[chapter 47] urinary elimination

Female urethra length

About 4 cm

Male urethra length

About 20 cm

Why do females get more UTIs?

Short urethra located close to the rectum, giving bacteria a short path to the bladder

Effect of aging on urination

Decreased bladder capacity, nocturia, urgency, weakened pelvic floor; BPH in men causes hesitancy and retention

Two common dietary bladder irritants and diuretics

Caffeine and alcohol

Why does diabetes increase urinary problems?

Neuropathy reduces bladder sensation causing retention; glucose in urine feeds bacteria increasing UTI risk

Medications causing urinary retention

Anticholinergics, antihistamines, opioids, some antidepressants

Nephrotoxic agents

Aminoglycosides, NSAIDs, contrast dye

Urinary retention

Inability to empty the bladder, causing urine to accumulate and the bladder to overdistend

Causes of urinary retention

Anesthesia, opioids, anticholinergics, BPH, urethral stricture, neurogenic bladder, post-op status, anxiety

Complications of urinary retention

UTI, overflow incontinence, hydronephrosis and kidney damage

Why does retained urine cause infection?

Stagnant urine is a culture medium and an overdistended bladder wall has reduced blood flow, weakening local immune defense

Cord injury ABOVE the sacral reflex arc causes

Reflex incontinence — the reflex fires on its own with no sensation or control

Cord injury AT or BELOW S2-S4 causes

Flaccid bladder with retention and overflow

Volume at which the urge to void is felt

150-200 mL

Why is urine output decreased for 24-48 hours after surgery?

The surgical stress response raises ADH and aldosterone, causing sodium and water retention

Signs of urinary retention

Bladder distention, absent output or frequent small voids, sensation of incomplete emptying, suprapubic discomfort, restlessness

Frequent small voids of 25-50 mL with a distended bladder means

Overflow from retention

Best way to assess for retention

Bladder scan

Most common organism causing UTI

E. coli

Signs of lower UTI (cystitis)

Dysuria, urgency, frequency, hematuria, cloudy foul-smelling urine, suprapubic tenderness

Signs of upper UTI (pyelonephritis)

Lower UTI signs plus fever, chills, flank/CVA tenderness, nausea and vomiting, malaise

First or only sign of UTI in an older adult

New-onset confusion, agitation, falls, or new incontinence (often without fever or dysuria)

UTI rank among healthcare-associated infections

Fifth most common

Asymptomatic bacteriuria

Bacteria in urine without symptoms; usually not treated except in pregnancy or before urologic procedures

Stress incontinence

Small leaks with coughing, sneezing, laughing, lifting, or exercise due to weak pelvic floor and increased intraabdominal pressure

Stress incontinence interventions

Kegel exercises, weight loss, avoid heavy lifting, treat chronic cough

Urge incontinence

Sudden strong urge with inability to reach the toilet in time; large-volume loss from an overactive detrusor

urge incontinence interventions

Bladder retraining to lengthen intervals, avoid caffeine and bladder irritants, antimuscarinics

Overflow incontinence

Constant dribbling and small frequent voids from a distended, overfull bladder

Overflow incontinence causes

Urinary retention from obstruction (BPH), weak detrusor, neurologic damage, or medications

Reflex incontinence

Bladder empties at predictable intervals with no sensation of urge, from a spinal cord lesion above the sacral reflex arc

Reflex incontinence interventions

Timed or intermittent catheterization and scheduled emptying

Functional incontinence

Urinary tract works normally but the patient cannot reach the toilet in time

Causes of functional incontinence

Impaired mobility or cognition, environmental barriers, restraints, unavailable assistance

Interventions for functional incontinence

Scheduled or prompted toileting, clear path, call light in reach, bedside commode, adaptive clothing

How to distinguish incontinence types

Pressure means stress, an unbeatable urge means urge, constant dribble with distention means overflow, no sensation with predictable timing means reflex, a working bladder the patient couldn't reach means functional

Ileal conduit

Incontinent diversion in which ureters are implanted into an ileal segment draining through a stoma into an external pouch

Is mucus in urine from a ileal conduit normal?

Yes, the bowel segment used to make the conduit secretes mucus.

Expected output from a urinary stoma

Continuous

No output from a urinary stoma for several hours means

Obstruction (urine can back up towards the kidneys)

Continent urinary reservoir

Internal pouch with a valve and no external bag; the patient catheterizes it on a schedule, typically every 4-6 hours

Healthy stoma appearance

Red or pink and moist

Stoma color requiring immediate reporting

Pale, dusky, purple, black (compromised circulation)

Why doesn't the patient feel stoma injury?

Stoma has no sensory nerve endings

Urgency

Sudden strong need to void

Dysuria

Painful or difficult voiding

Polyuria

Excessive urine output

Oliguria

Diminished output

Anuria

Essentially no output (less than 100mL/day)

Nocturia

Waking at night to void

Hematuria

Blood in the urine

Assessing the kidneys

Percuss for CVA tenderness at the costovertebral angle

CVA tenderness suggests

Pyelonephritis or kidney injury

Assessing the bladder

Inspect, palpat, percuss above the symphysis pubis

Distended bladder findings

Palpable and dull to percussion

Normal urine color

Pale straw to amber

Dark amber urine

Concentrated urine from dehydration

Cloudy or thick urine indicates

Infection, pus, protein, sediment

Foul or pungent urine odor indicates

Infection

Sweet or fruity urine odor indicates

Ketones from uncontrolled diabetes

Normal urine pH

4.6-8.0

Most specific lab for kidney function

Creatinine

Clean-catch midstream specimen rationale

The initial stream flushes out contaminating perineal organisms

24-hour urine collection

Discard the first void and start timing, collect all urine for 24 hours including the final void, keep refrigerated or on ice

Why should females not hover over the toilet?

Hovering keeps the pelvic floor contracted so the bladder cannot fully empty, causing residual urine and UTI risk

Why does constipation cause urinary symptoms?

A rectum full of stool presses on the bladder causing urgency, frequency, and incomplete emptying

Two reasons to teach smoking cessation for bladder health

Reduces bladder cancer risk and reduces chronic cough, which contributes to stress incontinence

What bladder changes should be reported to the provider?

Changes in bladder habits, frequency, urgency, pain with voiding, or blood in the urine

Credé method

Manual compression over the bladder (need provider order)

Why does Credé require an order?

In neurogenic bladder with sphincter dyssynergia, compression can force urine backward up the ureters and damage the kidneys

Uses of an intermittent (straight) catheter

Measuring post-void residual when a scanner is unavailable, managing chronic retention, self catheterization

Use of an indwelling catheter

Urologic of gynecologic surgery, obstruction, neurologic bladder, accurate I&O, palliative comfort

Short-term vs long-term indwelling catheter

Short term is 2 weeks or less; long term is more than 1 month

Preferred method for measuring post-void residual (PVR)

Bladder scan

Four textbook purposes of catheterization

Collecting a sterile specimen, measuring residual urine, intermittently emptying the bladder, continuously emptying the bladder

Appropriate clinical indications for an indwelling catheter

Acute retention or obstruction, accurate I&O in the critically ill, selected perioperative use, healing open sacral or perineal wounds, prolonged immobilization when movement is unsafe, comfort at end of life

Single-lumen catheter

Used for intermittent/straight catheterization (drainage only)

Double-lumen catheter

Indwelling; one lumen drains urine, one inflates the balloon

Triple-lumen catheter

Used for continuous bladder irrigation or bladder medication instillation (drainage, balloon, irrigation inflow)

Factors in choosing catheter material

Latex allergy, history of encrustation, anatomical factors, susceptibility to infection

Silicone catheter advantage

Larger internal diameter, useful for patients needing frequent changes due to encrustation

Coudé-tip catheter

Curved tip that helps maneuver through the prostatic urethra with an enlarged prostate; requires special training

Adult catheter size for short-term use

14 to 16 Fr

Catheter size when hematuria or clots are present

20 to 24

Pediatric catheter sizes

5-6 Fr infants, 8-10 Fr children, 12 Fr young girls

Why use the smallest effective catheter?

Larger catheters compress periurethral glands and cause urethral trauma, both raising infection risk

Adult balloon size and fill volume

5-mL balloon, inflated with 10 mL of fluid

Problems with routine 30-mL balloons

Discomfort, urethral irritation and trauma, catheter expulsion, incomplete emptying from urine pooling below the drainage eyes

Long-term catheter change interval

Every 4 to 6 weeks

Principle of a closed-drainage system

The tubing stays connected to maintain sterility and prevent introduction of pathogens

How to collect a specimen from an indwelling catheter

Aspirate from the sampling port in the tubing; never disconnect the system, never take urine from the bag

Why never hang the bag on a side rail?

It rises above bladder level when the rail is lowered, allowing urine reflux

Leg bag

Strapped to the leg and worn during the day, swapped for a standard bag at night

Belly bag

Worn across the abdomen with a one-way valve; the exception to the below-bladder rule

Daily CAUTI risk per catheter day

3% to 7% increased risk each day the catheter remains

Percent of adult inpatients with an indwelling catheter

12% to 16% at some point during hospitalization

Single most important CAUTI prevention intervention

Remove the catheter as soon as it is no longer needed

Portals of entry for bacteria

Urethral meatus, catheter-tubing junction, specimen port, drainage spigot, and reflux from the bag

When should a drainage bag be emptied?

When half full