More Disorders of The Urinary System

URINARY DISORDERS
URINARY RETENTION
• The inability to empty bladder completely.
• Chronic urine retention eventually leads to overflow
incontinence
• Normally, healthy adults younger than 60years should have
complete bladder emptying with each voiding.
• Older adults above 60 years have 50-100ml of residual urine
due to decreased contractility of detrusor muscles.
• General anesthesia also reduces bladder muscle innervation
and suppresses the urge to void post-operatively.
Causes
• Diabetes
• Prostatic enlargement
• Urethral infection, tumor or calculi
• Pelvic injuries
• Pregnancy
• Neurological disorders e.g. spinal cord injury
Cont’’
• Medications that inhibit bladder contractility.
• Anticholinergic agents e.g. atropine
• Antispasmodic agents e.g. oxybutynin
• Opioid suppositories
• Tricyclic antidepressant medications
• Medications that increase bladder outlet resistance
• Alpha-adrenergic agents
• Beta-adrenergic blockers e.g. metoprolol
Manifestations
• Patients may report
• Terminal dribbling
• Voiding small quantities of urine
• Lower abdominal pain/discomfort
• Swelling around the pelvic area due to bladder distention
• Restlessness
• Awareness of bladder fullness
Assessment and Diagnosis
• History taking-voiding problems
• Percussion of the pelvic area elicits dullness
• Urinalysis to assess for UTI
• Post-void bladder ultrasound to assess residual
volume
Complications
• Chronic UTI
• Renal calculi
• Pyelonephritis
• Sepsis
• Hydronephrosis
• Skin breakdown due to urine leakage
Management
• Goals
• to prevent over-distention of the bladder
• To prevent and treat infections
• Prevent and correct obstruction
• Identify and treat the cause
Nursing management
• Promote normal urinary elimination by:
• Ensuring privacy during voiding
• Availing bed pans for bedridden patients
• Assisting patients to use the bathroom
• Sitz baths and warm compresses to the perineum
• Catheterize/suprapubic catheters
• Bladder retraining to prevent uncontrolled voiding
Urinary Reflux
• Urethrovesical reflux
• backflow of urine from the urethra into the bladder.
• Causes
• decreased urethrovesical angle pressure,
• dysfunction of the bladder neck or urethra.
Vesicoureteral reflux
• Backflow of urine from the bladder into one or both
ureters.
Cont’’
• Normally, the ureterovesical junction prevents urine
from flowing back to the ureters.
• VUR occurs when the ureterovesical valve is impaired
• The cause is often genetic
• Can also be associated with severe nephropathy
Other causes
• Primary
• Inadequate detrusor backing
• Lateral displacement of the ureteral orifice
• Secondary causes
• Cystitis or UTI
• Neurogenic bladder
• Bladder outlet obstruction
Clinical presentation
• VUR does not cause any specific signs and symptoms
• It usually detected after causing kidney infection
• Manifestations may include; urgency, frequency,
dysuria
Lab and imaging studies
• Urinalysis
• UECs
• Renal and bladder ultrasonography to evaluate degree
of hydronephrosis
• Voiding cystourethrography
VUR staging
• Grade I: Urine backs up into the ureter only, and the renal pelvis appears
healthy, with sharp calyces.
• Grade II: Urine backs up into the ureter, renal pelvis, and calyces. The
renal pelvis appears healthy and has sharp calyces.
• Grade III: Urine backs up into the ureter and collecting system. The ureter
and pelvis appear mildly dilated, and the calyces are mildly blunted.
• Grade IV: Urine backs up into the ureter and collecting system. The ureter
and pelvis appear moderately dilated, and the calyces are moderately
blunted.
• Grade V: Urine backs up into the ureter and collecting system. The pelvis is
severely dilated, the ureter appears tortuous, and the calyces are severely
blunted.
Management
• Treatment depends on severity.
• Three approaches are considered
• Active surveillance
• Medical treatment
• Surgical treatment
Active Surveillance
• Spontaneous resolution of reflux is high in children
below 5years
• Active surveillance involves preventing infections
• Sterile reflux does not damage the kidneys
• Include bladder training to ensure complete emptying
• Encourage adequate hydration to prevent UTI
• Circumcision in boys to prevent UTI
Medical Management
• Correct the underlying voiding dysfunction
• Administer long-term broad-spectrum antibiotics
• Anticholinergic agents to prevent detrusor overactivity
• Follow-up radiographic studies
Surgical Interventions
• Preserved in
• Breakthrough pyelonephritis
• Progressive renal scarring in patients using antibiotics
• Uterovesical junction abnormality
• Ureteral implantation
• Intravesical re-implantation
Neurogenic Bladder
• A disorder in which the nerves innervating the bladder are
dysfunctional, causing loss of bladder control.
• It results from a lesion of the nervous system.
• Causes
• Spinal cord injury
• Spinal tumor
• Herniated vertebral disk
• Infection
• Congenital anomalies
• Multiple sclerosis
Pathophysiology
• Two types of neurogenic bladder.
• Spastic (reflex bladder).
• Caused by spinal cord lesion above the voiding reflex
arc (upper motor neuron lesion)
• The lesion results in loss of conscious sensation and
cerebral motor control.
• The spastic bladder empties on reflex with minimal
control to its activities
• Flaccid bladder
• Caused by a lower motor neuron lesion from trauma
• The bladder continues to fill and becomes greatly
distended.
• This causes overflow incontinence.
Assessment and Diagnostic
findings
• Fluid input and output monitoring
• Measuring residual urine volume
• Urinalysis
• Assessment of the sensory awareness of bladder
fullness
Complications
• Infection from urine stasis and catheterization
• Urolithiasis caused by urinary stasis, infection, bone
demineralization from prolonged immobility.
• Renal failure associated with vesicoureteral reflux and
hydronephrosis
Management
• Goals of management.
• Preventing overdistention of the bladder
• Emptying the bladder regularly and completely
• Maintaining urine sterility
• Maintain adequate bladder capacity
Interventions
• Intermittent or continuous catheterization
• Diet low in calcium to prevent renal stones formation
• Encourage ambulation
• Increase oral fluid intake
• Encourage double voiding in patients with flaccid bladder
• Cholinergic agents e.g. bethnechol to increase contraction of
detrusor muscles.
• Surgical interventions to correct bladder neck contractures or
urinary diversion.
Group Assignment
• Discuss urinary incontinence under the following
subheadings.
• Risk factors
• Types of incontinence
• Assessment and diagnostic findings
• Medical management
• Surgical management
• Nursing management

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URINARY DISORDERS

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