Physiology of Urinary Elimination

• Effective functioning of kidneys, ureters, bladder, and urethra.
•  Kidneys

• Nephron: functional unit
•  Glomerulus
• Bowman's capsule
• Proteinuria

• 10-12" long
• One way valve at the bladder to prevent reflux back into the ureter and kidney

Bladder

• Hollow, muscular organ behind the symphysis pubis
• Males: in front of the rectum and above the prostate gland
• Females: In front of the uterus and vagina
• Desire to void at 250-450ml of urine

• Males: two purposes
• Females: 3.7cm, Males: 20cm
• Ends at meatus
• Internal and external sphincter

• AKA Micturition, voiding, or urination
• Streth receptors
• Urinary incontinence
• Retention

• Age
• Psychological factors
• Fluid and food intake
• Medications
• Muscle tone and activity
• Pathologic conditions - Diabetes Insipidus -> causes excess urine O/P
• Surgical and diagnostic procedures -important to void after surgery

• Frequency and nocturia (waking up @ night to void a lot)
• Urgency
• Dysuria (burning - biggest indication of UTI)
• Enuresis (nocturnal enuresis = bed wetting)
• Urinary incontinence
• Retention: neurogenic bladder
• Urinary diversions: ileoconduit (advanced) and suprapubic catheter (just like foley -> but instead of inserting through ureters, suprapubic catheter put through abdomen directly into bladder)

• Hesitancy (delay/difficulty urination)
• Polyuria (increase in volume while excreting than intaking)
• Oliguria (<30cc/hr or <400cc/day. Urinary but limited)
• Anuria (No urination at all. Might have a little bit. Who? Dialysis patient.)
• Hematuria (RBC in urine - When? Trauma, kidney stones, bad UTI are common causes)
• Proteinuria

I. Inflammation

II. Obstruction

III. Hyper and hypoactivity

• Urinary tract infections
• - Cystitis
• - Prostatitis
•  - Urethritis
•  - Pylonephritis
• - interstitial nephritis

Lower Urinary Tract Infections: Cystitis

what happens?

which organisms?

Signs and Symptoms?

Management?

• Bacterial organisms enter
• Reflux
• Bacteriuria > 10^5
• Organisms: E. Coli, Staphylococcus saprophyticus, proteus, pseudomonas, Klebsiella, Enterobacter
• Signs and Symptoms: dysuria, frequency, urgency, nocturia, incontinence, suprapubic or pelvic pain, hematuria

Upper UTI

• Polynephritis: acute and chronic
• Incompetent ureterovesical valve: back-up into the kidneys
• Also: kidney stones, bladder tumors, strictures
• Prostatitis: bacterial or non-bacterial
• Inflammation
• Signs and symptoms: change in patterns, straining in urination, pain, fever, chills, general fatigue. Can have pain during or after ejaculation if they have prostatitis.
• Culture and sensitivity
• Treatment: Can do a CNS; Encouraged to sit in bathtub, helps; Stool softeners so they have no discomfort with BM.

• Urolithiasis: development of stones in the urinary tract
• Nephrolithiasis: stone formation within the kidney
• Stone = calculus, calculi
• Renal colic - severe pain with stone. intermittent pain. May go to upper abdomen, may radiate to groin. Often have vomiting, clamor.
• Staghorn calculus - stone with lithiasis of kidney
• Management - lithotripsy.

• Bladder Cancer - increased risk of cancer with cigarette smoking
• Management
• Cystectomy
• Ileoconduit - take ileum, turn it into a pouch (like a bladder), connect to ureters. Urine comes out. Same principle as colostomy

Obstruction and irritation

(describe how it happens and what happens)

• Gradual
• Urinary retention
• Kidney disorders with backflow

• Tests of renal function: BUN and creatinine
• PSA (next flashcard)
• Cystourethroscopy (next to next flashcard)
• IVP

• PSA = prostate specific antigen
• BPH - special protein that prostate secretes. First thing it indicates is prostate cancer. Can indicate other things though.

• Shows more
• Foley catheter into person, saline into bladder, shows the stones

• Changes in the size of the gland
• BPH common in men over 50

• Impingement on the urethra
• Hypertrophy of the bands of bladder muscles
• Changes in the contour of the bladder
• Muscle tone diminishes over time

• Transurethral prostatectomy (TURP)
• Small amount of tissue needing resection
• Large foley: 3 way
• Bladder irrigation
• Retrograde ejaculation

• Most common cancer in adult men
• Risk factors
• Detected on rectal examination and transrectal ultrasound
• Can spread slowly or aggressively
• Symptoms mimic BPH

• Hormone therapy
• Radiation therapy
• Cryosurgical ablation

• Suprapubic prostatectomy
• Retropubic prostatectomy
• Perineal prostatectomy
• Orchiectomy

III. Hyper and Hypoactivity

Types of continence

• Functional
• Reflex
• Stress
• Total
• Urge
• Overflow

DIAPPERS

• Delirium
• Infection
• Atrophic vaginitis
• Pharmacologic agents: ETOH, diuretics
• Psychological factors
• Excessive urine production
• Restricted activity
• Stool impaction

• Behavioral
• Pharmacologic
• Surgical management

• Physiological: enlarged prostate
• Interruption of the detrusor muscles
• Repeated UTIs with scarring
• Inflammation
• Medications

• Hereditary disease, cyst formation, massive kidney enlargement
• May result in renal failure

• Leading cause of renal failure
• Primary or secondary
• Azotemia
• Nephrotic syndrome

• Lupus
• Post group A beta Strep infections
• Hep B
• Varicella
• Hematuria: cocoa colored urine, proteinuria

• Abnormal dilatation of the renal pelvis
• Results fomr obstructive processes

• Those affecting renal blood flow and perfusion
• Vascular disorders of the kidney
• Renal artery occlusion: thrombus
• Nephrotoxic agents

• Indwelling
• Suprapubic: tube inserted into the bladder over the pubis but incision or puncture

• Hemodialysis
• Peritoneal dialysis
• Access
• fistula
• graft

• Normal voiding pattern
• Physical assessment
• Collecting urine specimens
• Assessment of urine
• Measuring urine output

• Kidney: costovertebral angle, dull, constant ache, or sharp, stabbing
• Bladder: pain over suprapubic area
• Ureteral: costovertebral angle, flank, lower abdominal area, testis, labia. Sharp and stabbing.
• Urethral: pain before and after voiding

• Specific gravity: normal 1.010-1.025
• Urinary pH
• Glucose
• Ketones
• blood

• Blood tests: creatinine and blood urea nitrogen
• Cytoscopy
• Intravenous Pylogram (IVP)
• Retrograde pylogram
• Computerized axial tomography
• Ultrasound

• High risk for infection
• Self-esteem disturbance
• High risk for impaired skin integrity
• Body image disturbance

• Outcome criteria related to urinary inconctinence and urinary retention

• Maintaining normal urinary elimination
• Maintaining normal bowel elimination
• Promoting fluid intake
• Assisting with toileting
• Bladder training
• Maintaining skin integrity
• Applying external urinary devices
• Performing or teaching catheterization
• Crede maneuver: manual pressure over the bladder

• Observing character of the urine
• Recording frequency
• Measuring I&O
• Inspecting skin around meatus and perineal area
• Percussing or palpating for bladder distention