Lower Urinary Tract Lower Urinary Tract ProblemsProblems

♦ A & P ReviewA & P Review

♦ Lower urinary tract infectionsLower urinary tract infections

♦ Bladder DiseaseBladder Disease

BladderBladder♦ Hollow,distensible, muscular organ Hollow,distensible, muscular organ

♦ 4 layers of muscle4 layers of muscle

♦ Reservoir for urineReservoir for urine

♦ Organ of excretionOrgan of excretion

♦ Expands as it becomes filled with urineExpands as it becomes filled with urine

♦ Pressure within bladder is lowPressure within bladder is low

♦ 600 ml capacity, normal voiding 300 ml600 ml capacity, normal voiding 300 ml

BladderBladder♦ Trigone-base of bladderTrigone-base of bladder – –

♦ Triangular area formed by the two ureteral openings and Triangular area formed by the two ureteral openings and the bladder neck at the base on the bladderthe bladder neck at the base on the bladder

♦ Muscular layer-detrusor muscleMuscular layer-detrusor muscle♦ Distention during filling & contraction during emptyingDistention during filling & contraction during emptying♦ Parasympathetic innervation stimulates detrusor during Parasympathetic innervation stimulates detrusor during

urination (smooth muscle contraction) resulting in bladder urination (smooth muscle contraction) resulting in bladder emptyingemptying

♦ Diurnal pattern of urinationDiurnal pattern of urination: 5-6x/day and : 5-6x/day and occasionally at nightoccasionally at night♦ Volume of urine produced at night is less than half that Volume of urine produced at night is less than half that

produced during the day -- ADHproduced during the day -- ADH

BladderBladder

♦ External Sphincter controlExternal Sphincter control ♦ voluntary controlvoluntary control

♦ Sympathetic innervationSympathetic innervation cause smooth cause smooth muscle relaxation allowing bladder to fillmuscle relaxation allowing bladder to fill

♦ Internal SphincterInternal Sphincter ♦ involuntary control by SNSinvoluntary control by SNS♦ causes urethrea to remain closed until person is causes urethrea to remain closed until person is

ready to voidready to void

♦ Control of MicturitionControl of Micturition: : the result of the result of coordination between the opening of the coordination between the opening of the sphincters and contraction of detrusorsphincters and contraction of detrusor

Alterations in Urinary Alterations in Urinary Elimination Elimination

Lower Urinary Tract Lower Urinary Tract InfectionInfection

♦ 7 million office visits a year7 million office visits a year♦ Most common nosocomial infection on U.S.Most common nosocomial infection on U.S.♦ Most from catheterization or post-opMost from catheterization or post-op♦ Bacteria in the urine may lead to the spread Bacteria in the urine may lead to the spread

of organisms into bloodstream (Urosepsis)of organisms into bloodstream (Urosepsis)

Urinary Tract Infection Urinary Tract Infection UTI UTI SymptomsSymptoms

♦ Pain or burning on urination (dysuria)Pain or burning on urination (dysuria)

♦ Fever, chills, malaiseFever, chills, malaise

♦ Hematuria - irritation of bladder & urethral mucosa resulting in blood-Hematuria - irritation of bladder & urethral mucosa resulting in blood-tinged urinetinged urine

♦ CystitisCystitis: Frequency and urgency, suprapubic pain, and foul smelling : Frequency and urgency, suprapubic pain, and foul smelling urineurine

♦ PyelonephritisPyelonephritis-infection spreads up to kidney from lower UTI- flank pain, -infection spreads up to kidney from lower UTI- flank pain, fever, nausea and vomitingfever, nausea and vomiting

Urinary Tract Infection Urinary Tract Infection UTI DiagnosisUTI Diagnosis

♦ History and physical examHistory and physical exam

♦ Urinalysis (UA)Urinalysis (UA)

♦ Urine for C&SUrine for C&S

♦ Imaging studies of the urinary tract (IVP, cysto)Imaging studies of the urinary tract (IVP, cysto)

Urinary Tract Infection Urinary Tract Infection Common Causative Common Causative

MicroorganismsMicroorganisms♦ Escherichia coliEscherichia coli

♦ 80% of cases without urinary tract structural abnormalities 80% of cases without urinary tract structural abnormalities or calculior calculi

♦ EnterococcusEnterococcus♦ KlebsiellaKlebsiella♦ EnterobacterEnterobacter♦ SerratiaSerratia♦ ProteusProteus♦ PseudomonasPseudomonas♦ StaphylococcusStaphylococcus

Urinary Tract Infection Urinary Tract Infection Treatment - uncomplicatedTreatment - uncomplicated

♦ Antibiotic – Sulfa; Broad-spectrumAntibiotic – Sulfa; Broad-spectrum♦ 1-3 day regimen1-3 day regimen

♦ Adequate fluid intakeAdequate fluid intake

♦ Urinary analgesic (Pyridium)Urinary analgesic (Pyridium)

♦ Pt Education: avoid recurrence Pt Education: avoid recurrence

Health PromotionHealth Promotion

Urinary Tract Infection Urinary Tract Infection Recurrent - uncomplicatedRecurrent - uncomplicated

♦ Repeat UA - Urine C&SRepeat UA - Urine C&S♦ Antibiotic 3-5 day courseAntibiotic 3-5 day course

♦ SulfaSulfa♦ Sensitivity-guided antibiotic – Ampicillin, cephalosporin, Sensitivity-guided antibiotic – Ampicillin, cephalosporin,

fluoroquinolonefluoroquinolone

♦ Consider 3-6 month trial of suppressive antibioticsConsider 3-6 month trial of suppressive antibiotics♦ Adequate fluid intakeAdequate fluid intake♦ Urinary analgesic – Pyridium Urinary analgesic – Pyridium

♦ or combination agent – Urisedor combination agent – Urised

♦ Counseling risk of recurrence / reduce risk factorsCounseling risk of recurrence / reduce risk factors♦ Imaging study of urinary tract in select casesImaging study of urinary tract in select cases

Urinary Tract InfectionUrinary Tract InfectionNursing ManagementNursing Management

♦ AssessAssess: Pain; urine elimination; : Pain; urine elimination;

♦ Nsg ActionNsg Action: Pain relief – urinary analgesics; : Pain relief – urinary analgesics; midstream specimens for C&S; midstream specimens for C&S;

♦ Pt EducationPt Education: Medications; force fluids; : Medications; force fluids; hygiene; signs & symptoms of recurrent UTI; hygiene; signs & symptoms of recurrent UTI; adequate hydration during healthadequate hydration during health

UTI - Nursing ManagementUTI - Nursing ManagementPatient / Family EducationPatient / Family Education

♦ Antibiotic therapyAntibiotic therapy – adherence after symptoms – adherence after symptoms subsidesubside

♦ HygieneHygiene♦ Cleansing perineal areaCleansing perineal area♦ Wiping from front to back after urinating & BMWiping from front to back after urinating & BM♦ Cleanse with soap & water after BMCleanse with soap & water after BM

♦ Empty bladderEmpty bladder before and after intercourse before and after intercourse♦ Establish regular urination patternEstablish regular urination pattern – every 2-4 – every 2-4

hourshours♦ AvoidAvoid harsh soaps, bubble baths, powders, talcs, harsh soaps, bubble baths, powders, talcs,

and sprays to the perineal areaand sprays to the perineal area♦ Report signs & symptoms of UTIReport signs & symptoms of UTI