as a
last resort in treating urinary incontinence.

The technique chosen takes into consideration the age of the patient, condition of the
bladder, body build, obesity, degree of ureteral dilation, status of kidney function, and
the patient’s learning ability and willingness to participate in postoperative care. We also
look at the patient’s functional ability.
Cutaneous Urinary Diversions
An ileal conduit is the most common
urinary diversion procedure. There are
few complications. Urine is diverted by
implanting the ureter into a 12-cm loop
of the ileum that is led out of the
abdominal wall. An ileostomy bag is
used to collect the urine. The ends of
the bowel are anastomosed to maintain
an intact bowel.

Stents are placed into the ureters to

prevent occlusion. They allow the urine
to drain from the kidney to the stoma.
They are removed after 10-14 days. JP
drains are used to prevent fluid
accumulation in the space where the
bladder once was.
Even though there are few complications, we still need to monitor for wound infection or
dehiscence, urinary leakage, ureteral obstruction, hyperchloremic acidosis, small bowel
obstruction, ileus, and a gangrenous stoma. Long-term complications include ureteral
obstruction, stenosis of the stoma, kidney deterioration, pyelonephritis, renal calculi, and
cancer recurrence.

Immediately postop, you will need to monitor urine output hourly. Urine output should be
greater or equal to 0.5 mL/kg/hr. Hematuria may be evident in the first 48 hours following
surgery. The wound/ostomy nurse is consulted for education and device options. The stoma
should be pink or red. You should inspect the skin for signs of irritation and bleeding,
encrustation and skin irritation around the stoma (from urine touching the skin), and
wound infection.

Monitor the site for leakage. Keep the pH of the urine below 6.5. We do this by giving oral
ascorbic acid. Make sure the appliance is properly fitted. We don’t want urine to contact
the skin around the stoma. There may be mucus in the urine; you will need to assure the
patient that this is normal.

The patient and caregiver will need to be educated on how to change, monitor, clean, and
deodorize the appliance as well as controlling odor. The patient should be instructed to
empty the appliance when it is one-third full to prevent weight. The patient should avoid
asparagus, cheese, and eggs if concerned about odor. They should not use ASA in the pouch
because the stoma may ulcerate. The appliance should be changed as recommended.
Continent Urinary Diversions
The most common continent urinary
diversion is the Indiana pouch. This uses
a segment of the ileum and cecum to
form a reservoir for urine. The ureters
are tunneled through the pouch and
anastomosed. The pouch is sewn to the
anterior abdominal wall.

The pouch should be drained at regular

intervals to prevent the absorption of
metabolic waste products, reflux to the
ureters, and UTI.
Ureterosigmoidostomy is done via transplantation of the ureters into the sigmoid colon.
Urine flows through the colon and out of the rectum. Urinary frequency will require an
adjustment lifestyle changes.

Antibiotic agents like neomycin or kanamycin are given to disinfect the bowel.
Immediately postop, a catheter is placed into the rectum to drain the urine and prevent
urine reflux to the ureters and kidneys. Because the bowel mucosa is exposed to urine,
there may be fluid and electrolyte imbalances. Diarrhea is caused by potassium and
magnesium in the urine. If the patient experiences acidosis, a low-chloride diet
supplemented with sodium potassium citrate will be ordered.

Anal sphincter exercises will be used as the patient learns to control it. Gas-forming
foods should be avoided to reduce the chance of stress incontinence. The patient will
need to refrain from chewing gum or smoking since these activities involve swallowing
air. Salt intake will be restricted to prevent hyperchloremic acidosis and potassium intake
is increased through food and medications to because of the loss of potassium with
acidosis.

You will need to instruct your patient that pyelonephritis is common because of the
reflux of bacteria from the colon. They may need to be prescribed prophylactic
antibiotics. Adenocarcinoma of the sigmoid colon is a late complication, so follow-up will
be maintained for life.