Urinary

Elimination
Disorders
 Urinary tract infections (UTIs)
• caused by pathogenic microorganisms in the urinary tract (the normal
urinary tract is sterile above the urethra)
• second most common infection in the body

Classifications of Urinary Tract Infections

1. Lower UTIs
2. Upper UTIs
 Lower UTIs
• Cystitis

• Prostatitis

• urethritis
 Upper UTIs
• Acute pyelonephritis

• chronic pyelonephritis

• renal abscess

• interstitial nephritis

• perirenal abscess
 Uncomplicated Lower or Upper UTIs
• Community-acquired infection; common in young women and not
usually recurrent

• Complicated Lower or Upper UTIs

Often acquired in the hospital and related to catheterization
occur in patients with urologic abnormalities
Pregnancy
Immunosuppression
diabetes
obstructions and are often recurrent
 Lower Urinary Tract Infections
Several mechanisms maintain the sterility of the bladder

• physical barrier of the urethra

• urine flow
• ureterovesical junction competence
• various antibacterial enzymes and antibodies
• antiadherent effects mediated by the mucosal cells of the bladder
 Pathophysiology

fecal organisms ascending from the perineum to the urethra

bladder and then adhering to the mucosal surfaces.

bacteria must gain access to the bladder

attach to and colonize the epithelium of the urinary tract to avoid being washed out
with voiding

evade host defense mechanisms

initiate inflammation.
 Reflux
• Mechanisms of urethrovesical and
ureterovesical reflux
 Clinical Manifestations
• Signs and symptoms of an uncomplicated lower UTI

• burning on urination,
• urinary frequency (voiding more than every 3 hours),
• urgency
• nocturia Incontinence
• suprapubic or pelvic pain.
• Hematuria
• back pain
 Assessment and Diagnostic Findings
• Urine Cultures- useful for documenting a UTI and identifying the
specific organism present

• Cellular Studies- microscopic hematuria is present in about half of

patients with an acute UTI
• Multiple-test dipstick often includes testing for WBCs, known as the
leukocyte esterase test, and nitrite testing
• Tests for sexually transmitted infections may be performed because
acute urethritis caused by sexually transmitted may be responsible for
symptoms similar to those of UTIs.
 Assessment and Diagnostic Findings
• X-ray images
• computed tomography (CT) scan
• ultrasonography,
• kidney scans
Medical Management
 Nursing Interventions
• RELIEVING PAIN
• MONITORING AND MANAGING POTENTIAL COMPLICATIONS
 Upper Urinary Tract Infections
• 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.
• Pathogenic bacteria from a bladder infection can ascend into the
kidney
• An incompetent ureterovesical valve or obstruction occurring in the
urinary tract increases the susceptibility of the kidneys to infection
 Pyelonephritis
• Acute Pyelonephritis - usually leads to enlargement of the kidneys
with interstitial infiltrations of inflammatory cells (Grossman & Porth,
2014)
• 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.
• Chronic pyelonephritis- the kidneys become scarred, contracted, and
nonfunctioning
• transplantation or dialysis.
 Acute Pyelonephritis
enlargement of the kidneys with interstitial infiltrations of inflammatory
cells

Abscesses on or within the renal capsule and at the corticomedullary

junction.

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
• pain and tenderness in the area of the
costovertebral angle
 Assessment and Diagnostic Findings
• An ultrasound study
• CT scan
• IV pyelogram
• Urine culture and sensitivity
Medical Management
Chronic Pyelonephritis
 Clinical Manifestations
• Fatigue
• Headache
• poor appetite
• Polyuria
• excessive thirst
• weight loss
 Assessment and Diagnostic Findings
• IV urogram
• creatinine clearance
• blood urea nitrogen
• creatinine levels
 Complications
• end-stage kidney disease

• Hypertension

• formation of kidney stones

 Nursing Management
• Unless contraindicated, 3 to 4 L of fluids per day is encouraged to
dilute the urine, decrease burning on urination, and prevent
dehydration.

• assesses the patient’s temperature every 4 hours and administers

antipyretic and antibiotic agents as prescribed.

• Patient education focuses on prevention of further infection by

consuming adequate fluids, emptying the bladder regularly, and
performing recommended perineal hygiene.
 ADULT VOIDING DYSFUNCTION
• The micturition process involves several highly coordinated neurologic
responses that mediate bladder function
• A functional urinary system allows for appropriate bladder filling and
complete bladder emptying
 Urinary Incontinence
• involuntary or uncontrolled loss of urine from the bladder
• overactive bladder syndrome
 • Genitourinary surgery
Risk Factors • High-impact exercise
Immobility
• Urinary Incontinence • Incompetent urethra due to
trauma or sphincter relaxation
• Age-related changes in • Medications—diuretic,
the urinary tract sedative,
• Caregiver or toilet • hypnotic, and opioid agents
unavailable • Menopause
• Cognitive disturbances— • Morbid obesity
dementia, Parkinson • Pelvic muscle weakness
disease • Pregnancy—vaginal delivery,
• Diabetes episiotomy
• Stroke
 Types of Urinary Incontinence
• Stress incontinence is the involuntary loss of urine through an intact
urethra as a result of sneezing, coughing, or changing position.
• women who have had vaginal deliveries
• radical prostatectomy
• Urge incontinence is the involuntary loss of urine associated with a
strong urge to void that cannot be suppressed
• The patient is aware of the need to void but is unable to reach a toilet
in time
• Functional incontinence refers to those instances in which lower
urinary tract function is intact but other factors, such as severe
cognitive impairment (e.g., Alzheimer dementia)
• Iatrogenic incontinence refers to the involuntary loss of urine due to
extrinsic medical factors, predominantly medications. One such
example is the use of alpha-adrenergic agents to decrease blood
pressure.
• Mixed urinary incontinence, which encompasses several types of
urinary incontinence, is involuntary leakage associated with urgency
and also with exertion, effort, sneezing, or coughing
 Assessment and Diagnostic Findings
• thorough history
• patient’s voiding history
• Urinalysis
• urine culture
 Medical Management
• Behavioral
Pelvic floor muscle exercises
voiding diary, biofeedback,
verbal instruction
physical therapy
 A
• Pharmacologic
Anticholinergic agents inhibit bladder contraction and are
considered first-line medications for urge incontinence

Surgical

lifting and stabilizing the bladder or urethra to restore the normal

urethrovesical angle or to lengthen the urethra.
 A
• Surgical correction may be indicated in patients who have not
achieved continence using behavioral and pharmacologic therapy.

• Periurethral bulking is a semipermanent 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
• The nurse must provide support and encouragement.
• Patient education is important and should be provided verbally and in
writing
 Urinary Retention
• inability to empty the bladder completely during attempts to void.
• Chronic urine retention often leads to overflow incontinence
(involuntary urine loss associated with overdistention of the bladder).
• Residual urine is urine that remains in the bladder after voiding.
 Pathophysiology
Diabetes, prostatic enlargement, urethral pathology (infection, tumor,
calculus), trauma (pelvic injuries), pregnancy, or neurologic disorders
(e.g., stroke, spinal cord injury, multiple sclerosis, or Parkinson disease).
Some medications cause urinary retention either by inhibiting bladder
contractility or by increasing bladder outlet resistance

Urinary retention may result from

 Assessment and Diagnostic Findings
• The assessment of a patient for urinary retention is multifaceted
because the signs and symptoms
 Signs and symptoms
• voiding small amounts of urine frequently
• dribbling urine
• pain or discomfort in the lower abdomen
• Hematuria
• Urgency
• Frequency
• nocturia
 Complications
• Urolithiasis
• nephrolithiasis
• Pyelonephritis
• Sepsis
• hydronephrosis
 Nursing Management
• Strategies are instituted to prevent overdistention of the bladder and
to treat infection or correct obstruction
• The nurse explains to the patient why normal voiding is not occurring
and monitors urine output closely.
• The nurse also provides reassurance about the temporary nature of
retention and successful management strategies
 Neurogenic Bladder
• dysfunction that results from a disorder or dysfunction of the nervous
system and leads to urinary incontinence
• spinal cord injury
• spinal tumor
• herniated vertebral disc
• multiple sclerosis
• congenital disorders (spina bifida or myelomeningocele)
• Infection
• complications of diabetes
 Pathophysiology for spastic (or reflex)
bladder
spinal cord lesion above the voiding reflex arc (upper motor neuron
lesion)

loss of conscious sensation and cerebral motor control

empties on reflex, with minimal or no controlling influence to regulate

its activity.
 Pathophysiology for Flaccid bladder
lower motor neuron lesion, commonly resulting from trauma patients
with diabetes.

bladder continues to fill and becomes greatly distended,

overflow incontinence

bladder muscle does not contract forcefully at any time.

Because sensory loss may accompany a flaccid bladder

patient feels no discomfort.

 Assessment and Diagnostic Findings
• measurement of fluid intake, urine output, and residual urine volume;
• urinalysis;
• assessment of sensory awareness of bladder fullness and degree of
motor control.
• Comprehensive urodynamic studies
 Complications
• Renal calculi
• impaired skin integrity
• urinary incontinence or retention
• UTI
 Medical Management
• preventing overdistention of the bladder
• emptying the bladder regularly and completely
• maintaining urine sterility with no stone formation,
• maintaining adequate bladder capacity with no reflux
• continous, intermittent, or self catheterization
• the use of an external condom-type catheter;
• a diet low in calcium (to prevent calculi);
• encouragement of mobility and ambulation
 Pharmacologic Therapy
• Parasympathomimetic medications, such as bethanechol
(Urecholine), 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.
UROLITHIASIS AND
NEPHROLITHIASIS
• Urolithiasis and
nephrolithiasis refer to
stones (calculi) in the urinary
tract and kidney, respectively

• Stones may develop in one

or both kidneys and yearly
episodes are increasing
 Pathophysiology
↑concentrations of substances such as calcium oxalate, calcium
phosphate, and uric acid infection, urinary stasis, and periods of
immobility, all of which slow kidney drainage and alter calcium metabolism

Referred to as supersaturation, this depends on the amount of the

substance, ionic strength, and pH of the urine.

Stones are formed

Stones may be found anywhere from the kidney to the bladder and may
vary in size from minute granular deposits, called sand or gravel, to bladder
stones as large as an orange.
 Clinical Manifestations
Signs and symptoms of stones in the nausea and vomiting
urinary system depend on the
renal colic
presence of obstruction, infection,
and edema
Pyelonephritis
UTI with chills
Fever
Frequency
excruciating pain
Hematuria
pyuria
 Assessment and Diagnostic Findings
• Blood chemistries and a 24-hour urine test
• Calcium
• uric acid
• Creatinine
• Sodium
• pH
• UTS
 Medical Management
• 0.5 to 1 cm in diameter stone
• eradicate the stone
• determine the stone type
• prevent nephron destruction
• control infection
• relieve any obstruction
• Opioid analgesic- given to prevent shock and syncope that may result
from the excruciating pain
• Nonsteroidal antiinflammatory drugs (NSAIDs)
• fluids are encouraged
Extracorporeal shock wave lithotripsy
Surgical Management
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