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Urinary tract disorders

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on 2 January 2014

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Transcript of Urinary tract disorders

Urinary tract disorders

Heba Al-khozae, BSN, RN, MSN Candidate.

Bladder spasm
Bladder spasms may be defined as a painful contraction of the bladder.
Their pathophysiology is not well understood, but they are probably caused by an overactive detrusor contraction against a closed or partially blocked bladder outlet.
Patients with
bladder outlet obstruction
due to a urologic
malignancy obstructing the bladder outlet, or secondary
blockage from a tumor outside the urinary tract, are at risk for
bladder spasm.
Foreign objects
within the urinary tract, such
as indwelling urinary catheters or ureteral stents, or recent urologic surgery are also associated with an increased risk for bladder spasm.
risk factors include pelvic radiation therapy, chemotherapeutic agents (particularly cyclophosphamide), intravesical tumors, urinary tract infections, and bladder or lower ureteral calculus.
Urinary stasis
It is defined as blockage of urine transport from the upper to lower urinary tract.
It is usually caused by
of one or both ureters. Th e obstruction is typically attributable to a primary or metastatic tumor, and most arise from the pelvic region. In men, prostatic cancer is the most common cause, whereas pelvic (cervical, uterine, and ovarian) malignancies produce most ureteral obstructions in women.
In addition to malignancies,

secondary to inflammation or radiation may obstruct one or both ureters.
Urinary Incontinence
Urinary incontinence is defined as the uncontrolled loss of urine of sufficient magnitude to create a problem.
intermittent episodes of excruciating, painful cramping localized to the suprapubic region. They are caused by high-pressure, overactive detrusor contractions in response to a specific irritation.

Painful bladder spasms may be the direct result of catheter occlusion by blood clots, sediment, or kinking; or they may be associated with a needlessly large catheter an improperly inflated retention balloon, or hypersensitivity to the presence of the catheter or stent.

Urine may bypass (leak around) the catheter or cause urge UI in the patient with a stent.

It is managed by
altering modifiable factors
, by changing the urethral catheter, altering the type of catheter.

about the position of the catheter, drainage tubes, and bags is reinforced; and the drainage tubes and urine are assessed for the presence of sediment or clots likely to obstruct urinary drainage.
In certain cases, such as when the urethral catheter produces significant urethritis with purulent discharge from the urethra, a
suprapubic indwelling catheter
may be substituted for the urethral catheter.
If conservative measures or catheter modifi cation fail to relieve bladder spasms, an

may be administered. These medications work by inhibiting the overactive contractions that lead to painful bladder spasms.
Urinary system overview.
Lower urinary tract symptoms, it's assessment and management.
Bladder spasm, it's assessment and management.
Urinary stasis, it's assessment and management.
Urinary retention, it's assessment and management.
Hematuria, it's assessment and management.
Describe the physiology of urinary system.
Identify lower urinary tract symptoms, bladder spasm, urinary stasis, urinary retention, and hematuria as urinary tract disorders. In addition to their assessment and management.
Urinary tract physiology:
Urinary system consist of
(Kidneys and ureters) and
urinary tract (bladder, urethra, and supportive structures within the pelvic floor). Together, these structures maintain
urinary continence
, which can be simply defined as control over bladder filling and storage and the act of micturition.

Continence is modulated by three interrelated factors:
(1) anatomic integrity of the urinary tract.
(2) control of the detrusor muscle.
(3) competence of the urethral sphincter mechanism.
The evaluation and management of urinary tract symptoms in the palliative care setting are influenced by considerations of the
goals of care
closeness to death

Urinary system disorders may be directly attributable to a malignancy, systemic disease, or a specific treatment such as radiation or chemotherapy.
Chronic UI is subdivided into types according to its presenting symptoms or underlying pathophysiology.
Factors resulting in transient UI clearly contribute to urinary leakage, but they often arise from outside the lower urinary tract.
It is typically
by a sudden occurrence of urinary leakage or an acute exacerbation of preexisting symptoms.

Transient UI is
by addressing its underlying cause:
is managed by treating the underlying infection of disease causing the delirium.
urinary tract infection
is treated with sensitivity-driven antibiotics.
regimens are altered as feasible if they produce or exacerbate UI.
Fecal impaction
must be relieved and constipation aggressively managed.
Transient (Acute)
Stress UI
Stress UI occurs when physical stress (exertion) causes urine loss in the absence of a detrusor contraction.

Two conditions lead to stress UI:
urethral hypermobility (descent of the bladder base during physical activity).
Intrinsic sphincter deficiency (incompetence of the striated or smooth muscle within the urethral sphincter mechanism), it occurs when the nerves or muscles necessary for sphincter closure are denervated or damaged.

Stress UI is characterized by urine loss occurring with physical exertion or a sudden increase in abdominal pressure caused by coughing or sneezing. It occurs in the absence of a precipitous and strong urge to urinate.

The initial management is with behavioral methods, often combined with use of absorptive products. Pelvic floor muscle training is strongly recommended for mild to moderate stress UI.
Medications also may be used to treat stress UI in selected cases.
, a tricyclic antidepressant with both α-adrenergic effects that increase urethral resistance and anticholinergic actions, may be useful for patients who experience stress UI or mixed stress and urge UI symptoms.
norepinephrine and serotonin reuptake inhibitor
has been approved by the US Food and Drug Administration for treatment of depression, but not stress UI, and its use for this indication is classified as off-label.
An indwelling catheter may be inserted if intrinsic sphincter deficiency and subsequent stress UI are severe.
Urge UI
Urge UI occurs when overactive detrusor contractions produce urinary leakage. It is a part of a larger symptom syndrome called
overactive bladder

Overactive bladder is characterized by
(a sudden desire to urinate that is difficult to defer), and it is typically associated with daytime voiding frequency (more than every 2 hours) and
(≥3 episodes per night).

It is managed by
Behavioral interventions
include reduction or avoidance of bladder irritants such as caffeine and modification of fluid intake.
antimuscarinic medications
block acetylcholine from binding to cholinergic receptors in the bladder wall. This increases functional bladder capacity, inhibits overactive detrusor contractions and associated incontinence episodes, and reduces voiding frequency.

Although antimuscarinic medications are often viewed as an alternative to behavioral therapies, they are better viewed as complementary modalities.
Indwelling catheterization is also indicated if urge UI is complicated by clinically relevant urinary retention or if the patient is near death and immobile.
Reflex UI
Reflex UI is caused by a
neurological lesion
below the brainstem micturition center.

It is
by diminished or absent sensations of bladder filling, neurogenic overactive detrusor contractions associated with urinary leakage, and a loss of coordination between the detrusor and sphincter muscles (detrusor–sphincter dyssynergia).

Because reflex UI is typically associated with diminished sensations of bladder filling, it is not usually responsive to behavioral treatments. A minority of patients with reflex UI retain the ability to urinate spontaneously, but most cases must be managed with an alternative program. For men, an external collection device may be used to contain urine.

α-adrenergic blocking agent
such as terazosin, doxazosin, tamsulosin, or alfuzosin is administered, to minimize the obstruction caused by detrusor–sphincter dyssynergia. Also
medication is usually required in addition to catheterization, to prevent UI.

If reflex UI develops near the end of life, an indwelling catheter may be inserted.
Functional UI
Functional UI occurs when long-standing deficits in mobility, dexterity, or cognition cause or contribute to urinary leakage. For example, neurological deficits or pain may reduce the patient’s ability to reach the toilet in a timely fashion.

Functional UI is treated by minimizing barriers to toileting and the time required to prepare for urination.

Strategies designed to remove barriers to toileting are highly individualized and are best formulated with the use of a multidisciplinary team, combining nursing with medicine, as well as physical and occupational therapy as indicated.
Extraurethral UI
Extraurethral UI occurs when a fistula creates an opening between the bladder and the vagina or skin, allowing urine to bypass the urethral sphincter. Within the context of palliative care, fistulas are usually caused by invasive pelvic or gynecological malignancies, extensive pelvic surgery, or radiation treatment.

It is managed initially by containment devices and preventive skin care.
In some cases, the fistula may be closed by conservative (nonsurgical) means. An indwelling catheter is inserted, and the fistula is allowed to heal spontaneously. This intervention is most likely to work for a traumatic (postoperative) fistula.
If the fistula is a result of an invasive tumor or radiation therapy, it is not as likely to heal spontaneously. In such cases,
fibrin glue
may be used to promote closure.
All patients who experience UI are at risk for developing Incontinence Associated Dermatitis (IAD), particularly when they also experience fecal incontinence and when urinary leakage.

IAD is usually associated with burning and itching, and it increases the risk for pressure ulceration.Prevention focuses on a structured regimen of skin cleansing, moisturization, and application of a skin protectant.
Patients usually report difficulty initiating urination and a dribbling, intermittent flow.

It is more likely to produce
flank pain
, it may
to the abdomen and even to the labia or testes if the lower ureter is obstructed. Its
varies from moderate to intense. It typically is
not relieved
by changes in position, and the patient is often

The patient with bilateral ureteral obstruction and acute renal failure may have
systemic evidence of uremia
, including nausea, vomiting, and hypertension. In some cases, obstruction may by complicated by pyelonephritis, causing a fever and chills.

abdominal assessment
reveals a nondistended bladder.

Blood analysis
reveals an elevated serum creatinine, blood urea nitrogen, and potassium for bilateral ureter obstruction.
It is initially managed by
reversal of fluid and electrolyte imbalances
and prompt drainage. Urinary outflow can be reestablished by insertion of a ureteral
via cystoscopy.
because the stents ofen produce bothersome LUTS, the patient is counseled to ensure
adequate fluid intake
while avoiding bladder irritants, including caffeine and alcohol.
In certain cases, an
medication may be administered to reduce the irritative LUTS or bladder spasms that sometimes are associated with a ureteral stent.

belladonna and opium (B&O) suppositories
may be administered if painful ureteral spasms occur that are not responsive to antimuscarinic agents.
If the ureter is significantly scarred because of radiation therapy or distorted because of a bulky tumor, placement of a
percutaneous nephrostomy tube
may be required.
Urinary retention
Urinary retention is the inability to empty the urinary bladder despite micturition.
It maybe acute or chronic, characterized by suprapubic discomfort produced by bladder filling and distention and the associated anxiety.
Urinary retention is caused by two disorders:
Bladder outlet obstruction
, occurs when intrinsic or extrinsic factors compress the urethral outflow tract such as malignant tumors of the prostate, urethra, or bladder.
Deficient detrusor contraction strength
, occurs as a result of denervation or medication, it may result from histological damage to the detrusor muscle itself, usually caused by radiation therapy or by detrusor decompensation after prolonged obstruction.
Patients usually report difficulty initiating urination and a dribbling, incomplete bladder emptying, a poor force of stream, and an intermittent urinary stream.

It is more likely to produce discomfort localized to the
suprapubic area
or the lower back. The patient with acute urinary retention also may feel
, although this perception is usually attributable to the growing and unfulfilled desire to urinate.
An abdominal assessment reveals that the bladder is grossly distended and may extend above the umbilicus.

Blood analysis
reveals a normal range for serum creatinine, blood urea nitrogen, and potassium.

of the kidneys and bladder reveals ureterohydronephrosis above the level of the obstruction or bladder distention.
It is managed by prompt placement of an indwelling urinary catheter.

It is important to measure the residual volume after changing the catheter, also can be estimated by bladder ultrasound.

Th e patient with chronic urinary retention may be managed by behavioral techniques, intermittent catheterization, or an indwelling catheter.

Behavioral methods are preferred because they are noninvasive and not associated with any risk of adverse side effects. The patient is taught to attempt voiding every 3 hours while awake and to double void (urinate, wait for 3 to 5 minutes, and urinate again before leaving the bathroom).
Management the indwelling catheter

In men, water-soluble lubricating jelly should be injected into the urethra before catheterization and, in women, the gel is liberally applied to the catheter.
A drainage bag that provides adequate storage volume and reasonable concealment under clothing should be chosen.
Th e patient is taught to keep the drainage bag level with or below the symphysis pubis.
All indwelling catheters should be secured using a manufactured leg strap or adhesive backed device to reduce unintentional traction against the bladder neck or inadverent urethral trauma.
Th e patient and family are also advised to monitor for signs and symptoms of clinically relevant infection, including fever, new hematuria, or urinary leakage around the catheter.
Hematuria is defined as the presence of blood in the urine. It results from a variety of renal, urological, and systemic processes.
Hematuria is divided into two subtypes according to its clinical manifestations:

hematuria: the presence of blood remains invisible to the unaided eye.
(gross) hematuria: also characterized by dipstick and microscopic evidence of RBCs in the urine, as well as a bright red or brownish discoloration that is apparent to the unaided eye.
Hematuria can also be subdivided into three categories depending on its severity:
Mild hematuria
is microscopic or gross blood in the urine that does not produce obstructing clots or cause a clinically relevant decline in hematocrit or hemoglobin.
Moderate and severe
hematuria are associated with more prolonged and high-volume blood losses.

Hematuria that originates within the
upper urinary trac
t is often associated with tubulointerstitial disease or an invasive tumor, whereas hematuria originating from the
lower urinary tract
is typically associated with trauma, an invasive tumor, or radiation- or chemotherapy-induced cystitis.
In the patient receiving palliative care, significant hematuria most commonly occurs as the result of a hemorrhagic cystitis related to
(viral, bacterial, fungal, or parasitic),
chemical toxins
(primarily from oxazaphosphorine alkylating agents),
anticoagulation therapy
, or an
idiopathic response to anabolic steroids
or another agent. Radiation and chemotherapeutic agents account for most cases of moderate to severe hematuria.
Taking history.

** Bleeding limited to initiation of the stream is often associated with a urethral source, bleeding during the entire act of voiding usually indicates a source in the bladder or upper urinary tract, and bleeding near the termination of the stream oft en indicates a source within the prostate or male reproductive system.

Physical examination.
laboratory testing.
imaging studies.
The management of hematuria is guided by its severity and its source or cause.

Preventive management for chemotherapy-induced hematuria begins with administration of sodium 2-mercaptoethanesulfonate (
) to patients receiving an alkylating agent for cancer.

Mild urinary retention is managed by identifying and treating its underlying cause. For example,
sensitivity-guided antibiotics
are used to treat a bacterial hemorrhagic cystitis, and
extracorporeal lithotripsy
may be used to treat hematuria associated with a urinary stone.

moderate to severe cases often lead to the formation of blood clots, causing acute urinary retention and bladder pain. In these cases, complete
of clots from the bladder is required before a definitive assessment and treatment strategy are implemented. Th e bladder is irrigated with saline until no further clots are obtained and the backfl ow is relatively clear.
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