Urinary disorders Part 1

Inflammation of the bladder

From infection, Not from infection

Primarily inflammation from bladder infection, Irritants can cause cystitis without infection, Infeciton can occur anywhere in the urinary tract (UTI), The are also different types of cyctitis (Karen how ever said we don’t need to know the types) So here they are just so you know they exist basically: Acute, recurrent, acute uncomplicated, and acute complicated

Cysititis from infection, No symptoms= colonization or asymptomatic bacteriuria (ABU); no treatment required, May progress to acute infection or renal insufficiency, Urine is normally sterile (except for the distal urethra) -Host defenses that protect against infection — Mucin in cells lining bladder (capture infection) — Urine pH -helps to kill bacteria — WBCs in urinary tract — Urine proteins — Prostate proteins — Voiding

More than 80% of UTIs are caused by E. coli (wiping incorrectly), Bacteria travel up the urethra to bladder, Catheters are most common factor associated with new onset UTI in hospital and long-term care facilities (CAUTI), Other factors: Stasis/retention Obstruction Stones Reflux, Other factors: Diabetes (glucose feeds bacteria) Age Sexual activity (both M&F urinate BEFORE & AFTER intercorse) Poor hygiene, Other factors: Constipation Obesity Pregnancy Delay in voiding

Up to 60% of women have had a UTI, Women 30 times more likely to have UTI than men (much shorter urethra), Pregnant women with UTI need aggressive tx to prevent acute pyelonephritis; can cause preterm labor!!

Incidence of UTI is second only to URI in primary care, One of most common health-care-related infections, 150 million people worldwide each year, Costs = 2.8 billion per year

Have patient void BEFORE exam, Vital signs lower abdomen, bladder palpation, bladder scan if it feels full or distended, Assess catheter (if present) -review quidelines for appropriation use! (if chronic maybe time to change it), Concern here is developing urosepsis, S/S ⬆️HR, ⬇️BP, ⬆️temp, ⬆️pain, ⬆️RR

Hallmark symptoms: 1,2,&3, 1. Frequency, 2. Dysuria, 3. Urgency

Flank pain (test CVA), Lower abd pain, incontinence during UTI, nocturia, Altered LOC = encephalopathy, Urosepsis 10% mortality rate, Retention, cloudy, dark foul smelling urine, Pyuria (pus or WBC in urine), Again concern urosepsis!

Clean catch urine specimen, Urinalysis: Leukocyte estrase (LE) + Nitrate (+) WBCs (pyuria) RBCs (hematuria) Casts ⬆️⬆️, Urine cutler (if complicated UTI suspected

Suspected retention/obstruction: -Pelvic US -CT scan (if with contrast assess kidney function, contrast also gives sensation of urinating self/ urgency), Recurrent UTIs, reflux, & interstitial cystitis: -cystoscopy (is like an EGD through the urethra, biopsies can be done, some bleeding normal, frank blood not normal!!, can have burning after)

Encourage fluid intake 2-3L/day (keep in mind fluid restrictions), Comfort measures: Sitz bath, Drug therapy (follow schedule & take entire course), Mantain an acidic urine, Surgical: Treats specific condition causing Reccurrent UTIs: Obstructions etc.

Thank you!

Antibiotics UTI specific: Monurol (one dose) Nitrofurantoin (macrobid, macrodantin) Trimethiprim (primsol) Trmethoprim/sulfamethoxazxole (Bactrim, Sentra), Urine acidifiers: Methenamine (Hiprex) Methylene blue (Urolene blue), Antifungal : Fluconazole (Diflucan), Antibiotics non-UTI specific: Ciprofloxacin, levofolxacin, cefixime, cephalexin (Keflex)

Fosfomycin (monurol):, F: convenient one time dose, F: GI SE limit usefulness for some patients, F: Used for cystitis during pregnancy (short exposure), Nitrofurantoin (Macrodantin), N: Older; not effective against as many gram negative bacteria, N: suppression therapy for chronic UTIs

Sulfonamides (Sulfa drugs):, trimethoprim (Primsol), trimethoprim-sulfamethoxazole (Bactrim, Spetra), Action: Broad spectrum; blocks folic acid production causing bacterial cell death, SE: Photophobia, GI distress, Steven Johnsons, Use with caution with renal impairment, take with full glass of water

Methenamin (Hiprex) -dosing guidlines for children, & available in suspension form, Methylene blue (Urolene blue), Teaching:, :Take with food, :8-10 8oz glasses of water per day, : Avoid alkalinizing products (citrus, milk, antacids, etc.)

Ciprofloxacin (Cipro), Levofloxican (Levaquin), Moxifloxacin (Avelox), Action: broad spectrum, interfere with DNA enzymes for cell reproduction; not UTI-specific, can be used for other types, SE: QT prolongation, liver toxicity, headache, BLACK BOX WARNING: Spontaneuous tendon rupture, CNS effects, peripheral neuropathy

Phenazopyridine(Pyridium, Azo-standard), SE: reddish-orange urine, GI upset-take with meal

For bladder spasm/ pain when necessary, Oxybutinin (Dirtopan)*, Tolterodine (Detroit)*, darifenacin (Enablex) fesoterodine (Toviaz), solifenacin (VESIcare), trospium (Sanctura)

Liberal fluid intake 2-3 L daily if not contraindicated, Clean/wipe perineum from front to back, Avoid bubble baths, scented lubricants/toilet tissue, Empty bladder before & after intercourse, Do not delay urination, Cranberry juice, Take medication as directed and finish script!

“Are you sexually active?”

48hrs

35-year-old with multiple sclerosis and incontinence

Encourage 2-3 L of fluid throughout day, Teach pt to wipe perineum from front to back, Reinforce completion of entire course of antibiotics, Instruct pt to empty bladder immediately before & after intercourse

Rare chronic inflammation of lower urinary tract, R/t genetic & immunity dysfunction, not infection, Women effected more than men, Difficult to diagnosis, UA: WBCs, RBCs, NO bacteria, Cystoscopy for accurate diagnosis, Small bladder capacity, hunner ulcers, small hemorrhages, S/S: pain with bladder filing/voiding; voiding frequency, urgency, nocturia, suprapubic & pelvic pain-can radiate to groin/rectum (like electricity like nerve pain), Tx: bladder protectant: pentosan polysulfate sodium (Elmiron) Avoid acidic stuff here!!

Inflammation of urethra, Infectious v. non-infectious, HIghest incidence in adults aged 20-24, STI is the most common cause, Symptoms include mucopurulen or purulent discharge, Dysuria, discomfort, pain could be from ghonorrhea, chlamydia, if no infectious-menopausal

History, and symtpoms, UA,STI testing, HIV testing, Pelvic exam and/or urethroscopy (if warranted), Non-infectious interventions: Can resolve on own, or estrogen cream can be used (keep in mind have to be consistent with cream)(postmenopausal) avoid irritants, Infectious interventions: Antibiotic therapy

Stricutres, Incontinence, Urolithiasis, Urothelial cancer

Is narrowing of urethra or ureters, Cause for both types is stones

More common in males, Causes: instrumentation, catheter, STIs, prostate surgery, S/S decreased urine stream, dribbling, S/S incomplete emptying, S/S spraying of stream, S/S straining/pain, UTI, Bladder scan after urinating to see post void residual

Cause: stones, S/S back pain, S/S blood in urine (hematuria), S/S nausea, S/S UTI, S/S pain wornsed with increased fluids, Can go into AKI, could increase BUN and Cr

Urinary flow test, Pelvic/urethral ultrasound, MRI, Cystoscopy

Depends on cause, STI/infeciton = Abx, Dilation, Urethroplasty, Implanteted stent, Catherization

Renal US, CT scan (if with dye, post I&O, reaction to dye, daily weights, monitor fluid status), Renal scan, MRI, Retrograde ureteroscopy

Depends on cause, Endoscopic treatment, Surgery, Stnents, Nephrostomy tube

P: Involuntary loss of urine severe enough to cause social or hygienic problems, Temporary or permenant causes, Surgery, Spinal cord injury- S2-S4, Brain and nervous system disorders, Disease treatment, Drugs (muscle relaxers, lasix), Factors associated with aging

As many as 45% of women over age 65 report incontinence, Risk increases with:, Chronis conditions, Vaginal deliveries, Pelvic prolapse, Prostate problems, Diabetes, Heart failure, Obeisty

Stress, Urge, Overflow, Functional

Involuntary loss of urine during activities that increase abdominal and detrusor pressure, Inability to tighten the urethra sufficiently to overcome the increased detrusor pressure, Leakage of urine, Small amounts of urine lost here

Weakening of bladder neck supports; associated with childbirth, Intrinsic sphincter deficiency, such as epispadias or myelomenigocele, Acquired Anatomic damage to the urethral sphincter from repeated incontinence surgeries, prostatectomy, radiation, and trauma, Vaginasl prolapse from vaginal birth

Weight reduction, Smoking cessation, Pelvic muscle therapy (kegels), Vaginal cone therapy, Bladder training, Pessary devices, Estrogen therapy (post-menopausal), Surgery

Hormones: - Estrogen vaginal cream or estrogen ring, Anticholinergics, Alpha-Adrenergic Agonsits, Beta3 agonist, Antidepressants: Tricyclics & SNRIs

Estrogen: Topical to peri & vaginal areas, Enhances nerve conduction to the urinary tract, improves blood flow, reduces tissue deterioration, strengthens muscles around vagina & urethra, Education 4-6 weeks to achieve benefits

Detrusor muscle contracting before bladder is full, Over active bladder, Inability to suppress the signals from the muscle to the brain that it is time to urinate, Large amounts of urine lost here

Can be idiopathic, Neurological disorders, such as a stroke, BPH (benign prostatic hypertrophy), Bladder inflammation or infection, Bladder irritants such as artificial sweeteners, caffeine, alcohol, citric intake, drugs, nicotine, Bladder cancer, Meds that increase bladder contractility

Bladder training (helps with all types of incontinence), Pelvic muscle therapy, Weight reduction, Avoiding bladder irritants, Smoking cessation, Drug therapy: anticholinegrics (most common), Botox

Anticholinegrics/antispasmodics:, :Supress involuntary bladder contracations & increase capacity, :Education: increase fluid intake to avoid dry mouth & constipation; may cause urinary retenetion; blurred vision, oxybutinin chloride (Ditropan), solifenacin (Vesicare), tolterodine (Detroit), **NURSING SAFETY ALERT** *Teach patient not to chew or crush extended release anticholinergics*

Involuntary loss of urine associated with overdistention of the bladder when the bladder capacity has reached its maximum, Detrusor under activity, Bladder outlet obstruction

Urethral obstruction such as benign prostate hypertrophy or uterine prolapse, Diabetic neuropathy, Some neuro disorders, such as MS or spinal cord damage, Med side effects, Constant dribbling of urine, Sense off incomplete emptying, Pelvic discomfort, Palpable bladder

Bladder training, Bladder compression (crede’ method, gets urine going), Intermittent self-catheterization (to prev. overflow), Drug therapy, Surgery (for obstruction)

Bethanechol chloride, Short term use; usually after surgery (not feeling sensation), Increases bladder pressure

Leakage of urine caused by factors other than disease of the lower urinary tract, Causes: decreased cognition such as with dementia, Causes: Impaired mobility, such as paralysis or inability to walk to the toilet, some neurologic disorders

Quantity and timing of urine loss varies, Difficult to detect patterns

Habit training (q2hrs), Prompted voiding, Devices: pessaries, condom catch, intermittent or long-term catheterization

Hx: use effective screening methods (i.e. do you know when you need to urinate? etc.), Consider risk factors:, Age/gender, Neuro disorders, Diabetes, Vaginal deliveries/prolapse, Urologic surgeries, Medications, Bowel patterns/ constipation/ impaction, Stress/anxiety, Explain the symptoms

Pain meds, Opiates, Diuretics, Anticholinergics, Tamp down sensory perception, Constipation, Masks signals from bladder

UTI, Neuro disorders, Dementia, TBI, CVA, Parkinson’s

Don’t want to move; which came first?, Incontinent because your depressed or depressed because your incontinent?

Supplies, Education, Might have no help, Migh not have homecare, No devices possible, Briefs very expensive

Assess abdomen, Inspect females for prolapse if indicated, Hesalthcare provider will perform exam including DRE

1st: Urinalysis to rule out infection, Culture if indicated, Bladder scan (PVR), CT of kidneys and ureters, VCUG (voiding cystourtethrogram, Urodynamic testing, EMG of pelvic muscles

Altered urinary elimination due to incontinence, Potential for altered tissue integrity

Maintian optimal urinary elimination through a reduction in the urinary incontinence episodes, Maintain tissue integrity of the skin and mucous membranes in the perineal area, Demonstrate knowledge of proper use of drugs and correct procedures for self-catch, use of the artificial sphincter, or care of an indwelling catheter, Demontrate effective use of the selected exercise or bladder-training program, Select and use incontinence interventions, devices, and products