genitourinary disorders (medical surgical nursing)

Aashish PariharNursing Tutor

College of NursingAIIMS, Jodhpur

contentReview of anatomy and physiology of genitourinary systemNursing assessment: history, and physical examinationEtiology, pathophysiology, clinical manifestations, diagnosis,

medical and surgical treatment modalities, alternative therapies, dietetics and nursing management (nursing process including nursing procedures).

Urological obstructions-Urethral stricturesRenal calculiNephrosis

content Disorders of kidney-GlomerulonephritisNephrotic syndromeNephrosisAcute renal failureChronic renal failureEnd stage renal diseaseDialysis, renal transplantCancer of kidneyCongenital disorder

contentDisorders of Ureters, urinary bladder and urethra-UTICystitisUrinary incontinenceUrinary retentionUrinary refluxBladder neoplasmUrinary bladder calculiUrethirtisUrethral tumorsUreteritisUreteral calculiTrauma of Ureters, bladder, urethraNeoplasm of ureters, bladder and urethraCongenital disorders of ureters, bladder and urethra

anatomy and physiology of genitourinary system




physiology of genitourinary system


Ureters, Bladder, and Urethra -Urine, which is formed within the nephrons, flows into the

ureter, a long fibromuscular tube that connects each kidney to the bladder.

The ureters are narrow, muscular tubes, each 24 to 30 cm long, that originate at the lower portion of the renal pelvis and terminate in the trigone of the bladder wall.

There are three narrowed areas of each ureter: the ureteropelvic junction, the ureteral segment near the sacroiliac junction, and the ureterovesical junction.

The angling of the ureterovesical junction is the primary means of providing antegrade, or downward, movement of urine, also referred to as efflux of urine.

This angling prevents vesicoureteral reflux, which is the retrograde, or backward, movement of urine from the bladder, up the ureter, toward the kidney.


Ureters, Bladder, and Urethra -During voiding (micturition), increased intravesical pressure

keeps the ureterovesical junction closed and keeps urine within the ureters. As soon as micturition is completed, intravesical pressure returns to its normal low baseline value, allowing efflux of urine to resume.

Therefore, the only time that the bladder is completely empty is in the last seconds of micturition before efflux of urine resumes.

The three areas of narrowing within the ureters have a propensity toward obstruction because of renal calculi (kidney stones) or stricture.

Obstruction of the ureteropelvic junction is the most serious because of its close proximity to the kidney and the risk of associated kidney dysfunction


Ureters, Bladder, and Urethra -During voiding (micturition), increased intravesical pressure

keeps the ureterovesical junction closed and keeps urine within the ureters. As soon as micturition is completed, intravesical pressure returns to its normal low baseline value, allowing efflux of urine to resume.

Therefore, the only time that the bladder is completely empty is in the last seconds of micturition before efflux of urine resumes.

The three areas of narrowing within the ureters have a propensity toward obstruction because of renal calculi (kidney stones) or stricture.

Obstruction of the ureteropelvic junction is the most serious because of its close proximity to the kidney and the risk of associated kidney dysfunction


Nursing assessment: history, and physical examination Multiparous women delivering their children vaginally are

at high risk for stress urinary incontinenceElderly women and persons with neurologic disorders such

as diabetic neuropathy, multiple sclerosis, or Parkinson’s disease often have incomplete emptying of the bladder with urinary stasis, which may result in-

urinary tract infection increasing bladder pressure leading to overflow

incontinence, hydronephrosis, pyelonephritis, renal insufficiency.


Nursing assessment: history, and physical examination The patient’s chief concern or reason for seeking health

care, the onset of the problem, and its effect on the patient’s quality of life

The location, character, and duration of pain, if present, and its relationship to voiding

Factors that precipitate pain, and those that relieve it History of urinary tract infections, including past treatment

or hospitalization for urinary tract infection Fever or chills Previous renal or urinary diagnostic tests or use of

indwelling urinary catheters


Nursing assessment: history, and physical examination Dysuria and when it occurs during voiding (at initiation or

termination of voiding) Hesitancy, straining, or pain during or after urination Urinary incontinence (stress incontinence, urge

incontinence, overflow incontinence, or functional incontinence)

Hematuria or change in color or volume of urine Nocturia and its date of onset Renal calculi (kidney stones), passage of stones or gravel in

urine


Nursing assessment: history, and physical examination Female patients: number and type (vaginal or cesarean) of

deliveries; use of forceps; vaginal infection, discharge, or irritation; contraceptive practices

Presence or history of genital lesions or sexually transmitted diseases

Habits: use of tobacco, alcohol, or recreational drugs Any prescription and over-the-counter medications

(including those prescribed for renal or urinary problems)


Nursing assessment: history, and physical examination





During physical examination for genitourinary dysfunction areas of emphasis include the abdomen, suprapubic region, genitalia and lower back, and lower extremities.

Direct palpation of the kidneys may help determine their size and mobility

The right kidney is easier to feel because it is somewhat lower than the left one


Nursing assessment: history, and physical examination Renal dysfunction may produce tenderness over the

costovertebral angle, which is the angle formed by the lower border of the 12th, or bottom, rib and the spine.

The abdomen is auscultated to assess for bruits (low-pitched murmurs that indicate renal artery stenosis or an aortic aneurysm).

The abdomen is also assessed for the presence of peritoneal fluid, which may occur with kidney dysfunction.


Nursing assessment: history, and physical examination The bladder should be percussed after the patient voids to

check for residual urine Percussion of the bladder begins at the midline just above

the umbilicus and proceeds downward. The sound changes from tympanic to dull when percussing

over the bladder.The bladder, which can be palpated only if it is moderately

distended, feels like a smooth, firm, round mass rising out of the abdomen, usually at midline

Dullness to percussion of the bladder following voiding indicates incomplete bladder emptying.




Nursing assessment: history, and physical examination The prostate gland is palpated by digital rectal examination

(DRE) Blood is drawn for PSA before the DRE because

manipulation of the prostate can cause the PSA level to rise temporarily.

The inguinal area is examined for enlarged nodes, an inguinal or femoral hernia, or varicocele (varicose veins of the spermatic cord)


Nursing assessment: history, and physical examination In female, the vulva, urethral meatus, and vagina are

examinedThe patient is assessed for edema and changes in body

weight. Edema may be observed, particularly in the face and dependent parts of the body, such as the ankles and sacral areas

An increase in body weight commonly accompanies edema. A 1-kg weight gain equals approximately 1,000 mL of fluid.

urological obstructionsurethral strictures

A urethral stricture is a scar in or around the urethra, which can block the flow of urine, and is a result of inflammation,

injury or infection.

Anatomy of the Male Reproductive System

urological obstructions


Risk factors-Urethral strictures are more common in men because

their urethras are longer than those in women. Thus men's urethras are more susceptible to disease

or injury. A person is rarely born with urethral strictures and

women rarely develop urethral strictures.


Etiology -Stricture disease may occur anywhere from the

bladder to the tip of the penis. The common causes of stricture are trauma to the

urethra and infections such as sexually transmitted diseases and damage from instrumentation.

Trauma such as straddle injuries, direct trauma to the penis and catheterization can result in strictures of the anterior part of the urethra.


Etiology -In adults, urethral strictures from instrumentation

trauma may occur after prostate surgery and urinary catheterization.

In children, urethral strictures most often follow reconstructive surgery for congenital abnormalities of the penis and urethra, cystoscopy and occasionally may be congenital.


Clinical features -painful urination.slow urine stream.decreased urine output.spraying of the urine stream.blood in the urine.abdominal pain.urethral discharge.urinary tract infections in men.infertility in men.


Diagnostic evaluation-Evaluation of patients with urethral stricture

includes a physical examination.Urethral imaging (X-rays or ultrasound).The retrograde urethrogram is an invaluable test

to evaluate and document the stricture and define the stricture recurrence. Combined with antegrade urethrogram, length of the stricture can be determined.

Normal Urethrogram Obstructive Urethrogram



Treatment-Treatment options for urethral stricture disease are

varied and selection depends upon the length, location and degree of scar tissue associated with the stricture.

The main treatment options include enlarging the stricture by gradual stretching (dilation).


Treatment-Cutting the stricture with a endoscopic equipment

(urethrotomy) and surgical repair of the stricture with reconnection and reconstruction called urethroplasty.

Urethral Stents where a biocompatible hollow tube is placed on the inside of the stricture to allow for free passage of urine.

urological obstructionsrenal calculi

Urolithiasis refers to stones (calculi) in the urinary tract.

Stones are formed in the urinary tract when urinary concentrations of substances such as calcium oxalate, calcium phosphate, and uric acid increase.

This is referred to as supersaturation and is dependent on the amount of the substance, ionic strength, and pH of the urine.


Incidence-The occurrence of urinary stones occurs predomi-

nantly in the third to fifth decades of life and Affects men more than women. About half of patients with a single renal stone have

another episode within 5 years. Most stones contain calcium or magnesium in

combination with phosphorus or oxalate. Most stones are radiopaque and can be detected by

x-ray studies


Types of stone-Calcium stoneOxalate stoneCystiene stone Struvite stone


Types of stone-Calcium stoneMost stones (75%) are composed mainly of calcium

oxalate crystals.Increased calcium concentrations in blood and urine

promote precipitation of calcium and formation of stones.

Causes of hypercalcemia (high serum calcium) and hypercalciuria (high urine calcium) include the following:


Types of stone-Calcium stone Hyperparathyroidism Renal tubular acidosis Cancers Granulomatous diseases (sarcoidosis, tuberculosis), which

may cause increased vitamin D production by the granulomatous tissue

Excessive intake of vitamin DExcessive intake of milk and alkali Myeloproliferative diseases (leukemia, polycythemia vera,

multiple myeloma), which produce an unusual proliferation of blood cells from the bone marrow


Types of stone-Uric acid stones 5% to 10% of all stones gout myeloproliferative disordersDiet high in purines and abnormal purine

metabolism


Types of stone-Struvite stones 15% of urinary calculi form in persistently alkaline, ammonia-rich urine caused by the presence of urease splitting bacteria

such as Proteus, Pseudomonas, Klebsiella, Staphy- lococcus, or Mycoplasma species.

Predisposing factors for struvite stones (commonly called infection stones) include neurogenic bladder, foreign bodies, and recurrent UTIs.


Types of stone-Cystine stones 1% to 2% of all stones occur in patients with a rare inherited defect in renal

absorption of cystine (an amino acid).

Urological obstrUctionsrenal calcUli

Causes and predisposing factors:Chronic dehydration, poor fluid intake, and immobilityLiving in mountainous, desert, or tropical areasInfection, urinary stasis, and periods of immobilityInflammatory bowel disease and in patients with an

ileostomy or bowel resection because these patients absorb more oxalate.

Medications- antacids, acetazolamide (Diamox), vitamin D, laxatives, and high doses of aspirin


Location of stones-KidneyUreterBladderUrethra


Site of obstruction-


Clinical features-PainHeamturiaDysuriaOedemaPyuria Associated symptoms-Nausea, vomiting, diarrhea, abdominal discomfortChills and fever (may)

Urological obstrUctionsrenal calcUliClinical features-

Pain- Stones in the renal pelvis may be associated with an

intense, deep ache in the costovertebral region Pain originating in the renal area radiates anteriorly

and downward toward the bladder in the female and toward the testis in the male.

If the pain suddenly becomes acute, with tenderness over the costovertebral area, and nausea and vomiting appear termed as renal colic


Pain- Stones lodged in the ureter (ureteral obstruction) cause

acute, excruciating, colicky, wavelike pain, radiating down the thigh and to the genitalia

It is called ureteral colic Colic is mediated by prostaglandin E, a substance that

increases ureteral contractility and renal blood flow and that leads to increased intraureteral pressure and pain

If the stone present in the bladder and obstruct he urine flow, produces the pain at suprapubic region along with bladder distension


Clinical features-Hematuria- Hematuria is often present because of the abrasive

action of the stone.Dysuria- Painful micturition is termed as dysuria. Obstruction in urine flow tend to cause the dysuria.


Clinical features-Oedema- When the stones block the flow of urine, obstruction

develops, producing an increase in hydrostatic pressure and distending the renal pelvis and proximal ureter.

Thereby GFR decreases leads to sodium and water retetion and gives rise to oedema.

Pyuria- Obstruction in urine flow, urinary retention and urinary

stasis may cause the UTI and featured as pyuria.


Associated symptoms-Nausea, vomiting, diarrhea, abdominal discomfort due to renointestinal reflexes and shared nerve supply

(celiac ganglion) between the ureters and intestine. and the anatomic proximity of the kidneys to the stomach,

pancreas, and large intestine. Features of infection- Due to UTI. These features may be chill, high grade fever dysuria

etc.


Diagnostic evaluation-History Physical examinationUrinanalysisBlood studiesStone chemistryRadiographic studies


Diagnostic evaluationHistory -DietWaterOccupation medication Past and recent medical historyCollect the informations regarding the reasons for

seeking health care services


Diagnostic evaluationPhysical examination -Locate, nature and characteristics of painAssess the level of pain ,tenderness etc.Observe for the associated symptoms.


Diagnostic evaluationUrinanalysis-hematuria and pyuriapH < 5.5 indicates uric acid stonepH > 7.5 indicates struvite stoneurine culture and drug sensitivity studies to detect

infection.24-hour urine test for measurement of calcium, uric

acid, creatinine, sodium,citrate and oxalate


Diagnostic evaluationBlood studies-HyperuracemiaHypercalcemiaNeutrophilia Elevated serum parathyroid hormone


Diagnostic evaluationStone chemistry-Collection of stone through a strainer is useful.Analyze the stone chemically to find out the

composition which helps in therapeutic management.


Diagnostic evaluationRadiographic studies-Kidney, ureters, and bladder radiography may show

stone.Intra venous urogram (intravenous pyelogram) to

determine site and evaluate degree of obstruction Retrograde pyelographyUltrasound Helical or axial CAT Scan


Management General PrinciplesIf small stone (< 4 mm) and able to treat as outpatient,

80% will pass stone spontaneously with hydration, pain control, and reassurance.

Hospitalized for intractable pain, persistent vomiting, high-grade fever, obstruction with infection, and solitary kidney with obstruction.

Medical managementSurgical managementNursing management


Management Medical managementGoal-Immediate goal- To relieve the pain until its causes can be eliminated.Long term goal (basic goal)-To eradicate the stoneTo determine the stone type To prevent nephron destructionTo control infectionTo relieve any obstruction


Management Medical management Opioid analgesics or NSAIDs are administered to

prevent shock and syncope that may result from the excruciating pain.

NSAIDs provide specific pain relief because they inhibit the synthesis of prostaglandin E.

Hot baths or moist heat to the flank areas may also be useful.


Management Medical managementFluids are encouraged. This increases the

hydrostatic pressure behind the stone, assisting it in its downward passage.

A high, around-the-clock fluid intake reduces the concentration of urinary crystalloids, dilutes the urine, and ensures a high urine output.


Management Medical managementCalcium stone-Cellulose sodium phosphate (Calcibind) may be effective in

preventing calcium stones. It binds calcium from food in the intestinal tract, reducing the

amount of calcium absorbed into the circulation. restrict calcium in dietTherapy with thiazide diuretics may be beneficial in reducing the

calcium loss in the urine and lowering the elevated paratharmone levels.

The urine may be acidified by use of medications such as ammonium chloride or acetohydroxamic acid

Sodium and protein restriction diet


Management Medical management

Uric acid stone-low-purine diet such as shellfish, anchovies,

asparagus, mushrooms, and organ meats are avoidedAllopurinol may be prescribed to reduce serum uric

acid levels and urinary uric acid excretion.Proteins may be limited in diet



Cystine stone -Low-protein dietPenicillamine is administered to reduce the amount

of cystine in the urineurine is alkalinized.



Oxalate stone -Encourage the increased fluid intakeAvoid the food contains oxalate such as- spinach,

strawberries, tea, peanuts, wheat bran


Management Non surgical management-UreteroscopyESWL (Extra Corporeal Shock wave lithotripsy)Endoscopic proceduresElectrohydrolic lithotripsyChemolysis


Management Non surgical management-Ureteroscopy Ureteroscopy involves visualizing the stone and then destroying it. Access to the stone is accomplished by inserting a ureteroscope into the

ureter and then inserting a laser, electrohydraulic lithotriptor, or ultrasound device through the ureteroscope to fragment and remove the stones.

A stent may be inserted and left in place for 48 hours or more after the procedure to keep the ureter patent


Management Non surgical management-ESWL-ESWL is a noninvasive procedure used to break up stones in

the calyx of the kidneyIn ESWL, a high-energy amplitude of pressure, or shock wave,

is generated by the abrupt release of energy and transmitted through water and soft tissues.

When the shock wave encounters a substance of different intensity (a renal stone), a compression wave causes the surface of the stone to fragment.

Repeated shock waves focused on the stone eventually reduce it to many small pieces. These small pieces are excreted in the urine, usually without difficulty.


Management Non surgical management-ESWL-


Management Non surgical management-Endoscopic procedures-A percutaneous nephrostomy or a percutaneous nephrolithotomy

may be performed, and a nephroscope is introduced through the dilated percutaneous tract into the renal parenchyma.

Depending on its size, the stone may be extracted with forceps or by a stone retrieval basket. Alternatively, an ultrasound probe may be introduced through the nephrostomy tube.


Management Non surgical management-Electrohydraulic lithotripsy-an electrical discharge is used to create a hydraulic

shock wave to break up the stone.A probe is passed through the cystoscope, and the

tip of the lithotriptor is placed near the stoneThis procedure is performed under topical

anesthesia.


Management Non surgical management-Chemolysis-Chemolysis, stone dissolution using infusions of

chemical solutions (eg, alkylating agents, acidifying agents)

A percutaneous nephrostomy is performed, and the warm irrigating solution is allowed to flow continuously onto the stone.


Management Surgical management- Nephrolithotomy - Incision into the kidney with

removal of the stone Nephrectomy – removal of kidney Pyelolithotomy - removal of stone from renal pelvisUreterolithotomy - removal of stone from ureter Cystostomy – removal of stone from bladderCystolitholapaxy - an instrument is inserted through

the urethra into the bladder, and the stone is crushed in the jaws of this instrument

DisorDers of kiDneyglomerUlonephritis ,acUte

(acUte nephritic synDrome )

Definition –

Acute glomerulonephritis refers to a group of kidney diseases in which there is an inflammatory reaction in the glomeruli.

It is not an infection of the kidney, but rather the result of the immune mechanisms of the body

DisorDers of kiDneyglomerUlonephritis , acUte(acUte nephritic synDrome )

Risk factors –Group A beta- hemolytic streptococcal infection of the

throat Impetigo (infection of the skin) Acute viral infections- upper respiratory tract infections,

mumps, varicella zoster virus, Epstein-Barr virus, hepatitis B, and human immunodeficiency virus [HIV] infection).

Antigens outside the body (eg, medications, foreign serum) In other patients, the kidney tissue itself serves as the

inciting antigen.

DisorDers of kiDneyglomerUlonephritis , acUte(acUte nephritic synDrome )

Categories –Primary: Disease is mainly in glomeruli Secondary: Glomerular diseases that are the

consequence of systemic disease Idiopathic: Cause is unknown Acute: Occurs over days or weeks Chronic: Occurs over months or years Rapidly progressing: Constant loss of renal function

with minimal chance of recovery

DisorDers of kiDneyglomerUlonephritis , acUte

(acUte nephritic synDrome )

Categories –Diffuse: Involves all glomeruli Focal: Involves some glomeruli Segmental: Involves portions of individual

glomeruli Membranous: Evidence of thickened glomerular

capillary walls Proliferative: Number of glomerular cells involved

is increasing


(acUte nephritic synDrome)



Clinical features-Hematuria - The urine may appear cola-colored because of

red blood cells (RBCs) and protein plugs or casts; RBC casts indicate glomerular injury.

Edema and hypertension OliguriaAnemia from loss of RBCs into the urine



Clinical features-In the more severe form of the disease, patients also

complain of headache, malaise, and flank pain. Elderly patients may experience circulatory overload

with dyspnea, engorged neck veins, cardiomegaly, and pulmonary edema.

Atypical symptoms include confusion, somnolence, and seizures, which are often confused with the symptoms of a primary neurologic disorder

DisorDers of kiDneyglomerUlonephritis , acUte(acUte nephritic synDrome)

Diagnostic evaluation-HistoryOn examination- kidney is large, tender, edematous and congestedUrinanalysis- protienuria, hematuria , oliguriaBlood studies-Serum creatinine, BUN increasedHypoalbuminemia, hyperlipidemiaElevated serum IgA levelAntistreptolysin O titers are usually elevated in post streptococcal

glomerulonephritisElectron microscopy and immunofluorescent analysis help identify the

nature of the lesionKidney biopsy may be needed for definitive diagnosis.



Complications-Hypertensive EncephalopathyHeart FailurePulmonary EdemaESRD



Management-Goal-To conserve renal functionTo treat complication adequatelyTypes of management-Non pharmacological managementDietary managementPharmacological managementNursing management



Non pharmacological management-Complete bed rest – as excessive activity may increase the

protienuria and hematuria. It should be encouraged until the urine clears and BUN, creatinine and BP return to normal.

Strict intake out put charting.Fluid restrictionsPlasmapheresis to decrease the serum anti body level Dialysis if, uremic symptoms are severe.



Dietary management- Protein restricted diet as the level of BUN and creatinine is

high in bloodLow fat diet due to hyperlipidemiaSodium restriction if hypertension, edema or congestive

heart failure are present.Increased carbohydrate diet to provide energy and to

prevent the catabolism of protein.

DisorDers of kiDneyGlomerulonephritis , acute(acute nephritic synDrome)

Pharmacological management- Residual streptococcal infection is suspected, penicillin is

the agent of choice.Diuretics and antihypertensive agents may be given to

control hypertension.Corticosteroids and cytotoxic agents are used to reduce

the inflammation.H2 blockers (to prevent stress ulcers)Phosphate binding agents (to reduce phosphate and

elevate calcium).

DisorDers of kiDneyGlomerulonephritis , acute

(acute nephritic synDrome)

Nursing management- Monitor vital signs, intake and output, and maintain dietary

restrictions during acute phase.Encourage rest during the acute phase as directed until the

urine clears and BUN, creatinine, and blood pressure normalize. (Rest also facilitates diuresis.)

Administer medications as ordered, and evaluate patient's response to antihypertensives, diuretics, H2 blockers, phosphate-binding agents, and antibiotics (if indicated).

DisorDers of kiDneyGlomerulonephritis , acute(acute nephritic synDrome)

Nursing management- Carefully monitor fluid balanceReplace fluids according to the patient's fluid losses (urine,

respiration, feces) Daily body weight as prescribed.Monitor pulmonary artery pressure and CVP, if indicated.Monitor for signs and symptoms of heart failure: distended neck

veins, tachycardia, gallop rhythm, enlarged and tender liver, crackles at bases of lungs.

Observe for hypertensive encephalopathy, any evidence of seizure activity.

DisorDers of kiDneyGlomerulonephritis , acute

(acute nephritic synDrome)

Nursing management-

Regular monitoring of blood pressure, urinary protein, and BUN concentrations to determine if there is exacerbation of disease activity.

Encourage patient to treat any infection promptly.Tell patient to report any signs of decreasing renal

function and to obtain treatment immediately.

DisorDers of kiDneyacute pyelonephritis

Definition-

Pyelonephritis is a bacterial infection of the renal pelvis, tubules, and interstitial tissue of one or both

kidneys.


Etiology- upward spread of bacteria from the bladder or spread from

systemic sources reaching the kidney via the bloodstream.Systemic infections (such as tuberculosis) can spread to the

kidneys and result in abscesses. Pyelonephritis can result from urinary obstruction such as

vesicoureteral reflux (incompetence of ureterovesical valve, which allows urine to regurgitate into ureters, usually at time of voiding), other renal disease, trauma, or pregnancy


Commonest microorganism- Enteric bacteria, such as E. coli, is most common pathogenother gram-negative pathogens include Proteus species,

Klebsiella, and Pseudomonas. Gram-positive bacteria are less common, but include

Enterococcus and Staphylococcus aureus


Pathophysiology-


Clinical features- Fever, chills, headache, malaise Flank pain (with or without radiation to groin)Nausea, vomiting, anorexiaCostovertebral angle tendernessUrgency, frequency, and dysuria may be present


Diagnostic evaluation- History – urinary obstruction, systemic infectionPhysical examination- pain and tenderness in the area of the

costovertebral angle Urinalysis- pyuria, bactriuria, RBCs and WBCs in urineHematology- elevated WBC countAn ultrasound study or a CT scan may be performed to

locate any obstruction in the urinary tract. An IV pyelogram may be indicated with pyelonephritis if

functional and structural renal abnormalities are suspected Urine culture and sensitivity tests are performed to

determine the causative organism


Management- For severe infections (dehydrated, cannot tolerate oral

intake) or complicating factors (suspected obstruction, pregnancy, advanced age), inpatient antibiotic therapy is recommended.Usually immediate treatment is started with a penicillin or

aminoglycoside I.V. to cover the prevalent gram-negative pathogens; subsequently adjusted according to culture results.

An oral antibiotic may be started 24 hours after fever has resolved and oral therapy continued for 3 weeks.


Management-

Oral therapy antibiotic therapy is acceptable for outpatient treatment.Co-trimoxazole (Bactrim, Septran) or a

fluoroquinolone is used; 10 to 14 days is the usual length of treatment.

Repeat urine cultures should be performed after the completion of therapy.

Supportive therapy is given for fever and pain control and hydration.


Complication-

Bacteremia with sepsisPapillary necrosis leading to renal failureRenal abscess requiring treatment by percutaneous

drainage or prolonged antibiotic therapyPerinephric abscessParalytic ileus


Nursing Management-

Administer or teach self-administration of antibiotics as prescribed, and monitor for effectiveness and adverse effects.

Assess vital signs frequently, and monitor intake and output; administer antiemetic medications to control nausea and vomiting.

Administer antipyretic medications as prescribed and according to temperature.


Nursing Management- Report fever that persists beyond 72 hours after initiating

antibiotic therapy; further testing for complicating factors will be ordered.

Use measures to decrease body temperature if indicated; cooling blanket, application of ice to armpits and groins, and so forth.

Correct dehydration by replacing fluids, orally if possible, or I.V.

Monitor CBC, blood cultures, and urine studies for resolving infection.

DisorDers of kiDneynephrotic synDrome

Definition-

Nephrotic syndrome is a clinical disorder characterized by marked increase of protein in the urine (proteinuria), decrease in albumin in the blood (hypoalbuminemia),

edema, and excess lipids in the blood (hyperlipidemia).

These occur because of increased permeability of the glomerular capillary membrane.


Classification of nephrotic syndrome-ETOLOGICAL CLASSIFICATIONPrimary NEPHROTIC syndrome. Disease limited to kidneySecondary NEPHROTIC syndrome. Other systems involvedHISTOLOGICAL CLASISIFICATIONMCD (Minimal change disease )FSGN (Focal segmental glomerulosclerosis )MN (Membranous nephropathy)MPGN (membranous proliferative glomerulonephrosclerosis)


Etiology-Membranous nephropathy (MN)Hepatitis B Sjogren's syndrome Systemic lupus erythematosus (SLE) Diabetes mellitus Sarcoidosis Syphilis Drugs Malignancy (cancer)

http://en.wikipedia.org/wiki/Hepatitis_B

http://en.wikipedia.org/wiki/Sjogren's_syndrome

http://en.wikipedia.org/wiki/Systemic_lupus_erythematosus

http://en.wikipedia.org/wiki/Diabetes_mellitus

http://en.wikipedia.org/wiki/Sarcoidosis

http://en.wikipedia.org/wiki/Syphilis

http://en.wikipedia.org/wiki/Malignancy


Etiology-Focal segmental glomerulosclerosis (FSGS)Hypertensive Nephrosclerosis Human immunodeficiency virus (HIV) Diabetes mellitus Obesity Kidney loss Minimal change disease (MCD)Drugs Malignancy, especially Hodgkin's lymphoma

http://en.wikipedia.org/wiki/Human_immunodeficiency_virus

http://en.wikipedia.org/wiki/Obesity

http://en.wikipedia.org/wiki/Hodgkin's_lymphoma


pathophysiology-


Clinical features-The major manifestation of nephrotic syndrome is

edema. It is usually soft and pitting and commonly occurs

around the eyes (periorbital), in dependent areas (sacrum, ankles, and hands), and in the abdomen (ascites).

Patients may also exhibit irritability, headache, and malaise.


Diagnostic evaluation-Urinalysis- marked proteinuria, microscopic hematuria, 24-hour urine for protein (increased) and creatinine

clearance (decreased)Protein electrophoresis and immunoelectrophoresis of

the urine to categorize the proteinuriaNeedle biopsy of kidney for histologic examination of

renal tissue to confirm diagnosisSerum chemistry- decreased total protein and albumin,

normal or increased creatinine, increased triglycerides, and altered lipid profile


Complications-Complications of nephrotic syndrome include- Infection (due to a deficient immune response)Thromboembolism (especially of the renal vein)Pulmonary emboliARF(due to hypovolemia) Accelerated atherosclerosis (due to hyperlipidemia)


Management-Treatment of causative glomerular diseaseDiuretics (used cautiously) and angiotensin converting

enzyme inhibitors to control proteinuriaCorticosteroids or immunosuppressant agents to decrease

proteinuriaGeneral management of edema

Sodium and fluid restriction; liberal potassiumInfusion of salt-poor albuminDietary protein supplements

Low-saturated-fat diet


Nursing Management-Monitor daily weight, intake and output, and urine specific

gravity.Monitor CVP (if indicated), vital signs, orthostatic blood

pressure, and heart rate to detect hypovolemia.Monitor serum BUN and creatinine to assess renal function.Administer diuretics or immunosuppressants as prescribed,

and evaluate patient's response.Infuse I.V. albumin as ordered.Encourage bed rest for a few days to help mobilize edema;

however, some ambulation is necessary to reduce risk of thromboembolic complications.

DisorDers of kiDneyacute renal failure

Definition-

Acute renal failure is a sudden and almost complete loss of kidney function caused by failure of renal

circulation or by glomerular or tubular dysfunction.


Etiology-Pre – renal (hypoperfusion of kidney)Intra – renal (actual damage to the kidney tissue) Post – renal (obstruction to urine flow)


Etiology-Pre – renal Volume depetionHemorrhageRenal losesGI lossesImpaired cardiac efficiencyVasodilationsepsisAnaphylaxisAntihypertensive medications


Etiology-Intra – renal Prolonged renal ischemiaPigment nephropathyMyoglobinuriaHemoglobinuriaNephrotoxic agentsAminoglycosides agentsRadiopaque contrast agentsHeavy metalsSolvents and chemicalsNSAIDsRenal infections


Etiology-Post – renal Urinary tract obstructionsRenal calculiTumorsBPHBlood clotsStrictutres


RISK FACTORSAdvanced ageBlockages in the blood vessels in your arms or legsDiabetesHigh blood pressureHeart failureKidney diseasesLiver disease


RISK FACTORSAdvanced ageBlockages in the blood vessels in your arms or legsDiabetesHigh blood pressureHeart failureKidney diseasesLiver disease


PHASES OF ARF Initiating phaseOliguric phase Diuretic phaseRecovery phase


PHASES OF ARF Initiating phase

Begins with the initial insult and ends when oliguria developsOliguric phase

Urine output less than 400 ml/dayDiuretic phase

Urine out put become normal but nitrogenous waste products still remain elevated in blood

Recovery phase

It signifies the improvement of renal function

It takes 3-12 months to return normal


Clinical features-Vomiting and/or diarrhea, which may lead to dehydration.Nausea. Weight loss. Nocturnal urination.pale urine. Less frequent urination, or in smaller amounts than usual,

with dark coloured urineHaematuria. Pressure, or difficulty urinating. Itching.


Clinical features-Bone damage. Non-union in broken bones. Muscle cramps (caused by low levels of calcium which can

cause hypocalcaemia)Abnormal heart rhythms. Muscle paralysis.Swelling of the legs, ankles, feet, face and/or hands. Shortness of breath due to extra fluid on the lungsPain in the back or sideFeeling tired and/or weak.


Clinical features-Memory problems. Difficulty concentrating.Dizziness.Low blood pressure. AnorexiaPruritusSeizures (if blood urea nitrogen level is very high)


Diagnostic evaluation-History regarding the etiological factors and risk factors.Physical symptomsUrine out put – scanty, bloody, and low specific gravityIncreased BUN and creatinine level in blood HyperkalemiaMetabolic acidosisHyperphoshatemiaHypocalcemiaAnemia


Prevention-

Provide adequate hydration to patient at high risk for dehydration

Prevent and treat shock with blood and fluid replacement therapy

Manage hypotensionMonitor critically ill patient for central venous and

arterial pressures and hourly urine output to detect the onset of renal failure as early as possible.

Continuously assess the renal function


Prevention-

Prevent and treat infectionsCautiously administer the bloodClosely monitor the all medications that

metabolized and excreted by the kidney for dosage and blood levels for the toxic effects.

Pay special attention to wound, burns and other precursors of sepsis.


COMPLICATIONS

ARF can affect the entire body in the form of –InfectionHyperkalaemia, Hyperphosphataemia, HyponatraemiaWater overloadPericarditisPulmonary oedema.Reduced level of consciousness.Immune deficiency


Management-

To correct fluid and electrolyte balance. To correct dehydration. To Keep other body systems working properly

DisorDers of kiDneyconGenital DisorDers of Genitourinary system

Common Renal anomalies

• Abnormal number: agenesis

• Abnormal form or position: horseshoe kid.

Common ureteral & renal pelvis anomalies

• UPJ obstruction.

• Vesico-uretral reflux.

• Duplication.

• Uretrocele.

• Ectopic ureter.

DisorDers of kiDneyconGenital DisorDers of Genitourinary system

Common Bladder anomalies

• Bladder Extrophy.

Common Urethral & penile anomalies

• Hypospadias.

• Epispadias.

DisorDers of kiDneyCongenital DisorDers of

genitourinary system

Renal agenesis

Bilateral renal agenesis

• both mesonephric ducts fail to develop.

• Incompatible with life.

Unilateral renal agenesis

• the mesonephric duct fails to develop.

• Usually there is absent ureter, trigone, kidney and (in boys) vas deferens.

DisorDers of kiDneyCongenital DisorDers of genitourinary system

Horseshoe kidney

• both metanephros are fused together.

• both kidneys rotated & their lower poles are joined in the shape of a horseshoe.

• As the fetus grows, the joined kidneys are held up by the inferior or superior mesenteric arteries at L3.



Pelviureteric junction obstruction

Obstruction of the junction between the renal pelvis & ureter.

Aetiology

• aperistaltic segment of ureter due to absent muscles.

or

• crossing vessels over UPJ.



Clinical features-

may present at any time (before birth, in childhood, or in adulthood) by:

• abdominal mass.

• abdominal pain.

• Haematuria after fairly minor abdominal trauma.

Diagnostic evaluation-IVU - shows delay in appearance of contrast and dilated renal

pelvis and calices. Renal scan -shows differential renal function and confirms

obstruction.



Management-

Surgery is indicated for:

1. obstructive symptoms,

2. stone formation,

3. recurrent urinary infection,

4. progressive renal impairment.

• Pyeloplasty is the treatment of choice

• Nephrectomy is performed if the affected kidney is <10% of total renal function.



Management-

alternative techniques:

1.Antegrade endopyelotomy .

2.Laparoscopic pyeloplasty


Vesicoureteric junction reflux

• Reflux can be defined as the retrograde flow of urine into upper urinary tract.

• incidence of reflux is equal in both sexes.

• Reflux can be classified into 5 grades -



• Evaluation

•Micturating cystourethrography is the gold standard for diagnosis and evaluation of VUR grade.

•Diuretic Renal scan (DMSA) is used to visualize scarring and quantify differential renal function.



Management

•antibiotic prophylaxis is recommended for children with reflux of grades I-II.

•Surgery (uretro - vesical reimplantation or endoscopic injection) is recommended in reflux of grades III-V and persistent reflux despite a trial of antibiotics.


Duplication of urinary system

• Ureteral duplication is the most frequent anomaly of urinary tract

• Female: male = 2 : 1

• The orifice draining the upper segment is often obstructed.

• The orifice of the lower segment generally refluxes.

• Duplication is usually discovered on an IVU .

• Management is according to segment affected and its function.



Ectopic ureter

• An ectopic ureter is one that opens in some location other than the bladder.

80% associated with duplicated system.

20% associated with single system.

• Most common sites (in female): urethra, vestibule, and vagina

• In female present as urinary incontinence.

• Most common sites (in male): posterior urethra and seminal vesicles.



Uretrocele

• A congenital cystic ballooning of the terminal submucosal ureter.

• It is classified as simple or ectopic.

• Simple ( Orthotopic ) Ureterocele : in trigone.

•Ectopic Ureterocele : can obstruct bladder neck or even prolapse from female urethra.


Hypospadias

• It is a condition in which the opening of the urethra is on the underside of the penis, instead of at the tip.

• congenital condition results in underdevelopment of urethra.

• affects 3 per 1000 male infants.

• Consists of 3 anomalies:

( 1 ) Abnormal ventral opening of the urethral meatus.

( 2 ) Ventral curvature of the penis ( chordee ).

( 3 ) Deficient prepuce ventrally


Hypospadias

• Site Of the meatus


Hypospadias

Treatment • The child should be referred for urological assessment and surgical treatment. • The ideal age for surgery is 6–12 months.


Epispadias

• Congenital condition in which the urethra opens on dorsal surface of penis..

• Usually associated with bladder extrophy (ectopia vesicae).


Bladder Extrophy (Ectopia vesicae)

• Failure of development of the lower abdominal wall.

• Anomaly include defect in anterior abdominal wall, defect in anterior bladder wall and epispadias (dorsal penile opening).

DisorDers of kiDneyCanCer of kiDney

Incidence-Cancer of the kidney accounts for about 3.7% of all cancers

in adults. It affects almost twice as many men as women. The most common type of renal tumor is renal cell or renal

adenocarcinoma, accounting for more than 85% of all kidney tumors.

These tumors may metastasize early to the lungs, bone, liver, brain, and contralateral kidney.

The incidence of all stages of kidney cancer has increased in last two decades.


Risk factors-Gender: Affects men more than women Tobacco use Occupational exposure to industrial chemicals, such as petroleum products,

heavy metals, and asbestos Obesity Unopposed estrogen therapy Polycystic kidney diseaseregular use of NSAIDs such as ibuprofen and naproxen, faulty genes; a family history of kidney cancer; having kidney disease that needs dialysis; being infected with hepatitis C; previous treatment for testicular cancer or cervical cancer.


Types-Most ocuuring renal cancer are renal cell carcinoma and renal pelvis

carcinoma, other, less common types of kidney cancer include:Squamous cell carcinomaJuxtaglomerular cell tumors (reninoma)angiomyolipomaRenal ancocytomaBellini duct carcinomaClear cell sarcoma of the kidneyMesoblastic nephromaWilm’s tumor, usually is reported in children under the age of 5.Mixed epithilial stromal cell tumors


Clinical features-Many renal tumors produce no symptoms and are discovered on a

routine physical examination as a palpable abdominal mass. The classic triad of signs and symptoms, comprises hematuria, pain,

and a mass in the flank. The usual sign that first calls attention to the tumor is painless

hematuria, which may be either intermittent and microscopic or continuous and gross.

There may be a dull pain in the back from the pressure produced by compression of the ureter, extension of the tumor into the perirenal area, or hemorrhage into the kidney tissue.

Colicky pains occur if a clot or mass of tumor cells passes down the ureter.

weight loss, increasing weakness, and anemia.


Assessment and Diagnostic Findings-

The diagnosis of a renal tumor may require intravenous urography, cystoscopic examination, nephrotomograms, renal angiograms, ultrasonography, CT scan.


Management-

Goal-

The goal of management is to eradicate the tumor before metastasis occurs.


Management-

Surgical management-A radical nephrectomy is the preferred treatment if the

tumor can be removed. This includes removal of the kidney (and tumor), adrenal gland, surrounding perinephric fat and Gerota’s fascia, and lymph nodes.

Radiation therapy, hormonal therapy, or chemotherapy may be used along with surgery.

ImmunotherapyNephron-sparing surgery


Management-

pharmacological management-use of biologic response modifiers such as interleukin-2 (IL-

2) and topical instillation of bacillus Calmette-Guerin (BCG) Patients may be treated with IL-2, a protein that regulates

cell growth. This may be used alone or in combination with lymphokine-activated killer cells

Interferon, another biologic response modifier, appears to have a direct antiproliferative effect on renal tumors.


Management-

Renal Artery Embolization-In patients with metastatic renal carcinoma, the renal artery

may be occluded to impede the blood supply to the tumor and thus kill the tumor cells.

DisorDers of kiDneyCanCer of blaDDer

Cancer of the urinary bladder is more common in people aged 50 to 70 years.

It affects men more than women (3:1) There are two forms of bladder cancer: superficial (which

tends to recur) and invasive. About 80% to 90% of all bladder cancers are transitional cell (which means they arise from the transitional cells of the bladder);

the remaining types of tumors are squamous cell and adenocarcinoma.


Risk factors- Cigarette smoking: risk proportional to number of packs

smoked daily and number of years of smoking Environmental carcinogens: dyes, rubber, leather, ink, or

paint Recurrent or chronic bacterial infection of the urinary tract Bladder stones High urinary pH High cholesterol intake Pelvic radiation therapy Cancers arising from the prostate, colon, and rectum in

males


Clinical ManifestationsBladder tumors usually arise at the base of the bladder and

involve the ureteral orifices and bladder neck. Visible, painless hematuria is the most common symptom of

bladder cancer. Infection of the urinary tract is a common complication,

producing frequency, urgency, and dysuria. Any alteration in voiding or change in the urine, however,

may indicate cancer of the bladder. Pelvic or back pain may occur with metastasis.


Assessment and Diagnostic Findings

The diagnostic evaluation includes –cystoscopy (the mainstay of diagnosis), excretory urography, a CT scan, ultrasonography, bimanual examination with the patient anesthetized. Biopsies of the tumor and adjacent mucosa


Management- surgical Transurethral resection or fulguration (cauterization) may be per-

formed for simple papillomas (benign epithelial tumors). eradicate the tumors through surgical incision or electrical current with the use of instruments inserted through the urethra.

After this bladder-sparing surgery, intravesical administration of BCG is the treatment of choice.

A simple cystectomy (removal of the bladder) or a radical cystectomy is performed for invasive or multifocal bladder cancer.

Radical cystectomy in men involves removal of the bladder, prostate, and seminal vesicles and immediate adjacent perivesical tissues.


Management- pharmacologicalChemotherapy with a combination of methotrexate, 5-fluorouracil,

vinblastine, doxorubicin (Adriamycin), and cisplatin Intravenous chemotherapy may be accompanied by radiation therapy. Topical chemotherapy (intravesical chemotherapy or instillation of

antineoplastic agents into the bladder, resulting in contact of the agent with the bladder wall) is considered when there is a high risk for recurrence, when cancer in situ is present, or when tumor resection has been incomplete.

Topical chemotherapy de- livers a high concentration of medication (doxorubicin, mitomycin, ethoglucid, and BCG) to the tumor to promote tumor destruction.

BCG is now considered the most effective intravesical agent for recurrent bladder cancer because it enhances the body’s immune response to cancer.


Management- radiation therapyRadiation of the tumor may be performed preoperatively to reduce

microextension of the neoplasm and viability of tumor cells,

DisorDers of kiDneyCanCer of ureter

Ureteral cancer is usually transitional cell carcinoma. Transitional cell carcinoma is "a common cause of ureter

cancer and other urinary (renal pelvic) tract cancers.“Cancer of the ureter begins in the cells that line the inside of

the tubes (ureters) that connect your kidneys to your bladder.Cancer of the ureter is uncommon. It occurs most often in older adults and in people who have

previously been treated for bladder cancer.Men>womenWhitish>black


Risk factors-Increased ageTreatment of bladder cancerTobacco smokingAnalgesics nephropathyIndustrial exposures


Clinical features-Symptoms of ureteral cancer may include –blood in the urine (hematuria); diminished urine stream and straining to void (caused by urethral stricture);

frequent urination and increased nighttime urination (nocturia); hardening of tissue in the perineum, labia, or penis; itching;incontinence; pain during or after sexual intercourse (dyspareunia); painful urination (dysuria); recurrent urinary tract infection; urethral discharge and swelling.


Diagnostic evaluation-Diagnosis may include- computed tomography urography (CTU), magnetic resonance urography(MRU), intravenous pyelography (IVP) x-ray, Ureteroscopy biopsy


Management-Treatment methods include -surgery Chemotherapy radiation therapy medication.

DisorDers of kiDneyCanCer of urethra

Urethral cancer is cancer originating from the urethra. Cancer in this location is rare, and the most common type is papillary transitional cell carcinoma

Having a history of bladder cancerHaving conditions that cause chronic, swollen, reddened part in the urethra.

Being 60 or older.Being a white female.


Clinical features-Bleeding from the urethra or blood in the urine.Weak or interrupted flow of urine.Urination occurs often.A lump or thickness in the perineum or penis.Discharge from the urethra.Enlarged lymph nodes in the groin area.Most common site being bulbomembranous urethra


Diagnostic evaluation-Diagnosis is established by transurethral biopsyTypes-transitional cell carcinoma squamous cell carcinoma adenocarcinoma melanoma


Management-Surgery-Open excision surgery.Electro-resection with flash surgery.Laser surgeryCystourethrectomy surgery.Cystoprostatectomy surgery.Anterior body cavity surgery.Incomplete or basic penectomy surgery.


Management-chemotherapy-Chemotherapy involves using drugs to destroy urethral cancer cells.

It is a systemic urethral cancer treatment (i.e., destroys urethral cancer cells throughout the body) that is administered orally or intravenously (through a vein; IV).

Medications are often used in combination to destroy urethral cancer that has metastasized.

Commonly used drugs include vincristine, cisplatin and methotrexate

Date post:	21-Jan-2018
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