Care of the Client with Urinary Dysfunction
June 28, 2002
Objectives:
•	Following this presentation, the participant will be able to discuss nursing management of patients with:
•	UTI
•	urinary stones
•	urinary and fecal incontinence
•	bladder CA

•	TURP
•	urinary retention
•	cystocyle/rectocele
Review of A&P
•	The urinary tract includes the kidneys, ureters, urethra and bladder
•	bladder is the reservoir for urine
•	the unidirectional nature of the peristaltic waves (occurring about one to 5 minutes per minute) from contraction of smooth muscle in ureter wall moves urine from kidney to bladder

•	Overdistension of bladder can lead to reflux of urine back into the kidney
•	causing pyelonephritis and hydronephritis (elevated pressure)
•	Bladder pressure is normally low
•	sensation felt about 100 to 150 ml in bladder
•	desire to void 200 to 300 ml
•	extreme desire at 400 ml
Voiding
•	Controlled by muscles and nerves
•	voluntary control is learned
•	micturition (voiding) occurs when external urethral sphincter is relaxed, the detrusor muscle in bladder contracts (under control of parasympathetic nervous system), urine is then expelled from bladder through urethra
Spinal pathways
•	If pelvic nerves to bladder and sphincter are destroyed impaired, voluntary control and reflex urination (from detrusor muscle) are abolished = overdistention
•	If spinal pathways from brain to reflex urination are impaired, reflex contraction is maintained but voluntary control is lost = residual urine > 50 mls.
Problems with urinary system
•	Assessment
•	changes in voiding - frequency, urgency, dysuria, hesitancy, nocturia, incontinence, enuresis, polyuria, oliguria, anuria, hematuria, proteinuria, microalbuminuria (page 1091)
•	pain
•	bladder palpation for distention 

Urinary tract infection (cystitis)
•	The urinary tract is sterile above the urethra
•	Lower UTIs include cystitis, prostatitis, urethritis
•	Classified as complicated or uncomplicated
•	bacteriuria - clean catch midstream urine > 105 colonies/ml

Common organisms
•	E. coli (account for 80 - 90% of uncomplicated cases)
•	Staphylococcus (10 to 15%)
•	Others: Proteus mirabilis, Pseudomonas aeruginosa, Klebsiella and Entrobacter species
•	Most common route of infection: transurethral
S & S - Uncomplicated
•	1/2 of infections are silent
•	frequent pain and burning on urination
•	frequency
•	urgency
•	nocturia 
•	incontinence
•	suprapubic, pelvic or back pain
•	hematuria( > 4 RBCs)
S & S - Complicated
•	Patients with indwelling catheters, trauma to bladder mucosa:
•	all of S & S of uncomplicated plus:
•	gram-negative sepsis
•	shock

•	In elderly, individuals may also become disoriented, loss of appetite (lack typical symptoms of UTI)
Testing for UTI
•	Urine cultures
•	Dipstick (WBCs) - pyuria
•	Tests for STDs
•	IVP
Elderly
•	More susceptible to UTIs
•	incomplete emptying - stasis of urine
•	absence of estrogen in women
•	antibacterial activity of prostatic secretions decreases in men
•	catheterization
•	incomplete emptying of bladder: ignore signals, bed-bound, incontinence
Medical Management
•	Drug therapy for symptoms
•	institutionalized and complicated: 7 to 10 days of therapy
•	uncomplicated: short course therapy (three days)

•	Common drugs:  Bactrim, Septra DS, Macrodantin, Pyridium

Nursing Management and Prevention
•	Meticulous handwashing when caring for chronically-ill
•	Meticulous catheter care for those with indwelling catheters
•	Meticulous skin care, hygiene, and prompt removal of soiled incontinence products (pads, undergarments, etc.) 

•	Hydration - 8 to 10 oz. of fluids per day
•	avoid coffee, tea, alcohol - urinary irritants
•	Relieve pain/discomfort/bladder irritability - heat to lower abdomen, antispasmodic agents, voiding every 2 to 3 hours
•	Patient education - take all medication even when symptoms subside; wear cotton underwear

Prevention
•	Shower vs. bath
•	Avoid powders in perineum
•	Clean from front to back
•	Drink liberal amount of fluids - 3000 cc per day of “mixed” fluids
•	Void every 2 to 3 hours
•	after intercourse
Prevention
•	For recurrent UTIs:
•	long-term therapy
•	self testing for bacteria
•	acidify urine (Vitamin C: 500 mg BID; cranberry juice)
•	notify primary care provider if symptoms persist

Case
•	You are caring for a 56 year old woman who was admitted for a DVT. She reports that she is experiencing burning upon urination.  You report this to her physician and obtain an order for a C & S.  When she hands you the urine, you notice several indications that she may have a UTI.  Discuss signs of UTI.
Urinary retention
•	The inability to empty the bladder completely during attempts to void
•	leads to overflow incontinence
•	leads to residual urine and potential for infection due to stasis of urine in the bladder
•	Causes:
•	general anesthesia
•	surgery of perineal or anal regions
Causes
•	Certain diseases/disorders:
•	diabetes, prostatic enlargement, infection, tumor, calculus, trauma, pregnancy, neurologic disorders (CVA, spinal cord injury, MS)
•	Medications: anticholinergics, tricyclic antidepressants, estrogens
S & S of urinary retention
•	passing small amounts of urine frequently
•	dribbling
•	pain or discomfort in lower abdomen
•	rounded swelling arising out of pelvis (distention)
•	dullness percussed over suprapubic region
•	restlessness/agitation
Nursing Management
•	Prevent complications such as infection, calculi, pyelonephritis, sepsis, deterioration of kidney, skin breakdown due to leakage of urine
•	monitor I & O
•	inspect color of urine
•	encourage voiding (privacy, sitting upright, standing)

•	Apply warmth to relax sphincters
•	use trigger techniques: turn on water while trying to void, dip patients’ hands in water, pour warm water over perineum
•	administer analgesics as prescribed
Catheterization
•	Indwelling vs. in & out (intermittent)
•	Suprapubic
•	Obtain specimens
Case
•	A male MVA patient comes into the clinic one week post discharge from rehab.  He had his indwelling catheter removed by a home health nurse yesterday.  The HHN reported that the patient’s 12 hours output was 120 cc.  The NP orders straight cath and to teach patient the technique. What are the nursing priorities?  
Urinary incontinence
•	Involuntary or uncontrolled loss of urine from the bladder
•	affects people of all ages, mostly elderly
•	it is a symptom!, not a disease
Types
•	Stress:  involuntary loss of urine through an intact urethra due to sudden increase in intra-abdominal pressure (sneezing, coughing, or changing positions)
•	causes: detrusor dysfunction, obstetric injury (childbirth)
Urge incontinence
•	Involuntary loss of urine associated with urgency - need to void by unable to reach the toilet in time and “get wet”
•	caused by: uninhibited bladder contractions from neurologic dysfunction that impairs inhibition of bladder contraction, patient with infection or tumors
Reflex incontinence
•	Loss of urine due to hyperreflexia or involuntary urethral relaxation in the absence of normal sensations
•	paraplegic without sensory awareness of the need to void
Overflow incontinence
•	Involuntary urine loss associated with overdistention of the bladder; the bladder cannot empty normally despite frequent urine loss
•	caused by neurologic abnormalities (spinal cord injuries), medications, tumors, structures, prostatic hyperplasia - these obstruct outflow
Functional incontinence
•	Instances in which the function of the lower urinary tract is intact but in which other factors, such as cognitive impairment make it difficult for the patient to identify the need to void
•	physical limitations with arthritis hands to remove clothing, etc.
Mixed incontinence
•	Usually a combination of stress and urge incontinence

•	All people with incontinence should be considered for evaluation and treatment; it is not a normal age change; goal is to reduce the incontinence episodes
Causes of transient incontinence
•	DIAPPERS
•	delirium
•	infection of urinary tract
•	atrophic vaginitis, urethritis
•	pharmacologic agents
•	psychologic factors
•	excessive urine production (diabetes)
•	restricted activity
•	stool impaction
The work-up
•	Diagnostic evaluation
•	urinalysis: color, clarity, odor, pH, specific gravity, protein, glucose, ketones, microscopic evaluation for red blood cells, white blood cells, casts, crystals, pus, bacteria
•	culture and sensitivity
Urodynamics
•	Noninvasive procedures
•	Bladder ultrasonography - ultrasound of bladder to display bladder volume - indicated for urinary frequency, inability to void after catheter removal or post-op, measurement of postvoiding residual urine volume 
•	CT and MRIs - used to view masses, urolithiasis, urinary tract trauma, CA, soft tissue abnormalities
Invasive bladder studies
•	Cystography - catheter inserted into bladder, contrast agent instilled to outline bladder wall, X-ray taken - used to evaluate vesicoureteral reflux (backflow of urine from bladder into one or both ureters) and bladder injury
Voiding cystourethrography
•	Used to visualize the lower urinary tract and examine urine storage and blackflow - instill contract medium, remove catheter when urge to void, patient voids and flouroscopy is used to visualize backflow and emptying
Nursing management
•	Prepare for anaphylactic reaction if contract agent is used (establish . . . . .)
•	Obtain allergy history with emphasis on iodine, shellfish, or other seafood which contains iodine
•	ascertain previous allergic reaction during tests using dyes

•	Instruct patient about a temporary feeling of warmth, face flushing, unusual taste (seafood) when contract agent is infused
•	Precautions should be taken in those with chronic illnesses such as diabetes, renal insufficiency, volume depletion, elderly
Urologic endoscopic procedures
•	Cystoscopic exam (cysto): cystoscope inserts through urethra into bladder, optical lens provides illuminated view of bladder, urethra, ureters and pelvis of kidneys
•	calculi can be removed, urine specimens from bladder and kidney obtained, biopsies taken
Nursing management
•	Prepare patient for the procedure:
•	describe procedure (spinal or general anesthesia may be used)
•	keep patient NPO
•	explain that there may be post-op discomfort, burning, blood in urine, frequency
•	Post-procedure:
•	I & O (observe for urinary retention)

•	Warm sitz baths, analgesics, fluids
Urodynamic tests
•	Used to evaluate voiding problems
•	urinary retention of unknown causes, neuropathic bladder dysfunction, incontinence, bladder outlet obstruction, recurrent urinary tract infections
Most common
•	Uroflowmetry (record the volume of urine passing through the urethra per time unit)
•	Cystometrogram (recording of pressures in bladder) - two portions: filling and emptying of the bladder
•	fluid instilled into bladder, the patient’s sensations of bladder fullness and urge to void, the degree of straining or hesitancy, and the amount, size, and force of stream are recorded
Types of tests
•	Video flourodynamic study (optimal) - combines a study of filling and voiding phases with simultaneous visualization of the lower urinary tract
•	Others: urethral pressure profile (amount of urethral pressure), Valsalva’s leak-point pressure test (assesses internal sphincter function)
Nursing Management
•	Patient preparation:
•	inform patient: in-depth interview, will be asked to describe sensations during procedures, change positions, cough, bear down, might have catheters in rectum or vagina to measure pressures, bladder will be filled, feel pressure, may experience hematuria, have irritated urinary meatus, take an antibiotic before procedure
Potential nursing diagnoses
•	Knowledge deficit related to procedure and diagnostic tests
•	Pain related to invasive diagnostic procedures, infection, edema, obstruction
•	Fear related to possible diagnosis of serious illness, altered bladder function, and embarrassment secondary to discussion of urinary function and invasion of genitalia
Review
•	Read page 1099 for overview of care of patient undergoing diagnostic testing
Nursing management of the incontinent patient
•	Ambulatory incontinent individual
•	review DIAPPERS
•	bladder retraining/biofeedback/behavioral
•	drugs (estrogen - decreases obstruction to urine flow by restoring the mucosal, vascular, and muscular integrity of the urethra)
•	collagen injections-periurethral bulking agent
•	surgical - anterior vaginal repair, needle suspension

•	Sling procedures
•	artificial sphincters
•	electronic stimulation through intra-anal plug
•	transurethral resection for prostatic enlargement
•	exercises (Kegel) - described in Chap 43
Patient education
•	Diary of amount of fluid, timing of voiding, amount of voiding
•	avoid diuretics after 4 pm
•	avoid bladder irritants (NutraSweet, caffeine, alcohol)
•	avoid constipation
•	stop smoking
•	pelvic floor muscle exercises
Bed-bound patients
•	Keep patient dry
•	use moisture barriers on perineum
•	meticulous perineal care
•	take patient to bathroom at regularly scheduled intervals
•	encourage fluids
Question????
•	What is one of the most important nursing considerations for elderly clients with urinary tract problems??

Neurogenic bladder
•	Dysfunction that results from a lesion of the nervous system
•	spinal cord injury
•	spinal tumor
•	herniated vertebral disk
•	multiple sclerosis
•	spina bifida
•	infection, diabetes (sensory, motor, ANS)
Types
•	Spastic or reflex (most common)
•	any lesion above the voiding reflex arc (upper motor neuron lesion) - loss of conscious sensation and motor control - bladder empties on reflex 
•	flaccid- lower motor neuron lesion from trauma (seen in patients with diabetes) - distention without detrusor contraction - leakage of urine without awareness
Neurogenic bladder
•	Assessment - I & O, residual urine, UA, evaluation of sensory awareness
•	Complications - infection from stasis
•	urolithiasis (stones in urinary tract) from stasis, infection, and demineralization of bone from prolonged immobilization
•	renal failure from backflow (reflux)
•	hydronephrosis (collection of urine in renal pelvis) and kidney atrophy
Nursing care
•	Objectives:  prevent overdistention
•	empty bladder at regular intervals
•	maintain urine sterility w/o stone formation
•	maintain adequate bladder capacity

•	Interventions: catheterization (external and internal)
•	low calcium

•	Encourage mobilization
•	liberal fluid intake
•	timed or habit voiding
•	bladder retraining
•	proper medications
•	surgical procedures: continent pouches, urinary diversions
Care of patient with catheter
•	How would you assess for infection?
•	What are important considerations for a closed drainage system?
•	How frequently should catheter care be performed?
•	What are special considerations for the patient with a suprapubic catheter?

Other urinary problems

•	Urolithiasis - stones (calculi) in the urinary tract (75% of all stones are calcium based, fewer are from uric acid or oxalate)
•	in the lower urinary tract, stones can lodge in the ureter - cause excrutiating pain, patient has urge to void but little urine is passed, if it is, it can be bloody - most can be passed if less than 1 cm in diameter
Nursing management
•	Pain - use NSAIDs, warm baths, heating pads
•	Encourage fluids - reduces concentration of urinary crystals, dilutes urine, ensures high urine output (encourage >2 L per day)
•	Nutrition - may restrict protein and sodium and oxalate-containing foods (peanuts, wheat bran, tea, spinach)
Care of patient after stone retrieval procedures
•	Endoscopic - ureteroscopy, scope, laser, electrohydraulic lithotriptor, or ultrasound device - stent for 48 hours to keep ureter patent
•	ESWL - shock waves to kidney
•	percutaneous nephrostomy or nephrolithotomy 
•	chemolysis

•	Surgery is rarely performed
•	for bladder, cystolithalopaxy - insert scope, crush stone

•	Your patient just returned after a cysto for which a stone was removed.  What is your primary consideration?
Cancer of the bladder
•	Two types: superficial (tends to recur) and invasive (most types are transitional cells) the rest are squamous and adenocarcinoma
•	major cause is cigarette smoking
•	metastasis from colon, rectum, prostrate and lower gynecologic tract

•	Primary symptom: hematuria (painless)
•	infection produces frequency, urgency, dysuria
•	alteration in voiding patterns
•	change in color of urine
•	pelvic or back pain with mets
Treatment
•	Depends on grade of tumor, state of growth, multicentricity, age, physical, mental and emotional status
•	surgical management of superficial - transurethral resection or fulguration (cauterize)
•	for invasive, simple cystectomy (removal of bladder) or radical (more structures removed)
Bladder removal
•	Cystectomy
•	Requires urinary diversion (page 1173)
•	ileal conduit
•	cutaneous ureterostomy
•	vesicostomy
•	nephrostomy
Radiation
•	May be performed pre-operatively
•	used in combination with surgery or to control the disease when Ca is inoperable

•	Chemotherapy
•	can be infused systemically
•	directly into the bladder (intravesical)
Nursing Management
•	I & O - >30 ml/hour
•	if a stoma present, inspect for viability, color, bleeding, infection, encrustation, leakage of urinary collection device (appliance), odor of urine (there may be mucous mixed with urine)
•	promote fluid intake
•	teach patients self-care
Self care
•	How to change appliance
•	controlling odor
•	how to empty appliance
•	clean the appliance
•	stoma care
•	nutrition/hydration
•	reporting problems
Continent urinary diversions
•	Types:  Indiana, Charleston, Koch pouch (must be drained by catheter at regular intervals), ureterosigmoidostomy (see page 1174)
•	monitor fluid and electrolytes
•	retrain the anal sphincter if ureterosigmoidostomy
•	avoid gas-forming foods
•	monitor for pyelonephritis

Nurse role
•	Pre-op teaching
•	address anxiety
•	explain surgery and aftermath
•	consult with ostomy nurse
•	explain nutrition/hydration needs
•	Post-op 
•	maintain peristomal skin integrity
Post-op
•	Relieve pain - PCA
•	address body image issues
•	sexuality
•	monitor for potential complications
•	peritonitis, stoma necrosis and ischemia, stoma retraction and separation, anemia
Benign Prostatic Hyperplasia 
•	BPH - enlarged prostrate (hypertrophy)
•	assessment reveals a large, rubber, and non-tender upon DRE (digital rectal examination)
•	symptoms - increased frequency of urination, nocturia, urgency, hesitancy in starting urination, straining, interruption of stream, dribbling after urination, sensation of having to urinate (may have urinary retention of >60 ml), recurrent UTIs
Treatment
•	Watchful Waiting!!
•	Drug therapy, lasers, needle ablation, heat
•	Transurethral resection - TURP - most common procedure - remove prostrate tissue at the bladder neck through instruments introduced directly through the urethra to the prostrate
TURP
•	Goal:  observe for hemorrhage and maintain patency of the catheter and infusion
•	retention catheter
•	continuous bladder irrigation
•	measure output hourly and deduct amount of instillate from total output
•	teach patient to report decreased output to urologist
Nursing care
•	Monitor for bleeding
•	observe for symptoms of urethral stricture (dysuria, straining, weak urinary stream)
Cystocele/rectocele
•	Cystocele - downward displacement of the bladder toward the vaginal orifice resulting from injury, childbirth - usually appears later in life
•	Rectocele - rectum “pouches” upward, pushing the posterior wall of the vagina forward
•	Prolapse of uterus
S & S
•	Patient may report sense of pelvic or rectal pressure, urinary incontinence, frequency, urgency, back and pelvic pain, constipation, uncontrollable gas, fecal incontinence
Medical/surgical management
•	Kegel exercises
•	pessary (ring-shaped or doughnut-shaped device inserted into the vagina to keep the “organ” in place (see page 1238)
•	if surgical repair, post-op, check voiding, may have catheter, perineal care, may have sterile douches, ice packs to perineum, laxatives
Prostate cancer
•	Check PSA (prostate specific antigen)
•	serum acid phosphatase level
•	DRE
•	ultrasound
•	needle biopsies
•	bone scans to detect metastasis
Treatment/management
•	Treatment affects sexual functioning
•	Treatment based on age and state of disease
•	Surgical management via radical prostatectomy - causes impotence
•	Radiation if caught early
•	Hormonal therapy

•	Hormone therapy with DES - diethylstilberstrol suppresses all androgen stimuli to prostate causing prostatic epithelium atrophy - side effects are “feminizing tendencies such as breast tenderness, smooth skin
•	Orchiectomy - removal of testes which lower testosterone levels resulting in prostatic atrophy
•	Cryosurgery of prostate
•	Chemotherapy
Complications post-op
•	Hemorrhage
•	infection
•	DVT 
•	obstructed catheter
•	Patient ed: measures to control pain, care of catheter, wound care, perineal exercises, avoid lifting heavy objects
Study
•	In the study guide accompanying the text
•	#’s: 2, 3, 4, 5, 6, 7, 8, 9

•	In Mosby
•	#’s: 526, 527, 528, 529, 532, 539, 540, 541, 542, 543, 558, 559, 560, 561, 562, 563, 564