GENITO-URINARY DISORDERS-1.pptx

URINARY DISORDERS
•Voiding disorders,
•Urinary tract infections,
•Primary glomerular disorders,
•renal failure,
•urolithiasis,
•renal trauma
• and renal tract cancers.

MALE REPRODUCTIVE DISORDERS
• Erectile dysfunction
• Ejaculation problems.
• Infections of male GUT.
• Conditions of prostate(prostatitis,BPH,cancer of
prostate)
• Testicular
conditions(orchitis,epididymitis,crytorchidism,
testicular
cancer,vasectomy,hydrocele,varicocele,testicular
torsion)
• Hypospadias and epispadias,phimosis,priapism,Cancer
of penis.

COURSE OBJECTIVE
• By the end of the course,the student will
define ,outline the causes/predisposing
factors,describe the pathophysiology,outline
the clinical manifestations,decribe the
medical/surgical management of the
condition,apply the nursing process in the
management of the condition and provide
appropriate health education to patients with
genito -urinary disorders.

Anatomy and physiology
•ANATOMY
•Location/position of kidneys
•Functions of the kidneys
•Blood supply and innervation of the kidneys.
•Parts of the kidney
Nephrons
PHYSIOLOGY
•Mechanism of urine formation
•Factors regulating glomerular filtration.
•Mechanism of urine concentration.

ANATOMY AND PHYSIOLOGY
• Structure and function of ureters.
• Structure,function,location,blood
supply,innervation of the bladder.
• Structure of urethra.
• Micturation reflex.
• Anatomy and physiologyof the male
reproductive
system.(penis,glands,testis,epididymis,sperma
tic cord,urethra)

HEALTH HISTORY
Common urological symptoms
•DYSURIA-Is pain or burning with voiding.
Signifies UTI.
•FREQUENCY-Voiding multiple times during the
day.Signifies UTI,retention,hyperglycemia with
increased fluid intake,prostatic hypertrophy.
•URGENCY-Need to void immediately. Signifies
UTI,bladder irritation,trauma,tumor.
•NOCTURIA-Awakening to void.Signifies use of
diuretics, prostatic hypertrophy,kidney failure or
insufficiency,increased fluid intake,congestive
heart failure.

UROLOGIC SYMPTOMS CONTD
•HESITANCY-Difficulty initiating voiding. Signifies partial
urethral obstruction,neurogenic bladder.
•INCONTINENCE-Loss of voluntary control of urination.
Signifies UTIs,urethral obstruction,posturinary catheter
removal,CNS or spinal cord
disease.postprostatectomy,laxity of perineal muscles.
•FROTHING-excessive foaming of urine.Signifies
presence of proteins in urine.
•FOUL ODOR-Signifies UTIs.
•POLYURIA-Urinary output <3000ml/24 hr.Signifies
DM,hormonal abnormality,DI,high output kidney failure.

UROLOGIC SYMPTOMS CONTD
•OLIGURIA-Urinary output <400ml/24 hr.Signifies
kidney failure,urinary retention or obstruction.
•ANURIA-Urinary output<100 ml/24 hr.Signifies
kidney failure,total obstruction.
•HEMATURIA-Signifies renal
calculi,UTI,inflammation of kidney or
bladder,trauma to kidney or urinary
tract,posturinary catheter removal,menses.
•Kidney failure commonly cause EDEMA of the
eyelids,hands,feet and ankles.

DIAGNOSTIC TESTS
•Serum creatinine levels-0.6-1.2mg/dl
•Blood urea nitrogen-7-18mg/dl
•Urine specific gravity-1.010-1.025
•Urine osmolality-300-900mg/kg/24 hours.
•Urine chemistry-Sodium,potassium,calcium.
•Urinalysis-Tests urine colour,clarity,pH,specific
gravity,proteins,glucose,ketones,RBCs,WBCs and
casts.
•Radiological tests.
•Ultrasonography.
•Kidney biopsy
•Cystoscopy.

PRIMARY GLOMERULAR DISEASE
•Include: acute and chronic
glomerulonephritis, and nephritic syndrome.
• In all these cases the glomerular capillaries
(filtering portion of the kidneys) are involved.
•Major clinical manifestations of glomerular
injury include proteinuria, hematuria,
decreased GFR and alteration in sodium
excretion.

OBJECTIVES
• Define acute glomerulonephritis.
• Describe the pathophysiology of acute
glomerulonephritis.
• Outline the clinical manifestations of acute
glomerulonephritis.
• State the diagnostic evaluation of acute
glomerulonephritis.
• Explain the medical management of a patient with
acute glomerulonephritis.
• Apply the nursing process in the care of a patient with
glomerulonephritis.
• Provide appropriate health education to a patient
with glomerulonephritis.

ACUTE GLOMERULONEPHRITIS
•Glomerulonephritis is an inflammation of the
glomerular capillaries.
•Primarily a disease of children older than 2 years of
age but can occur at nearly any age.

PATHOPHYSIOLOGY
•May follow group A beta-hemolytic
streptococcal infection of the
throat,impetigo,acute viral infection and antigens
outside the body e.g.medication,foreign serum.
•Other etiological factors include: vascular
injury(hypertension),metabolic diseases(DM),
and DIC.
•Antigen-antibody complex get deposited in the
glomeruli producing swelling and death of
capillary cells. Scarring and obstruction of
circulating blood follows.
•In some patients,kidney tissue itself serves as
the inciting agent.

CLINICAL MANIFESTATIONS
• Hematuria
• Protenuria
• BUN and serum creatinine levels rise
• Urine output drops
• Patient may be anemic.
• Edema and hypertension.
• Headache, malaise, flank pain. Circulatory
overload and dyspnea, engorged neck veins,
cardiomegally and pulmonary edema.
• Atypical symptoms: confusion, somnolence,
seizures.

ASSESSMENT AND DIAGNOSTIC
FINDINGS
•Electron microscopy and kidney biopsy-Show all
renal tissues to be affected (glomeruli, tubules,
blood vessels)
•Antistreptolysin O or Anti-DNase B titers
elevated in post-streptococcal
glomerulonephritis

COMPLICATIONS
•Hypertensive encephalopathy.
•Heart failure.
•Pulmonary edema.
•End stage renal failure.

MEDICAL MANAGEMENT
•Penicillin to treat residual streptococcal
infection.
•Corticosteroids and immunosuppressants to
reduce inflammation in patients with rapidly
progressing acute glomerulonephritis.
•Dietary protein restricted when BUN is elevated.
•Sodium restricted when the patient has
hypertension, edema, and heart failure.
•Loop diuretics and antihypertensive to control
hypertension.

NURSING MANAGEMENT
•CHO given to provide energy and reduce protein
catabolism.
•Intake and output carefully measured and recorded.
•Fluid given according to pts fluid losses and daily body
weight.
•Bed rest prescribed.
•Patient instructed to notify physician if symptoms of
renal failure occur.e.g.fatigue, nausea, vomiting
diminished urine output.
•Importance of follow up evaluation of BP, urinalysis
for protein ,and serum BUN and creatinine levels.
•Review of dosage, desired actions and adverse effects
of medications and precautions to be followed.

CHRONIC GLOMERULONEPHRITIS
AETIOLOGY
•Repeated episodes of AGN.
•Hypertensive nephrosclerosis.
•Hyperlipidemia.
•Chronic tubular interstitial injury.
•Hemodynamically mediated glomerular sclerosis.

PATHOPHYSIOLOGY
•Characterized by progressive destruction of
glomeruli and gradual loss of renal function.
•Glomeruli have varying degrees of
hypercellularity and becomes
sclerosed(hardened).
•The kidney decreases in size.
•Eventually,tubular atrophy,chronic interstitial
inflammation and arteriosclerosis occur.

•May be asymptomatic
•Hypertension.
•Raised BUN,serum creatinine levels.
•Vascular changes or retinal hemorrhage
on eye examination
•Swollen feet

• General symptoms: weight loss, increased
irritability, nocturia.Headeaches, dizziness,
digestive disturbances.
• Cardiomegally, a gallop rhythm, distended
neck veins and symptoms of heart failure, pale
mucous membranes because of edema.
• Peripheral neuropathy, diminished deep
tendon reflexes
• Confusion.

FINDINGS
Urinalysis-Urine specific gravity 1.010,
variable proteins, urinary casts.
-GFR below 50ml/min
-Hyperkalemia, acidosis.
-Anemia
-Hypoalbuminemia.
-Increased serum phosphorus.

DIAGNOSTIC FINDINGS
• Decreased serum calcium levels (binds to
phosphorus)
• Hypermagnesaemia.
• Impaired nerve conduction due to electrolyte
abnormalities and uremia.
• Chest x –ray-cardiac enlargement, pulmonary
oedema
• Electrocardiogram-Tall, peaked T waves
associated with hyperkalemia..

MEDICAL MANAGEMENT
•Hypertension treated with sodium and water
restriction, antihypertensive agents.
•Weight monitored daily.
•Diuretic medication to treat fluid overload.
•Proteins of high biologic value to promote good
nutritional status.

MEDICAL MANAGEMENT
• Adequate calories to spare proteins for tissue
growth and repair.
• UTIs treated promptly to prevent further renal
damage.
• Early initiation of dialysis-to keep pt in optimal
physical condition, prevent fluid and
electrolyte imbalances; minimize risks of
complications of renal failure.

NURSING MANAGEMENT
•Nurse observes patient for signs of deteriorating renal
function,fluid and electrolyte levels,cardiac and
neurological status.
•Emotional support as anxiety levels are often high.
•Patient teaching to maintain a healthy lifestyle, avoid
infections,eat a balanced diet,take prescribed
medication,maintain follow up care and report any
exacerbation in signs and symptoms to the health care
providers.

PATIENT EDUCATION
• Teaching about therapy.
• Scheduling for follow up evaluation.
• Teaching about dialysis if needed, care of
access site,dietary restrictions,lifestyle
modification.

NEPHROTIC SYNDROME
• Define nephrotic syndrome.
• Describe the etiological factors of nephrotic
syndrome.
• Describe the pathophysiology of nephrotic
syndrome.
• Outline the diagnostic evaluation of a patient
with nephrotic syndrome.
• Describe the medical management of
nephrotic syndrome.

OBJECTIVES
• Apply the nursing process in the care of a
patient with nephrotic syndrome.
• Provide appropriate health education to a
patient/guardian for a patient with nephrotic
syndrome.

NEPHROTIC SYNDROME
A primary glomerular disease characterized by:
proteinuria, hypoalbuminemia, edema and
hyperlipidemia.

ETIOLOGY
Associated with:
•Allergic reactions-Insect bites,pollen,acute
glomerulonephritis.
•Infections-herpes zoster.
•Systemic disease-diabetes mellitus,lupus
erythromatosus,sickle cell disease.

ETIOLOGY
• Circulatory problems-Severe congestive heart
failure, chronic constrictive pericarditis.
• Cancers-Hodgkins disease,lung,colon and
breast cancer.
• Renal transplant
• Pregnancy.

EPIDEMIOLOGY
•Most oftenly seen in children.
•In adults,the most common cause of nephrotic
syndrome is membranous glomerulopathy.

CHANGE IN BASEMENT
CELL
MEMBRANE(Increased
porosity)
PROTEINURIA
HYPOALBUMINEMIA
(Decreased serum osmotic pressure)
EDEMA
DECREASED PLASMA
VOLUME
INCREASED SODIUM
RESORBTION,INCREASED H2O
RETENTION
INCREASED ALDOSTERONE SECRETION,DECREASED
GLOMERULAR FILTRATION RATE

•Severe generalized edema.
•Significant proteinuria.
•Hypoalbuminemia.
•Hyperlipidemia.
•Malaise
•Headache
•Irritability
•Fatigue.

ASSESSMENT AND DX FUNCTIONS
•Proteinuria exceeding 3 to 3.5g/day.
•Urine contains WBCs as well as granular and
epithelial casts.
•Needle biopsy of the kidneys.

COMPLICATIONS
•Infection
•Thrombo-embolism (renal veins)
•Pulmonary emboli.
•Acute renal failure (due to hypovolemia)
•Accelerated atherosclerosis (due to hyperlipidemia)

MEDICAL MANAGEMENT
•Diuretics for pts with severe oedema.
•Corticosteroids such as prednisolone.
•Antineoplastic agents (cyclophosphamide) or
immunosuppressant medication (azathioprine,
chlorambucil) for patients who are unresponsive to
corticosteroids.

MEDICAL MANAGEMENT
• Angiotensin converting enzyme inhibitors
reduces protein loss in urine, diuretics and
albumin reduce edema.
• Hypertension treated aggressively,antibiotics
indicated if infection is present.
• Pt placed on low sodium diet.
• Protein intake about 0.8g/kg/day with
emphasis on biologic proteins and diet low in
saturated fat.

NURSING MANAGEMENT
•Diet-Sodium restricted,small frequent
feedings,vitamin and iron. supplementation,Proteins
of high biologic value.
•Nurse offers oral hygiene at regular intervals.
•Nurse monitors laboratory data including serum
protein,lipids and calcium to assess protein stores.
•Patient weighed daily.
•Nurse teaches patient how to assess their fluid
status including signs and symptoms of hypovolemia
and hypervolemia.

RENAL FAILURE(OBJECTIVES)
• Define renal failure.
• Outline the forms of renal failure.
• Describe the classification of renal failure.
• Outline the phases of renal failure.
• Explain the pathophysiology of acute renal failure.
• State the diagnostic evaluation of ARF.
• Describe the medical management of a patient with
acute renal failure.
• Apply the nursing process in the management of ARF.
• Provide appropriate health education for a patient with
ARF.

RENAL FAILURE
•Results when the kidneys cannot remove the body’s
metabolic wastes or perform their regulatory
functions.
•Substances normally eliminated in urine accumulate
in the body fluids, leading to disruption in endocrine
and metabolic function as well as fluid, electrolyte
and acid-base disturbances.
•FORMS
•Acute renal failure.
•Chronic renal failure.

ACUTE RENAL FAILURE
•ARF is a sudden and almost complete loss of
kidney function over a period of hours to
days.
•ARF manifests with oliguria, anuria or normal
urine volume.
•Oliguria(less than 400ml/day) anuria(less
than 50ml/day)
•Regardless of volume of urine excreted, the
patient with ARF experiences rising serum
creatinine and BUN levels and azotemia.

CLASSIFICATION OF ARF
PRERENAL CONDITIONS
Occur as a result of impaired blood flow that
results in hypo perfusion of the kidneys and in
drop in GFR.
CAUSES
1. HYPOVOLEMIA
-Hemorrhage -Dehydration -vomiting
-Diabetes insipidus -Cirrhosis -Diarrhoea.
-Inappropriate use of diuretics -Diaphoresis
-Burns -Peritonitis -Pancreatitis

CAUSES
2. DECREASED CARDIAC OUTPUT
-Congestive heart failure
-Myocardial infarction.
-Tamponade
-Dysrrhythmias.

CAUSES
3. SYSTEMIC VASODILATION
-Sepsis
-Acidosis
-Vasodilating medications.
-Anaphylaxis.
4. HYPOTENSION OR HYPOPERFUSION
-Cardiac failure
-Shock

INTRARENAL/INTRINSIC
Is the result of actual parenchymal damage to the glomeruli or
kidney tubules
CAUSES
1. TUBULE OR NEPHRONIC DAMAGE
-Acute tubular necrosis
-Glomerulonephritis
-Rhabdomyolysis.
2. VASCULAR CHANGES
-Coagulopathies
-Malignant hypertension.
-Abdominal aortic aneurysm.
-Sclerosis
-Renovascular disease.

CAUSES
3. NEPHROTOXINS
-Antibiotics (gentamycin, tobramycin,
AmphotericinB, PolymyxinB, neomycin,
kanamyicin, vancomycin)
-Chemicals
-Heavy metals (Arsenic, mercury)
-Drug induced interstitial nephritis-NSAIDs,
tetracycline, furosemide, thiazides, phenytoin, and
penicillin.

POSTRENAL
Are a result of an obstruction somewhere distal to
the kidney. Pressure rises in the kidney tubules,
eventually, the GFR decreases.
URETERAL AND BLADDER NECK OBSTRUCTION
-Calculi
-Neurogenic bladder
-Neoplasms
-Prostatic hyperplasia.

PHASES OF ARF
1. INITIATION-Begins with the initial insult and ends
when oliguria develops.
2. OLIGURIA PERIOD-Accompanied by a rise in
serum concentration of substances excreted by the
kidneys (urea, creatinine, uric acid, organic acids,
intracellular cations (K, mg).In this phase uremic
symptoms first appear and life threatening
conditions such as hyperkalemia develop.

PHASES CONTD
3. DIURETIC PERIOD-Pt experiences gradual
increase in urine output signaling recovery of
glomerular filtration. Lab values stop rising and
eventually decrease. Patient must be observed
for dehydration during this period.
4. RECOVERY PHASE-Laboratory values return to
normal levels.

ISCHAEMIA OR NEPHROTOXINS
GLOMERULAR INJURY
TUBULAR INJURY
VASOCONSTRICTION
DECREASED
PERMEABILITY N
SURFACE AREA
CAST FORMATION
OBSTRUCTION
TUBULAR BACK LEAK
INCREASED
IINTRALUMINAL
PRESSURE
DECREASED GFR
OLIGURIA

PATHOPHYSIOLOGY CONTD
•Three major electrolyte problems in ARF
are:hyperkalemia,sodium imbalance,and metabolic
acidosis.
•Hyperkalemia(serum 5.5mEq/l),occur due to failure
of exchange of K ions at the DCT for Na or H ions.
•Hyponatremia most often develop with
overhydration.
•Metabolic acidosis develops when H ion secretion
and bicarbonate ion production diminish in the
tubules.

CLINICAL MANIFESTATION
•Pt critically ill and lethargic.
•Persistent nausea, vomiting, diarrhea.
•Urine-specific gravity low,urinary casts.
•Skin and mucous membranes dry from
dehydration.
•Breath may have odor of urine.
•CNS symptoms-Drowsiness, headache, muscle
twitching, seizures.

ASSESSMENT AND DX FINDINGS
•Urine output varies, hematuria, specific gravity 1.010
or less.
•Urinary casts
•Ultrasonography
•Increased BUN and creatinine levels (azotemia)
•Hyperkalemia-Inability to excrete K normally, protein
catabolism that releases cellular K.
•Metabolic acidosis.
•Increased serum phosphorus, low serum calcium
levels.

MEDICAL MANAGEMENT
•Any possible cause of damage is identified, treated and
eliminated.
•Prerenal azotemia treated by optimizing renal perfusion,
whereas post renal azotemia is treated by relieving the
obstruction.
•Treatment of intrarenal azotemia is supportive with
removal of causative agents.
•Shock and infection if present are treated promptly.
•Maintain fluid balance by: daily weighing, measurement
of CVP,serum and urine concentration, fluid losses, BP
and clinical status of the patient.
•Fluid excesses detected by clinical findings of dyspnea,
tachycardia, distended neck veins.

MANAGEMENT CONTD
•Mannitol, furosemide prescribed to initiate diuresis and
prevent or minimize subsequent renal failure.
•Dialysis corrects many biochemical abnormalities.
•Elevated K levels may be reduced by administering cation
exchange resins (sodium polysterylene sulfonate) orally or by
retention enema.
•Medication dosage must be reduced when a pt has ARF.
•In patients with severe acidosis, arterial blood gases or serum
bicarbonate levels must be monitored.
•Dietary proteins are limited to about 1g/kg during the oliguric
phase to minimize protein breakdown and prevent
accumulation of toxic end products.
•High carbohydrate diet.
•Foods and fluids containing K or phosphorus are restricted.

NURSING MANAGEMENT
•Monitoring fluid and electrolyte balance.
•Reducing metabolic rate-bed rest, fever and infection
treated promptly.
•promoting pulmonary function-Pt assisted to turn,
cough and take deep breaths frequently.
•Preventing infection-Asepsis, avoid indwelling urinary
catheter whenever possible.
•providing skin care-Turning frequently, massaging
bony prominences, bathing.
•Providing support.

CHRONIC RENAL FAILURE
Is a progressive, irreversible deterioration in the renal
function in which the body’s ability to maintain
metabolic and fluid and electrolyte balance fails
resulting in uremia.

CAUSES
•Systemic
disease:DM,hypertension,pyelonephritis,sickle cell
anemia.
•Obstruction of the urinary tract:Prostatic and bladder
tumors,ureteral obstruction,calculi.
•Glomerular dysfunction:Glomerulonephritis,diabetes
nephropathy,hypertensive nephrosclerosis.
•Other:Polycystic kidney disease,vascular
disease,Infection,medication or toxic
agents,Nephrotic syndrome.

PATHOPHYSIOLOGY
•Unlike in ARF,damage to the kidneys is progressive
and irreversible.
•CRF progresses through four stages:Decreased
kidney reserve,kidney insufficiency,kidney
failure,ESRD.
Decreased kidney reserve
40% to 70% loss of nephron function.
GFR,40% to 50% of normal.
BUN and serum creatinine levels normal.
Patient asymptomatic.

PATHO CONTD
Kidney insufficiency
•75% to 80% loss of nephron function.
•GFR,20% to 40% of normal.
•BUN and serum creatinine levels begin to rise.
•Mild anaemia,mild azotemia which worsen with physiologic
stress.
•Nocturia,polyuria.
•Kidney failure
•GFR 10% to 20% normal.
•BUN and serum creatinine levels increase.
•Anemia,azotemia,metabolic acidosis.
•Urine specific gravity low.
•Polyuria,nocturia.
•Symptoms of kidney failure present.

END STAGE RENAL DISEASE
•85% loss of nephron function.
•GFR:10% normal
•BUN and serum creatinine at high levels.
•Anemia,azotemia,metabolic acidosis.
•Urine specific gravity fixed at 1.010.
•Oliguria.
•Symptoms of kidney failure present.

•CARDIOVASCULAR-hypertension, heart failure,
pulmonary edema, pericarditis.
•DERMATOLOGIC-Pruritus,pigment changes,capo4
deposition,echymosis,excoriations,uremic
frost,dry,scaly skin.
•GASTROINTESTINAL-Anorexia, nausea, vomiting,
hiccups,uremic fetor.
•NEUROLOGIC-Altered levels of consciousness,
inability to concentrate, muscle twitch, seizures.

• Endocrine/reproductive-Hyperparathyroidism,thyroid
abnormalities,amenorrhea,infertility,sexual
dysfunctionn,azoospermia.
• Metabolic-Carbohydrate
intolerance,hyperlipidemia,nutritional
deficiencies,gout.
• Hematologic-Anemia,bleeding,infection.
• Peripheral neuropathy-Paresthesis, motor weakness,
restless legs syndrome.

FINDINGS
•GFR-Detected by obtaining 24 hour urinalysis for
creatinine clearance.
•Serum creatinine and BUN levels.
•Acidosis-From inability of the kidneys to excrete
ammonia and reabsorb sodium bicarbonate.
•Anemia
Calcium and phosphorus imbalance.

COMPLICATIONS
•Hyperkalemia
•Pericarditis
•Hypertension
•Anemia
•Bone disease and metastatic calcifications

MEDICAL MANAGEMENT
PHAMACOTHERAPY
-ANTACIDs- Aluminium based antacids to treat
hyperphosphatemia and hypocalcaemia.
-Antihypertensive and cardiovascular agents-
Diuretic agents, inotropic agents (digitalis) dialysis.
-Antiseizure agents-valium, phenytoin
-Erythropoietin.

MEDICAL MANAGEMENT
• NUTRITIONAL THERAPY
Regulation of protein intake, sodium intake to
balance losses and some restriction of potassium.
Allowed proteins must be of high biologic value.
Fluid allowance 500-600ml more than previous
days 24 hours urine output.
Calories to prevent wasting.
Vitamins supplementation necessary.
• DIALYSIS

NURSING MANAGEMENT
•Assess fluid status and identify potential sources of
imbalance.
•Implementing a dietary program to ensure proper
nutrition.
•Encourage positive feelings by encouraging increased
self care and greater independence.
•Provide information concerning ESRD, treatment
options, potential complications.
•Emotional support.

PATIENT EDUCATION
• Nutritional needs.
• Vascular access patency.
• Problems to report to the health care
provider(hyperkalemia)
• Follow up examination and treatment.

OBSTRUCTIVE DISORDERS
Renal calculi,urinary strictures and
tumors.

RENAL CALCULI(OBJECTIVES)
• Describe the causes of renal stones.
• State the risk factors of renal stones.
• Describe the pathophysiology of renal stones.
• State the clinical manifestations of a patient with
renal stones.
• Outline the diagnostic tests for renal stones.
• Describe the medical/surgical management of renal
stones.
• Apply the nursing process in the management of a
patient with renal stones.
• Provide appropriate health education to a patient
with renal stones.

RENAL CALCULI/UROLITHIASIS
•Urinary stones may develop at any level in the
urinary system but are most frequent within the
kidney (nephrolithiasis)

ETIOLOGY AND EPIDEMIOLOGY
•A kidney stone forms when urine is supersaturated with a stone
forming salt.
•Approx.75% of kidney stones consists of calcium
salts.(oxalates,phosphates).
•Causes of hypercalcemia and hypercalciuria include the
following:myeloproferative diseases(leukemia,polycythemia
vera,multiple myeloma)parathyroidism,renal tubular
acidosis,cancers,Granulomatous diseases(sarcoidosis,tuberculosis),
•The remaining stones are made of:Struvite,uric acid or cysteine.
•Uric acid stone seen in patients with gout or myeloproliferative
disorders.
•Struvite stones caused by urease splitting
bacteria:Proteus,pseudomonas,Klebsiella,Mycoplasma spp.

ETIOLOGY CONTD
•Cystine stones occur exclusively in patients with a
rare inherited defect in renal absorption of cystine.
•Renal calculi are 2.5 times more common in men
than women and in persons between the ages of 20
and 50 years old.

RISK FACTORS
•Inadequate hydration.
•Hypercalciuria.
•High intake of proteins and sodium.
•Urinary tract infections.
•High intake of dietary purines found in red meat, fish
and poultry.
•Periods of immobility
•Disorder in purine metabolism.

PATHOPHYSIOLOGY
Kidney stones are made up of crystalline
components which require three major steps for
formation. Nucleation, growth and aggregation.
Nucleation seeds the stone process and may be
initiated by a variety of materials such as protein,
foreign bodies or crystals.

•Pain-Severe flank pain accompanied by tenderness at
the costovertebral angle.
•Urinary urgency and burning sensation during
urination.
•Hematuria in 95% of persons.
•Nausea and vomiting.
•Abdominal pain.

COMPLICATIONS
•Severe pain
•Hydronephrosis(dilation of renal calyces and pelvis)
•Kidney failure
•Increased risk of infection.

DIAGNOSTIC TESTS
•X ray film of the kidneys, ureters and bladder reveals radio
opaque stones larger than 2mm.
•Intravenous pyelography-Evaluates potential structural and
anatomical abnormalities of the urinary tract.
•Ultrasound
•BUN and creatinine,a complete blood count,urinalysis,urine
culture
•Urine ph measured-Urine PH <6 is seen with calcium and uric
acid stones, pH>7.2 with struvite stones. A nitroprusside urine
test performed to check for cystine.
•A 24hr urine specimen is collected to measure calcium,
oxalates, and phosphorus and uric acid levels.

MEDICAL MANAGEMENT
-I.v opioids or non steroidal are a good choice for analgesia.
-Hot baths or moist heat to the flank areas may also be
useful.
-Fluid intake should be increased to 3L/day and dietary
oxalates and sodium limited.
-For calcium stones chelating agent such as cellulose sodium
phosphate is administered with meals and binds to calcium
and impedes absorption in the small bowel.
-Thiazide diuretics decrease calcium content by increasing
reabsorption in the renal tubules.

MEDICAL MANAGEMENTCONTD
•Those with hyperparathyroidism require surgical resection of
the parathyroid adenoma.
•Prophylaxis for uric acid stones consists of alkalinizing the urine
by administering sodium bicarbonate or citrate solution.
•Allopurinol is usually prescribed to inhibit synthesis of uric acid.
The patient is placed in a low purine diet.Shell fish, anchovies,
asparagus .mushrooms and organ meats are foods high in
purines.
•Treatment for struvite stones is complete surgical removal and
treatment of infection with antibiotics.
•Cysteine stones can be treated with penicillamine, which acts
by combining with cysteine to form a soluble compound.
•For oxalate stones dilute urine is maintained and the intake of
oxalates is limited. Foods rich in oxalates include: spinach,
strawberries, chocolates, tea, peanuts and wheat bran

OTHER SURGICAL MODALITIES
•Ureteroscopy-A ureteroscope is inserted followed by a
ureterohydraulic lithotripter, or ultrasound devise through the
ureteroscope to fragment and remove the stone.
•Extracorporal shock wave lithotripsy-In this procedure, high
amplitude of shock wave is generated by an abrupt release of
energy and transmitted through water and soft tissues.
Repeated shock waves eventually reduce the stone to small
pieces.
• Percutaneous nephrostomy—A nephroscope is introduced
through the dilated percutaneous tract into the renal
parenchyma. The stone may be extracted with forceps or a
stone retrieval

NURSING MANAGEMENT
•. Pain relieve-Opioid analgesics, NSAIDs, Patient assisted
to assume comfortable position.
•Monitoring and managing potential complications-
Patient instructed to report decreased urine volume, and
bloody or cloudy urine.
-Vital signs monitored closely.
-All infections should be treated with the appropriate
antibiotic agents.

NURSING MANAGEMENT
Teaching patient self care
• Maintain a high fluid intake
• Urine cultures may be performed every 1 to 2
months the first year and periodically
thereafter.
• Increased mobility is encouraged whenever
possible.
• Excessive ingestion of vitamins particularly
vitamin D and minerals is discouraged.

DIALYSIS(OBJECTIVES)
• State the uses of dialysis
• Describe methods of dialysis.
• Describe the principles of dialysis.
• Explain patient preparation for dialysis.
• Explain the vascular access in hemodialysis.
• State the complications of hemodialysis and
peritoneal dialysis.

DIALYSIS
USES
•Is used to remove fluid and uremic waste
products from the body when the kidneys
cannot do so.
•It may be used to treat edema that does not
respond to treatment, hepatic coma,
hyperkalemia, hypertension, and uremia.
•Remove excessive amounts of drugs and toxins

USES
• Maintain kidney function when shutdown
occurs as a result of transfusion reaction.
• Replace kidney function temporarily in
persons with AKF
• Permanently substitute for loss of kidney
function in persons with ESRD

METHODS
•Hemodialysis
•Continous renal replacement therapy
•Peritoneal dialysis.

INDICATIONS
•Hyperkalemia
•Fluid overload
•Impending pulmonary edema
•Increasing acidosis
•Pericarditis
•severe confusion
•Poisoning or medication overdose.
•In chronic renal failure

HEMODIALYSIS
•A dialyzer serves as a synthetic semi permeable
membrane, replacing the renal glomeruli and
tubules as the filter for the impaired kidneys.
•It doesn’t compensate for the loss of endocrine or
metabolic activities of the kidneys.
•Patients receiving hemodialysis must undergo
treatment for the rest of their lives or until they
undergo a successful kidney transplant.

HEMODIALYSIS
• Treatment usually occur three times a week
for at least 3 to 4 hours per treatment.
• The trend in managing end stage real damage
is to initiate treatment before signs and
symptoms associated with uremia become
worse.

PRINCIPLES OF HEMODIALYSIS
•Diffusion, osmosis, and ultra filtration are the
principles on which hemodialysis is based.
•Toxins and wastes in blood are removed by
diffusion i.e. they move from an area of higher
concentration in the blood to an area of lower
concentrations. The semi permeable membrane
impedes the diffusion of large molecules such as
red blood cells and proteins.

PRINCIPLES OF HEMODIALYSIS
• Excess water is removed from blood by osmosis,
in which water moves from an area of higher
solute concentration to an area of lower solute
concentration (the dialysate bath).
• Ultra filtration is defined as water moving under
high pressure to an area of lower pressure. It is
accomplished by applying negative pressure or a
suction force to the dialysis membrane.Efficient
for removal of fluid.

DIALYZERS
•Most dialyzers are either flat-plate or hollow –fiber
artificial kidneys that contain thousands of tiny
cellophane tubules that act as permeable
membranes.
•The blood flows through the tubules, while a
solution (the dialysate) circulates around the tubules.
•The exchange of waste from the blood to the
dialysate occurs through the semipermiable
membranes of the tubules.

VASCULAR ACCESS
Subclavian, internal jugular and femoral
catheters’-Immediate access to the patient’s
circulation for acute hemodiaysis is achieved
by inserting a double lumen or multilumen
catheter into the subclavian, internal jugular
or femoral vein.This method involves some
risk of hematoma, pneumothorax, infection,
thrombosis of the subclavian vein and
inadequate flow.

VASCULAR ACCESS
• FISTULAS-Created surgically by joining an artery
to a vein either side to side or end to end.
Needles are inserted into the vessel to obtain
blood flow adequate to pass through the dialyzer.
Arterial segment of the fistula is used for arterial
blood flow and the venous segment for
reinfusion of the dialyzed blood. The fistula takes
4 to6 weeks to mature before it is ready for use.
This gives time for healing and for the venous
segment of the fistula to dilate to accommodate
two large-bore needles.

VASCULAR ACCESS CONTD
GRAFT-An arteriovenous graft can be created by
subcutaneously interposing a biologic, semibiologic,
or synthetic graft material between an artery and
vein.Usualy created when the patient’s vessels aren’t
suitable for a fistula. Infection and thrombosis are the
most common complications of arteriovenous grafts.

COMPLICATIONS
•Atherosclerotic cardiovascular disease-
Disturbances of lipid metabolism appear to be
accentuated by hemodialysis.
•Anemia –Use of erythropoietin before dialysis
improve hematocrit values.
•Increased dialyzer clotting may occur which is
prevented by adjusting heparin doses.
•Gastric ulcers-From physiological stress of chronic
illness, medication, and related problems.

COMPLICATIONS
• Osteodystrophy-From disturbed calcium
metabolism.
• Fluid overload associated with heart failure,
malnutrition, infection, neuropathy and pruritus.
• Hypotension from fluid removal.
• Painful muscle cramping as fluid and electrolyte
rapidly leave the extracellular space.
• Dysrhythmias from electrolyte and pH changes.

LONG TERM MANAGEMENT
•The Pt, the dialyzer and the dialysate bath require
constant monitoring because numerous complications
are possible.
• Pharmacologic therapy-Many medications are
removed from the blood during hemodialysis;
therefore the physician needs to adjust the dosage.
Metabolites bound to proteins aren’t removed during
dialysis. Patients undergoing hemodialysis who
require medications are monitored closely to ensure
that blood tissue levels of these medications are
maintained without toxic accumulation.

LONG TERM MANAGEMENT
• Nutritional and fluid therapy-Restriction of
proteins, fluid, sodium and potassium.
Proteins must be of a high biological value to
maintain a positive nitrogen balance.

PERITONEAL DIALYSIS
•Patients with diabetes, or
cardiovascular disease, many older
patients, and those who may be at
risk for adverse effects of systemic
heparin are likely candidates for
peritoneal dialysis.

UNDERLYING PRINCIPLE
•The peritoneum with a surface area of
approx.22000cm2 acts as the semipermeable
membrane.
• Sterile dialysate fluid is introduced into the
peritoneal cavity through an abdominal catheter at
intervals.
•Urea, creatinine cleared from the blood by
diffusion and osmosis as waste products move from
an area of higher concentration (peritoneal blood
supply) to an area of lower concentration
(peritoneal cavity) across a semi permeable
membrane.

UNDERLYING PRINCIPLE
• Ultra filtration (water removal), occurs in
peritoneal dialysis through an osmotic
gradient created by using a dialysate fluid with
a higher glucose concentration.

PATIENT PREPARATION
•The nurse explains the procedure to the patient and
obtains consent for it.
• Vital signs, weight, and serum electrolyte levels are
recorded.
•The patient is encouraged to empty the bladder and
bowels to reduce risk of puncturing internal organs.
•Nurse assesses the patients’ anxiety about the
procedure and provides support and instruction.
•Broad spectrum antibiotic agents may be
administered to prevent infection

PREPARATION OF EQUIPMENT
•Equipment assembled
•Concentration of the dialysate determined.
•Heparin may be added to the dialysate to prevent
blood clotting.
•Potassium chloride may be prescribed to prevent
hypokalemia.
•Antibiotics may be added to treat peritonitis.
•Dialysate is warmed to body temperature to prevent
patient discomfort and abdominal pain and to dilate
vessels of the peritoneum to increase urea clearance.

INSERTING THE CATHETER
•Ideally the peritoneal catheter is inserted in
the operating room to maintain surgical
asepsis .
•And minimize the risk of contamination.
•The skin is prepared with a local antiseptic
to reduce skin bacteria and the risk of
contamination
and infection.

INSERTING THE CATHETER
• The physician anesthetizes the site before making
a small incision in the lower abdomen, 3 to 5 cm
below the umbilicus.
• A trocar is used to puncture the peritoneum as
the patient tightens the abdominal muscles by
raising the head. Previously prepared dialysate is
infused into the peritoneal cavity, pushing the
omentum away from the catheter.
• The catheter is secured with a suture and
antibacterial ointment and sterile dressing over
the site.

PERFOMING THE EXCHANGE
•Peritoneal dialysis involves a series of exchanges or
cycles (infusion, dwell, and drainage)
•A period of 5 to 10 minutes is required to infuse 2L of
fluid.
•At the end of the dwell time, the drainage portion of
the exchange begins. The tube is unclamped and the
solution drains from the peritoneal cavity by gravity
through a closed system.
•Drainage is usually completed in 10 to 30 minutes.
Drainage fluid is normally colorless or straw coloured.

COMPLICATIONS
•Peritonitis
•Leakage
•Bleeding
•Hyperglyceridemia
•Abdominal hernias (incision, inguinal, diaphragmatic,
umbilical)

UTIs(OBJECTIVES)
• Classify urinary tract infections.
• Define different urinary tract infections.
• Outline the causes and predisposing factors of
urinary tract infections.
• Describe the pathophysiology of urinary tract
infections.
• State the clinical manifestations of urinary
tract infections.

OBJECTIVES
• Outline the diagnostic evaluation of urinary
tract infections.
• Describe the medical management of urinary
tract infections.
• Apply the nursing process in the management
of a patient with urinary tract infection.
• Provide appropriate health messages to a
patient with urinary tract infection.

URINARY TRACT INFECTIONS
•Urinary tract infections are caused by pathogenic
micro-organisms in the urinary tract.
•Urinary tract infections are generally classified as
infections involving the upper or lower urinary
tract.
•Lower UTIs include:Bacterial cystitis
(inflammation of the urinary bladder), bacterial
prostitis (inflammation of the prostate), urethritis
(inflammation of the urethra)
•Upper UTIs include-Acute and chronic
pyelonephritis, interstitial nephritis and renal
abscesses.

PREDISPOSING FACTORS
•Proximity of the urethra to the anus
especially in women.
•Urethrovesical reflux i.e. backflow of urine
from the urethra to the bladder e.g.
narrowed urethra.
•Vesico-ureteral reflux-That is backflow of
urine from the bladder to the ureters incase
of obstruction to the urinary tract e.g.
enlargement of the prostate gland leading to
full bladder.

PREDISPOSING FACTORS
• Instrumentation e.g. in catheterization,
endoscopy or cystoscopic procedure carrying
micro-organism into the urinary system.
• Stasis of urine, keeping full bladder for a long
time hence giving more time to
microorganisms to thrive i.e. during
pregnancy.
• Some systemic diseases like diabetes mellitus.
• Sexual intercourse with an infected partner.

PATHOPHYSIOLOGY
-Bacterial invasion of the urinary tract-Glycosaminoglycan,
which normally exerts a nonadherent protective effect against
various bacteria, may be impaired.
-Reflux-Urethrovesical reflux (backflow of urine) is caused by
dysfunction of the bladder neck.
Ureterovesical reflux may be impaired by congenital causes or
ureteral abnormalities, the bacteria may reach and eventually
destroy the kidneys.
-Uropathogenic bacteria-Bacteriua is generally defined as more
than 105 colonies of bacteriuria per milliliter of urine. Organisms
most frequently responsible for UTIs are those normally found
in the lower GIT. They include E.coli, pseudomonas and
Enterococcus.
-Routes of infection-Urethra (ascending infection), through the
bloodstream, or by means of a fistula.

•About half of all patients with bacteriuria have no
symptoms.
•Frequent pain and burning on urination, frequency,
urgency, nocturia, incontinence and suprapubic or
pelvic pain.
•Hematuria and back pain may also be present.

•Colony count-A colony count of at least 105 per
milliliter of urine on a clean catch midstream
specimen is a major criterion for infection.
• Cellular studies-Microscopic hematuria (>4 RBCs per
high –power field), Pyuria (>4WBCs per high power
field) occur in all patients with UTIs.
• Urine cultures.

MEDICAL MANAGEMENT
•In uncomplicated lower UTIs ,single dose
administration, short course (3 to 4 days) medication
regimen or 7 to 10 day therapeutic.
•In complicated UTI (i.e. pyelonephritis) the general
treatment of choice is usually a cephalosporin or an
ampicillin/aminoglycoside combination for 7 to 10
days. Other commonly used medication includes
septrin, and nitrofurantoin, ciprofloxacin.
•Nitrofurantoin should not be used for patients with
renal insufficiency because it is ineffective at GFR of
less than 50mL/minute and may cause peripheral
neuropathy.

NURSING MANAGEMENT
•Pain relieve-Relieved once effective antimicrobial therapy
is initiated.
Antispasmodic agents also useful in relieving irritability and
pain.
-Patient encouraged to drink liberal amounts of fluid to
promote bloodflow and flash bacteria from the urinary
tract.
-Frequent voiding encouraged to empty the bladder
completely ass this lowers urine bacterial count,reduce
urinary stasis and prevents reinfection.

NURSING MANAGEMENT
• Monitoring potential complications
• -Patient instructed to notify physician if
fatigue,nausea,vomiting or pruritus occur.
• -Periodic monitoring of renal
function(BUN,creatinine clearance,serum
creatinine) indicated in repeated episodes of UTIs
• Indwelling catheter if posssible should be avoided
and removed at the earliest opportunity.

NURSING MANAGEMENT CONTD
If an indwelling catheter is necessary, however, specific
nursing interventions are initiated to prevent infection.
These include the following:
-Using strict aseptic technique during insertion of the
smallest catheter possible.
-Securing the catheter with tape to prevent movement.
-Frequently inspecting urine colour, odour and
consistency
-Performing meticulous daily perineal care with soap
and water.
-Using the catheters port to obtain urine specimen.

UPPER URINARY TRACT INFECTIONS

ACUTE PYELONEPHRITIS
•Dfn-Is a bacterial infection of the renal pelvis,
tubules, and interstitial tissue of one or both kidneys.
•Bacteria reach the bladder by means of the urethra
and ascend the kidneys. Fewer than 3% of cases are
due to hematogenous spread.

CAUSES
Pyelonephritis is frequently secondary to
ureterovesical reflux, in which an incompetent
ureterovesical valve allows the urine to backup into
the ureters.
-Urinary tract obstruction
-Bladder tumors
-Strictures
-Benign prostatic hyperplasia
-Urinary stones.

•Patients with pyelonephritis usually have enlarged
kidneys with interstitial infiltrations of inflammatory
cells.
•Abscesses may be noted on the renal capsule and at
the corticomedullary junction.
•Eventually, atrophy and destruction of tubules and
the glomeruli may result.
•When pyelonephritis becomes chronic, the kidneys
become scarred, contracted and nonfunctioning.

•Patient appears acutely ill.
•Chills,
• Fever,
• Leukocytosis,
•Bacteriuria and pyuria.
• Flank pain
• Costovertebral tenderness.

•Ultrasound or CT scan to locate obstruction in the
urinary tract.
•Urine culture and sensitivity to determine the
causative organism.
•Intravenous pyelography-Radiographic examination
of the urinary tract after injection of
radio-opaque solution.

MEDICAL MANAGEMENT
•A 2 week course of antibiotics is recommended
because renal parenchymal disease is more difficult to
eradicate than mucosal bladder infection.
•Commonly prescribed agents include Septrin,
ciprofloxacin, gentamicin with or without ampicillin,
or a third generation cephalosporin.
•A follow up urine culture is done 2 weeks after
completion of antibiotic therapy to document clearing
of infection.

CHRONIC PYELONEPHRITIS
•Repeated bouts of acute pyelonephritis may lead to
chronic pyelonephritis.
•Patients with chronic pyelonephritis often have no
symptoms of infection.
• Noticeable manifestations may include: fatigue,
headache, poor appetite, polyuria, excessive thirst,
and weight loss.

•Renal function tests
•Colony count
COMPLICATIONS
•ESRD
•Hypertension
•Formation of kidney stones (from chronic infection
with urea-splitting organisms)

MEDICAL MANAGEMENT
-Nitrofurantoin, TMP-SMZ may be used to suppress bacterial
growth.
NURSING MANAGEMENT
-Unless contraindicated, fluids are encouraged (3 to 4Lday) to
dilute urine, decrease burning on urination, and prevent
dehydration.
-Temperature monitored and antipyretics’ and antibiotic
administered as indicated.
-Patient is more comfortable on bedrest.
-Pt teaching focuses on prevention of UTIs by consuming
adequate fluids, emptying the bladder regularly, and performing
recommended perineal hygiene.
-Importance of taking antimicrobials medication as prescribed is
stressed to the patient.

RENAL ABSCESS
Renal abscess may be localized to the renal cortex or
extend into the fatty tissue around the kidney.

PATHOPHYSIOLOGY
•A renal abscess may be caused by an infection of the
kidney (pyelonephritis) or may occur as a
hematogenous (spread through the bloodstream)
infection originating elsewhere in the body.
•Offending organisms include staphylococcus and
proteus species and E.coli. Occasionally, infection
spreads from adjacent areas, such as with
diverticulitis or appendicitis.

•Manifestations of a perinephric abscess often are
acute in onset.They include:
• Chills,
• Fever,
•Leukocytosis,
•A dull ache or palpable mass in the flank,
• Abdominal pain with guarding and CVA tenderness
on palpation.

•Leukocytosis with sterile urine is present with renal
abscess localized to the renal cortex.
•CT examination results are important to establish the
extent of the lesion and to assess the
effectiveness of treatment.

MEDICAL MANAGEMENT
-Small localized abscesses are usually cured by intravenous
antibiotic medications alone but may require incision and
drainage.
-Perinephritic abscesses require percutaneous drainage of the
abscess.
-Culture and sensitivity tests are performed and appropriate
antibiotic therapy prescribed.
-Drains are usually inserted and left in the perinephric space
until all significant drainage has ceased.
-Because the drainage is often profuse, frequent changes of the
outer dressings may be necessary.
-The patient is monitored for sepsis, fluid intake and output, and
general response to treatment.
-Surgery may be indicated for extensive perinephritic abscess.

URETHRITIS
•This is the inflammation of the urethra.
•Urethritis can be classified as Gonococcal and
nongonococcal.
•Gonococcal urethritis is caused by N.gonorrhoeae and is
transmitted by sexual contact. In men inflammation of
the urethral meatus occurs with burning on urination. A
purulent urethral discharge appears 3 to 14 days longer
after sexual exposure, although the disease is
asymptomatic in up to 10% of men.
•The infection affects tissues around the urethra causing
preriurethritis, prostatitis, epididymitis and urethral
stricture. Sterility may occur due to vasoepididymal
obstruction.

URETHRITIS CONTD
•Gonorrhea in women is frequently not diagnosed
and reported because urethral discharge is not always
present and the disease may be asymptomatic.
•Nongonococcal urethritis is usually caused by
C.trachomatis or Ureaplasma urealyticum.Males with
symptoms usually complain of mild to severe urethral
discharge. Patients with nongonococcal urethritis
require prompt treatment with tetracycline,
doxycycline or erythromycin.
•All sexual partners of patients with nongonococcal
urethritis should be examined for STDS treated

DYSFUNCTIONAL VOIDING PATTERN
•Presents in the form of urinary incontinence or
urinary retention.
•Urinary incontinence is the unplanned loss of urine
that is sufficient to be considered a problem.
•Urinary retention is the inability to empty the urinary
bladder.

URINARY INCONTINENCE
TYPES OF INCONTINENCE
1. Stress incontinence-Is the involuntary loss of urine through
an intact urethra as a result of a sudden increase in intra-
abdominal pressure.(sneezing, coughing, or changing
position)
CAUSES-vaginal deliveries as a result of decreasing ligament
and pelvic floor support, after a radical prostatectomy.
2. Urge incontinence-Involuntary loss of urine associated with
a strong urge to void that cannot be suppressed. The patient
is aware of the urge to void but is unable to reach the toilet in
time.
Occurs in patients with neurogenic dysfunction that impairs
inhibition of bladder contraction.

TYPES CONTD
3. Reflex incontinence-Involuntary loss of urine due to
hyperreflexia in the absence of normal sensation
associated with voiding. Occurs in patients with spinal
cord injury because they have neither neurologically
mediated motor control of the detrusor nor sensory
awareness of the need to void.
4. Overflow incontinence-Involuntary loss of urine
associated with distention of the bladder. Such over
distention results from the bladders inability to empty
normally, despite frequent urine loss. Both neurologic
abnormalities and factors that obstruct the outflow of
urine (e.g. tumors, strictures, and prostatic hyperplasia)
can cause overflow incontinence.
5. Iatrogenic incontinence-Drugs such as alpha-
adrenergic agent

ASSESSMENT AND DX FUNCTIONS
•History-patients voiding history, fluid intake and
output,
•Urinalysis and urine culture to identify hematuria,
glycosuria, pyuria and bacteriuria all which may
identify transient causes of urinary incontinence.

MEDICAL MANAGEMENT
1. Behavioral therapy-Lifestyle changes, dietary modification,
bladder retraining, pelvic floor muscle exercises etc.
2. Pharmacologic therapy-Anticholinergic agents (oxybutin,
dicyclomine) inhibit bladder contraction and are considered
first-line medications for urge incontinence.
Several tricyclic antidepressants (imipramine, doxepin,
desipramine and nortriptyline) also decrease bladder
contractions as increase bladder neck resistance.
Stress incontinence may be treated using pseudoephrine.
Estrogen has been shown to be beneficial for all types of
urinary incontinence. Estrogen decreases obstruction to urine
flow by restoring the mucosal, vascular, and muscular
integrity of the urethra.

SURGICAL MANAGEMENT
•Indicated in patients who have not achieved continence
using behavioral and pharmacologic therapy.
•Most procedures involve lifting and stabilizing the bladder or
urethra to restore the normal urethra-vesical angle or to
lengthen the urethra.
•Women with stress incontinence may have an anterior
vaginal repair, retropubic suspension, or needle suspension to
reposition the urethra.
•Peri-urethral bulking is a semi permanent procedure in which
small amounts of artifial collagen are placed within the walls
of the urethra to enhance the closing pressure of the urethra.

NURSING MANAGEMENT
•The nurse should provide support and
encouragement
•Patient teaching about the bladder program is
important and should be provided verbally and in
writing.
•If pharmacologic treatment is used its purpose is
explained to the patient and family. If surgical
correction is undertaken the procedure and the
desired outcome are described to the patient and
•Family.

PATIENT EDUCATION
Strategies for managing urinary incontinence:
•Increase your awareness and timing of all fluid intake.
•Avoid taking diuretics after 4pm.
•Avoid bladder irritants such as caffeine, and alcohol.
•Take steps to avoid constipation: drink adequate fluids, eat a
well balanced diet high in fiber, exercise regularly, and take
stool softeners if recommended.
•Void regularly 5 to 8 times a day.
•Perform all pelvic floor muscle exercises as prescribed, every
day.
•Stop smoking (smokers often cough frequently which
increases incotinence).

URINARY RETENTION
•This is the inability to empty the bladder completely
during attempts to void.
•Chronic urine retention often leads to overflow
incontinence.
•Urinary retention can occur postoperatively in any
patient, particularly if the surgery affects the
perineal or anal regions and resulted in reflex spasm
of the sphincters.
•General anaesthesia reduces bladder muscle
innervations and suppresses the urge to void,
impeding bladder emptying.

PATHOPHYSIOLOGY
•Urinary retention may result from diabetes, prostatic
enlargement, urethral
Pathology (infection, tumor, calculus) trauma (pelvic injury),
pregnancy, or neurologic disorders such as
Cerebrovascular accident, spinal cord injury, multiple sclerosis,
or Parkinson’s disease.
•Some medications cause urinary retention either by inhibiting
bladder contractility or by increasing bladder outlet
resistance.e.g.anticholinergic agents (atropine sulfate,
dicyclomine hydrochloride), antispasmodics agents (oxybutin
chloride, belladonna, opioid suppositories), and tricycle
antidepressant medications (imipramine, doxepin)
•Medications that cause urine retention by increasing bladder
outlet resistance include alpha-adrenergic

The following questions serve as a guide in assessment:
-What was the time of the last voiding, and how much urine
was excreted.
-Is the patient voiding small amounts of urine frequently?
-Is the patient dribbling urine?
-Does the patient complain of pain or discomfort in the lower
abdomen?
-Is the pelvic area rounded and swollen?
-Does percussion of the suprapubic region elicit dullness?
-Does postvoid bladder ultrasound test reveal residual urine?

COMPLICATION
•-Infections
•-Calculi
•-Pyelonephritis
•-Sepsis
•-Perineal skin breakdown

MEDICAL MANAGEMENT
•Retention caused by sensory or neurologic problems
may be treated with cholinergic medications e.g.
bethanechol chloride.
•These medication stimulate bladder contraction and
shouldn’t be used if obstruction is suspected.
•If the obstruction occurs below the bladder
continuous drainage provided by cystostomy tubes
placed directly into the bladder through a suprapubic
incision.

SURGICAL MANAGEMENT
•If a ureter becomes obstructed ,a catheter may be
placed directly into the renal pelvis.
•For complete obstruction,a nephrostomy or
pyelostomy tube may be inserted into the renal
pelvis.
•Ureterostomy tube can also be passed for ureteral
obstruction.

NURSING MANAGEMENT
1. Provide normal urinary elimination-Provide privacy,
ensure an environment conducive to
Voiding, assist the patient with the use of the commode.
Additional measures include applying warmth t
relax the sphincters, giving the patient hot tea, and
offering encouragement and reassurance.
2. Promoting urinary elimination-When the patient
cannot void, catheterization is used to prevent over
distention of bladder. In the case of prostatic obstruction,
attempts at catheterization may not be successful
requiring the insertion of a suprapubic catheter. After
urinary drainage is restored, bladder retraining is initiated
for the patient who cannot void spontaneously.

KIDNEY TRANSPLANTATION
Patients choose kidney transplantation for :
•Desire to avoid dialysis.
•Improve sense of wellbeing and the wish to lead a
normal life.
•Organ donors include:Living donors,Non-heart
beating donors and human cadavers.
•Kidney transplants from a well matched living donor
related to the patient (Compatible ABO and HLA
antigens) are slightly more successful than those of
cadaver donors.

PREOPERATIVE MANAGEMENT
MANAGEMENT GOALS
-Bringing the patients metabolic state to a level as
close to normal as possible.
-Making sure the patient is free of infection.
-Preparing the patient for surgery and postoperative
course.

MEDICAL MANAGEMENT
•Physical exam done to detect and treat any condition that
could cause complications after transplantation.
•Tissue typing,blood typing and antibody screening to
determine compatibility of tissues and cells of the donor
and recipient.
•Lower urinary tract studied to assess bladder neck
function and detect ureteral reflux.
•Patient evaluated and treated for any infection including
gingival disease and dental caries.
•Psychosocial evaluation to assess ability to adjust to
transplant,coping styles,social history,social support
available and financial resources.
•Hemodialysis to optimize patients physical status.

SURGICAL MANAGEMENT
•Donor kidney,renal artery and vein and the ureter are
dissected free.
•Kidney removed,flushed with chilled,sterile electrolyte solution
and prepared for transplant into the recipient.
•Transplanted kidney placed extraperitoneally in the iliac fossa.
•The donor ureter is tunnelled through the bladder submucosa
and sutured in place.This allows the bladder to clamp down on
the ureter as it contracts for micturation,thereby preventing
reflux of urine up the ureter into the transplanted kidney.
•Patients kidney not removed ignored to maintain
erythropoietin production,BP control,prostaglandin synthesis
and metabolism.

POST-OP MANAGEMENT
Immunosuppressive therapy-Given to minimize or
overcome bodys defence
mechanism.e.gAzathioprine,corticosteroids,cyclosporine
and monoclomnal antibodies.
Assessing patient for transplant rejection-Check
for:oliguria,edema,fever,increasing BP, weight gain and
swelling or tenderness over the transplanted kidney or
graft.BUN,creatinine and leukocyte count monitored
closely because immunosuppression depresses the
formation of leukocytes and platetelets.
Preventing infection-Urine cultures perfomed frequently
due to high incidence of bacteuria during early and late
stages of transplantation.Frequent hand washing and
wearing of face masks.

POST-OP
Monitoring urinary function-Vascular acess for
hemodialysis monitored for patency and signs of
infection.
Output from the urinary catheter measured every
hour.
I.V fluids measured on the basis of urine volume and
serum electrolyte levels.
Hemodialysis may be required if fluid overload and
hyperkalemia occur.
Addressing psychological concerns-Fear of kidney
rejection and complications of immunosuppressive
therapy.

ASSESSMENT OF MALE
REPRODUCTIVE FUNCTION
• Begins with evaluation of urinary function and
symptoms.
• Assessment of sexual function as well as
sexual dysfunction.
• Symptoms may include: Increased urine
frequency,decreased force of urine
stream,dysuria,hematuria,hematospermia(blo
od in ejaculate)

ASSESSMENT CONTD
• Assessment of factors that affect sexual
function:chronic illness(e.g.DM,multiple
sclerosis,stroke,cardiac disease),use of
medication that affect sexual function
(e.g.antihypertensive and
anticholesterolemics,psychotropic
agents),stress and alcohol use.

PHYSICAL ASSESSMENT
Digital rectal examination.
Testicular examination.

DIGITAL RECTAL EXAMINATION
 Recommended as part of regular health
check up for every man older than 40 years of
age.
Is invaluable for screening for cancer of the
prostate gland.
Enables examiner to assess the size,shape and
consistency of the prostate gland.
Tenderness and presence,consistency of any
nodules noted.

TESTICULAR EXAMINATION
Male genitalia inspected for abnormalities and
palpated for masses.
Scrotum palpated carefully for
nodules,masses or inflammation.
Examination can reveal:hydrocele,hernia or
tumors of the testis.
Penis inspected and palpated for
ulceration,nodules,inflammation and
discharge.

DIAGNOSTIC EVALUATION
Prostate specific antigen-measured in a blood
specimen.Levels increase with prostate
cancer,BPH,infections of prostate and urinary
tract.Normal ranges of PSA(0.2-4ng/ml)
Ultrasonography-Transurethral ultrasound
used in detecting non palpable prostate
cancers and in staging localized prostate
cancer.

Prostate fluid or tissue analysis-To obtain
tissue for histologic examination.Obtained at
the time of prostatectomy by means of
perineal or transrectal needle biopsy.

MALE REPRODUCTIVE DISORDERS
• Erectile dysfunction.
• Ejaculation problems.
• Infections of the male GUT
• Conditions of prostrate(prostatitis,BPH,cancer
of the prostate)
• Orchitis,epididymitis,crytorchidism,trsticular
cancer,vasectomy,hydrocele,varicocele,cancer
of penis.

PROSTATITIS
• Inflammation of prostate gland.
• Cause:Bacteria(E.coli),fungi,Mycoplasma,uret
hral stricture,prostatic hyperplasia.

Symptomless
Perineal discomfort.
Burning,urgency,frequency,pain with or after
ejaculation.
Pain on voiding or perineal pain.
Fever and chills.
Complications: urinary
retention,epididymitis,bacteremia,pyelonephritis.

• Culture of prostatic fluid or tissue.
• Histological examination of tissue.
• Urinary specimen for culture.

MEDICAL MANAGEMENT
• Goal:Avoid complication of abscess formation and
septicaemia.
• Antibiotics to which the causative organism is
sensitive is administered for 10-14 days.
• Bed rest encouraged to alleviate symptoms quickly.
• Comfort achieved by administering analgesics to
relieve pain,antispasmodics and bladder sedatives
to relieve bladder irritability,sitz baths to relieve
pain and spasms and stool softeners to prevent pain
from straining.
• Patient taught to recognize recurrence.

BENIGN PROSTATIC HYPERPLASIA
• Is the enlargement or hypertrophy of the
prostate.
• Common in patients older than 50 years.

CAUSE
• Change in size and shape of prostate is
attributed to increased tissue mass resulting
from cellular proliferation.
• Cell growth stimulated by an increase in
hormone androgen,estrogen and an enzyme
5-alpha reductase.
• 5-alpha reductase converts testosterone to
dihydrotestosterone which further stimulates
prostate growth.

• DRE reveals an enlarged, rubbery and non
tender prostate gland.
• Incomplete emptying of bladder due to
obstruction of the bladder neck.
• Hydroureter,hydronephrosis,UTI from urinary
stasis.

FINDINGS
• Frequency of
urination,urgency,hesitancy,nocturia.
• Abdominal straining with urination.
• Decreased force and volume of urinary
stream,dribbling,sensation that bladder has
not been completely emptied.
• Azotemia and renal failure can occur.

• DRE,Urinalysis.
• BUN,Serum creatinine levels.
• Complete blood studies.
• PSA
• Cystourethroscopy to assess for outflow
obstruction.

MEDICAL MANAGEMENT
• If patient cannot void,he is immediately
catheterized.
• Suprapubic cystostomy to provide drainage if
transurethral catheterization isn't possible.
• Ultrasound guidance resection of prostate.

MEDICAL MANAGEMENT
• Alpha adrenergic receptor blockers(terazosin)
relax smooth muscles of the bladder neck and
prostate and reduce obstructive symptoms in
many patients.
• 5-alpha reductase inhibitors(finasteride)
prevent conversion of testosterone to
dihydrotestosterone suppressing glandular
activity and prostate size.

CANCER OF THE PROSTATE
• Risk factors-Increasing
age,race(blacks),familial predisposition,diet
high in red meat and fats.

• Symptomless in early stages.
• Symptoms from urinary obstruction.
• Blood in urine and semen.
• Painful ejaculation.
• Hematuria if urethra or bladder is invaded.
• Symptoms related to metastasis:Backache,hip
pain,perineal and rectal
discomfort,anaemia,weight
loss,weakness,nausea and oliguria.

• DRE as part of regular health check up.
• Histologic examination of tissue removed
surgically by transurethral resection,open
prostatectomy or transrectal needle
biopsy,FNA.
• Bone scans to detect metastasis.

MANAGEMENT
• Radical prostatectomy-removal of prostate
and seminal vesicles for early stage potentially
curable disease.Sexual impotance and various
degrees of urinary incontinence follows.
• Radiation therapy-Involves teletherapy with a
linear accelerator or interstitial
irradiation(brachytherapy).
• Hormonal therapy-

MANAGEMENT CONTD
• Hormonal therapy-Androgen withdrawal by
orchiectomy.Most prostate cancers are
androgen dependent.Diethylstilbestrol inhibit
gonadotropins responsible for testicular
androgenic activity.Others are lutenizing
hormone releasing hormone
agonists(leuprolide and goserelin) and
antiandrogen agent(flutamide).
• Cryosurgery of the prostate.

PATIENT UNDERGOING PROSTATE
SURGERY
• Indications:BPH,prostate cancer
OBJECTIVES
• Asess general health status.
• Establish optimal renal function.

SURGICAL PROCEDURES
Approaches include:
• Transurethral resection(endoscopic)
• Suprapubic prostatectomy.
• Perineal prostatectomy.
• Retropubic prostatectomy.
• Transurethral incision of the prostate.
Complications-Hemorrhage,clot formation,catheter
obstruction,sexual dysfunction.

PREOPERATIVE NURSING DIAGNOSIS
• Anxiety about surgery and its outcome.
-Assess understanding of diagnosis and planned
surgical procedure.
-Clarify nature of surgery and expected post
operative outcome.
-Provide privacy and establish trusting and
professional relationship as patient may be
sensitive and embarrassed discussing problems
relating to the genitalia and sexuality.

.
• Relieving discomfort
-By bedrest,analgesic agents,catheterization if
indicated.
• Providing instruction
-Review of anatomy of the affected parts and
functions in relation to urinary and
reproductive system.
-Description of type of incision,type of urinary
drainage system expected, type of anaesthesia
and recovery room procedure.
-Instruction about postoperative use of
medications for pain management.

• Preparing the patient
-Preoperative preparation provided.
-Elastic compression stockings applied to
prevent DVT.
-Enema administered evening before surgery or
morning before surgery.

POST OPERATIVE NURSING DIAGNOSIS
• Maintaining fluid balance.
-Patient is at risk of imbalanced fluid volume
because of irrigation of the surgical site during
and after surgery.(absorption through open
surgical site,water retention,water intoxication).
-Urine output and amount used for irrigation must
be closely monitored to determine if irrigation
fluid is being retained and ensure adequate urine
output.
-Patient monitored for electrolyte imbalance,rising
BP,confusion and respiratory distress.

.
• Relieving pain
Pain is due to bladder irritability and
spasm,excoriation of skin at the catheter
site,kidney problem and surgical incision.
-Medications that relax smooth muscles ,warm
compresses to the pubis or sitz bath ease spasms.
-Nurse monitors drainage tubing and irrigates the
systems to relieve obstruction.Analgesics
administered as prescribed.
-When ambulatory,patient encouraged to walk but
not to sit for prolonged periods because this
increases intra-abdominal pressure,discomfort
and bleeding.
-stool softeners administered to ease bowel
movement and prevent excess straining.

MONITORING AND MANAGING
POTENTIAL COMPLICATIONS
• Hemorrhage-Risk increased in BPH because
hyperplastic prostate gland is very
vascular.Bleeding may result in the formation of
clots which obstruct urine flow.
- Drainage begins as reddish pink then clears to a
alight pink within 24 hours after surgery.
- Bright red bleeding with increased viscosity and
numerous clots indicate arterial bleeding,venous
blood appears darker and less viscous.

-If blood loss is extensive,fluid and blood
component therapy may be administered.
-Nursing interventions include:Close monitoring
of vital signs,administering medications,IV
fluids,blood component therapy,record of
intake and output and careful monitoring of
drainage.

• Infection-Aseptic technique during dressing
changes and sitz baths to promote healing.
-patient assessed for occurrence of UTIs and
epididymitis and antibiotics administered if
they occur.
-Patient and family instructed to monitor for
signs and symptoms of infection after
discharge(fever,chills,sweat,myalgia,dysuria,ur
inary frequency and urgency)

• DVT-Assess frequently for manifestations of
DVT and apply elastic compression
stockings.Low dose heparin therapy
prescribed prophylactically.
• Obstructed catheter-Furosemide prescribed
to promote urination and initiate post-
operative diuresis thereby keeping the
catheter patent.Drainage bag,dressing and
incisional site examined for bleeding.

-Colour of urine noted and documented-Should
change from pink to amber .
-BP,pulse,respiration monitored to detect
hypotension.
-Bladder drainage accomplished by gravity through
a three-way drainage system for irrigating the
bladder and preventing clot formation.
-Maintain intake and output record,including
amount of fluid used for irrigation.

-After catheter removal,urine leak around the
wound for several days in patients who have
undergone perineal,suprapubic and
retropubic surgery.
-Urinary incontinence may occur after
catheter removal and patient is informed that
this is likely to subside in time.

• Sexual dysfunction-Include erectile
dysfunction,decreased libido and fatigue.
-Erectile dysfunction restored by
medication,surgically placed implants or
negative pressure devices.
-Usual libido returns following recuperation
from surgery.

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