Management of Patients With Upper or Lower Urinary Tract Dysfunction p.2

1. Management of PatientsWith Upper or LowerUrinary Tract Dysfunction p.2 Miss ImanShaweesh 2008 Miss Iman Shaweesh

2. Fluid and Electrolyte Imbalancesin Renal Disorders • Patients with renal disorders commonly experience fluid and electrolyte imbalances and require astute assessment and close monitoring for signs of potential problems. The fluid intake and output record, a key monitoring tool, is used to document important fluid parameters, including the amount of fluid taken in (orally or parenterally), the volume of urine excreted, and other fluid losses (diarrhea, vomiting, diaphoresis). • These records and changes in the patient’s weight are essential for determining the daily fluid allowance and indicating signs of fluid overload or deficit. Miss Iman Shaweesh

3. Clinical Manifestations • The nurse should continually assess, monitor, and inform appropriate members of the health care team if the patient exhibits any of these signs. Miss Iman Shaweesh

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7. Dysfunctional Voiding Patterns • Presents in the form of urinary incontinence or urine retention. • Urinary incontinence is the unplanned loss of urine that is sufficient to be considered a problem. Urinary continence relies on intact urinary, neurologic, and musculoskeletal systems. Continence is maintained via a complex communication system of suprasacral, sacral, and local nerve-mediated loops of information, all of which must be functioning efficiently and synergistically. Miss Iman Shaweesh

8. Any break in these loops of communication (for example, an upper or lower neuron lesion, spinal stenosis, or bladder outlet obstruction) can cause some degree of urinary dysfunction. Depending on the location of the insult, both incontinence and incomplete bladder emptying can occur. Miss Iman Shaweesh

9. Anatomic integrity of the upper and lower urinary system must be intact; otherwise, urine extravasation into the peritoneal or perivesical cavity (as seen in acute trauma) or extraurethral incontinence (as seen in some forms of congenital malformations) will occur. • Genitourinary fistula formation between the bladder wall and other areas, such as the vagina, will result in extraurethral incontinence. The etiology of dysfunctional voiding can be congenital or acquired in adulthood. Each is reviewed separately. Miss Iman Shaweesh

10. CONGENITAL VOIDING DYSFUNCTION • Congenital anomalies usually result in voiding dysfunction early in life and are usually partially or completely surgically corrected. • When voiding dysfunction occurs in adults, it may affect only the lower urinary system (eg, the bladder and urethra); when voiding dysfunction occurs in children, it commonly involves damage to the upper urinary system (ie, the ureters and kidneys) as well. Many congenital anomalies are discovered early in utero because of prenatal care measures such as ultrasound. Miss Iman Shaweesh

11. The urinary system begins developing days after conception, and anomalies can be seen on a sonogram as early as 20 weeks. Depending on the anomaly, intrauterine surgery may be performed on the fetus. • Because the urinary system may be only one of several organ systems that are abnormal due to genetic disorders, any defects not noted during gestation should be immediately apparent at birth. Such anomalies include renal agenesis (complete absence of one or both kidneys), ectopic ureter, and Eagle-Barrett syndrome (als oknown as prune-belly syndrome), with exstrophy of the bladder. Miss Iman Shaweesh

12. On the other hand, voiding dysfunction can be discovered insidiously (for example, during toilet training). At times congenital anomalies, such as posterior urethral valves, typically seen only in males, may escape detection until early adolescence or adulthood, when the voiding dysfunction or its sequelae cause the individual to seek a urologic evaluation. Although pediatric in nature, these disorders may affect urinary tract function when the patient becomes an adult. Miss Iman Shaweesh

13. ADULT VOIDING DYSFUNCTION • Both neurogenic and non-neurogenic disorders can cause adult voiding dysfunction (Table 44-2). • The micturition (voiding) process involves several highly coordinated neurologic responses that mediate bladder function. A functional urinary system allows for appropriate bladder filling and complete bladder emptying. Miss Iman Shaweesh

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16. URINARY INCONTINENCE • More than 17 million adults in the United States are estimated to have urinary incontinence, with most of them experiencing overactive bladder syndrome, making this disorder more prevalent than diabetes or ulcer disease. • Despite widespread media coverage, urinary incontinence remains underdiagnosed and underreported. Patients may be too embarrassed to seek help, causing them to ignore or conceal symptoms. Many patients resort to using absorbent pads or other devices without having their condition properly diagnosed and treated. Miss Iman Shaweesh

17. Although urinary incontinence is commonly regarded as a condition that occurs in older multiparous women, it is also common in young nulliparous women, especially during vigorous high-impact activity. • Age, gender, and number of vaginal deliveries are established risk factors (Chart 44-1); they explain, in part, the increased incidence in women. Urinary incontinence is a symptom with many possible causes. Miss Iman Shaweesh

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19. Clinical Manifestations:Types of Incontinence • Stress incontinence is the involuntary loss of urine through an intact urethra as a result of a sudden increase in intra-abdominal pressure (sneezing, coughing, or changing position). It predominately affects women who have had vaginal deliveries and is thought to be the result of decreasing ligament and pelvic floor support of the urethra and decreasing or absent estrogen levels within the urethral walls and bladder base. • In men, stress incontinence is often experienced after a radical prostatectomy for prostate cancer because of the loss of urethral compression that the prostate had supplied before the surgery, and possibly bladder wall irritability Miss Iman Shaweesh

20. Urge incontinence • is the involuntary loss of urine associated with a strong urge to void that cannot be suppressed. The patient is aware of the need to void but is unable to reach a toilet in time. An uninhibited detrusor contraction is the precipitating factor. This can occur in a patient with neurologic dysfunction that impairs inhibition of bladder contraction or in a patient without overt neurologic dysfunction Miss Iman Shaweesh

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22. Reflex incontinence • is the involuntary loss of urine due to hyperreflexia in the absence of normal sensations usually associated with voiding. • This commonly occurs in patients with spinal cord injury because they have neither neurologically mediated motor control of the detrusor nor sensory awareness of the need to void. Miss Iman Shaweesh

23. Overflow incontinence is the involuntary loss of urine associated with overdistention of the bladder. Such overdistention results from the bladder’s inability to empty normally, despite frequent urine loss. Both neurologic abnormalities (eg, spinal cord lesions) and factors that obstruct the outflow of urine (eg, tumors, strictures, and prostatic hyperplasia) can cause overflow incontinence Miss Iman Shaweesh

24. Assessment and Diagnostic Findings • Once incontinence is recognized, a thorough history is necessary. This includes a detailed description of the problem and a history of medication use. The patient’s voiding history, a diary of fluid intake and output, and bedside tests (ie, residual urine, stress maneuvers) may be used to help determine the type of urinary. incontinence involved. Extensive urodynamic tests may be performed; Management depends on the type of urinary incontinence and its causes. Urinary incontinence may be transient or reversible Miss Iman Shaweesh

25. Gerontologic Considerations • Many older individuals experience transient episodes of incontinence that tend to be abrupt in onset. When this occurs, the nurse should question the patient, as well as the family if possible, about the onset of symptoms and any signs or symptoms of a change in other organ systems. Miss Iman Shaweesh

26. Acute urinary tract infection, infection elsewhere in the body, constipation, decreased fluid intake, a change in a chronic disease pattern, such as elevated blood glucose levels in patients with diabetes or decreased estrogen levels in menopausal women, can provoke the onset of urinary incontinence. If the cause is identified and modified or eliminated early at the onset of incontinence, the incontinence itself may be eliminated. Miss Iman Shaweesh

27. Medical Management • BEHAVIORAL THERAPY Behavioral therapies are always the first choice to decrease or eliminate urinary incontinence. In using these techniques, clinicians help patients avoid potential adverse effects of pharmacologic or surgical interventions • PHARMACOLOGIC THERAPY Pharmacologic therapy works best when used as an adjunct to behavioral interventions. Anticholinergic agents (oxybutynin Miss Iman Shaweesh

28. [Ditropan], dicyclomine [Antispas]) inhibit bladder contraction and are considered first-line medications for urge incontinence. Several tricyclic antidepressant medications (imipramine, doxepin, desipramine, and nortriptyline) also decrease bladder contractions as well as increase bladder neck resistance. Stress incontinence may be treated using pseudoephedrine (eg, Sudafed). • Estrogen (taken orally, transdermally, or topically) has been shown to be beneficial for all types of urinary incontinence. Estrogen decreases obstruction to urine flow by restoring the mucosal, vascular, and muscular integrity of the urethra. Miss Iman Shaweesh

29. Gerontologic Considerations • Elderly individuals may experience cognitive decline when taking short-acting anticholinergic medications. The long-acting forms of anticholinergic medications such as oxybutynin (Ditropan XL) Miss Iman Shaweesh

30. SURGICAL MANAGEMENT • Surgical correction may be indicated in patients who have not achieved continence using behavioral and pharmacologic therapy. Surgical options vary according to the underlying anatomy and the physiologic problem. • Most procedures involve lifting and stabilizing the bladder or urethra to restore the normal urethrovesical angle or to lengthen the urethra. Women with stress incontinence may have an anterior vaginal repair, retropubic suspension, or needle suspension to reposition the urethra. Miss Iman Shaweesh

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32. Nursing Management • Nursing management is based on the premise that incontinence is not inevitable with illness or aging and that it is often reversible and treatable. The nursing interventions are determined in part by the type of treatment that is undertaken. • For behavioral therapy to be effective, the nurse must provide support and encouragemen to because it is easy for the patient to become discouraged if therapy does not quickly improve the level of continence. Miss Iman Shaweesh

33. Patient teaching regarding the bladder program is important and should be provided verbally and in writing. • The patient is assisted to develop and use a log or diary to record timing of Kegel exercises, changes in bladder function with treatment, and episodes of incontinence. Miss Iman Shaweesh

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35. URINARY RETENTION • Urinary retention is the inability to empty the bladder completely during attempts to void. Chronic urine retention often leads to overflow incontinence (from the pressure of the retained urine in the bladder). Residual urine is urine that remains in the bladder after voiding. • In a healthy adult younger than age 60, complete bladder emptying should occur with each voiding. In adults older than age 60, 50 to 100 mL of residual urine may remain after each void because of the decreased contractility of the detrusor muscle. Miss Iman Shaweesh

36. Urinary retention can occur postoperatively in any patient, particularly if the surgery affected the perineal or anal regions and resulted in reflex spasm of the sphincters. • General anesthesia reduces bladder muscle innervation and suppresses the urge to void, impeding bladder emptying Miss Iman Shaweesh

37. Pathophysiology • Urinary retention may result from diabetes, prostatic enlargement, urethral pathology (infection, tumor, calculus), trauma (pelvic injuries), pregnancy, or neurologic disorders such as cerebrovascular accident, spinal cord injury, multiple sclerosis, or Parkinson’s disease. Some medications cause urinary retention, either by inhibiting bladder contractility or by increasing bladder outlet resistance. Miss Iman Shaweesh

38. Pathophysiology • Medications that cause retention by inhibiting bladder contractility include anticholinergic agents (atropine sulfate, dicyclomine hydrochloride [Antispas, Bentyl]), antispasmodic agents (oxybutynin chloride [Ditropan], belladonna, and opioid suppositories), and tricyclic antidepressant medications (imipramine [Tofranil], doxepin [Sinequan]). • Medications that cause urine retention by increasing bladder outlet resistance include alpha-adrenergic agents (ephedrine sulfate, pseudoephedrine), beta adrenergic blockers (propranolol), and estrogens. Miss Iman Shaweesh

39. Assessment and Diagnostic Findings • The assessment of a patient for urinary retention is multifaceted because the signs and symptoms may be easily overlooked. The following questions serve as a guide in assessment: • What was the time of the last voiding, and how much urine was excreted? • Is the patient voiding small amounts of urine frequently? • Is the patient dribbling urine? • Does the patient complain of pain or discomfort in the lower abdomen? (Discomfort may be relatively mild if the bladder distends slowly.) Miss Iman Shaweesh

40. Does percussion of the suprapubic region elicit dullness (possibly indicating urine retention and a distended bladder)? • Are other indicators of urinary retention present, such as restlessness and agitation? • Does a postvoid bladder ultrasound test reveal residual urine? Miss Iman Shaweesh

41. The patient may verbalize an awareness of bladder fullness and a sensation of incomplete bladder emptying. The nurse also assesses the patient for signs and symptoms of urinary tract infection, such as hematuria and dysuria. • The patient may complete a voiding diary to provide a written record of the amount of urine voided and the frequency of voiding. Post void residual urine can be measured accurately without the need for post void straight catheterization using a portable ultrasound bladder scanner Miss Iman Shaweesh

42. Complications • Urine retention can lead to chronic infection. Infections that are unresolved predispose the patient to calculi, pyelonephritis, and sepsis. The kidney may also eventually deteriorate if large volumes of urine are retained, causing backward pressure on the upper urinary tract. In addition, urine leakage can lead to perineal skin breakdown, especially if regular hygiene measures are neglected. Miss Iman Shaweesh

43. Nursing Management • Management strategies are instituted to prevent overdistention of the bladder and to treat infection or correct obstruction. Many problems, however, can be prevented with careful nursing assessment and appropriate nursing interventions. The nurse should explain why normal voiding is not occurring and should monitor urine output closely. The nurse should also provide reassurance about the temporary nature of retention and successful management strategies. • PROMOTING NORMAL URINARY ELIMINATION • PROMOTING HOME AND COMMUNITY-BASED CARE Miss Iman Shaweesh

44. Gerontologic Considerations • If nurses and other health care providers accept incontinence as an inevitable part of illness or aging or consider it irreversible and untreatable at any age, it cannot be treated successfully. Collaborative, interdisciplinary efforts are essential in assessing and effectively treating urinary incontinence. Miss Iman Shaweesh

45. NEUROGENIC BLADDER • is a dysfunction that results from a lesion of the nervous system. It may be caused by spinal cord injury, spinal tumor, herniated vertebral disk, multiple sclerosis, congenital anomalies (spina bifida or myelomeningocele), infection, or diabetes mellitus. Miss Iman Shaweesh

46. Pathophysiology • The two types of neurogenic bladder are spastic (or reflex) bladder and flaccid bladder • Spastic bladder is the more common type and is caused by any spinal cord lesion above the voiding reflex arc (upper motor neuron lesion). The result is a loss of conscious sensation and cerebral motor control. A spastic bladder empties on reflex, with minimal or no controlling influence to regulate its activity. Miss Iman Shaweesh

47. Flaccid bladder is caused by a lower motor neuron lesion, commonly resulting from trauma. This form of neurogenic bladder has increasingly been recognized as a problem in patients with diabetes mellitus. The bladder continues to fill and becomes greatly distended, and overflow incontinence occurs. The bladder muscle does not contract forcefully at any time. Because sensory loss may accompany a flaccid bladder, the patient feels no discomfort. Miss Iman Shaweesh

48. Assessment and Diagnostic Findings • Evaluation for neurogenic bladder involves measurement of fluid intake, urine output, and residual urine volume; urinalysis; and assessment of sensory awareness of bladder fullness and degree of motor control. Comprehensive urodynamic studies are also performed. Miss Iman Shaweesh

49. Complications • The most common complication of neurogenic bladder is infection resulting from urinary stasis and catheterization. Urolithiasis (stones in the urinary tract) may develop from urinary stasis, infection, or demineralization of bone from prolonged immobilization. • Renal failure can also occur from vesicoureteral reflux (backward flow of retained urine from the bladder into the ureters) with eventual hydronephrosis (dilation of the pelvis of the kidney resulting from obstruction to the flow of urine) and atrophy of the kidney. Indeed, renal failure is the major cause of death of patients with neurologic impairment of the bladder. Miss Iman Shaweesh

50. Medical Management • The problems resulting from neurogenic bladder disorders vary considerably from patient to patient and are a major challenge to the health care team. There are several long-term objectives appropriate for all types of neurogenic bladders: •Preventing overdistention of the bladder • Emptying the bladder regularly and completely • Maintaining urine sterility with no stone formation • Maintaining adequate bladder capacity with no reflux Miss Iman Shaweesh