GENITOURINARY
SYSTEM
Michelle Gardner
NUR-224
URINARY SYSTEM
ASSESSMENT OF THE
URINARY SYSTEM
Subjective Data
a. Good communication skills
b. Avoid medical terminology
c. Anxiety/embarrassment –
“forget/deny”--
ASSESSMENT DATA
Past Health History
a. Presence/history of diseases r/t
urologic problems – DM, HTN
b. Neurologic conditions – back
injury, stroke, trauma
c. Urinary problems – BPH, renal
calculi, cancer, infection
ASSESSMENT DATA
Medications
a.
b.
c.
d.
Prescription / OTC / Herbs
Nephrotoxic medications -- antibiotics
Quantity & character of urine output –
diuretic, anticholinergic, antihistamine
Change in color – Pyridium, Macrodantin
ASSESSMENT DATA
Surgery
a. Previous hospitalizations r/t
urologic disease
b. Pelvic surgeries
c. Urinary instrumentation
d. Urinary problems during past
pregnancies
e. Radiation/chemotherapy
ASSESSMENT DATA



Pain
Changes in voiding
Affects of aging on the urinary
system
a. Decrease muscle tone
b. Decrease bladder capacity
c. Prostate enlargement
d. Changes in metabolism
BLOOD CHEMISTRIES
Blood Chemistries
 Serum Creatinine: 0.6 – 1.2mg/dl
o End product of muscle & protein
metabolism
o Excellent indicator of kidney function
o Renal disease results in increase
creatinine
BLOOD CHEMISTRIES

o
o
BUN/Blood Urea Nitrogen: 7-18mg/dl
Used to identify renal problems
Nonrenal factors may increase BUN
a. Fever
b. Dehydration
c. High protein diet
d. Athletic activity
e. Drugs and vitamins (acetaminophen,
ibuprofen, vitamin D)
DIAGNOSTIC STUDIES

o
o
KUB (kidneys, ureters, bladder)
X- ray exam of abdomen & pelvis
Used to detect abnormalities
o
o
o
o
Urinary calculi
Cysts
Tumors
Hydronephrosis
DIAGNOSTIC STUDIES

o
o
IVP (INTRAVENOUS PYLEOGRAM)
Urography
Intravenous injection of radiopaque
imaging dye
X-ray imaging of dye through upper
and lower urinary system
INTRAVENOUS
UROGRAPHY
INTRAVENOUS
UROGRAPHY

o
o
o
o
o
o
Patient preparation:
Consent form
Cathartic/enema the night before
Identify allergies – shellfish,
iodine
Pre-medicate–antihistamine
(Benadryl)
NPO 8 hr. before procedure
Transitory effects – contrast medium
INTRAVENOUS
UROGRAPHY

o
o
o
o
Post-procedure
Monitor vital signs
Assess for s/s anaphylactic reactions
Monitor urine output
Force fluids
RENAL ANGIOGRAPHY

o
o
o

1.
2.
3.
RENAL ANGIOGRAM:
Catheter inserted into femoral artery
Contrast material injected through the
catheter
Visualize renal blood vessels
Findings :
Renal artery stenosis
Differentiate renal cysts from tumors
Evaluate hypertension
RENAL ANGIOGRAPHY

o
o
o
o
Patient preparation
Consent form
Cathartic/enema the evening before
Assess allergic reaction
Mark peripheral pulses
RENAL ANGIOGRAPHY

o
o
o
o
o
Post-Procedure
Monitor vital signs
Pressure dressing over insertion site
Assess insertion site Bedrest with affected leg straight
Palpate peripheral pulses
RENAL BIOPSY

o
o
Done as a needle biopsy with needle
insertion into lower lobe of the
kidney OR open biopsy via small
flank incision
Obtain renal tissue to determine
type of renal disease
Kidneys are vascular organs –
hemorrhage/complication
RENAL BIOPSY
Patient preparation
o Consent form signed
o NPO status 8 hrs. prior to test
o Assess baseline coagulation status
o Medications that may alter clotting
function
RENAL BIOPSY
RENAL BIOPSY
Post-Procedure
o Pressure dressing applied
o Check puncture site –
swelling/tenderness
o Prone position for 30-60 minutes
o Monitor vital signs
o Observe for gross bleeding
o Assess for flank pain, Hgb./Hct. levels
o Avoid lifting heavy object/strenuous
activity – 7 days
UROLOGIC ENDOSCOPIC
PROCEDURES
o
o
a.
b.
c.
d.
Visualize/inspect the interior of the
urethra and bladder with a tubular
lighted scope (cystoscope)
Used to:
Treat bleeding lesions
Insert ureteral catheters
Remove calculi
Obtain biopsy specimens
CYSTOSCOPY

o
o
o
o
Patient preparation
Signed consent form
NPO prior to the procedure
Local topical anesthetic
Lithotomy position – leg cramps
CYSTOSCOPY

o
o
o
o
Post-procedure
Expected side effects - burning on
urination, blood-tinged urine,
urinary frequency
Encourage increased fluids
Warm sitz bath
Mild analgesics
RENAL CALCULI
UROLITHIASIS/
NEPHROLITHIASIS





500,000 people in the U.S. have kidney
stone disease
Incidence is highest in Southern &
Midwest states.
Occurs between the 3rd-5th decade of life.
Recurrence of stones – 50% of pts.
More common in men than in women
RENAL CALCULI
Risk Factors





Family history of stone formation
Dehydration  increase urine
concentrations
Excess dietary intake of calcium, oxalate,
or proteins
Sedentary lifestyle/immobility
Genetic predisposition
RENAL CALCULI
o
o
o
Stones can be found anywhere from
kidney to bladder
Vary in size
Factors that contribute to urolithiasis
* supersaturation
* nucleation
RENAL CALCULI
Pathophysiology
 Concentration of an insoluble salt is
high in the urine supersaturation
 Crystals form from supersaturated
urine
 Growth continues by aggregation to
form larger particles – stone
formation
RENAL CALCULI
RENAL CALCULI

1.
2.
3.
4.
4 Major Categories of Stones
Calcium
Oxalate
Uric acid
Cystine
Calcium Calculi




High concentration
of calcium in the
blood/urine
70-80% of kidney
stones are calcium
stones
Smaller stones
maybe trapped in
the ureter
Seen more in men
Calcium Calculi (Oxalate)
Risk factors
 Hypercalciuria/hypercalcemia,
immobility, vit.D, urine intoxication,
dehydration
Management
 Thiazide diuretics
 Limit foods that acidify urine
 Hydration/exercise
Uric Acid Stones
Uric Acid Calculi
Urine
concentration of
uric acid is high
o Common in men
Causes:
1. Gout
2. Increased dietary
intake of purine
3. Acid urine
o
1.
2.
3.
Reduce dietary
purines–
sardines,
mussels, organ
meats, aged
cheese
Administer
allopurinol
(Zyloprim)
Reduce urinary
concentration of
uric acid
Struvite Calculi
Struvite Calculi
(Staghorn)
15-20 % of stones magnesium/ammonium/phosphate
Risk Factors
 UTIs, esp Proteus infections
 Stones are large fill renal pelvis
Management
 Antibiotics
 Surgical intervention/lithotripsy

Cystine Calculi
o
o
o
o
o
Make up 1-2% of
all stones
Caused by genetic
defect
Tend to form in
acid urine
Stones appear
during childhood /
adolescence
Rare in adults
o
o
Increase hydration
Low-protein diet
RENAL CALCULI

o
o
o
o
o
Clinical Manifestations:
Severe flank pain / renal colic
Abdominal pain
Hematuria
Oliguria/anuria
Nausea /Vomiting/Diarrhea
RENAL CALCULI
Diagnostic Studies:
o Urinalysis
o 24 hr urinary measurement for calcium,
uric acid
o X-ray - KUB
o Renal Ultrasonography
o CT Scan
RENAL CALCULI
Management
Pain management
o Opiod analgesics – Morphine
o NSAID
Toradal
o Comfort measures
o Increase fluid intake (oral/intravenous)
RENAL CALCULI
Stones may pass spontaneously
 Stones larger than 4mm are unlikely
to pass through the ureter
 Chemical analysis of the stone to
determine the composition of the
stone
 STRAIN ALL URINE

RENAL CALCULI


o
o
o
o
o
o
o
THERAPUETIC INTERVENTIONS
ESWL-Extracorporeal shock-wave
lithotripsy
Non-invasive procedure
External shock-waves break up the stone
No damage to surrounding tissue
Stones are fragmented into fine sand
Fragments are excreted in the urine
All urine is strained -- chemical analysis
Anesthesia is necessary
RENAL CALCULI
o
o
o
o
o
Cystoscopy passed – removes stones
located in the ureter close to the bladder
Stone removed -- grasping basket,
forceps
Stent may be placed
Foley catheter -- facilitate passage stone
fragments
Minimal complications
RENAL CALCULI
After episode of urolithiasis
a. Increase fluid intake – 3000ml/day
b. High urine output – 2L/day
c. Water is the preferred fluid
d. Avoid tea, coffee, colas
e. Limit foods high in oxalate,
calcium, & purines
STRAIN ALL URINE 
BENIGN PROSTATIC
HYPERPLASIA (BPH)

•



Age–related, nonmalignant enlargement
of the prostate gland
Enlargement of the prostate gland -compress the urethra/bladder
This impedes the normal flow of urine
Begins at the age of 40 and continues
slowly throughout the rest of life
Symptoms appear slightly earlier in AfroAmerican men
BPH
Begins with small layers in the
periuretheral gland
 Prostate enlarges through formation
/growth of nodules and enlargement
of glandular cells
 Enlargement compresses against the
urethra  urologic symptoms
 Changes occur over a long period of
time

BPH
Clinical Manifestations
 Difficulty starting urinary stream
 Urinary frequency
 Nocturia
 Leakage or dribbling of urine
 Urgency
BPH
Complications
 Urinary retention
 Urinary tract infections
 Bladder stones
BPH
Diagnostic Studies
 History & physical exam
 Urinalysis/ C&S
 Digital rectal exam (DRE)
 Prostatic Specific Antigen(PSA)
-- R/O Prostate Cancer
 Serum Creatinine
MEDICATION THERAPY
ALPHA-ADRENERGIC BLOCKERS

•
•
Relax the smooth muscle of the
bladder neck and prostate
Improves urine flow
Relax smooth muscle of the prostate
BPH
ALPHA-ADRENERGIC BLOCKERS
 Flomax- (tamsulosin)
 Cardura - (doxazosin)
 Hytrin – (terazosin)
 Uroxatral – (alfuzosin)
Side effect


orthostatic hypotension
dizziness
BPH
5 ALPHA-REDUCTASE INHIBITORS
 Decreases the size of the prostate
gland
 Proscar (finasteride)
 Avodart – (dutasteride)
 Side effect *decreases libido,
*erectile dysfunction
BPH
Minimally Invasive Therapy



used when medication not effective
relieves the manifestations of BPH
less invasive than traditional surgery
BPH

Transuretheral Needle Ablation
(TUNA)

Low-wave radio frequency – to burn away
a region of the enlarged prostate
Improves the flow of urine
70% of pt. show marked improvement
Little pain
Early return to regular activities




TUNA
BPH
Transuretheral Resection of the
Prostate (TURP)

Removal of inner prostate tissue

Most common procedure
Advantages
1. No external incision made
2. Shorter hospitalization
3. Complications – clot retention,
hemorrhage, infection, catheter
obstruction
TURP
CONTINOUS BLADDER
IRRIGATION






3- way drainage system- useful in
irrigating the bladder & preventing clot
formation
3000 ml sterile normal saline
Irrigation -- consist of continuous inflow &
outflow of solution & drainage
Maintain patency of catheter & tubing
Urine drainage – light pink
Blood clots are expected 1st 24-36hrs.
after surgery
CBI
Catheter removal –
 assess amount, color and
consistency of urine
 may experience burning on
urination, dribbling is common
BPH
Complications
 Hemorrhage

Obstructed catheter

Urinary incontinence
URINARY DIVERSIONS
 Procedure
performed to divert urine
from the bladder to a new exit site –
STOMA
 Used to treat
a. Cancer of the bladder
b. Congenital anomalies
c. Trauma to the bladder
d. Neurogenic bladder
URINARY DIVERSIONS

1.
2.
2 CATERGORIES
Incontinent urinary diversion
Continent urinary diversion
URINARY DIVERSIONS
 INCONTINENT
•
•
•
DIVERSION
Urine drains through an opening
created in the abdominal wall
An appliance is needed
Most common – Ileal Conduit
URINARY DIVERSIONS
 INCONTINENT
•
•
•
•
DIVERSIONS – ileal
conduit
Ureters are excised from the bladder
& resected to a part of the ileum
Proximal end is sewn closed
Distal end created to form a stoma
Remaining intestinal segments –
anatomosed
URINARY DIVERSIONS
 INCONTINENT
DIVERSIONS
• Stents -- prevent occlusion from
post-surgical edema
Disadvantages:
• Requires a external collection device
• Visible stoma
URINARY DIVERSIONS
INCONTINENT DIVERSIONS
Pre-op Management
•
Discuss social aspects of living with a
stoma
1. Clothing
2. Changes in body image
3. Odor
4. Sexuality
5. Exercise

URINARY DIVERSIONS
INCONTINENT DIVERSIONS
Post-op Management
•
Assess for complications
a. Paralytic ileus/SBO
•
Make sure urinary stents are draining
•
U/O < 30cc/hr –
dehydration/obstruction
•
Hematuria –1st 24-48 hours
•
Mucous threads in urine – normal
occurrence

URINARY DIVERSIONS
 Post-op
•
•
•
•
•
management (cont’d)
Check stoma color– beefy red
Increase fld. intake
Empty pouch when 1/3 full/q2-3 hr.
Meticulous skin care
Avoid foods that give strong odor–
cheese, eggs, asparagus
URINARY DIVERSIONS
 CONTINENT
•
•
•
•
•
DIVERSIONS
Intra-abdominal urinary reservoir
Self catheterize every 4-6 hours
No need external attachments
Reservoirs constructed from
different parts of the ileum/colon
Kock, Indiana, Charleston pouch
URINARY DIVERSION
 CONTINENT
DIVERSIONS
Post-op Management
• Teach patient to catheterize pouch
• Irrigate pouch
• Adhere to strict catheterization
schedule
• Enterostomal therapy nurse
QUESTION
A patient returns to the unit following a TURP
. His urinary drainage bag is filled with dark
red fluid with obvious bloods clots. And he is
having bladder spasms. What would you do
first?
a. Assess his intake/output since surgery
b. Administer pain medication as ordered
c. Report your assessment to the urologist
d. Nothing, these are manifestations that are
expected following a TURP
QUESTION

a.
b.
c.
d.
The nurse evaluates her teaching as
effective when a patient with a newly
continent ileal diversion is able to do which
of the following?
Demonstrate care for the collection device
State the importance of reporting cloudy
urine to the physician
Demonstrate self-catherization of the stoma
Identify factors that contribute to this
condition
Urinary Tract Cancers
Prostate Cancer
Cancer of the Bladder
Cancer of the Prostate
Most common cancer among men
after skin cancer
 Highest incidence in AfricanAmerican men
 Risk Factors

increases rapidly after age 50
 Family history
 High intake of red meat and high fat
dairy products

Cancer of the Prostate
Signs and Symptoms
Often asymptomatic
 As malignancy enlarges, may have
symptoms of urinary obstruction
 Blood in urine, semen and painful
ejaculation may occur
 C/O back and hip pain, weight loss,
anemia, oliguria may indicate
metastases

Cancer of the Prostate
Assessment and Diagnosis
Screening tools
 DRE
 PSA


Normal: 0-4 ng/mL
Transrectal Ultrasound (TRUS)
 Biopsy

Cancer of the Prostate
Treatment




Surgical removal of the prostate
 TURP
 Laproscopic radical prostatectomy
Radiation
 Teletherapy
 Brachytherapy
Hormone Therapy
 Casodex
 DES
Chemotherapy
Cancer of the Bladder

Most commonly seen in ages 50-70
Transitional-cell carcinoma of the
bladder
 Papilillomatous growths in the bladder


Risk factors
Cigarette smoking (twice as much)
 Environmental carcinogens
 Frequent/recurrent bacterial infections
 History of urogenital cancers

Cancer of the Bladder
Assessment and Diagnosis
Hematuria
 Bladder irritability
 Pelvic or back pain
 Diagnostic tests:

Cystoscopy
 Ultrasound/CT
 Biopsies

Cancer of the Bladder
Treatment
Transurethral Resection of Bladder
Tumor (TURBT)
 Chemotherapy/Radiation

BCG
 Methotrexate/5-FU/
vinblastin/Adriamycin


Cystectomy
Cancer of the Bladder
Treatment
Transurethral Resection of Bladder
Tumor (TURBT)
 Chemotherapy/Radiation

BCG
 Methotrexate/5-FU/
vinblastin/Adriamycin/cisplatin


Cystectomy
Partial
 Radical
