Management of patients

with Urinary Disorders

BY: JED KEONI UY JOLO, RN
Glossary
Infections of the Urinary Tract
 Urinary tract infections (UTIs) are caused by pathogenic
microorganisms in the urinary tract (the normal urinary
tract is sterile above the urethra).

 UTIs are generally classified by location as infections of

the lower urinary tract, involving the bladder and
structures below the bladder, or upper urinary tract,
involving the kidneys and ureters.

 A UTI is the second most common infection in the body.

Infections of the Urinary Tract
Fifty percent of all hospital-acquired infections are UTIs,
and in the majority of cases these are catheter-
associated urinary tract infections (CAUTI)

A CAUTI is a UTI associated with indwelling urinary

catheters. The definition used for ongoing monitoring is a
UTI that occurs while the patient had an indwelling
urinary catheter in place for more than 2 calendar days on
the day that the infection was detected.
Lower Urinary Tract Infections
The sterility of the bladder is maintained by several
mechanisms, especially important since the urethra is
considered a clean, not a sterile space.

The physical barrier of the urethra assists in keeping

bacteria away from the bladder, while urine flow helps to
carry any bacteria away from the bladder.
Lower Urinary Tract Infections
The sterility of the bladder is maintained by several
mechanisms, especially important since the urethra is
considered a clean, not a sterile space.

The physical barrier of the urethra assists in keeping

bacteria away from the bladder, while urine flow helps to
carry any bacteria away from the bladder.
 Reflux
 An obstruction to free-flowing urine is a condition known
as urethrovesical reflux, which is the reflux (backward
flow) of urine from the urethra into the bladder

 Ureterovesical or vesicoureteral reflux refers to the

backward flow of urine from the bladder into one or both
ureters
 Uropathogenic Bacteria
• Bacteriuria is the term used to describe the presence of
bacteria in the urine.
 Routes of Infection
• Bacteria enter the urinary tract in three ways: by the
transurethral route (ascending infection), through the
bloodstream (hematogenous spread), or by means of a
fistula from the intestine (direct extension).
 Routes of Infection
• Bacteria enter the urinary tract in three ways: by the
transurethral route (ascending infection), through the
bloodstream (hematogenous spread), or by means of a
fistula from the intestine (direct extension).
 Clinical Manifestations
 Burning on urination
 Urinary frequency (voiding more than every 3 hours)
 Urgency
 Nocturia (awakening at night to urinate)
 Incontinence
 Suprapubic or pelvic pain
 Hematuria
 Urosepsis (the spread of infection from the urinary tract to
the bloodstream that results in a systemic infection).
 Gerontologic Considerations
• UTI is the most common infection of older adults and
increases in prevalence with age.

• UTIs occur more frequently in women than in men at

younger ages but the gap between the sexes narrows in
later life, which is due to reduced penile-vaginal
intercourse in women and a higher incidence of bladder
outlet obstruction secondary to benign prostatic hyperplasia
in men
 Gerontologic Considerations
Structural Abnormalities:
Neurogenic bladder (dysfunctional bladder) secondary to stroke,
or autonomic neuropathy of diabetes may prevent complete
emptying of the bladder and increase the risk of UTI

Older women often have incomplete emptying of the bladder and

urinary stasis.
Absence of estrogen, postmenopausal women are susceptible to
colonization and increased adherence of bacteria to the vagina and
urethra.
Gerontologic Considerations
Gerontologic Considerations
Escherichia coli is the most common organism seen in
older patients in the community or hospital

However, patients with indwelling catheters are more

likely to be infected with organisms such as Proteus,
Klebsiella, Pseudomonas, or Staphylococcus.
Assessment and Diagnostic Findings
 Urine Cultures- A colony count greater than 100,000
CFU/mL of urine on a clean-catch midstream or
catheterized specimen indicates infection
 Cellular Studies
 X-ray
 CT scan
 Ultrasonography
 Medical Management
 Pharmacologic Therapy
 Patient education
Patient Education
 Upper Urinary Tract Infection
Pyelonephritis is a bacterial infection of the renal pelvis,
tubules, and interstitial tissue of one or both kidneys.

 Causes involve either the upward spread of bacteria from

the bladder or spread from systemic sources reaching the
kidney via the bloodstream.
 Bacteria from a bladder infection can ascend into the
kidney, resulting in pyelonephritis
 An incompetent ureterovesical valve or obstruction
occurring in the urinary tract increases the susceptibility of
the kidneys to infection
 Pyelonephritis may be acute or chronic.
 Acute Pyelonephritis
 Acute pyelonephritis is the cause of more than 25,000
hospital admissions annually and usually leads to
enlargement of the kidneys with interstitial
infiltrations of inflammatory cells

 Abscesses may be noted on or within the renal

capsule and at the corticomedullary junction.
Eventually, atrophy and destruction of tubules and the
glomeruli may result.
 Clinical Manifestations
• Chills
• Fever
• Leukocytosis
• Bacteriuria
• Pyuria
• Low back pain
• Flank pain
• Nausea and Vomiting
• Headache
• Malaise
• Painful urination
• Tenderness upon palpation of the bladder
Assessment and Diagnostic Findings
• CT Scan
• IV pyelogram may be indicated if functional and structural
renal abnormalities are suspected
• Radionuclide imaging with gallium citrate and indium-111
(111In)–labeled WBCs may be useful to identify sites of
infection that may not be visualized on CT scan or ultrasound
• Urine culture and sensitivity tests are performed to determine
the causative organism so that appropriate antimicrobial
agents can be prescribed
Medical Management
 Chronic Pyelonephritis
 Repeated bouts of acute pyelonephritis may lead to chronic
pyelonephritis. When pyelonephritis becomes chronic, the kidneys
become scarred, contracted, and nonfunctioning.

 Chronic pyelonephritis is a cause of chronic kidney disease that can result

in the need for renal replacement therapy (RRT) such as transplantation or
dialysis
 Clinical Manifestations
The patient with chronic pyelonephritis usually has no
symptoms of infection unless an acute exacerbation
occurs. Noticeable signs and symptoms may include:

• Fatigue
• Headache
• Poor appetite
• Polyuria
• Excessive Thirst
• Weight loss
• Persistent and recurring infection may produce
progressive scarring of the kidney, resulting in chronic
kidney disease
Assessment and Diagnostic Findings
The extent of the disease is assessed by an IV urogram
and measurements of creatinine clearance, blood urea
nitrogen, and creatinine levels (Fischbach & Fischbach,
2018)
 Complications
Complications of chronic pyelonephritis include end-
stage kidney disease (from progressive loss of nephrons
secondary to chronic inflammation and scarring),
hypertension, and formation of renal calculi (from
chronic infection with urea-splitting organisms).
 Medical Management
• Bacteria, if detected in the urine, are eradicated if
possible. Long-term use of prophylactic antimicrobial
therapy may help limit recurrence of infections and
kidney scarring.

• Impaired kidney function alters the excretion of

antimicrobial agents and necessitates careful monitoring
of kidney function, especially if the medications are
potentially toxic to the kidneys
 Nursing Management
• Monitor fluid intake and output
• 3-4 L of fluids per day is encouraged to dilute the
urine decrease burning on urination, and prevent
dehydration.
• Monitor patient’s temperature every 4 hours
• Administer medications as ordered
 Adult Voiding Dysfunction
The micturition (voiding or urination) process involves
several highly coordinated neurologic responses that
mediate bladder function.
Adult Voiding Dysfunction
 Urinary Incontinence
More than 25 million adults in the United States are
estimated to have urinary incontinence (unplanned,
involuntary, or uncontrolled loss of urine from the bladder);
however, it is difficult to determine exact numbers as there
are many types of urinary incontinence
 Urinary Incontinence
More than 25 million adults in the United States are estimated
to have urinary incontinence (unplanned, involuntary, or
uncontrolled loss of urine from the bladder); however, it is
difficult to determine exact numbers as there are many types
of urinary incontinence
Types of Urinary Incontinence
• Stress incontinence is the involuntary loss of urine through an
intact urethra as a result of exertion, sneezing, coughing, or
changing position
• Urge incontinence is the involuntary loss of urine associated
with a strong urge to void that cannot be suppressed
• Functional incontinence is the involuntary loss of urine due to
physical or cognitive impairment.
• Iatrogenic incontinence is the involuntary loss of urine due to
extrinsic medical factors, predominantly medications
• Mixed incontinence, which encompasses several types of
urinary incontinence, is involuntary leakage associated with
urgency and also with exertion, effort, sneezing, or coughing
• Overflow incontinence occurs when there is continual leakage
of urine from an overdistended bladder
Assessment and Diagnostic Findings
 Once incontinence is recognized, a thorough history is
necessary. This includes a detailed description of the
problem and a history of medication use.
 Patient’s voiding history
 Diary of fluid intake and output
 Bedside tests (residual urine, stress maneuvers)
 Urinalysis and urine culture
 Medical Management
Behavioral Therapy:

Behavioral therapies, also known as nonpharmacologic, or

conservative treatments, are the first choice to decrease or
eliminate urinary incontinence
 Medical Management
Behavioral Therapy:

Behavioral therapies, also known as nonpharmacologic, or

conservative treatments, are the first choice to decrease or
eliminate urinary incontinence
 Medical Management
Pharmacologic Therapy:
Pharmacologic therapy works best when used as an
adjunct to behavioral interventions.

 The particular antibiotic used will be dependent on the

type of incontinence diagnosed
 Anticholinergic
 Mirabegron
 Tricyclic antidepressant medication (amitriptyline)
 Pseudoephedrine sulfate
 Medical Management
Surgical Management
 Most procedures involve lifting and stabilizing the
bladder or urethra to restore the normal urethrovesical
angle or to lengthen the urethra.

 Women with stress incontinence may undergo an

anterior vaginal repair, retropubic suspension, or needle
suspension to reposition the urethra.

 Periurethral bulking is a minimally invasive procedure

in which small amounts of artificial collagen are placed
within the walls of the urethra to enhance the closing
pressure of the urethra
Nursing Management
 Pathophysiology
 Urinary retention may result from diabetes, prostatic
enlargement, urethral pathology (infection, tumor,
calculus), trauma (pelvic injuries), pregnancy, or
neurologic disorders (e.g., stroke, spinal cord injury,
multiple sclerosis, Parkinson’s disease).

 Some medications cause urinary retention either by

inhibiting bladder contractility or by increasing
bladder outlet resistance
Assessment and Diagnostic Findings
Assessment and Diagnostic Findings
• Monitor the amount of urine voided and
frequency of voiding
• Post void residual urine may be assessed by an
ultrasound bladder scanner
 Complications
 Chronic infections
 Renal Calculi (Nephrolithiasis or
Urolithiasis)
 Pyelonephritis
 Sepsis
 Hydronephrosis
 Skin breakdown if regular measure of
hygiene is neglected
Nursing Management
 Neurogenic Bladder
Neurogenic bladder is a dysfunction that results
from a disorder or dysfunction of the nervous
system and leads to urinary incontinence.

It may be caused by spinal cord injury, spinal

tumor, herniated vertebral disc, multiple sclerosis,
congenital disorders (spina bifida or
myelomeningocele), infection, or complications of
diabetes
 Pathophysiology
The two types of neurogenic bladder are spastic (or
reflex) bladder and flaccid bladder.
 Spastic Bladder
• Spastic bladder is the more common type and is
caused by any spinal cord lesion above the voiding
reflex arc (upper motor neuron lesion)

• The result is a loss of conscious sensation and

cerebral motor control.

• A spastic bladder empties on reflex, with minimal

or no controlling influence to regulate its activity.
 Flaccid Bladder
is caused by a lower motor neuron lesion, commonly
resulting from trauma.

This form of neurogenic bladder is also increasingly

being recognized in patients with diabetes.

The bladder continues to fill and becomes greatly

distended, and overflow incontinence occurs.

The bladder muscle does not contract forcefully at

any time. Because sensory loss may accompany a
flaccid bladder, the patient feels no discomfort.
Assessment and Diagnostic Findings
 Measure fluid intake and urine output
 Residual urine volume
 Urinalysis
 Assessment of sensory awareness of bladder
fullness and degree of motor control.
 Complications
 Infection resulting from urinary stasis and
catheterization.
 Renal calculi
 Impaired skin integrity
 Urinary incontinence or retention
 Medical Managementx`
Pharmacologic Therapy
Parasympathomimetic medications, such as
bethanechol, may help to increase the contraction of
the detrusor muscle.

Surgical Management
Surgery may be carried out to correct bladder neck
contractures or vesicoureteral reflux, or to perform a
urinary diversion procedure.
Urinary Catheters
Urinary Catheters
Indwelling Catheters
 Suprapubic Catheters
Suprapubic catheterization allows bladder drainage by inserting
a catheter or tube into the bladder through a suprapubic (above
the pubis) incision or puncture

Suprapubic drainage offers certain advantages:

• Patients can usually void sooner after surgery than those with
urethral catheters, and they may be more comfortable.

• The catheter allows greater mobility, permits measurement of

residual urine without urethral instrumentation, and presents
less risk of bladder infection.

• The suprapubic catheter is removed when it is no longer

required, and a sterile dressing is placed over the site.
Suprapubic Catheters
Suprapubic Catheters
Nursing Management
Nursing Management
UROLITHIASIS AND NEPHROLITHIASIS
 Urolithiasis and nephrolithiasis refer to stones (calculi)
in the urinary tract and kidney, respectively.

 Urinary stones predominantly occur in the third to fifth

decades of life and affect men twice as often as women

 The prevalence of renal calculi is 10.6% for males and

7.1% for females; however, recent studies show that
rates are increasing among women with estimates that
the ratio of affected males-to-females is 1.3 to 1

 Stones may develop in both kidneys

 Risk factors
1. Immobility- Bedridden, Post-op, Elderly/ Increase Ca+
Resorption (Bone-Blood)
2. Hyperparathyroidism- Increased Ca+ (Blood)
 PATHOPHYSIOLOGY
Increased Calcium in the blood (resorption) Urinary Stasis
Supersaturation of urine (increased particles) Crystals
formation (Stones or Calculi) Increase Backward pressure
(Reflux) Hydronephrosis (Distention of Kidney) Renal
Damage or Renal Failure
PATHOPHYSIOLOGY
 Clinical Manifestations
Distended Renal Pelvis and Ureter
UTI and Pyelonephritis
Fever
Chills
Excruciating pain and discomfort
Hematuria is often present; pyuria may also be
noted
Deep ache and distention in the costovertebral
region
Nausea and Vomiting
Assessment and Diagnostic Findings

 Noncontrast CT scan
 Blood chemestries and a 24 hour urine test of
measurement of calcium, uric acid , creatinine,
sodium, and pH.
 Dietary and medication history
 Family history of renal calculi
 Medical Management
In general, the patient is able to pass stones 0.5 cm
in diameter

Stones larger than 1 cm in diameter usually must be

removed or fragmented (broken up by lithotripsy)
so that they can be removed or passed
spontaneously
 Medical Management
The goals of management are to eradicate the stone,
determine the stone type, prevent nephron destruction,
control infection, and relieve any obstruction that may
be present.
Patient Education
 Interventional Procedure
 Ureteroscopy

 Extracorporeal shock wave lithotripsy (ESWL)

 Percutaneous nephrolithotomy - A percutaneous

tract is formed, and a nephroscope is inserted
through it. Then, the stone is extracted or
pulverized.
Interventional Procedure
 Surgical Management
If the stone is in the kidney, the surgery performed may
be a nephrolithotomy (incision into the kidney with
removal of the stone) or a nephrectomy, if the kidney is
nonfunctional secondary to infection or hydronephrosis.

Pyelolithotomy- stones in the kidney pelvis are removed

Ureterolithotomy- stones in the ureter
Cystostomy- in the bladder
Cystolitholapaxy - a procedure to break up bladder stones
into smaller pieces and remove them.
Surgical Management
 Genitourinary Trauma
Ureteral Trauma- The main causes of ureteral trauma are motor vehicle
crashes, sports injuries, falls, and assaults. Penetrating trauma, such as
gunshot wounds, is the most frequent etiology, accounting for 90% of
ureteral injuries (Blair, 2017). Injuries range from contusions to
complete transection.

Bladder Trauma- Injury to the bladder may occur with pelvic fractures,
multiple trauma, or from a blow to the lower abdomen when the bladder
is full.
Blunt Trauma- ecchymosis—a large bruise resulting from escape of
blood into the tissues and involving a segment of the bladder wall

Urethral Trauma- blunt trauma to the lower abdomen or pelvic region.

 Medical Management

 Control hemorrhage
 Control pain and infection
 Maintain urinary drainage
 Hematocrit and Hemoglobin levels are monitored
closely
 Monitor for oliguria
 Monitor for signs of hemorrhagic shock
 Monitor signs and symptoms of peritonitis
 Nursing Management
 The patient with genitourinary trauma should be assessed frequently
during the first few days after injury to detect flank and abdominal
pain, muscle spasm, and swelling over the flank

 patients are educated about care of the incision and the importance of
adequate fluid intake

 instructions about changes that should be reported to the primary

provider, such as fever, hematuria, flank pain, or any signs and
symptoms of decreasing kidney function, are provided

 Follow-up nursing care includes monitoring the blood pressure to

detect hypertension and advising the patient to restrict activities for
about 1 month after trauma to minimize the incidence of delayed or
secondary bleeding
 Urinary Tract Cancer
Urinary tract cancers include those of the urinary
bladder; kidney and renal pelvis; ureters; and other
urinary structures, such as the prostate.
 Cancer of the Bladder
• Twenty-five percent of cancers of the urinary bladder occur in adults
older than 65 years

• It is the sixth most common cancer with a much higher incidence in

men than women for reasons that are still not well understood

• Bladder cancer is a leading cause of death, accounting for more than

15,000 deaths in the United States annually

• Cancers arising from the prostate, colon, and rectum in males and from
the lower gynecologic tract in females may metastasize to the bladder.

• Tobacco use, especially cigarettes, continues to be a leading risk factor

for all urinary tract cancers
 Clinical Manifestations
 Bladder tumors usually arise at the base of the bladder and
involve the ureteral orifices and bladder neck
 Visible, Painless hematuria
 UTI
 Altered voiding
 Pelvic or back pain may occur with metastasis
Clinical Manifestations
 Assessment and Diagnostic Findings
 Cystography
 Excretory urography
 CT and MRI scans
 Ultrasonography
 Bimanual examination with the patient anesthetized
 Biopsies of the tumor and adjacent mucosa are the
definitive diagnostic procedures
 Surgical Management
 Transurethral resection or fulguration (cauterization)
 Radical Cystectomy
 Cystoscopy
 Pharmacologic Therapy
 Chemotherapy with a combination of methotrexate, 5-
fluorouracil, vinblastine, doxorubicin, and cisplatin has
been effective in producing partial remission of
transitional cell carcinoma of the bladder in some patients.

 IV chemotherapy may be accompanied by radiation

therapy
 Radiation Therapy
 Radiation of the tumor may be performed preoperatively
to reduce microextension of the neoplasm and viability of
tumor cells, thus decreasing the chances that the cancer
may recur in the immediate area or spread through the
circulatory or lymphatic systems.
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