Chapter 65: Disorders of the Bladder

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Chapter 65 Disorders of the Bladder Urethra
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Overview Pg. 1153

• Disorders of the bladder urethra are common and
  can be the source of severe problems that become
  chronic, altering a clients lifestyle.
• Many disorders affecting the bladder and urethra
  are treated on an outpatient basis, but the more
  serious disorders require hospitalization

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Voiding Dysfunction

• Urinary retention urinary incontinence are
  voiding dysfunctions
• 1. Urinary retention is the inability to urinate
  or effectively empty the bladder.
• 2. Urinary incontinence is the inability to
  control the voiding of urine.
• Both require sensitivity to the clients needs,
  both physiologic and psychosocial

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Urinary Retention pg 1153

• May be either acute or chronic.
• Acute urinary retention is seen in complete
  urethral obstruction, after general anesthesia,
  or with the administration of certain drugs such
  as Atropine or a Phenothiazine.

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Urinary Retention

• Chronic urinary retention is often seen in
  clients with disorders such as prostatic
  enlargement or neurologic disorders that result
  in a neurogenic bladder ( a bladder that does not
  receive adequate nerve stimulation)

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Urinary Retention

• The client with acute urinary retention usually
  is not able to void at all.
• The client with chronic urinary retention may be
  able to void but does not completely empty the
  bladder (retention with overflow) and has a large
  residual volume.
• The residual urine is urine retained in the
  bladder after the client voids. The amount may
  vary from 30 mL to several hundred milliliters.

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S/S

• S/S Acute sudden inability to void, distended
  bladder, and severe lower abdominal pain and
  discomfort
• S/S Chronic may produce no symptoms because the
  bladder has stretched over time and accommodates
  large volumes without producing discomfort.

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S/S

• The overstretched bladder does not contract
  effectively and the client is unaware that the
  bladder is not emptying completely.
• If the amount of residual urine is large, the
  client may void frequently in small amounts.
• Signs of a bladder infection (eg, fever, chills,
  pain on urination) and dribbling of urine may
  also be present.

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Urinalysis

• How do you collect??????
• 24 hour Urine collection
• From indwelling foley catheter
• For pregnancy test
• For C S

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Medical Management pg 1154

• Acute requires immediate catheterization.
• Chronic managed by permanent drainage with a
  urethral catheter, suprapubic cystostomy tube (a
  catheter inserted through the abdominal wall
  directly into the bladder), or clean intermittent
  catheterization (CIC)

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Medical Management

• Permanent catheterization of the bladder carries
  the risk of bladder stones, renal disease,
  bladder infection, and urosepsis, a serious
  systemic infection from microorganisms in the
  urinary tract invading the bloodstream.
• Clean intermittent catheterization (CIC) is the
  preferred method.

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Box 65-1 pg 1154

• Crede apply gentle downward pressure to the
  bladder during voiding. This maneuver may be
  done by the client or family member. The client
  may also do this by sitting on the toilet and
  rocking back and forth gently.
• Valsalva instruct the client to bear down as
  with defecation. Do not teach this method to a
  client with cardiac problems or who may be
  adversely affected by a vagal response (heart
  rate slows)

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Nursing Management

• An important nursing responsibility is measuring
  I O, palpating the abdomen for a distended
  bladder, promoting complete urination, and
  monitoring the voiding pattern of clients

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Acute Urinary Retention pg 1155

• Catheters are sized according to the French
  system, for example, 14F to 24F. The higher the
  number, the larger the diameter of the catheter.
  
• Examples of the various types of catheter tips
  are shown in Figure 65-1

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Acute Urinary Retention

• If the volume of urine is larger (gt 700 mL), it
  may be necessary to clamp the catheter before the
  bladder has emptied completely to prevent bladder
  spasms or loss of bladder tone.
• This practice varies so check agency policy
• NCLEX!!!!

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Acute Urinary Retention

• Clients managed by CIC, establish a schedule.
  They are catheterized every 4 to 6 hours
  depending on the amount of urine obtained and the
  fluid intake.
• The bladder should not be allowed to get
  distended beyond 350 mL because bladder over
  distention results in loss of bladder tone,
  decreased blood flow to the bladder, and
  reduction in the layer of mucin that protects the
  bladder mucosa.

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Acute Urinary Retention

• CIC continues until the post void residual volume
  is less than 30 mL
• To obtain accurate results very important to
  let the pt void first then immediately after the
  attempt perform the catheterization.
• Record both the volume voided (even if it is
  zero) the volume obtained by catheterization.
• Post-op urinary retention usually resolves within
  24 to 48 hours.

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Intermittent Catheterization pg 1155

• Hospital is sterile!!
• Home is clean rather than aseptic technique.
• They use a red rubber catheter that can be washed
  and reused for 2 to 3 months before replacing.
• Gloves are not required but client must wash
  their hands thoroughly before and after the
  procedure.

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Intermittent Catheterization

• The schedule is usually 3 to 4 times a day,
  although the frequency can be increased depending
  on residual volume.
• If more than 400 mL is returned, the client
  should be catheterized more often.

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Indwelling Catheters pg 1156

• A urethral indwelling catheter is one route for
  permanent bladder catheterization
• Cystostomy tube, also called a suprapubic
  catheter, is an alternative that is inserted
  through an abdominal incision into the bladder.
• Clients require catheter care including careful
  cleansing of the urethral meatus or cystostomy
  site and proximal catheter, maintenance of the
  integrity of the closed drainage system, proper
  anchoring of the tube to avoid tension and
  promote drainage.

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Urinary Incontinence pg 1156

• May result either bladder or urethral dysfunction
  (or both).
• The bladder can contract without warning, fail to
  accommodate adequate volumes of urine, or fail to
  empty completely and become overstretched,
  resulting in overflow incontinence.
• These conditions result from neurologic disease,
  prostatic enlargement, bladder outlet
  obstruction, or trauma in all clients, and
  bladder prolapse or low estrogen levels in women.

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Urinary Incontinence

• A neurogenic bladder may be spastic, causing
  incontinence, or it may be flaccid, causing
  retention.

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Incontinence

• Complain of urgency, frequency, leaking small
  amounts when coughing or sneezing, or complete
  inability to control urine, depending on the
  underlying cause.Treatment medications, CIC,
  surgeries
• Nursing focuses on instruction on exercises to
  increase muscle tone and voluntary control (Kegel
  Exercises), techniques to assist bladder
  emptying, and bladder training. 65-3 pg 1158

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Cystitis pg 1160

• An inflammation of the urinary bladder.
• Usually caused by a bacterial infection.
• S/S urgency, frequency, low back pain, dysuria,
  perineal and suprapubic pain, hematuria,
  especially at the termination of the stream
  (terminal hematuria)
• If bacteria is present may have chills fever.

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Medical Management

• Antimicrobial therapy and correction of
  contributing factors.
• Cranberry juice or vitamin C may be recommended
  to keep the urine acidic and enhance the
  effectiveness of drug therapy.
• Cranberry juice helps to acidify the urine and
  provides a less favorable climate for bacterial
  growth.
• Guidelines 65-4 Preventing cystitis

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Interstitial Cystitis (IC) Pg. 1161

• A chronic inflammation of the bladder mucosa.
• The bladder wall contains multiple pinpoint
  hemorrhagic areas that join and form larger
  hemorrhagic areas that may progress to fissuring
  and scarring of the bladder mucosa.

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Interstitial Cystitis (IC)

• Superficial erosion of the bladder mucosa
  (Hunners ulcer) may develop.
• Eventually the bladder shrinks from scarring.
• S/S frequent, painful urination and passing a
  small volume of urine are the most common
  symptoms.
• The pain may be described as searing or burning.
  Has the need to void ASAP when a small amount of
  urine is present in the bladder

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Nursing Management

• Instruct to avoid spicy and acidic foods because
  they may contribute to pain and discomfort.
• Disrupts their daily lives due to the pain and
  frequent trips to the bathroom to void.
• Emotional support and referral to a chronic pain
  center to cope and an support group.

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Urethritis Pg. 1161

• Inflammation of the urethra (gt in men)
• Urethritis caused by microorganisms other than
  gonorrhea is called nongonococcal urethritis.
• May be secondary to vaginal infections.
• Soaps, bubble baths, sanitary napkins, or scented
  toilet paper may also cause urethritis.

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• MenChlamydia, irritation during vigorous
  intercourse, rectal intercourse, or intercourse
  with a woman who has a vaginal infection

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S/S of Urethritis

• Discomfort on urination varying from a slight
  tickling sensation to burning or severe
  discomfort and urinary frequency.
• Fever is not common, but fever in the male client
  may be due to further extension of the infection
  to areas such as the prostate, testes, and
  epididymis.

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Urethritis

• Tx antibiotic therapy, liberal fluid intake,
  analgesics, warm sitz baths, good diet, rest.
• !!!!!Even when a female patient has a foley
  catheter, remember to clean from front to back.
  !!!!!!

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Obstructive Disorders Pg 1163

• Obstruction of the lower urinary tract is a
  blockage in the bladder or in the urethra.
• Many obstructions are r/t congenital anomalies,
  but in adults, obstructions occur from stones
  that block the passage of urine, or from a
  narrowing that occurs as a result of a trauma,
  inflammation, or infection.

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Box 65-4 S/S

• Straining to empty bladder
• Feeling that bladder does not empty completely
• Hesitancy
• Weak stream
• Frequency
• Overflow incontinence
• Bladder distention

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Bladder Stones pg 1163

• Large bladder stones develop in those with
  chronic urinary retention and urinary stasis.
• Clients who are immobile (eg, the unconscious
  client or those with paraplegia or quadriplegia)
  also may have a tendency to form bladder stones.

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Assessment

• Symptoms of bladder stone formation include
  hematuria, suprapubic pain, difficulty starting
  the urinary stream, symptoms of a bladder
  infection, and a feeling that the bladder is not
  completely empty.
• Some clients may have few or no symptoms.

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Medical Management

• Bladder stones may be removed through the
  transurethral route, using a stone-crushing
  instrument (lithotrite).
• This procedure, called a litholapaxy, is suitable
  for small and soft stones and is performed under
  general anesthesia.
• Larger, non-crushable stones must be removed
  through a surgical (suprapubic) incision into the
  bladder.

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Medical Management

• When it is possible to determine the chemical
  composition of stones that have been passed or
  removed, dietary treatment may be attempted to
  adjust the pH of the urine to keep the urinary
  salts in solution and thus prevent the formation
  of stones.

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Medical Management

• Uric acid stones may be prevented by a low-purine
  diet
• Increased fluid intake and the administration of
  sodium bicarbonate may prevent the formation of
  cystine stones.
• Clients with a hx of calcium stone formation may
  have to limit their intake of milk and milk
  products.

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Nursing Management

• Report any evidence of gross hematuria
  IMMEDIATELY!!
• Encourage fluids unless contraindicated by heart
  failure or renal disease
• Filter the urine for stones by straining all
  urine through gauze or wire mesh. If solid
  material is found, send it in a labeled container
  to the lab for analysis.

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Nursing Management

• For moderate to severe pain, administer a
  narcotic analgesic as ordered
• If undergoes a litholapaxy, a urethral catheter
  may be left in place to keep the bladder
  continuously empty for 1 to 2 days.
• Monitor I O
• Encourage fluids once tolerated

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Nursing Management

• If open removal is required, the bladder is
  incised and the stone removed.
• A urethral catheter may be left in place for a
  week or more to keep the bladder empty and
  prevent tension on the bladder sutures.
• Instruct to contact the physician if hematuria,
  burning, chills, fever, or pain occurs.

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Urethral Strictures pg 1164

• Strictures of the urethra are caused by
  infections such as untreated gonorrhea or chronic
  nongonoccoccal urethritis.
• Other causes include trauma to the lower urinary
  tract or pelvis, such as accidents, childbirth,
  intercourse, or surgical procedures.
• May be congenital
• A stricture (narrowing) in the urethra obstructs
  the flow of urine and can cause complications in
  the bladder or upper urinary tract.

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Urethral Strictures

• The kidney pelvis can become distended with the
  backflow of urine.
• The bladder distends when the urethra is
  obstructed and a diverticulum (outpouching) of
  the muscular bladder wall may form. (fig 65-5)
• In some instances more than one diverticulum may
  be seen

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Urethral Strictures

• Urine becomes trapped in the diverticulum,
  stagnates, and becomes a culture medium for
  bacteria.
• For this reason, infection occurs often and is
  difficult to control until the obstruction is
  corrected.

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S/S

• Slow or decreased force of stream of urine,
  hesitancy, burning, frequency,nocturia, and the
  retention of residual urine in the bladder, which
  may lead to bladder distention and infection.
• The client may be able to pass more urine after
  voiding and waiting a few minutes.
• The final quantity of urine comes form the
  diverticulum and may be malodorous.

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Medical Management

• Treated by dilation, which is the use of
  specially designed instruments called bougies,
  sounds, filiforms, and followers. (fig 65-6) that
  are passed gently into the urethra.
• Although done gently, the procedure is usually
  painful

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• Because forceful stretching of the urethra may
  cause bleeding and further stricture formation,
  dilation begins with a 6F or 8F urethral dilator.
• During subsequent treatments, the MD increases
  the size of the dilator until a 24F or 26F can be
  tolerated.
• Periodic dilatations are usually required
  indefinitely or until the condition is corrected
  surgically.

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Nursing Management

• Advise the client that the urine may be blood
  tinged following urethral dilatation and that it
  may burn when voiding.
• Suggest sitz baths and nonnarcotic analgesics to
  relieve discomfort.
• Contact md if difficulty voiding or frank
  bleeding occurs.

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Malignant Tumors of the Bladder Pg. 1165

• Are frightening for clients
• Bloody urine is often the first sign of problems
  and is the reason that clients seek medical
  attention.
• Malignant tumors of the bladder are the most
  common tumors in the urinary system.

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Hazards Include

• Exposure to industrial dyes, paint, or rubber
• Occupational exposure to sewage
• Coal gas
• Cigarette smoking and second-hand smoke
• Coffee drinking
• Use of artificial sweeteners

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S/S

• First symptom of a malignant tumor of the bladder
  is painless hematuria
• UTI with symptoms such as fever, dysuria,
  urgency, and frequency.
• R/T Metastases pelvic pain, urinary retention,
  and urinary frequency due to occupation of
  bladder space by the tumor.

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Medical Management

• Varies according to the grade and stage of the
  tumor.
• Resection of the tumors may be done. Have a high
  incidence of recurrence, consequently, a
  cystoscopic examination is performed every 2 to 3
  months.
• Clients having no recurrence of the tumor for at
  least a year require cystoscopic examinations
  every 6 months for the rest of their lives so
  that recurrence of the tumor or a new malignant
  growth can be detected early.

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Surgical Management

• A cystectomy surgical removal of the bladder and
  a urinary diversion procedure are necessary when
  the tumor has penetrated the muscle wall.
• When a cystectomy is performed, the bladder and
  lower third of both ureters are removed.

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Surgical Management

• Once a cystectomy is performed, urine must be
  diverted to another collecting system.
• This is called a urinary diversion
• Some urinary diversions require external ostomy
  bags to collect the urine other types create a
  reservoir within the body and the reservoir is
  catheterized to drain the urine.
• In some instances the urine is diverted to the
  colon and the client voids rectally.
• The more common types of urinary diversion
  procedures are described in Table 65-7 pg 1167

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Preoperative

• The client faces drastic changes in the manner of
  excreting urine from the body, the diagnosis of
  cancer, and the changes in body image
• Encourage the client to talk about the surgery
  and the changes that will occur.
• Suggest a visit from a member of a local ostomy
  group to provide emotional support as well as
  information.
• Photographs or drawings are useful in showing the
  placement of the stoma and urostomy pouch.

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Postoperative Period

• Management issues related specifically to urinary
  diversion procedures include observing for
  leakage of urine or stool from the anastomosis,
  maintaining renal function, assessing for s/s of
  peritonitis, maintaining integrity of the urinary
  diversion and urine collection devices,
  maintaining skin and stomal integrity,promoting a
  positive body image, and teaching the client how
  to manage the diversion.

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Postoperative Period

• Label all urinary drainage tubes, and measure and
  record the urine output from EACH catheter or
  stoma every hour.
• Record each measurement SEPARATELY!
• Maintaining accurate I O measurements during
  the post-op period is important because it
  indicates both renal function and the integrity
  of the urinary diversion structures.

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Postoperative Period

• Obstruction of urine flow can severely damage the
  kidneys if urinary drainage stops or decreases
  to less than 30 mL/hour, or if the client
  complains of back pain, notify the physician
  immediately.
• Inspect the urine for color, clarity, and
  presence of blood.
• Immediately report concentrated, cloudy, or
  bloody urine to the MD.
• Ureteral stents will remain in place for several
  days after surgery.

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Postoperative Period

• Connect the NG tube to low intermittent suction.
  This prevents distention and pressure on the
  suture line due to the collection of gas in the
  bowel.
• The NG tube is removed once peristalsis has
  returned and the diet can be advanced.

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Trauma pg 1171

• Various types of injury can affect the urinary
  tract.
• Gunshot and stab wounds, crushing injuries,and
  forceful blows can result in tears, hemorrhage,
  or penetration of one or more parts of the
  urinary tract.
• Injuries to the kidney area may result in
  bruising or tearing of the kidney and its
  capsule.
• Depending on the severity of the injury, blood
  and urine may leak into the peritoneal cavity.

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Assessment

• Symptoms vary according to the area affected and
  the type of injury.
• Anuria, hematuria, pain in the abdomen (which may
  indicate bleeding or leakage of urine into the
  abdominal cavity), pain in the bladder or kidney
  areas, and symptoms of shock may be indicators of
  urinary tract injury.

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Assessment

• During treatment of a client with extensive
  injury, an indwelling catheter may be inserted,
  and hematuria or lack of urine output may be the
  first sign that a traumatic injury to the urinary
  tract injury has occurred.
• Certain other types of injuries, such as stab or
  gunshot wounds, may be immediately identified
  because of outward signs of injury (eg, entry
  wounds on the skin surface)

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Management

• Tx depends on the type, location, and extent of
  injury as well as on the condition of the client.
• The most important nursing task is recognition of
  abnormal findings.
• Lack of urinary output, diffuse and severe
  abdominal pain, and hematuria are examples of s/s
  that may be indicative of an injury to the
  urinary tract.
• In some instances, the injury may be such that
  symptoms DO NOT appear for several hours or days
  after the initial trauma.