Renal Disorders

chapter 50

Urinary Tract Infection

Most common outpatient infection, caused by E. coli. Classified by upper and lower UTIs.

• Lower UTI

Cystitis

Urethritis

• Upper UTI 

Pyelonephritis

• Systemic

Urosepsis

Diagnosis of UTI

- Dip stick urinalysis; this test can identify the presence of nitrites (indicating bacteriuria), white blood cells (WBCs), and leukocyte esterase (an enzyme present in WBCs, indicating pyuria).

- Microscopic urinalysis can confirm these findings.

- Urine culture (clean catch urine sample)

Pyuria

presence of pus (WBCs) in the urine, typically from bacterial infection

Treatment for UTI

• Antibiotics

Uncomplicated – short course (3 days)

Complicated – longer course (7-14 days)

• Urinary analgesic

Phenazopyridine (AZO)

• push fluids

• Teach pts to avoid caffeine, alcohol, citrus juices, chocolate, and highly spiced foods or beverages because they are bladder irritants.

Phenazopyridine (AZO)

-may relieve discomfort caused by severe dysuria.
It is taken up to 2 concurrent days.
A dye excreted in urine. There it exerts a topical analgesic effect on the urinary tract mucosa.
-Teach patients that this drug causes the urine to turn orange or red.

Cystitis

inflammation of the bladder

Urethritis

inflammation of the urethra

Pyelonephritis

inflammation (usually caused by infection) of the renal parenchyma (renal pelvis) and collecting system.

Urosepsis

spread of infection from the urinary tract to the bloodstream that results in a systemic infection

Uncomplicated UTIs

occur in an otherwise normal urinary tract. They usually only involve the bladder.

Complicated UTIs

occur in a person with an underlying disease or with a structural or functional problem in the urinary tract.

Examples include obstruction, stones, catheters, abnormal genitourinary (GU) tract, acute kidney injury (AKI), chronic kidney disease (CKD), kidney transplant, diabetes, or neurologic disease.

The person with a complicated infection is at risk for pyelonephritis, urosepsis, and renal damage.

Dysuria

painful or difficult urination

Lower UTI s/s

dysuria, urgency, frequency, nocturia, suprapubic discomfort, gross hematuria, sediment, cloudy urine

Upper UTI s/s

fever, chills, flank pain, nausea, vomiting, malaise

s/s of UTI in older adults

fatigue, confusion, disorientation, delirium, abdominal pain, afebrile, absence of dysuria, loss of appetite, altered mental status

Catheter-associated urinary tract infections (CAUTIs)

UTIs are the most common health care-associated infection (HAI). They are mainly due to the use of an indwelling catheter.

Lead to extended hospital stays, increased health care costs, and increased mortality.

Prevention of CAUTI

-Appropriate indications for use
-Proper insertion technique
-maintain asepsis
-Appropriate care and maintenance
-Timely removal of catheter

Nephrolithiasis

kidney stone disease, renal calculi. The term calculus refers to the stone, and lithiasis refers to stone formation.

Urinary Tract Calculi

• Highest incidence in South and Southwest

• More common in men

• Incidence increases with age

• Common in Whites and Asians

• Family history

Types of stones

• Calcium oxalate

• Calcium phosphate

• Cystine

• Struvite

• Uric acid

Calcium Oxalate

Most common type of stone. More frequent in men. Incidence: 70%–80%

Risk factors: Idiopathic hypercalciuria, hyperoxaluria, independent of urinary pH, family history

tx: Increase hydration. Reduce oxalate intake, animal protein, and sodium. Increase intake of calcium, fruits, and vegetables. Give thiazide diuretics. Give potassium citrate to maintain alkaline urine. Avoid vitamin C and calcium supplements.

Calcium Phosphate

Mixed stones (typically), with struvite or oxalate stones. Incidence: 15%

risk factors: Alkaline urine, primary hyperparathyroidism

tx: Increase hydration. Treat underlying causes and other stones. Reduce sodium and animal protein intake. Increase calcium intake.

Cystine

Genetic autosomal recessive defect. Defective absorption of cystine in GI tract and kidney, excess concentrations causing stone formation. Incidence: 1%–2%

risk factor: Acidic urine

tx: Increase hydration. Give α-penicillamine, captopril, or tiopronin to prevent cystine crystallization. Give potassium citrate to keep urine alkaline.

Struvite (Magnesium Ammonium Phosphate)

More common in women. Always associated with UTIs. Large staghorn type (usually) Incidence: 1%

risk factor: UTIs (Urease-producing bacteria, usually Proteus)

tx: Give antimicrobial agents, acetohydroxamic acid. Typically need surgery to remove stone. Take measures to acidify urine.

Uric Acid

Predominant in men. Incidence: 5%–8%

risk factor: Gout, acidic urine, high urinary uric acid

tx: Increase hydration. Reduce urinary concentration of uric acid. Alkalinize urine with potassium citrate. Consider allopurinol. Reduce purine intake

Clinical Manifestations for Kidney Stones

• Sudden, severe pain in flank, low back, or abdomen

• CVA tenderness

• Kidney stone dance

• Groin pain as stone moves lower

Kidney stone diagnostics

• CT without contrast (contrast is hard on kidneys)

• Ultrasound

• X-ray (KUB)

• Urinalysis: Measure pH, check for UTI

• Urine collection kit with strainer; determine the type of stone

Kidney stone treatment

• Pain control: NSAIDS, Opioids, IV lidocaine

• α-adrenergic blockers (tamsulosin (Flomax) or terazosin): Relax smooth muscle in ureter

• IV fluids

• Surgery: Lithotripsy 

Lithotripsy

a procedure used to break up stones, thus allowing them to pass from the urinary tract. Lithotripsy techniques include (1) laser lithotripsy, (2) extracorporeal shock-wave lithotripsy (ESWL), (3) ultrasonic lithotripsy, and (4) electrohydraulic lithotripsy.

Hematuria is common and can last a few days to a few weeks.

Encourage fluids to help dilute the urine and reduce the pain from passing stone fragments.

Benign prostatic hyperplasia (BPH)

• Prostate gland increases in size; disrupting the outflow of urine from the bladder through the urethra.

-Difficulty starting to pee

-Weaker flow of urine

-urine Frequency

• Not related to prostate cancer

Pathophysiology of BPH

• Hormonal changes

. Dihydroxytestosterone (DHT) stimulates prostate cell growth

Decreased testosterone w/ age

Higher proportion of estrogen

Stimulates prostate cell growth

• No relationship between prostate size and degree of obstruction

Depends on location of enlargement

Clinical manifestations of BPH

• Gradual onset

• Irritative symptoms, related to inflammation or infection; nocturia, urinary frequency, urgency, dysuria, bladder pain, and incontinence.

• Obstructive symptoms, related to obstruction; a decrease in the caliber and force of the urinary stream, difficulty in starting a stream, intermittency (stopping and starting stream several times while voiding), and dribbling at the end of urination.

• Complications

Urinary retention, UTI, kidney damage

Treatment of BPH

• Based on severity of symptoms, not size of prostate

• Medications; 5α-reductase inhibitors, α-adrenergic receptor blockers, erectogenics

• Minimally invasive procedures

• Surgery

• Diet changes (decreasing intake of bladder irritants, like caffeine, alcohol, carbonated drinks, artificial sweeteners, and spicy or acidic foods), avoiding certain drugs (e.g., decongestants, anticholinergics), and restricting evening fluid intake may improve symptoms. A timed voiding schedule (also called “bladder retraining”) may reduce symptoms and eliminate the need for further treatment.

Surgery for BPH

• Prostatectomy; Robotic

• TUIP

• TURP

Transurethral Vaporization of Prostate (TUVP)

Electrosurgical modification of the standard TURP. Vaporization and desiccation used together to destroy prostatic tissue. Can use a variety of energy delivery mediums (e.g., button, rollerball, vaportrode).

Disadvantages: Retrograde ejaculation, intermittent hematuria

Advantages: Minimal risks, minimal bleeding and sloughing

Transurethral Incision of Prostate (TUIP)

Involves transurethral incisions into prostatic tissue to relieve obstruction. Effective for small to moderate prostates.

Advantages: Outpatient procedure, minimal complications, low occurrence of ED or retrograde ejaculation, outcomes similar to TURP

Disadvantages: Urinary catheter needed after

Transurethral Resection of Prostate (TURP)

Use of excision and cauterization to remove prostate tissue via cystoscope. Standard for treatment of BPH.

Advantages: ED unlikely

Disadvantages: • Bleeding, clot retention, retrograde ejaculation, catheter needed after

Simple Prostatectomy (Open, Laparoscopic, or Robotic Assisted)

If laparoscopic and/or robotic assisted, involves several small abdominal incisions and 1 slightly larger incision near the umbilicus.

Advantages: Complete visualization of the prostate and surrounding tissue

Disadvantages: ED, bleeding, pain, risk for infection

*BPH meds are stopped prior to surgery. Blood thinners/anticoags are stopped before surgery. a

After surgery, assess for transurethral resection syndrome (TUR or TURP syndrome). Signs and symptoms include nausea, vomiting, confusion, bradycardia, and hypertension. TUR syndrome is due to hyponatremia from long operative times and prolonged intraoperative bladder irrigation with iso-osmolar fluid.