Genitourinary Disorders and Reproductive Health

What to know about a urinary teact infection?

• Can cause:

  • Lower Tract UTIs

    • Cystitis

    • Prostatitis

    • Urethritis

  • Upper Tract UTI

    • Pyelonephritis

• E. Coli – most common bacteria

• Predisposing factors: catheters, diabetes

• Increased risk: urinary obstruction and reflux, neurogenic disorders, sexually active women, men with prostate diseases, elderly persons

  • Urethrovesical reflux – urine moves from urethra to bladder (coughing, sneezing)

  • Vesicourethral reflex – short intravesical ureter…no mucosal flap

What are the symptoms of a UTI?

• About half are asymptomatic

• Dysuria (burning, tingling, or stinging)

  • Central to diagnosis

  • More than 90% accuracy for UTI in young people in the absence of concomitant vaginal discharge or irritation

• Suprapubic pain

• Increased urinary frequency

• Increased urinary urgency

• Hematuria

What are the symptoms of UTI in older adults?

• Delirium / Confusion

• Malaise

• Nocturia

• Urinary incontinence

• Foul-smelling urine

• Burning/urgency/fever 

  • Some older adults will not have fever r/t decreased immune response

What is included in the diagnostic of UTIs?

• Urinalysis

  • Often used as a screening test performed in the office to detect UTIs

  • Results are rapid

  • Visual and chemical examination for blood, pH levels, WBCs, etc.

• Urine Culture

  • May be a reflex test for positive urinalysis results or ordered separately and is performed in a lab

  • Results can take 24 to 74 hrs

  • Microscopic examination for bacterial growth, levels of infection, and sensitivity to antibiotic treatment

  • Recommended for patients with recurrent UTIs or those at risk for complicated infections

What is included in the treatment of a UTI?

• Change or remove indwelling catheters

• Antibiotics

  • Short course - 3-5 days

    • Nitrofurantoin, Trimethoprim/sulfamethoxole, fosfomycin

  • 7 days if complicated (ie pyelonephritis, indwelling catheter or device, male gender)

• Pyridium sometimes given for pain control

• Men should be evaluated for prostatitis

What are the non-pharm prophylaxis?

• Limited evidence for effectiveness, however inexpensive and low risk may be of value to some people.

  • Hydration

    • Controversial. Some reputable sources say no evidence for improving UTI outcomes or preventing, but textbook recommends

• Cranberry

  • Has been shown to inhibit bacterial adhesion proteins potentially blocking adhesion to epithelial cells

  • Meta-analysis suggests no benefit for preventing UTIs, but textbook recommends

• Probiotics

  • Limit evidence for effectiveness despite plausible scientific basis

• Urinate before/after intercourse

• Limit frequent bubble baths

What to know about benign prostatic hyperplasia (BPH)?

• Non-cancerous enlargement of prostate

• Usually occurs in men >40 yr

• Risk factors: age, smoking, obesity, alcohol, western diet, sedentary lifestyle

• Symptoms

  • Range in severity

  • Urinary frequency and urgency

  • Hesitancy starting urine stream

  • Decreased or intermittent urinary stream

  • Sensation of incomplete bladder emptying

• Diagnosis: PSA lab, digital rectal exam

• Causes complications of urinary retention and UTI

• 60 yo = 50%

• 85 yr = 90%

• Start testing at 50 yrs

What is included in the BPH pharmacological treatment?

• Alpha-adrenergic blockers: relaxes smooth muscle of bladder neck and prostate

  • Tamsulosin

  • Terazosin (Hytrin)

  • Doxazosin (Cardura)

  • Alfuzosin (Uroxatral)

• 5-alpha-reductase inhibitors: prevents conversion of testosterone to DHT to reduce prostate size

• Finasteride (Proscar)

• Dutasterude (Avodart)

What is included in the surgical treatment of BPH?

• Transurethral microwave thermotherapy (TUMT) – minimally invasive

• Transurethral resection of the prostate (TURP)

  • Benchmark surgical intervention

  • Overnight hospital stay

  • Nursing Implications

    • Monitor for hemorrhage

    • Observe for urethral stricture (dysuria, straining, weak stream)

  • Continuous bladder irrigation may be used

• Open prostatectomy 

What to know about a neurogenic bladder?

• Treatment: Continuous, intermittent, or self- catheterization; bladder retraining

• Autonomic Dysreflexia

  • Severe HTN

  • Bradycardia

  • Sweating

What to know about urinary incontinence?

• Involuntary loss or leakage of urine

• Stress Incontinence

  • Causes: tight/ineffective pelvic muscles or sphincter, surgery, neurological disorder

  • Associated with sneezing, coughing, changing positions

• Urge Incontinence (Overactive Bladder)

  • Strong urge to void that cannot be suppressed

  • Neurogenic or myogenic (bladder changes)

• Functional Incontinence

  • Urinary tract intact, but physical or cognitive impairment (Alzheimers, immobility, etc) prevent patient from recognizing need to void or reaching toilet

What is included in the treatment for urinary incontinence?

• pelvic floor physical therapy

• bladder retraining

• anticholinergic  (urge incontinence) – inhibit bladder contractions

• surgical options – lift and stabilize bladder or urethra

• avoid bladder irritants (caffeine, alcohol)

• avoid diuretics after 4pm

• stop smoking (smokers cough)

What is a strategy to promote urinary continence?

Voiding at least every 2-3 hrs

What to know about urinary retention?

• Inability to completely empty the bladder

• Chronic urine retention can lead to overflow incontinence

• CAUSES:

  • Diabetes

  • Prostatic enlargement

  • Urethral pathology: infection, tumor, calculus

  • Trauma

  • Pregnancy

  • Neurological disorders: stroke, spinal cord injury, MS, Parkinson’s

  • Medications

What is included in the assessment of urinary retention?

• Time and amount of last void

• Frequency

• Discomfort in lower abdomen

• Distended bladder

• Restlessness / agitation

• Bladder scan

• Symptoms of UTI

What are the nursing interventions for urinary retention?

• Environment conducive to voiding: privacy, body position, assistance

• Apply warmth to relax sphincters

• Provide fluids

• Turn on faucet

• Bladder scan as needed: catheterization as indicated

What to know about erectile dysfunction (impotence)?

• the inability to achieve or maintain an erect penis

• Causes:

  • Psychogenic: anxiety, fatigue, depression, pressure to perform sexually, negative body image, absence of desire, and privacy, as well as trust and relationship issues

  • Organic: cardiovascular disease, endocrine disease, cirrhosis, chronic kidney injury, genitourinary conditions (radical pelvic surgery), neurologic disorders, trauma to the pelvic or genital area, smoking, medications (see Chart 53-1), and substance use disorder.

• Treatment: depends on the cause. Oral medication (sildenafil/Viagra), penile suppository, penile injection, penile implant, penile vacuum pump.

What are the medications associated with erectile dysfunction?

• Antiadrenergics and antihypertensives

• Anticholinergics and phenothiazines

• Anticonvulsant agents

• Antidepressants

• Antifungals

• Antihistamines

• Antihormone

• Antipsychotics

• Antispasmodics

• Anxiolytics, sedative-hypnotics, and tranquilizers

• Beta-blockers

• Calcium channel blockers

• Carbonic anhydrase inhibitors

• Chemotherapeutic agents

• Diuretics

• Histamine-2 antagonists

• Nonsteroidal anti-inflammatory drugs

• Other substances: alcohol, amphetamines, barbiturates, cocaine, marijuana, methadone, nicotine, opioids

• Parkinson’s disease medications

What are the sexually transmitted infections?

• Prevalence rates highest among adolescents.

  • 30% of teens had vaginal sex by age 19.

  • Female adolescents/young women are more susceptible to cervical infections.

  • STIs frequently asymptomatic in women

• Bacterial

  • Neisseria gonorrhoeae

  • Chlamydia trachomatis

  • Treponema pallidum

  • Haemophilus ducreyi (Chancroid)

  • Lymphogranuloma

  • Mycoplasma

• Viruses

  • Herpes simplex II

  • Hepatitis B

  • Hepatitis C

  • HIV

  • Papillomavirus

• Yeasts and fungi

  • Candida albicans

  • Candida glabrata

  • Candida tropicalis

• Parasites

  • Trichomonas Vaginalis

  • Entamoeba histolytica

What is the impact of STIs?

• On women

  • Cancer

  • Cervical

  • Vulvar

  • Vaginal

  • Anal

  • Liver

  • T-cell leukemia

  • Body cavity lymphoma

• Reproductive problems

  • Pelvic inflammatory disease

  • Infertility

  • Spontaneous abortion

  • Tubal scarring

• Pregnancy problems

  • Ectopic pregnancy

  • Preterm delivery

  • Premature rupture of membranes

  • Puerperal sepsis

  • Postpartum infection

What are the 5P’s of Sexual health screening?

• Partner’s (Do you have sex with men or women, number of  partners, partners having sex with others)

• Practices (vaginal sex, condom use, anal sex, oral sex)

• Prevention of Pregnancy (Contraception?)

• Protection from Sexually Transmitted Infections (protection for STD’s?)

• Past History of Sexually Transmitted Infections (previous STD’s)

• Have you ever injected drugs?

• What else can you tell me about your sexual practices that I need to know

What to know about syphilis?

• Etiology: Treponema pallidum, a mobile spirochete

• Progresses in stages  in periods of active symptoms

  • Periods of active symptoms; periods of asymptomatic latency

  • Can affect any tissue or organ in body.

  • Systemic disease

• Symptoms

  • First stage: painless chancre

  • Second stage: Maculopapular Rash

    • hands & soles of feet

    • hard palate of the mouth

• Treatment

  • Penicillin G Benzathine IM antibiotics

  • Dosing depends on stage

• Diagnosis

  • Primary stage: is noted by the lesion or chancre @ site of entry

    • Small & painless

  • Serum Testing: VDRL/ RPR

• Complex infection

  • can lead to serious systemic disease, even death when left untreated.

• **Most contagious during the primary & secondary stages

• ***Very dangerous in pregnancy causing congenital syphilis

What to know about gonorrhea and chlamydia?

• Etiology:  Bacteria called Neisseria gonorrhea and Chlamydia trachomatis

• More common in adolescents

• Diagnosis

  • culture 

  • NAAT( called gen probe cervical swab)

  • urine sample (clean catch) for Chlamydia

• Symptoms

  • 1/2 women asymptomatic

  • Purulent discharge- thick yellowish color

  • Dysuria or irritation/itching

  • Spotting after intercourse, dyspareunia

  • Low abdominal pain

  • Painful, swollen testicles

• Treatment

  • Ceftriaxone or cefixime + azithromycin or doxycycline

• Complication

  • Women: PID, endometriosis, spontaneous abortion, ectopic pregnancy, infertility, spread to newborn, conjunctivitis

  • Men: epididymitis, infertility

• *Undetected gonorrhea can lead to neonatal blindness ophthalmic Neonatorum

What to know about herpes simplex virus?

• Etiology: Herpes Simplex Virus- 1&2 types

• Chronic and incurable viral infection

• HSV-2 sexual transmission (GENITAL)

  • at least 50 million persons in the United States are infected with HSV 2; often goes undetected

  • Genital (70%  of all HSV)

• Viral Shedding: majority of genital herpes infections are transmitted by persons unaware or are asymptomatic, can shed up to 3 weeks post outbreak. One of the most common STIs in U.S.

• Signs & Symptoms

  • Initial infection may be very painful

  • Macules and papules, may progress to vesicles and ulcers

  • Flu-like symptoms (malaise, headache, myalgia, dysuria) may occur

  • Blisters may take 2-4 weeks to heal, but can be asymptomatic

  • Recurrences generally less painful, less severe symptoms

• Diagnosis

  • PCR (blood test)

  • swab viral culture

• Medical Treatment

  • Currently, no cure

  • Treatment aimed at relieving symptoms and prevent spread

  • Antiviral agents: acyclovir, valacyclovir, famciclovir

    • Can suppress symptoms

    • Shorten course of infection