Renal and Urology Problems

urinary tract infections (uti) an clinical manifestations 

-most common pathogen e.coli

-cystitis=bladder

-urethritis=urthra

-urosepsis=systemic

^life threatening

^emergency treatment

-if there is a complicated UTI the pt. is at risk for pyelonephritis, urosepsis, renal damage

CLINICAL MANIFESTATIONS

-lower urinary tract symptoms (LUTS)

^emptying symptoms and storage symptoms

^hematuria and/ or cloudy appearance

-upper urinary tract symptoms

^flank pain, chills, fever

^fatigue, anorexia, asymptomatic

^older adults classic manifestations are absent (abdominal discomfort, cognitive impairment, or generalized deterioration often afebrile)

urinary tract infection (uti) diagnostic studies + interprofessional care

Diagnostic Studies

initial: dipstick for nitrates, WBC, and leukocyte esterase 

-urine culture/ sensitivity 

-history 

-imaging: ultrasound or CT scan

Interprofessional Care

-management uncomplicated: phenazopyridine and antibiotics (empiric) for 3 days 

-recurrent uti

^antibiotics 7 to 14 days loner 

-drug therapy uncomplicated or initial utis

^trimethoprim/ sulfamethoxazole (TMP-SMX)

^nitrofurantoin cephalexin

^fosfomycin

^ampicillin, amoxicillin or cephalosporins

-complicated: fluconazole

-urinary analgesic: phenazopyridine (azo dye)

pyelonephritis + clinical manifestations + diagnostic studies 

-initial colonization and infection of lower urinary tract from urethra

Clinical Manifestations

-classic:fever, cills, nausea, vomiting, malaise, flank pain 

-dysuria, urgency, frequency 

-costovertebral angle (CVA) tenderness 

Diagnostic Studies 

-urinalysis: pyuria, bacteriuria, hematuria; WBC cast

-urine cultures and sensitivities 

-blood cultures

-decreased kidney and function tests

-ultrasound

-ct scan- preferred imaging study

pyelonephritis interprofessional care

Interprofessional Care

-mild symptoms (outpatient or short in patient)

^fluids, NSAIS, follow up cultures and imaging 

^antibiotics oral= 5 to 14 days; IV= 14 to 21 days 

-severe symptoms (as above except)

^IV fluids until oral tolerated 

^combination parenteral antibiotics 

*relapses=6 weeks antibiotics 

*recurrent= prophylactic antibiotics 

*urosepsis= monitor for and treat septic shock to prevent irreversible damage or death 

chronic pyelonephrtis

-kidneys inflamed cause scarring leading to loss of renal function

diagnosis: radiologic imaging and biopsy

treatment: treat infection and underlying contributing factors 

urethritis 

-inflammation of the urethra to bacterial or viral infection 

^trichomonas or monilia, chlamydia, or gonorrhea 

Clinical Manifestations

-males= sexually transmitted, see discharge, dysuria. urgency, and frequency 

-females= diagnosis difficult, see LUTS

Treatment

-antimicrobials, sitz baths

Patient Education

-avoid vaginal sprays, perineal hygiene, no sex for 7 days, and contact partners

interstitial cystitis (IC)/ painful bladder syndrom (PBS) clinical manifestations 

IC= chronic, painful, inflammatory disease of the bladder, IC causes PBS

Clinical Manifestations

*pain and bothersome LUTS*

-severe: void more than 60 times/ day-night

-pain:usually suprapubic but may involve perineum

-increase pain with bladder filling, postponed urination, physical exertion, suprapubic pressure, certain foods, emotional distress

-decreased pain when voiding (temporary)

interstitial cystitis (IC)/ painful bladder syndrome (PBS): treatment

-reduce intake of bladder irritants

-calcium glycerophosphate—- reduces irritation 

 Stress management strategies

 Tricyclic antidepressants, analgesics, antihistamines

 Physical therapy and bladder hypo-distention

 Botox; cyclosporine A

 Surgery—with debilitating pain (sacral neuromodulation or

fulguration: using high-frequency energy to destroy a lesion

interstitial cystitis (IC)/ painful bladder syndrome (PBS): nursing management

 Pain assessment

 Diet/lifestyle factors that increase or decrease pain

 Bladder/voiding log for 3 days; pain record

 Monitor for UTI with diagnostic studies

 Monitor nutrition

 Avoid restrictive clothing

 Coping strategies/reassurance

glomerulonephritis

-inflammation of the glomeruli

acute: sudden symptoms, temporary or reversible

chronic: slow, progressive, irreversible renal failure 

APSGN + clinical manifestations 

-common type of acute glomerulonephritis

-develops 1 to 6 weeks after an infection of tonsils, pharynx, or skin by nephrotoxic strains of group B-hemolytic streptococci

Clinical Manifestations 

-generalized edema, hypertension, oliguria, hematuria, degrees of proteinuria, fluid retention 

-periorbital edema first then progresses into ascites and peripheral edema 

-smoky urine: bleeding in upper urinary tract 

-abdominal flank pain 

-may be asymptomatic: found on routine urinalysis 

APSGN diagnostics

-h& p

-antistreptolysin- O (ASO) titers

-decreased complement components

-renal biopsy

-dipstick urinalysis ad urine sediment microscopy

-BUN and serum creatinine- renal impairment

-with a positive streotococci culture= antibiotics

chronic glomerulonephritis

-syndrome of permanent and progressive renal fibrosis can progress to ESRD

-symptoms develop slowly; unaware

-decreased renal function causes ESRD (over several years)

Clinical Manifestations

- Hematuria, proteinuria, urinary excretion of formed elements (RBCs, WBCs, casts)

 Increased BUN and creatinine

Diagnosis

 H&P, exposure to drugs (NSAIDs), microbial infections, and viral infections

 Evaluate for immune disorders

 Ultrasound and CT scan; renal biopsy

 Treatment: depends on cause

 Symptomatic and supportive car

ASPGN interprofessional management

 Rest—decreased inflammation and HTN

 Restrict Na+ & fluids/ administer diuretics—decreased edema

 Restrict protein—decreased BUN

 Antibiotics—if streptococcal infection present

rapidly progressive glomerulonephritis (RPGN) + clinical manifestations

-loss of renal function in days to months

Clinical Manifestations 

-hTN, edema, proteinuria, hematuria, RBC cast 

Treatments 

-correct fluid overload, HTN, uremia, and injury to kidney 

-corticosteroids, cyclophosphamide, plasmapheresis

-last resort/ worse case dialysis and transplant 

nephrotic syndrome

Clinical Manifestations

-peripheral edema, massive proteinuria, HTN, hyperlipidemia, hypoalbuminemia, foamy urine 

^ Decreased albumin; ascites and anasarca when severe

hypoalbuminemia is present

 Immune response altered results in infection

 Hypocalcemia and skeletal abnormalities

 Hypercoagulability

Treatment (depends on cause)

-corticosteroids and cyclophosphamide

-manage diabeyes 

-ACE inhibitors, ARB, diuretics

-antihyperlipidemic drugs

-anticoagulants

-low sodium, modrate protein diet, small frequent meals

obstructive uropathies

-urinary obstruction= blocks/ impedes urine flow 

bladder outlet obstruction

-increase pressure with filling or storage 

-vesicoureteral reflux (backflow)

-hydroureter (ureteral dilation)

-progressive obstruction can lead to renal failure 

urinary tract calculi

nephrolithasis=kidney stone disease

-risk increases with age 

-summer (hot climate and dehydration)

-uric acid stones in jewish men 

risk factors

-metabolic

-climate

-diet

-genetic 

-lifestyle 

*reduce risk by keeping urine dilute and free flowing

higher ph= calcium and phosphate less soluble

lower ph= uric acid and cysteine less soluble

urinary tract calculi clinical manifestations 

-sudden severe pain (renal colic)

^flank area, back, or lower abdomen

^ureter stretches, dilates, and spasms

^n/v “kidney stone dance”, dysuria, fever, chills, moist, cool skin

common sites of obstruction

-ureteropelvic junction (UPJ)

^dull costovertebral flank pain or renal colic

-ureterovesical junction (UVJ)

urinary tract calculi clinical manifestations: diagnostic studies

 Non-contrast helical (spiral) CT scan

 Ultrasound

 Urinalysis

 24-hour urine

urinary tract calculi: interprofessional care

1. manage acute attacks

^opioids, NSAIDS, ACE inhibitors 

2. evaluate cause of stone formation and prevent further development 

 Struvite stones: antibiotics and acetohydroxamic acid;

surgery

-stones 4mm or less may pass on their own 

-endourologic, lithotripsy, or open surgical stone removal may be considered if stones 

^are too large to pass 5mm and larger

^are associated with bacteriuria or symptomatic infection 

^cause persistent pain, nausea, or paralytic ileus 

endourologic procedures

 Cystoscopy—remove stone in bladder

 Cystolitholapaxy—large stones broken

up with lithotrite (stone crusher)

 Cystoscopic lithotripsy—ultrasonic

waves break stones

 Complications of above procedures:

^Hemorrhage, retained stone fragments, and infection

lithotripsy

-eliminate stones from urinary tract

-stent removed in 2 weeks

postprocedure 

-hematuria (blood in urine)

-antibiotics 

-encourage fluids to dilute urine and reduce pain 

complications (rare)

-hemorrhage

-infection

-obstruction 

surgical therapy 

indications

-pain, infection, obstruction

 Nephrolithotomy—kidney

 Pyelolithotomy—renal pelvis

 Ureterolithotomy—ureter

 Cystotomy—bladder

nutritional therapy

-adequate fluids but don’t force fluids… can lead to pain

after urolithiasis

 Water is best!

 Prevents supersaturation of minerals

 Reduce risk of dehydration

 Limit colas, coffee, and tea—increased stone formation

Adequate fluid intake (3 L/day) if no CV or renal compromise; produce 2.5 L urine/day; increase if very active

ureteral strictures

causes:

-congenital, adhesions or scar formation, or large tumor in peritoneal cavity 

clinical manifestations:

-mild to moderate colic, flank pain, and CVAT

treatments:

-bypass with stent or nephrostomy tube placement; ballon or catheter dilation

-surgery: endoureteromy, ureteroureterostomy, or ureteronecocystostomy 

 Fibrosis or inflammation of urethral lumen leads to narrowing and compromised opening and closing with bladder filling and voiding

 Causes: trauma, urethritis, surgical intervention or repeated catheterizations, congenital defect, idiopath

urethral strictures manifestations, diagnostic studies, treatment

manifestations

-straining to void

-urine stream: diminished, sprayed, or split

-postvoid dribbling

-incomplete bladder emptying, frequency, and nocturia 

-severe obstruction= urinary retention 

diagnostic studies 

 Retrograde urethrography (RUG), ultrasound urethrography,

cystourethrogram, and VCUG

treatment

 Dilation with metal instruments or stents

of increasing size; stenosis may occur

 Self-catheterization every few days

 Endoscopic or surgical procedure

^Urethroplasty

^Resection and re-anastomosis or urethr

renal trauma

causes:

abdominal, flank, or back injury; sports injuries, MVAs, and falls  

clinical manifestations 

hematuria

diagnostic studies 

urinalysis, ultrasound, CT, MRI, renal arteriogram

treatments

-bed rest, fluids, analgesia 

-exploratory surgery and repair 

-nephrectomy 

polycystic kidney disease (PKD)

-one of the most common life threatening genetic diseases in the world

-affects both kidneys in men and women 

clinical manifestations

-HTN

-hematuria

-pain or heavy feeling in back

-side or abdomen 

-UTI or urinary stones 

-may be asymptomatic 

diagnostic 

ultrasound or CT scan

treatment

-no cure

-prevent or treat UTI

-nephrectomy

-dialysis and kidney transplant

kidney cancer

risk factors

-cigarette smoking, ACKD, obesity, HTN, exposure to abestos, cadmium, and gasoline 

common manifestations

-hematuria, flank pain, palpable mass in flank or abdomen 

diagnostic studies

-CT scan, ultrasound, angiography, biopsy, MRI, radionuclide isotope scan 

treatments

 Surgeries—Nephrectomy: partial, simple total, or radical; open or laparoscopic

 Ablation: cryoablation or radiofrequency

 Immunotherapy— -interferon and interleukin-2 (IL-2); nivolumab

 Targeted therapy—kinase inhibito

bladder cancer

clinical manifestations

-microscopic or gross, painless hematuria

diagnostic studies

 Urine specimens for cancer or atypical cells, and bladder

tumor antigens

 CT scan, ultrasound, or MRI

 Cystoscopy and biopsy—confirm cancer

surgical therapy 

-transurethral resection of the bladder tumor (turbt)- superficial lesions removed with cystoscope 

disadvantages: re-occurance, scarring, or inability to hold urine

 Segmental (partial) cystectomy—remove large tumors in 1 area of bladder wall and margin of normal tissue

 Radical cystectomy—invasive tumors or trigone area but no metastasis beyond pelvic area; must have urinary diversion

patient education 

-pink for several days; not bright red or with clots 

-may have dark red or rust-colored flecks for 7 to 10 days 

urinary incontinence (UI)

men= common with BPH or prostate cancer… overflow incontinence from urinary retention 

women= stress and urge incontinence 

D.R.I.P

d= delirium, dehydration, depression

r= restricted mobility, rectal impaction

i= infection, inflammation, impaction 

p= polyuria, polypharamcy 

diagnostic studies

 Urinalysis, post void residual, urodynamic studies,

ultrasound

 Post void residual (PVR)—normal 50 to 75 mL

 More than 100 mL—repeat or further evaluation with UTIs

 More than 200 mL—further evaluation

acute urinary retention— emergency patient education

-drink small amounts throughout the day

-be warm when trying to void

-drink caffeinated coffee or tea to increase urgency

catheterization

indications for indwelling

 Relief of urinary retention

 Bladder decompression preop or postop

 Facilitate surgery

 Facilitate healing

 Accurate I & O—critical care

 Stage III or IV pressure ulcer

 Terminal illness—comfort

complications of long-term use (more than 30 days)

 CAUTI—most common HAI

 Other: bladder spasms, periurethral abscess, chronic pyelonephritis, urosepsis, urethral trauma or erosion, fistula or stricture formation, and stone

ureteral catheters (stents)

-placed through ureter into renal pelvis

-used postop to prevent obstruction by edema 

^ Record output separately from urethral catheter

^Bedrest

^Check placement; avoid tension; do not clamp

^Aseptic technique with irrigation

^Monitor output q. 1 to 2 hours

^Renal pelvis holds 3 to 5 mL; increased volume can cause tissue

damage

suprapubic catheters

-can be temporary or long term

-tape to prevent disloadgement

- bladder spasms—- andtispasmodics 

nephrostomy tubes

-temporary insertion though small flank 

complications: infection and secondary stone formation 

intermittent catheterization

used with:

-neurogenetic bladder, bladder outlet obstruction in men, post op to treat UI

-inserted every 3 to 5 hours or 1 to 2 times a day to ensure an empty bladder 

incontinent urinary diversion + continent urinary diversion

incontinent urinary diversion

-most common: ileal conduit (ileal loop)

continent urinary diversion

-intraabdominal urinary reservoir that can be catheterized; has internal pouch 

-patient self catherterizes every 4 to 6 hours 

orthotopic bladder reconstruction

 Candidates: normal renal and liver function; 1-2

yr life expectancy; adequate motor skills; no

inflammatory bowel disease or colon cancer; not

obese

nursing management

prevent complications

-atelectasis, shock, throbophlebitis, small bowel obstruction, paralytic ileus, and UTI

-avoid alkaline encrustations with dermatitis and yeast infections, product allergies, and shearing effect excoriations 

-empty bladder every 2-4 hours by relaxing outlet sphincter and bearing down with abdominal muscles