NSG210 Hinkle Ch. 49: Management of Patients with Urinary Disorders

Source: Hinkle & Cheever, Brunner & Suddarth’s Medical-Surgical Nursing 15e, Chapter 49, pp. 1604-1636 (textbooks/HINKLE_MS_CH49.pdf, also in textbooks/exam04/). Week 13 reading (pyelonephritis, urolithiasis, bladder cancer); Exam 4 content. Numbering note: the Week 13 syllabus lists “Ch. 50” (16th edition); urinary disorders is Ch. 49 in the 15th edition (see nsg210-textbook-chapter-crosswalk). Kidney cancer and renal trauma are in nsg210-hinkle-ch48-kidney-disorders; prostate disorders in nsg210-hinkle-ch53-male-reproductive.

Learning Outcomes

1. Explain factors contributing to upper and lower urinary tract infections.
2. Use the nursing process for the patient with a lower UTI.
3. Differentiate adult dysfunctional voiding patterns and develop an education plan for urinary incontinence.
4. Identify causes of urinary tract obstruction and their medical, surgical, and nursing management.
5. Describe genitourinary trauma and urinary tract cancers.
6. Use the nursing process for renal calculi and urinary diversion surgery.

Key Terms

• Bacteriuria: bacteria in urine. Pyuria: WBCs in urine
• CAUTI: UTI with an indwelling catheter in place more than 2 calendar days
• Cystectomy: bladder removal. Cystitis: bladder inflammation. Urethritis, prostatitis: urethral or prostate inflammation
• Pyelonephritis: inflammation of the renal pelvis
• Interstitial cystitis: bladder wall inflammation leading to loss of lining and elasticity
• Ileal conduit (ileal loop): ureters implanted into a segment of terminal ileum brought out as a stoma
• Neurogenic bladder: bladder dysfunction from a nervous system disorder
• Incontinence types: stress (exertion, cough, sneeze), urge (strong urge cannot be suppressed), functional (physical or cognitive impairment), iatrogenic (medical factors, mostly drugs), mixed (urge plus stress), overflow (overdistended bladder)
• Residual urine: urine left after voiding
• Suprapubic catheter: inserted through a suprapubic incision into the bladder
• Urethrovesical reflux: urine flows from urethra back into bladder (brings bacteria). Ureterovesical (vesicoureteral) reflux: urine flows from bladder up the ureters
• Urinary frequency: voiding more often than every 3 hours
• Urosepsis: urinary infection spreading to the bloodstream

I. Urinary Tract Infections

A. Overview

• Second most common infection; about 25 percent of all infections; 8.1 million women diagnosed yearly; over 100,000 hospitalizations.
• 50 percent of hospital-acquired infections are UTIs, mostly CAUTI. CAUTI risk rises 3 to 7 percent per catheter day; CMS “never event” (no reimbursement). Urosepsis mortality after catheterization 25 to 60 percent.
• Lower UTIs: cystitis, prostatitis, urethritis. Upper UTIs: pyelonephritis, interstitial nephritis, renal abscess.

B. Pathophysiology

• Bladder defenses: urethral barrier, urine flow, ureterovesical junction competence, antibacterial enzymes and antibodies, antiadherent mucosa, shedding of epithelial cells, glycosaminoglycan (GAG) water barrier (impaired by cyclamate, saccharin, aspartame, tryptophan metabolites), normal vaginal and urethral flora, urinary IgA.
• Risk factors (Chart 49-1): female, diabetes, pregnancy, neurologic disorders, gout, incomplete emptying and stasis, immunosuppression, urethral inflammation or abrasion, instrumentation (catheter, cystoscopy), obstruction (congenital, strictures, bladder neck contracture, tumors, stones, ureteral compression).
• Most UTIs: fecal organisms ascend from perineum. Routes: transurethral (most common), hematogenous, fistula from intestine. Short female urethra; intercourse pushes bacteria into the bladder.
• Postmenopausal changes in urethrovesical angle and closure pressure raise infection risk.

C. Clinical Manifestations

• Uncomplicated lower UTI: burning on urination, frequency, urgency, nocturia, incontinence, suprapubic or pelvic pain; possibly hematuria, back pain.
• Complicated UTI: from asymptomatic bacteriuria to gram-negative sepsis; broader organisms; recur. Any catheterized patient with sudden signs of septic shock: evaluate for urosepsis.

D. Older Adults

• UTI is the most common infection in older adults; sex gap narrows with age (less intercourse, more BPH obstruction).
• Contributing (Chart 49-2): cognitive impairment, frequent antibiotics, chronic conditions, immunocompromise, immobility and incomplete emptying, low fluid intake, obstruction, poor hygiene.
• E. coli most common; with catheters: Proteus, Klebsiella, Pseudomonas, Staphylococcus; after antibiotics: Enterococcus.
• Early symptoms: malaise, nocturia, incontinence, foul-smelling urine; also burning, urgency, fever; may present with incontinence and delirium.
• Postmenopausal women: oral or topical estrogen may help recurrent cystitis. Men: chronic bacterial prostatitis is the most common cause of recurrent UTI.
• Adjust antibiotics for renal and hepatic changes; increase fluids if cardiac status allows.

E. Diagnosis

• Culture: over 100,000 CFU/mL on clean-catch midstream or catheter specimen = infection (sepsis can occur with lower counts). Any bacteria by suprapubic aspiration, straight catheter, surgery, or cystoscopy is significant.
• Culture indicated for: all children, all men, recent hospitalization or long-term care, recent instrumentation, diabetes, prolonged symptoms, 3 or more UTIs in a year, postmenopausal, pregnant, sexually active women, new partners, immunocompromise or renal problems.
• Microscopic hematuria in about half; pyuria in all (not specific).
• Dipstick: leukocyte esterase and nitrite. STI testing (chlamydia, gonorrhea, herpes, trichomonas, candida mimic UTI). Imaging: CT (pyelonephritis, abscess), ultrasound and kidney scans (obstruction, abscess, tumor, cyst).

F. Medical Management

• Antibiotics (Table 49-1): nitrofurantoin; cephalexin, cefadroxil; fluoroquinolones (ciprofloxacin, levofloxacin and others; pyelonephritis); trimethoprim-sulfamethoxazole (UTI, pyelonephritis); ampicillin and amoxicillin (not used alone due to E. coli resistance); phenazopyridine (urinary analgesic for burning and pain).
• Uncomplicated cystitis in women: single-dose, 3-day, or 7-day regimens; trend toward 3 days. Take all doses even if symptoms stop. Longer courses for men, pregnant women, pyelonephritis, complicated UTI. Evaluate men for prostatitis.
• Recurrence in about 20 percent of women; within 2 weeks = same organism (relapse, upper tract source or inadequate treatment). Recurrent: short 3-4 day course then nightly prophylactic dose. Cranberry (especially capsules) reduces recurrence; antibiotics more effective but more adverse effects.

G. Nursing Process: Lower UTI

• Assess: pain, frequency, urgency, hesitancy, urine changes, voiding pattern, symptoms after intercourse, contraception, hygiene, knowledge, urine appearance and odor, CAM use (women with interstitial cystitis use behavioral therapy, physical therapy, stress reduction, diet changes).
• Diagnoses: acute pain; lack of knowledge. Complications: urosepsis; AKI or CKD from extensive infection.
• Pain: antibiotics relieve quickly; antispasmodics; analgesics; heat to perineum; liberal fluids (water, cranberry juice); avoid irritants (coffee, tea, citrus, spices, colas, alcohol); void every 2 to 3 hours.
• Complications: report fatigue, nausea, vomiting, fever, pruritus; monitor VS and LOC for kidney involvement or sepsis; report positive blood cultures and rising WBC; IV antibiotics and fluids; aggressive early treatment (especially older adults, anemia, high glucose).
• Teaching (Chart 49-3): shower rather than tub bath; wipe front to back after bowel movements; drink liberal fluids (one glass of cranberry juice daily may help); avoid irritants; void every 2 to 3 hours and empty completely; women void right after intercourse; take medication exactly as prescribed; long-term prophylaxis possible; test urine if prescribed; report fever or persistent symptoms; regular follow-up.
• Outcomes: 8 to 10 glasses of fluid daily; void every 2 to 3 hours; urine output over 400 mL/day.

II. Upper UTIs: Pyelonephritis

A. Acute Pyelonephritis

• Bacterial infection of renal pelvis, tubules, interstitium; ascending from bladder or bloodstream; incompetent ureterovesical valve or obstruction (tumors, strictures, BPH, stones) increases risk; over 25,000 admissions yearly.
• Signs: chills, fever, leukocytosis, bacteriuria, pyuria, low back and flank pain, nausea, vomiting, headache, malaise, painful urination, CVA tenderness, urgency, frequency.
• Diagnosis: ultrasound or CT for obstruction (relief essential), IV pyelogram, radionuclide imaging (gallium, indium-111 WBCs), urine culture and sensitivity.
• Treatment: outpatient if no sepsis, dehydration, nausea, or vomiting and adherent; 2-week antibiotic course; up to 6 weeks if relapse; follow-up culture 2 weeks after therapy; hydration.

B. Chronic Pyelonephritis

• Repeated acute episodes: scarred, contracted, nonfunctioning kidneys; cause of CKD and RRT.
• Usually asymptomatic except exacerbations: fatigue, headache, poor appetite, polyuria, thirst, weight loss.
• Diagnosis: IV urogram, creatinine clearance, BUN, creatinine.
• Complications: ESKD, hypertension, stones (urea-splitting organisms).
• Treatment: eradicate bacteria; long-term prophylactic antibiotics; monitor renal function with nephrotoxic drugs.
• Nursing: I&O; 3 to 4 L fluid daily unless contraindicated; temperature every 4 hours; antipyretics and antibiotics; teach fluids, regular voiding, perineal hygiene, adherence, follow-up.

III. Adult Voiding Dysfunction

• Neurogenic and nonneurogenic causes (Table 49-2). Chronic incomplete emptying causes recurrent infection; outlet obstruction (BPH) with high detrusor pressure can cause hydronephrosis.
• Examples: stroke, dementia (prompted voiding, anticholinergics); diabetes, MS, Parkinson (timed voiding, biofeedback, anticholinergics); acute spinal injury (retention: indwelling catheter); overactive bladder (bladder drill, anticholinergics); post general surgery (acute retention: catheterize); stress incontinence (biofeedback, bladder drill, bulking, surgery).

A. Urinary Incontinence

• Over 25 million US adults; 9 to 12 percent of adults; women twice men; 50 to 90 percent of institutionalized older adults; 35 to 41 percent of older women. Underdiagnosed and underreported.
• Risk factors (Chart 49-4): aging changes, no caregiver or toilet, dementia, Parkinson, class III obesity, diabetes, GU surgery, high-impact exercise, immobility, incompetent urethra, diuretics, sedatives, hypnotics, opioids, menopause, pelvic muscle weakness, vaginal delivery, episiotomy, stroke. 40 percent of men with Parkinson disease.
• Stress: women after vaginal deliveries (weak pelvic support, low estrogen); men after radical prostatectomy.
• Urge: uninhibited detrusor contraction.
• Functional: lower urinary tract intact but cognitive or physical barriers.
• Iatrogenic: for example alpha-adrenergic blockers for BP relax bladder neck; resolves when stopped.
• Overflow: overdistended bladder from weak detrusor or outlet obstruction (BPH, prolapse, tumors).
• Not a normal part of aging; transient incontinence often abrupt; causes (Chart 49-5): atrophic vaginitis, urethritis, prostatitis; delirium; excess urine (high intake, diabetes, DKA); limited activity; drugs (anticholinergics, sedatives, alcohol, analgesics, diuretics, muscle relaxants, adrenergics); depression; stool impaction or constipation; UTI.
• Assessment: history, medications, voiding diary, I&O, residual urine, stress maneuvers, urodynamics, urinalysis and culture.

B. Management of Incontinence

• Behavioral therapy is first line for nonneurologic incontinence (Chart 49-6):
  • Fluid management: about 1500 to 1600 mL/day in small amounts between breakfast and evening meal; water best; avoid caffeine, carbonation, alcohol, artificial sweeteners; prevent constipation.
  • Timed voiding (by the clock, for example every 2 hours); prompted voiding (caregiver checks, assists, praises dryness; for cognitive impairment); habit retraining (more frequent than usual, restores sensation, for example after stroke); bladder retraining or “bladder drill” (timed voiding plus urge inhibition; lengthen interval by 10 to 15 minutes at a time).
  • Pelvic muscle (Kegel) exercises: tighten muscles used to stop flatus or urine stream for 5 to 10 seconds, rest 10 seconds; 10 to 30 repetitions, 2 or 3 times a day, at least 6 weeks; biofeedback helps identify muscles; for stress, urge, mixed incontinence and men after prostate surgery.
  • Vaginal cones: retain 15 minutes twice daily.
  • Electrical stimulation (high frequency for stress; low for urge; intermediate for mixed); neuromodulation.
• Medications (adjunct to behavioral therapy): anticholinergics first line for urge incontinence; mirabegron (beta-3 agonist; caution in hypertension); tricyclic antidepressants (amitriptyline) decrease contractions and increase bladder neck resistance; pseudoephedrine for stress incontinence (caution with BPH and hypertension). Anticholinergics do not help the stress component of mixed incontinence.
• Surgery: anterior vaginal repair, retropubic or needle suspension, sling procedures; periurethral bulking (collagen via cystoscope; 10-20 minutes; discharged after voiding; lasts 12-24 months; may need repeat); artificial urinary sphincter (cuff around urethra, pump in scrotum); TURP for men with overflow or stress incontinence from prostate enlargement.
• Nursing: incontinence is often reversible and treatable; skin assessment to distinguish incontinence-associated dermatitis from pressure injury; support during behavioral therapy; teaching (Chart 49-8): avoid caffeine, alcohol, aspartame; no diuretics after 4 PM; track fluids; daily pelvic floor exercises; stop smoking (coughing); prevent constipation; void 5 to 8 times daily (on waking, before meals, at bedtime, once at night if needed); keep a diary.

C. Urinary Retention

• Inability to empty bladder completely; chronic retention causes overflow incontinence. Under 60: no residual expected; over 60: 50 to 100 mL residual may be normal.
• Causes: postoperative (perineal or anal surgery, general anesthesia), diabetes, prostatic enlargement, urethral pathology, pelvic trauma, pregnancy, neurologic disorders, medications.
• Assessment: time and amount of last void; frequent small voids or dribbling; lower abdominal discomfort; rounded swollen suprapubic area; dullness on percussion; restlessness, agitation; postvoid bladder scan; voiding diary; urodynamics.
• Complications: chronic infection, stones, pyelonephritis, sepsis, hydronephrosis, perineal skin breakdown.
• Promote voiding: privacy, normal position (commode rather than bedpan; men stand to use urinal), warmth (sitz bath, warm compress, shower), hot caffeine-free drink, running water, stroking abdomen or inner thigh, tapping suprapubic area, hands in warm water, analgesics for perineal pain.
• If unable to void: bladder scan, then straight catheterization; suprapubic catheter if prostatic obstruction prevents urethral catheterization; then bladder retraining.
• Home: clear path to bathroom, grab bars, commode or urinal within reach, night lights, easy-off clothing.

D. Neurogenic Bladder

• Causes: spinal cord injury, spinal tumor, herniated disc, MS, spina bifida, infection, diabetes.
• Spastic (reflex) bladder: upper motor neuron lesion above the voiding reflex arc; loss of sensation and control; empties by reflex. More common.
• Flaccid bladder: lower motor neuron lesion (trauma; increasingly diabetes); bladder overdistends; overflow incontinence; no discomfort.
• Complications: infection (most common), stones, skin breakdown, incontinence or retention.
• Management: prevent overdistention, empty completely and regularly, keep urine sterile and stone free, adequate capacity without reflux; continuous, intermittent, or self-catheterization; external condom catheter; low-calcium diet (prevent stones); mobility; liberal fluids; bladder retraining, timed voiding; double voiding for flaccid bladder (stay on toilet 1 to 2 minutes and void again); bethanechol (parasympathomimetic) increases detrusor contraction; surgery for bladder neck contracture, reflux, diversion.

E. Urinary Catheters

• Indications: postoperative drainage, accurate output in critical illness, neurogenic bladder, retention, end-of-life care, stage III-IV pressure injuries, obstruction. Place only if necessary.
• CAUTI prevention: strict asepsis, smallest catheter, secure catheter, inspect urine, daily perineal care with soap and water, closed system, use sampling port, remove as soon as feasible.
• Chart 49-9: separate receptacle for emptying; no routine catheter changes (only for leakage, blockage, encrustation); minimal handling; hand hygiene; free flow, no kinks or dependent loops; clamp tubing if bag must be raised above bladder; patient must void within 8 hours after removal (else straight catheter); never disconnect to sample, irrigate, ambulate, or transport; never irrigate routinely (use 3-way continuous irrigation if clots); culture at first sign of infection; bag never on floor; empty at least every 8 hours; wash perineum at least twice daily, no to-and-fro motion, no powder.
• Cleanse from meatus along catheter away from body; disposable wipes (water, aloe, vitamin E) reduced CAUTI; avoid wash basins. Confused patient: prevent removal with balloon inflated (urethral injury). Liberal fluids. Bacteriuria is inevitable; treating asymptomatic bacteriuria is controversial (resistance); watch for fever, chills.
• High-risk patients: women, older adults, debilitated, malnourished, chronically ill, immunosuppressed, diabetes. CAUTI signs: cloudy malodorous urine, hematuria, fever, chills, anorexia, malaise.
• Suprapubic catheter: urethra impassable (injury, stricture, prostate), after gynecologic or abdominal surgery, pelvic fractures, permanent after spinal cord injury. Voiding trial: clamp 4 hours, attempt to void, unclamp and measure residual; removed if residual under 100 mL twice (morning and evening). Advantages: void sooner, more comfortable, more mobile, residual measured without urethral instrumentation, less infection. Liberal fluids prevent encrustation; risks: bladder stones, infection.
• Bladder retraining after indwelling catheter (Chart 49-10): measured fluids 8 AM to 10 PM, sips only after 10 PM; timed voiding every 2 to 3 hours with triggers; bladder scan after each attempt; straight catheterize usually for residual over 300 mL; stop catheterization when residual under 100 mL; watch for signs of full bladder without sensation (sweating, cold hands and feet, anxiety). Postcatheterization detrusor instability.
• Intermittent self-catheterization: protects kidneys, fewer UTIs, better continence and self-esteem; clean technique at home (antibacterial liquid soap, rinse, dry, store in plastic bag); every 4 to 6 hours by day and at bedtime. Women: Fowler position, mirror, insert 7.5 cm (3 in) downward and backward. Men: Fowler or sitting, hold penis at right angle, insert 15 to 25 cm (6 to 10 in) until urine flows. Mitrofanoff appendicovesicostomy (appendix as stoma) as alternative.

IV. Urolithiasis and Nephrolithiasis

A. Pathophysiology

• Stones in urinary tract or kidney; ages 30s to 50s; men about twice women (gap narrowing, 1.3 to 1); prevalence 10.6 percent men, 7.1 percent women.
• Supersaturation of calcium oxalate, calcium phosphate, uric acid (depends on amount, ionic strength, pH); infection, stasis, immobility promote stones.
• Hypercalcemia and hypercalciuria causes: hyperparathyroidism, renal tubular acidosis, cancers (leukemia, multiple myeloma), dehydration, granulomatous diseases (sarcoidosis, TB), excess vitamin D, excess milk and alkali, myeloproliferative diseases (polycythemia vera), intestinal bypass.
• Uric acid stones: 72 percent of stones in men (gout, myeloproliferative disorders). Struvite stones: 72 percent of stones in women; alkaline ammonia-rich urine from Proteus, Pseudomonas, Klebsiella, Staphylococcus, Mycoplasma; neurogenic bladder, foreign bodies, recurrent UTI. (Percentages as reported in the text.)
• Other risks: PKD, horseshoe kidney, strictures, medullary sponge kidney, inflammatory bowel disease, ileostomy, bowel resection (more oxalate absorption); drugs: antacids, acetazolamide, vitamin D, laxatives, high-dose aspirin.

B. Clinical Manifestations

• Depend on obstruction, infection, edema; obstruction raises hydrostatic pressure and distends renal pelvis and ureter.
• Renal pelvis stones: intense deep ache at CVA; hematuria, pyuria; pain radiates anteriorly and down toward bladder (women) or testes (men). Renal colic: sudden acute pain, CVA tenderness, nausea, vomiting; diarrhea and abdominal discomfort (renointestinal reflexes).
• Ureteral stones: ureteral colic: acute, excruciating, colicky, wavelike pain radiating down the thigh to genitalia; frequent urge but little bloody urine. Mediated by prostaglandin E. Stones about 0.5 cm usually pass; over 1 cm usually must be removed or fragmented.
• Bladder stones: irritation, UTI, hematuria; retention if bladder neck obstructed. Stone plus infection: risk of urosepsis.

C. Diagnosis

• Noncontrast CT confirms. Blood chemistries; 24-hour urine for calcium, uric acid, creatinine, sodium, pH, volume; diet, medication, family history. Stone analysis guides treatment.

D. Medical Management

• Goals: eradicate stone, identify type, prevent nephron loss, control infection, relieve obstruction.
• Pain: opioids (prevent shock and syncope) plus NSAIDs (specific relief; inhibit prostaglandin E, reduce swelling, help passage).
• Fluids encouraged unless vomiting or heart failure (push stone down; dilute urine). Urine output over 2 L/day; 8 to 10 eight-oz glasses water daily.
• Chart 49-11 prevention: avoid excess protein (lowers calcium and uric acid excretion); limit sodium to 3 to 4 g/day; low-calcium diet not generally recommended (osteoporosis) except true absorptive hypercalciuria; avoid oxalate foods (spinach, Swiss chard, chocolate, peanuts, pecans); fluids every 1 to 2 hours plus one glass of cranberry juice daily; two glasses of water at bedtime and one at each night waking; avoid overheating and sweating; report UTI early.
• Calcium stones: liberal fluids; calcium restriction only for type 2 absorptive hypercalciuria; ammonium chloride; thiazides if hyperparathyroid-related (reduce urinary calcium loss).
• Uric acid stones: low-purine diet (avoid shellfish, anchovies, asparagus, mushrooms, organ meats); allopurinol.
• Cystine stones: low-protein diet; alkalinize urine with potassium alkali salts; more fluids.
• Oxalate stones: dilute urine; limit oxalate.

E. Interventional and Surgical

• Ureteroscopy: visualize and fragment (laser, electrohydraulic, ultrasound) or remove; ureteral stent 48 hours or more.
• ESWL (lithotripsy): noninvasive shock waves fragment stones in the renal calyx to sand that is voided; may feel discomfort; strain all urine; observe for obstruction and infection; several treatments may be needed.
• Percutaneous nephrolithotomy or nephrostomy: nephroscope through skin; forceps, basket, or ultrasound probe; nephrostomy tube left to ensure drainage; complications: hemorrhage, infection, urinary extravasation.
• Electrohydraulic lithotripsy via cystoscope (topical anesthesia).
• Chemolysis: continuous warm chemical solution via nephrostomy (struvite stones dissolve easily); monitor renal pelvis pressure.
• Surgery if other methods fail: nephrolithotomy, nephrectomy (nonfunctional kidney), pyelolithotomy (renal pelvis), ureterolithotomy (ureter), cystotomy (bladder), cystolitholapaxy (crushing bladder stone).

F. Nursing Process: Renal Calculi

• Assess: pain severity, location, radiation; nausea, vomiting, diarrhea, distention; UTI signs (chills, fever, frequency, hesitancy); obstruction (frequent small voids, oliguria, anuria); blood in urine; strain for stones; history of risk factors; knowledge.
• Diagnoses: acute pain; lack of knowledge. Complications: infection and urosepsis; obstruction and AKI.
• Pain: opioids plus IV NSAID; position of comfort; ambulate if it helps; report increasing pain (fragment obstructing ureter).
• Fluids (IV if needed); monitor output and voiding pattern; ambulation helps stone pass; strain all urine, crush clots, inspect urinal and bedpan sides; report decreased volume, bloody or cloudy urine, fever, pain; monitor temperature; treat infection before dissolving stones.
• Teaching: urine output over 2000 mL (preferably 3000 to 4000 mL) per 24 hours; urine cultures every 1 to 2 months the first year; mobility; avoid excess vitamins (especially D) and minerals; monitor urine pH; medications.
• After ESWL: increase fluids to pass fragments (6 weeks to months); hematuria expected but should clear in 4 to 5 days (longer with stent); check temperature daily; report temperature over 38 C (about 101 F) or unrelieved pain; bruise on treated side of back possible.
• Outcomes: at least eight 8-oz glasses daily; voids 200 to 400 mL clear urine.

V. Genitourinary Trauma

• Blunt about 85 percent, penetrating 15 percent. Kidney trauma in Ch. 48.
• Ureteral: gunshot wounds 90 percent of ureteral injuries; also unintentional injury in gynecologic or urologic surgery; no specific signs, often found at surgery; repair with stents; missed leak can form fistula.
• Bladder: pelvic fractures, multiple trauma, blow to full bladder; contusion or extra- or intraperitoneal rupture; uncommon (protected by pelvis); complications: hemorrhage, shock, sepsis, extravasation.
• Urethral: blunt lower abdominal or pelvic trauma, often with pelvic fracture. Classic triad: blood at meatus, inability to void, distended bladder. Men 5 times women; complete rupture more in children.
• Management: control hemorrhage, pain, infection; maintain drainage; monitor Hgb and Hct, oliguria, shock, peritonitis. Urethral injury: urethrography BEFORE catheterization (avoid disruption, stricture, incontinence, impotence); suprapubic catheter if unstable; after repair indwelling catheter 1 to 2 months.
• Nursing: assess flank and abdominal pain, spasm, swelling; incision care, fluids; report fever, hematuria, flank pain, decreasing kidney function; ruptured bladder may bleed for several days after repair; restrict activity about 1 month; monitor BP.

VI. Bladder Cancer

• 25 percent occur over 65; sixth most common cancer; much more common in men; over 15,000 US deaths yearly. Metastasis to bladder from prostate, colon, rectum, gynecologic tract.
• Risk factors (Chart 49-12): tobacco (leading risk for all urinary tract cancers); arsenic; occupational paint, dye, metal, petroleum chemicals; family history; pelvic radiation or prior cancer treatment; genetic mutations.
• Tumors usually at bladder base near ureteral orifices and bladder neck. Most common symptom: visible, painless hematuria. UTI common (frequency, urgency); any voiding change may indicate cancer; pelvic or back pain with metastasis.
• Diagnosis: cystography, excretory urography, CT, MRI, ultrasound, bimanual exam under anesthesia; biopsy is definitive; urine cytology and bladder washings for staging and recurrence.
• Treatment by grade and stage:
  • Transurethral resection or fulguration for papillomas; then intravesical BCG Live (attenuated Mycobacterium bovis; local inflammatory and immune response) is the treatment of choice, at least 1 year; 43 percent advantage in preventing recurrence vs 16 to 21 percent for intravesical chemotherapy; eradicates carcinoma in situ in over 80 percent; optimal course is 6 weekly instillations, then a 3-week course at 3 months for nonresponding tumors; high-risk cancers may get 3-week maintenance courses at 6, 12, 18, and 24 months. Patient may eat and drink first; retain solution 2 hours, then void and drink liberally to flush.
  • Whole urothelium at risk; lifelong surveillance cystoscopy.
  • Simple or radical cystectomy for invasive or multifocal cancer. Radical in men: bladder, prostate, seminal vesicles, perivesical tissue. In women: bladder, lower ureters, uterus, tubes, ovaries, anterior vagina, urethra; may include pelvic nodes. Requires urinary diversion.
  • Chemotherapy (methotrexate, 5-FU, vinblastine, doxorubicin, cisplatin) with or without radiation; intravesical chemotherapy (thiotepa, doxorubicin, mitomycin, BCG) for high recurrence risk, carcinoma in situ, incomplete resection; intra-arterial infusion.
  • Radiation preoperatively or for inoperable tumors; hydrostatic balloon therapy or formalin, phenol, silver nitrate instillation for intractable hematuria and strangury.

VII. Urinary Diversions

• Divert urine to a stoma, mostly after cystectomy for high-grade or muscle-invasive bladder cancer; also pelvic malignancy, birth defects, strictures, trauma, neurogenic bladder, chronic infection, interstitial cystitis, last-resort incontinence.

A. Ileal Conduit

• Oldest and most common; ureters implanted into a 12-cm loop of ileum brought out through the abdominal wall; bowel reanastomosed; continuous urine drainage into a bag. Advantages: few complications, simple, no bladder retraining, no nocturnal incontinence.
• Bilateral ureteral stents (10 to 21 days) prevent edema occlusion and allow accurate output; Jackson-Pratt drains.
• Complications: wound infection or dehiscence, urine leakage, ureteral obstruction, hyperchloremic acidosis, small bowel obstruction, ileus, stoma gangrene. Delayed: ureteral obstruction, stomal stenosis, reflux kidney damage, peristomal hernia, retraction, pyelonephritis, stones, recurrence.
• Preop: stoma site marked (with WOC nurse) sitting, standing, lying; away from bony prominences, creases, folds, scars, umbilicus, belt line; patient must see and reach it; marked with indelible ink; check tape, adhesive, and latex allergies; low-residue diet and bowel antibiotics; nutrition support; hydration.
• Postop: hourly urine; output under 0.5 mL/kg/h may mean dehydration or obstruction or leak; irrigate stents only as instructed (5 to 10 mL sterile saline, no tension); hematuria first 48 hours may resolve.
• Stoma: healthy is pink or red and moist; purple, brown, or black = compromised blood supply (report immediately; may need surgery). Stoma insensitive to touch; peristomal skin sensitive. Inspect stoma at least every 4 hours early.
• Odor of urine or wet linens = leak. Foul urine: catheterize stoma for culture if prescribed.
• Mucus in urine is normal (intestinal mucosa); encourage fluids.
• Appliance: one or two piece; disposable or reusable; skin barrier essential; never patch a leaking pouch with tape; avoid moisturizing soaps; opening no more than 1.6 mm (1/8 inch) larger than stoma and same shape; measure stoma every 3 to 6 weeks for first months as edema subsides; change early morning (less urine); wick (rolled gauze or tampon) over stoma during change.
• Odor: avoid asparagus, cheese, eggs; deodorizer or dilute white vinegar in pouch.
• Empty pouch when one third full (weight pulls it off skin); night drainage bottle (leave a little urine in bag); rinse night tubing daily with cool water and weekly with 3:1 water and white vinegar; reusable pouch soaked 30 minutes in 3:1 water and vinegar, air-dry away from sunlight; two appliances alternate.
• Long-term: vitamin B12 deficiency anemia (terminal ileum removed) years later: B12 injections. United Ostomy Associations of America.

B. Orthotopic Neobladder

• About 38 percent of cystectomy patients; new bladder from intestine attached to the urethra; closer to natural voiding; higher quality of life than ileal conduit.
• Disadvantages: not everyone eligible; bladder retraining; incontinence (only 80 percent achieve full continence, nocturnal leakage common); metabolic acidosis (intestinal wall absorbs electrolytes), dehydration (concentrated urine), postoperative ileus (especially day 5 and later).
• Contraindications (Chart 49-14): creatinine over 150 micromol/L, lack of motivation or ability for strict voiding regimen, impaired liver function, cannot accept incontinence, radiation or inflammatory bowel disease, cancer at prostatic apex or bladder neck, cannot self-catheterize, metastatic cancer.
• Postop: indwelling and suprapubic catheters; irrigate commonly 100 mL normal saline every 6 to 8 hours (mucus); electrolytes; IV fluids; high carbohydrate and protein, high fiber; discharged with catheters for 2 to 3 weeks while neobladder heals.
• Neobladder training (Chart 49-15): void sitting with Valsalva; daily pelvic floor exercises; prevent constipation; void 5 to 8 times daily (every 2 to 3 hours, including once at night); diary.

C. Indiana Pouch and Other Continent Diversions

• Ileum and cecum reservoir; continent stoma flush with skin; drained by catheter at regular intervals (prevents absorption of wastes, reflux, UTI). Multiple tubes (cecostomy, stoma catheter, stents, Penrose, urethral); irrigate cecostomy 2 or 3 times daily early to remove mucus.

D. Nursing Process: Urinary Diversion Surgery

• Preop assessment: cardiopulmonary function (often older adults), nutrition, learning needs with WOC nurse, self-concept, coping, mental status, dexterity, vision.
• Preop diagnoses: anxiety, impaired nutrition, lack of knowledge. Address body image, sexual impotency in men (penile implant), women’s body image; ostomy support groups.
• Postop diagnoses: risk for impaired skin integrity, acute pain, disturbed body image, impaired sexual function, lack of knowledge. Complications: peritonitis (anastomotic leak), stoma ischemia and necrosis, stoma retraction and mucocutaneous separation.
• Interventions: monitor catheters and output; sudden drop in urine with more drain or incision output = leak; NG decompression until bowel sounds, flatus, soft abdomen; early ambulation; meticulous skin care; liberal analgesia (PCA, around the clock); private teaching; explain glove use; sexuality counseling.
• Peritonitis signs: abdominal pain and distention, rigidity with guarding, nausea, vomiting, ileus, fever, leukocytosis.
• Stoma ischemia: from mesenteric tension, twisted conduit, arterial insufficiency; necrotic stoma needs surgery; superficial dusky stoma may slough in days.
• Retraction or mucocutaneous separation: antireflux pouch, keep area clean and dry, karaya powder, stoma paste, fitted barrier; retraction into peritoneum requires surgery.
• Teaching: look at and touch stoma early; normal stoma is pink or red, moist, painless, may bleed when cleaned; mucus normal; supplies and written instructions; follow-up calls; long-term: leaks, stones, stomal stenosis, renal deterioration, incontinence, B12 anemia.

High-Yield Numbers

Priority Nursing Actions and Red Flags

• Catheterized patient with sudden fever, hypotension, confusion: urosepsis.
• Remove indwelling catheters as soon as possible; never disconnect a closed system.
• Older adult with new confusion or incontinence: consider UTI.
• Flank pain, fever, chills, CVA tenderness: pyelonephritis; check for obstruction.
• Renal or ureteral colic: opioids plus NSAIDs; strain all urine; report sudden pain increase.
• Stone plus infection or obstruction: urosepsis and AKI risk.
• Blood at meatus after pelvic trauma: do NOT insert a urethral catheter before urethrography.
• Painless gross hematuria in an older smoker: evaluate for bladder cancer.
• New stoma purple, brown, or black: report immediately.
• Decreased urine with increased drain output after diversion: anastomotic leak.
• Anticholinergics can worsen retention and confusion; pseudoephedrine caution with BPH and hypertension.

Medications

Related

• nsg210-hinkle-ch47-kidney-urinary-assessment
• nsg210-hinkle-ch48-kidney-disorders
• nsg210-hinkle-ch53-male-reproductive
• nsg210-hinkle-ch63-neurologic-trauma (neurogenic bladder after SCI)
• INDEX