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NR507 Week 4 edapt: Urinary System Pathologies: Common Diseases and
Disorders Urinary Tract Infections/ Benign Prostatic Hypertrophy/ Renal
Calculi/ Urinary Incontinence/ Acute Kidney Injury/ Chronic Kidney Disease
Urinary Tract Infections
Upper UTIs occur in organs that are above the urinary bladder and include
ureter infections and pyelonephritis (kidney infection).
Cystitis (bladder infection), urethritis (infection of the urethra), and
prostatitis (infection of the prostate) occur in the lower urinary tract.
Pathophysiology of Urinary Tract Infections
The most common organisms that cause urinary tract infection (UTI)
are Escherichia coli ( E. coli ), Staphylococcus saprophyticus , Proteus mirabilis ,
and Klebsiella. E. coli causes approximately 80% of the cases of UTI as
it is the most common organism contained in fecal matter that is easily
accessible from the anus to the urethra.
???The sequence of events starts with the bacteria entering the urethra and
end with the client having symptoms of infection. The correct order is:
1. Bacteria enter the lower urinary tract
2. An inflammatory response is triggered
3. Neutrophils arrive
4. Bacteria continue to multiply
5. Biofilm forms
6. Bacteria adhere to the bladder wall
7. Client experiences pain with urination
Urinary Tract Infection Clinical Manifestations
1. Frequent Urination : Increased urge to urinate, often with the feeling of incomplete
emptying is associated with a bladder infection due to inflammation of the bladder and
urethra.
2. Painful Urination : Discomfort or a burning sensation during urination is associated
with inflammation of the bladder and urethra (lower UTI).
3. Urgency : A sudden and intense need to urinate is associated with inflammation of the
bladder and urethra (lower UTI).
5. Pelvic Pain : Pain in the pelvic area is associated with a bladder infection, especially in
women with a bladder infection.
6. Cloudy or Strong-Smelling Urine : Changes in the appearance or odor of urine
can be caused by an infection anywhere in the urinary tract.
7. Blood in Urine (Hematuria) : The presence of blood, giving the urine a pink or reddish
color can be caused by an infection anywhere in the urinary tract.
8. Fever : In some cases, a UTI can be accompanied by a systemic fever.
9. Back Pain : Pain in the lower back is associated with an infection in the kidneys.
Assessment for pain or tenderness at the costovertebral angle (CVA) can increase both
pain and inflammation and should be part of a routine assessment.
10. Fatigue : Feeling tired or generally unwell can be caused by an infection anywhere in
the urinary tract.
11. Discomfort or Pain During Sex : Women with bladder or urethra infections may
experience pain or discomfort during sexual activity.
Symptoms of infection, including fatigue, bacteria in the urine, and an
elevated temperature, may be present for any infection, including lower
UTI, upper UTI, and STI. Note: The presence of bacteria in the urine from
an STI may indicate contamination of the urine sample.
Foul smelling urine and painful urination can be present with both lower
and upper UTI.
Pelvic pain is more likely to be present in a female with a lower UTI or STI.
An urgency to void is associated with lower UTI.
Urinary Tract Infection Diagnosis
Client History: The nurse practitioner (NP) will conduct a focused health history, inquiring about previous UTIs, chronic conditions, medications, and relevant lifestyle factors. Symptom Assessment: The NP will inquire about the specific symptoms the client is experiencing, such as frequency and urgency of urination, pain or discomfort during urination, and any associated symptoms like fever or back pain. Physical Examination: A physical examination may be conducted to assess for signs of infection. This may include checking for tenderness or pain in the lower abdomen or back. Note: The NP should assess for costovertebral tenderness by palpating the costovertebral angle (CVA). Dipstick Test: A urine dipstick test can quickly identify the presence of blood, protein, leukocytes, and nitrites at the point of care. The presence of leukocytes indicates inflammation. The presence of nitrites is highly specific for gram-negative bacterial infection. Urinalysis: A urine sample is collected for urinalysis (UA) to determine the presence of white blood cells, red blood cells, and bacteria in the urine. Elevated white blood cell counts and the presence of bacteria are indicative of a possible infection. A microscopic examination of the urine for a client with cystitis is characterized by a white blood cell (WBC) count of greater than 5000 high power field (hpf) and hematuria. For the client with pyelonephritis , the urine will contain WBC casts. The presence of casts in the urine indicates that the protein in the lumen of the kidney tubules has solidified, especially in the nephron. This indicates kidney disease rather than a lower UTI. Urine Culture and Sensitivity: If the initial tests suggest a UTI, a urine culture may be ordered to identify the specific bacteria causing the infection and determine its susceptibility to antibiotics. Urinary Tract Imaging : For clients with known or suspected alterations of the urinary tract, urinary imaging should be used to rule out changes in the physical structures that may contribute to the current infection. These can include x-rays (kidneys, ureters, and bladder [KUS]), ultrasounds, or other imaging studies. Complex Presentation : In some cases, the client’s presentation may mimic a UTI but have a different cause. For example, if a vaginal discharge or itching is involved, a genital exam is indicated to rule out or diagnose a sexually transmitted infection (STI). Pyelonephritis Presentation : The signs and symptoms of pyelonephritis are often acute and include all the symptoms associated with cystitis plus fever, flank pain, costovertebral angle (CVA) tenderness, nausea, and vomiting. Malaise is also a common complaint for the client with pyelonephritis. Signs of shock may occur if the infection has entered the circulation from the kidney via the renal vein. Think of the symptoms of pyelonephritis in a classic triad: vomiting, flank pain, and fever.
• Urinary Tract
Infection Treatment
- Requires a short course of antibiotics if symptomatic or pregnant Complicated Urinary Tract Infection Characteristics
- Urinary tract is altered
- Renal function is decreased
- Higher risk for permanent renal damage or sepsis
- White Blood Cell (WBC) casts present
- No response to IV antibiotics
- Presence of blood in the urine
- Recurrent UTIs (more than 3 in a year or 2 occurrences in 6 months.) Uncomplicated UTIs
- Treatment can be deferred if the client has no symptoms.
- Treatment can be initiated based on symptoms without waiting for laboratory reports.
- 3- to 5-day course of oral antibiotics is the standard treatment.
- If needed, a urine culture can be obtained prior to starting antibiotic therapy.
- For a client with a history of recurrent UTI, symptoms may resolve before the infection is resolved.
- Repeat urine culture 1 week after antibiotics were started and at monthly intervals for 3 months. Complicated UTIs
- Start with intravenous (IV) broad-spectrum antibiotic.
- Change to an organism-specific antibiotic after culture and sensitivity results are known.
- After a course of IV antibiotics, oral antibiotics should be continued.
- Relieve any obstruction within the urinary tract.
- Treat other symptoms (e.g., antipyretic for fever, pain medication).
The client appears to have an uncomplicated lower UTI; therefore, blood cultures are not indicated
at this time.
Benign Prostatic Hypertrophy
BPH, an enlargement of the prostate gland, is caused by an increase in the number of cells, which
is caused by hormonal changes associated with aging. As the prostate enlarges, it compresses the
prostatic urethra and restricts the flow of urine.
BPH is not a tumor (either benign or malignant) and does not predispose the client to developing
prostate cancer that requires chemotherapy or surgery.
Risk factors for developing benign prostatic hypertrophy (BPH) include the following:
- age greater than 50 years
- smoking and alcohol use
- sedentary lifestyle, obesity
- high-fat, high-protein, low-fiber diet
- chronic disorders, such as diabetes mellitus and cardiovascular disease
Renal Calculi
Dissolution therapy: Potassium citrate or sodium bicarbonate therapy is used to alkalinize the urine for suspected uric acid-based stones, as it can help dissolve them. Depending on stone etiology, different medications may be recommended.
- Calcium stones (most common):
- Thiazide diuretics can be used in hypercalciuria.
- Uric acid stones:
- Allopurinol can lower renal uric acid excretion, preventing the formation of uric acid stones.
