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Chapter 40
Urologic Disorders
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Learning Objectives
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List the data to be collected when assessing a patient who has a urologic
disorder.
Describe the diagnostic tests and procedures for patients
with urologic disorders.
Explain the nursing responsibilities for patients having
tests and procedures to diagnose urologic disorders.
Describe the nursing responsibilities for common therapeutic
measures used to treat urologic disorders.
Explain the pathophysiology, signs and symptoms, complications,
and treatment of disorders of the kidneys, ureters, bladder, and urethra.
Assist in developing a nursing care plan for patients with
urologic disorders.
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Anatomy of the Urinary System
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Components
• The urinary system consists of
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Two kidneys
Two ureters
The bladder
The urethra
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Figure 40-1
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Kidneys and Ureters
• Kidneys are bean-shaped organs located just
under and below the 12th rib near the waist in
the body trunk
• The hilus, or entry, to the kidney is located on
the concave surface of the kidney near the
spine
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Kidneys and Ureters
• Cortex: outer layer; medulla: inner layer
• Cortex receives a large blood supply; very sensitive to
changes in blood pressure and blood volume
• Medulla organized into 8-18 pyramidal structures; concentrate
and collect urine; drain it into the calices
• The calices then drain urine into the renal pelvis
• Renal pelvis forms funnel-shaped proximal end of
ureter
• Ureter carries urine from renal pelvis to bladder
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Figure 40-2
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Figure 40-3
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Kidneys and Ureters
• The nephron is the functional unit of the kidney
• 1 to 1.25 million nephrons in each kidney
• Vascular tubular system: glomerulus, Bowman’s capsule, and
tubule
• Glomerulus: mass of blood vessels tucked into the cuplike
Bowman’s capsule
• Each tubule consists of a proximal tubule, the loop of Henle, a
distal tubule, and a collecting duct
• Nephron located mostly in the cortex of the kidney; loop of
Henle dips into the medulla; and the collecting ducts travel
through the medulla to the calices
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Figure 40-4
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Bladder and Urethra
• Bladder: muscular sac; stretches to store urine
• On floor of pelvic cavity behind the peritoneum
• In front of the rectum in men; in front of the vagina and
uterus in women
• Trigone: triangular-shaped area on posterior wall
• Control possible by sensory and motor nerves
• Urethra: muscular tube lined with mucous membranes;
carries urine from bladder out of the body
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Figure 40-5
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Physiology of the Urinary System
• Regulation and excretion
• Urine production
• Glomerular filtration, tubular reabsorption, and tubular
secretion
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Urine elimination
Regulation of serum calcium and phosphate
Regulation of blood pressure
Hormonal stimulation of red blood cell production
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Figure 40-6
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Age-Related Changes in the
Urinary System
• Loss of nephrons, thickening of membranes in
nephrons, and sclerosis of renal blood vessels
• Creatinine clearance decreases with age
• Nocturia: awaken from sleep to void
• Bladder muscles weaken; connective tissue increases
• Incontinence not normal consequence of age, but it is
common
• In men, urethral obstruction often a problem
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Health History
• Chief complaint
• Changes in urine quality or quantity, pain
• History of present illness
• Patient’s normal or usual pattern of urination
• Pain or discomfort
• Problem initiating or controlling urination
• Document circumstances under which these problems
occur
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Health History
• Past medical history
• A history of streptococcal infections, recurrent
urinary tract infections (UTIs), renal calculi
(“stones”), gout, or hypercalcemia
• Family history
• Congenital kidney problems, such as polycystic
kidneys or urinary tract malformations, diabetes
mellitus, and hypertension
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Health History
• Review of systems
• Changes in skin color, respiratory distress, edema,
fatigue, nausea, vomiting, chills, and fever
• Functional assessment
• Daily fluid intake
• Effects of the chief complaint on daily life
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Physical Examination
• Skin color (ashen, yellow); crystals on skin (uremic frost)
• Tissue turgor: to detect dehydration or edema
• Periorbital edema: suggests fluid retention. Inspect the mouth for
moisture and odor
• Observe respiratory rate, pattern, and effort
• Auscultate the lungs for crackles or rhonchi
• Inspect the abdomen for scars and contours, and palpate for
tenderness and bladder distention
• Auscultate the kidney area over costovertebral angle (Figure 40-2)
to detect renal bruits
• Edema
• Inspect the genitalia
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Figure 40-2
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Diagnostic Tests and Procedures
• Urine tests
• Urinalysis
• Urine culture and sensitivity
• Creatinine clearance
• Blood tests
• Blood urea nitrogen
• Serum creatinine
• Serum electrolytes
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Diagnostic Tests and Procedures
• Radiographic tests and procedures
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Kidneys, ureters, bladder (KUB)
Intravenous pyelogram
Arteriogram
Cystogram
Renal scan
CT scan and MRI
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Diagnostic Tests and Procedures
• Ultrasonography
• Invasive procedures
• Renal biopsy
• Cystoscopy
• Urodynamic studies
• Cystogram and voiding cystourethrogram
• Cystometrogram
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Therapeutic Measures
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Catheterization
Ureteral catheter
Nephrostomy tube
Urinary stent
Drug therapy
• Urologic surgery
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Nephrectomy
Removal of calculi
Lithotripsy
Cystectomy
Cystotomy
Urinary diversions
Cystostomy
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Disorders of the Urinary Tract
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Urethritis
• Inflammation of the urethra
• By microorganisms, trauma, or hypersensitivity to
chemicals in products such as vaginal deodorants,
spermicidal jellies, or bubble baths
• Signs and symptoms
• Dysuria, frequency, urgency, and bladder spasms
• Urethral discharge may be noted
• Medical diagnosis
• Based on patient signs and symptoms, urinalysis, and urethral
smear
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Urethritis
• Medical treatment
• Antimicrobials
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Urethritis
• Assessment
• Comfort, possible causative factors, and understanding of
treatment and prevention
• Interventions
• Sitz baths
• Instruct female patients to wipe from front to back after
toileting; void before and after sexual intercourse
• Discourage bubble baths and vaginal deodorants
• Instruct uncircumcised male patients to clean the penis under
the foreskin regularly
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Cystitis
• Inflammation of the urinary bladder
• Common cause is bacterial contamination
• Other factors: prolonged immobility, renal calculi,
urinary diversion, and indwelling catheters
• Signs and symptoms
• Urgency, frequency, dysuria, hematuria, nocturia, bladder
spasms, incontinence, and low-grade fever
• Urine may be dark, tea-colored, or cloudy
• Fever, fatigue, and pelvic or abdominal discomfort
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Cystitis
• Medical diagnosis
• Urinalysis, culture, and sensitivity
• White blood cells (WBCs)
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Medical treatment
• Antibiotics
• Mild analgesic; hyoscyamine (Cystospaz) and
flavoxate (Urispas)
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Cystitis
• Assessment
• Patient symptoms, causative factors, and
understanding of treatment and prevention
• Interventions
• Patient teaching regarding medications, fluids, and
prevention
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Interstitial Cystitis
• Pathophysiology and diagnosis
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Inflammatory disease of the bladder, usually chronic
Cause is unknown
Bladder/pelvic pain; urinary frequency and urgency
Diagnosed by cystoscopy
• Medical treatment
• Symptom management; attempts to treat causes
• Nursing care
• Primary role is teaching and support
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Pyelonephritis
• Inflammation of the renal pelvis
• Acute pyelonephritis most often caused by
ascending bacterial infection, but it may be
bloodborne
• Chronic pyelonephritis often the result of reflux
of urine from inadequate closure of the
ureterovesical junction during voiding
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Pyelonephritis
• Signs and symptoms
• Acute pyelonephritis
• High fever, chills, nausea, vomiting, and dysuria;
severe pain or a constant dull ache occurs in the
flank area
• Chronic pyelonephritis
• Bladder irritation, chronic fatigue, and slight
aching over one or both kidneys
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Pyelonephritis
• Medical treatment
• Antibiotics, urinary tract antiseptics, analgesics, and
antispasmodics
• Drink at least eight 8-ounce glasses of fluids daily
• Intravenous fluids may be ordered if nausea and
vomiting
• Dietary salt and protein restriction for patient with
chronic disease
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Pyelonephritis
• Assessment
• Related signs and symptoms, history of urinary tract disorders,
predisposing factors, and effects of the infection on daily
activities
• Interventions
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Acute Pain
Activity Intolerance
Deficient Fluid Volume and Imbalanced Nutrition
Ineffective Management of Therapeutic Regimen
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Polycystic Kidney Disease
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Hereditary disorder
Two types: childhood and adult
In adults usually manifested by age 40 years
Grapelike cysts in place of normal kidney tissue
Cysts enlarge, compress functional renal tissue, and
result in renal failure
• Signs and symptoms
• Dull, aching abdominal, lower back or flank pain, or colicky
pain that begins abruptly
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Figure 40-7
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Polycystic Kidney Disease
• Medical treatment
• Supportive treatment is recommended to preserve
kidney function, treat UTI, and control hypertension
• Infections treated promptly with antibiotics
• Dialysis, nephrectomy, and transplantation once
end-stage renal disease develops
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Acute Glomerulonephritis
• Pathophysiology
• Immunologic disease: inflammation of the capillary loops in the
glomeruli
• Signs and symptoms
• Urine becomes tea colored as output decreases
• Peripheral and periorbital edema
• As glomerular filtration decreases, mild to severe hypertension
occurs and hypervolemia results
• Medical diagnosis
• Patient assessment and laboratory tests
• Urinalysis, BUN, creatinine, and albumin
• Renal ultrasound, renal biopsy, or both
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Acute Glomerulonephritis
• Medical treatment
• Diuretics, antihypertensive medications, and
antibiotics
• Bed rest; activity restriction
• Fluids, sodium, potassium, and protein may be
restricted
• If renal failure develops, dialysis is necessary
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Acute Glomerulonephritis
• Assessment
• Signs and symptoms, recent infections, and
changes in urine
• Interventions
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Excess Fluid Volume
Activity Intolerance
Self-Care Deficit
Anxiety
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Renal Calculi
• Urinary tract obstruction
• Pathophysiology
• Precipitations of calcium salts (calcium phosphate or
calcium oxalate), uric acid, magnesium ammonium
phosphate, or cystine
• All are normally found in the urine
• Factors for development of calculi
• Concentrated urine; excessive intake of calcium, vitamin D,
protein, oxalates, calcium-based antacids; familial tendency;
hyperparathyroidism; immobility, urinary stasis; sedentary
lifestyle; altered urine pH; lack of kidney substance that
inhibits calculi formation
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Renal Calculi
• Signs and symptoms
• Pain
• Dull flank pain: a calculus in the renal pelvis or stretching of
the renal capsule from urine retention (hydronephrosis)
• If calculus lodges in a ureter, excruciating pain in the abdomen
that radiates to the groin or the perineum
• Nausea, vomiting, hematuria may accompany pain
• Medical diagnosis
• KUB, IVP, retrograde pyelogram, or ultrasound
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Renal Calculi
• Medical treatment
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Most calculi are passed spontaneously
Ambulation and adequate hydration facilitate passage
Opioid analgesics/antispasmodics relieve pain
Lithotripsy
Endourologic procedures
Surgical procedures
• Nephrolithotomy
• Pyelolithotomy
• Ureterolithotomy
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Figure 40-8
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Figure 40-9
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Renal Calculi
• Prevention
• High fluid intake to keep urine dilute, dietary
restrictions for specific elements (i.e., calcium and
purines), regular exercise, medications to alter urine
pH
• Assessment
• Patient’s usual fluid intake and diet, including
vitamin and mineral supplements
• Location, severity, and nature of the pain
• Changes in urine amount or characteristics
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Renal Calculi
• Interventions
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Acute Pain
Impaired Urine Elimination
Risk for Deficient Fluid Volume
Risk for Infection
Decreased Cardiac Output
Ineffective Breathing Patterns
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Figure 40-10
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Urologic Trauma
• Penetrating injuries most often from knives or
guns
• Blunt trauma: a force is applied to the
abdominal wall and the energy is diffused into
the abdominal cavity
• When blunt trauma suspected, observe for
bruising on abdomen or in the flank area
• Assess for signs of shock, pain, and palpable
abdominal mass
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Urologic Trauma
• Grey Turner’s sign
• Bruising over the flank and lower back; occurs with
retroperitoneal bleeding
• Physician may order a KUB, urography, CT, or
ultrasound to determine extent of injury
• Most common indication is hematuria
• Severe injuries require surgery to repair
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Renal Cancer
• 80% of malignancies: adenocarcinomas; primarily
affect men 55-60 years of age
• Less common squamous cell carcinomas of the renal
pelvis affect men and women equally
• Tumor may be large before it is detected. Renal
malignancies metastasize to the liver, lungs, long
bones, and the other kidney
• Early symptoms: anemia, weakness, and weight loss;
painless, gross hematuria classic sign, but usually
occurs in the advanced stage. A dull ache in the flank
area also is a late symptom
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Renal Cancer
• Medical diagnosis
• Excretory urography, IVP, retrograde pyelography,
ultrasound, arteriography, computed tomography,
magnetic resonance imaging, and renal biopsy
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Renal Cancer
• Medical treatment
• Radical nephrectomy
• In general, renal tumors are not responsive to
radiation or chemotherapy; radiation is sometimes
used as a palliative measure for inoperable cancer
• Biotherapy with alpha-interferon and interleukin-2
for metastatic disease
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Renal Cancer
• Assessment
• Weakness, fatigue, and changes in the urine
• Patient’s emotional state, usual coping strategies,
and support systems
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Renal Cancer
• Preoperative Care
• Ineffective Coping related to potentially fatal disease
• Deficient Knowledge of tests, procedures, and
effects of nephrectomy
• Postoperative Care
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Monitor vital signs; record intake and output
Routinely check drains and tubes
Monitor dressings for drainage
Auscultate breath sounds and bowel sounds
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Renal Cancer
• Interventions
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Acute Pain
Risk for Deficient Fluid Volume
Ineffective Breathing Pattern
Risk for Injury
Risk for Infection
Ineffective Coping
Deficient Knowledge
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Bladder Cancer
• Most common malignancy of urinary tract
• Ureteral orifices and bladder neck are the most
common sites
• Tars in smoking tobacco, aniline dyes in
industrial compounds, and tryptophan have
been implicated in development of bladder
cancer
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Bladder Cancer
• Signs and symptoms
• Painless, intermittent hematuria
• Other signs and symptoms: bladder irritability;
infection, with dysuria, frequency, and urgency; and
decreased stream of urine
• Medical diagnosis
• Urinalysis, IVP, CT scan, and cystoscopy
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Bladder Cancer
• Medical treatment
• Surgery is the treatment of choice
• Cystoscopic resection and fulguration or laser
photocoagulation
• Segmental bladder resection and radical cystectomy
• Urinary diversion
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Bladder Cancer
• Assessment
• Description of urinary signs and symptoms
• Fatigue and weight loss
• Health history may reveal use of tobacco or
exposure to carcinogenic chemicals
• Patient’s emotional state, coping strategies, and
sources of support
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Figure 40-11
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Bladder Cancer
• Interventions
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Acute Pain
Impaired Urinary Elimination
Impaired Skin Integrity
Risk for Infection
Risk for Injury
Deficient Knowledge
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Acute Renal Failure
• Causes
• Prerenal failure: decreased blood flow to glomeruli
• Intrarenal failure: nephrotoxic agents, kidney
infections, occlusion of intrarenal arteries,
hypertension, diabetes mellitus, or direct trauma to
the kidney
• Postrenal failure: obstructions beyond the kidneys
that cause urine to back up
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Acute Renal Failure: Stages
• Onset stage
• Short (1-3 days); increasing BUN and serum creatinine with
normal to decreased urine output
• Oliguric stage
• The urine output decreases to 400 mL/day or less
• Serum values for BUN, creatinine, potassium, and phosphorus
increase
• Serum calcium and bicarbonate decrease
• Follows onset stage and continues for up to 14 days
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Acute Renal Failure: Stages
• Diuretic stage
• Urine output exceeds 400 mL/day; may rise above
4 L/day
• Kidneys excrete BUN, creatinine, potassium, and
phosphorus and retain calcium and bicarbonate
• Recovery stage
• As renal tissue recovers, serum electrolytes, BUN,
and creatinine return to normal
• This stage lasts 1 to 12 months
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Acute Renal Failure
• Medical treatment
• Fluid and dietary restrictions, restoration of
electrolyte balance, and dialysis
• Drug therapy
• Diet
• Fluids
• Hemodialysis and peritoneal dialysis
• Continuous renal replacement therapy
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Figure 40-12
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Acute Renal Failure
• Assessment
• Monitoring fluid status is critical
• Signs and symptoms of electrolyte imbalances
• Signs and symptoms related to immobility: pressure
sores, impaired circulation, constipation, and
atelectasis
• Fears, anxiety, coping strategies, sources of support
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Acute Renal Failure
• Interventions
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Excess Fluid Volume
Decreased Cardiac Output
Anxiety
Disuse Syndrome
Deficient Knowledge
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Chronic Kidney Disease
• Progressive nephron destruction of both kidneys
• Creatinine clearance: important measure of renal
function
• <15 mL/min, dialysis or transplantation necessary
• Uremia: when kidneys unable to maintain fluid and
electrolyte or acid-base balance
• Also called end-stage renal disease
• Causes: hypertension, diabetes mellitus, and
atherosclerosis
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Chronic Kidney Disease:
Signs and Symptoms
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Azotemia
Hyperkalemia
Hypocalcemia
Metabolic acidosis
Fluid balance (hypernatremia and hypervolemia)
Insulin resistance
Anemia
Suppressed immunologic function
Cardiovascular system (CHF and dysrhythmias)
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Chronic Kidney Disease:
Signs and Symptoms
• Neurologic system (mental status changes)
• Integumentary system (accumulation of waste
products)
• GI system (irritation, nausea, vomiting, a metallic taste
in the mouth, and bleeding)
• Musculoskeletal system (renal osteodystrophy)
• Reproductive system (sex hormones decline and libido
is diminished)
• Endocrine function (hyperparathyroidism)
• Emotional and psychological effects
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Chronic Kidney Disease:
Medical Treatment
• IV glucose and insulin, calcium carbonate, calcium acetate, or
sodium polystyrene sulfonate to treat hyperkalemia
• Calcium, active vitamin D, and phosphate binders to treat
hypocalcemia
• Fluid restriction and diuretics to treat hypervolemia
• Diuretics, beta blockers, calcium channel blockers, and ACE
inhibitors for hypertension
• Iron supplements, folic acid, and synthetic erythropoietin to treat
anemia
• Hypertonic glucose to treat disequilibrium syndrome
• High-carbohydrate, low-protein diet to prevent excess urea
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Chronic Kidney Disease: Dialysis
• Passage of molecules through semipermeable membrane into
special solution called dialysate solution
• Dialysis operates like the kidney
• Small molecules (urea, creatinine, and electrolytes) pass out of
the blood, across a membrane, and into a solution
• The goals of dialysis
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Remove end products of protein metabolism from the blood
Maintain safe concentrations of serum electrolytes
Correct acidosis and replenish the body’s bicarbonate buffer system
Remove excess fluid from the blood
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Chronic Kidney Disease: Dialysis
• Hemodialysis
• Blood is removed and circulated through an “artificial kidney”
to remove excess fluid, electrolytes, wastes
• Dialyzed blood then returned to the patient
• Requires vascular access
• By catheter, cannula, graft, or fistula
• Subclavian or femoral catheters for temporary access for dialysis
during acute renal failure while a graft or fistula matures (dilates
and toughens) or for patients on peritoneal dialysis who need
immediate access for hemodialysis
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Figure 40-13
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Figure 40-14
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Chronic Kidney Disease: Dialysis
• Peritoneal dialysis
• Uses the patient’s own peritoneum as a semipermeable
dialyzing membrane
• Fluid instilled into peritoneal cavity
• Waste products drawn into the fluid, which is then drained from
the peritoneal cavity
• May be temporary or permanent
• Temporary: catheter inserted into the peritoneal cavity through the
abdominal wall
• Long-term: catheter is implanted into the peritoneal cavity
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Chronic Kidney Disease: Dialysis
• Peritoneal dialysis
• Advantages over hemodialysis: less anemia,
reduced cost, fewer dietary and fluid restrictions,
independence, closer to normal kidney function
• Disadvantages: risk of peritonitis (the major
complication) and catheter site infection,
hyperglycemia, elevated serum lipids, and body
image disturbance
• Three phases: inflow, dwell, and drain
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Figure 40-15
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Chronic Kidney Disease
• Assessment
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Frequent monitoring for changes important
Fluid balance evaluated closely
Accurate intake and output records
Signs and symptoms of fluid volume excess that can lead to
cardiac failure: increasing edema, dyspnea, tachycardia,
bounding pulse, rising blood pressure
• Signs and symptoms of electrolyte imbalances
• Appetite, usual daily intake, weight gain or loss pattern, and
prescribed diet
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Chronic Kidney Disease
• Interventions
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•
•
Excess Fluid Volume
Imbalanced Nutrition: Less Than Body Requirements
Disturbed Sensory Perception
Ineffective Coping
Situational Low Self-Esteem
Risk for Infection
Risk for Injury
Constipation
Diarrhea
Sexual Dysfunction
Self-Care Deficit
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Renal Transplantation
• Kidney donation
• Healthy kidney from live donor (a relative) or cadaver
• Tissues must match or recipient will reject new kidney
• Matching based on ABO blood groups and human leukocyte
antigens
• Crossmatching reveals any cytotoxic preformed antibodies—
would certainly result in organ rejection
• Kidney donors must be at least 18 years of age, free of
systemic disease or infection, have no history of cancer or
renal disease, have normal renal function, and be without
major medical problems
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Renal Transplantation
• Preoperative nursing care
• Patient must be prepared mentally and physically
• Recipient and live donor have complete diagnostic workups to
rule out other medical problems and evaluate function of the
urinary tract
• Recipient given medications to bring blood pressure within
normal limits
• Immunosuppressants: to control the body’s response to
foreign tissue
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Renal Transplantation
• Interventions
• Encourage patient to discuss concerns
• Factual information helps the patient cope by
reducing the fear of the unknown
• When patients are active participants in their care,
they feel less helpless and less anxious
• Preoperative teaching begins when the patient is
identified as a candidate for transplantation
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Renal Transplantation
• Surgical procedure
• Donor kidney removed from live donor in OR; taken to
adjacent room where the recipient has been prepared
• Cadaver kidney removed under sterile conditions and
transported to the hospital where recipient is waiting
• Donor kidney placed in recipient’s abdomen and anastomosed
(attached) to bladder and blood vessels
• Complications
• Acute tubular necrosis, rejection, renal artery stenosis,
hematomas, abscesses, and leakage of ureteral or vascular
anastomoses
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Figure 40-16
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Renal Transplantation
• Postoperative nursing care
• Assessment
• Fluid intake, urine output, weight changes, and vital signs
• Interventions
•
•
•
•
•
Impaired Urinary Elimination
Deficient Fluid Volume
Risk for Infection
Ineffective Management of Therapeutic Regimen
Anxiety
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The Kidney Donor
•
•
•
•
Physical care of the donor similar to that for a nephrectomy
Nephrectomy may be conventional or laparoscopic
Pain worse with conventional approach; provide good pain control
Conventional approach: patient hospitalized 4 to 7 days and return
to work in 6 to 8 weeks
• Laparoscopic approach: donor hospitalized 2 to 4 days and can
return to work in 4 to 6 weeks
• Donor usually feels good about the experience
• If kidney fails, donor may be disappointed; be sensitive
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