genitourinary disorders (medical surgical nursing)

Aashish Parihar
Nursing Tutor
College of Nursing
AIIMS, Jodhpur

content
Review of anatomy and physiology of genitourinary system
Nursing assessment: history, and physical examination
Etiology, pathophysiology, clinical manifestations, diagnosis,
medical and surgical treatment modalities, alternative
therapies, dietetics and nursing management (nursing
process including nursing procedures).
Urological obstructions-
Urethral strictures
Renal calculi
Nephrosis

content
 Disorders of kidney-
Glomerulonephritis
Nephrotic syndrome
Nephrosis
Acute renal failure
Chronic renal failure
End stage renal disease
Dialysis, renal transplant
Cancer of kidney
Congenital disorder

contentDisorders of Ureters, urinary bladder and urethra-
UTI
Cystitis
Urinary incontinence
Urinary retention
Urinary reflux
Bladder neoplasm
Urinary bladder calculi
Urethirtis
Urethral tumors
Ureteritis
Ureteral calculi
Trauma of Ureters, bladder, urethra
Neoplasm of ureters, bladder and urethra
Congenital disorders of ureters, bladder and urethra

anatomy and physiology of
genitourinary system

physiology of genitourinary
system

Ureters, Bladder, and Urethra -
Urine, which is formed within the nephrons, flows into the
ureter, a long fibromuscular tube that connects each kidney to
the bladder.
The ureters are narrow, muscular tubes, each 24 to 30 cm long,
that originate at the lower portion of the renal pelvis and
terminate in the trigone of the bladder wall.
There are three narrowed areas of each ureter: the ureteropelvic
junction, the ureteral segment near the sacroiliac junction, and
the ureterovesical junction.
The angling of the ureterovesical junction is the primary means of
providing antegrade, or downward, movement of urine, also
referred to as efflux of urine.
This angling prevents vesicoureteral reflux, which is the
retrograde, or backward, movement of urine from the bladder, up
the ureter, toward the kidney.

During voiding (micturition), increased intravesical pressure
keeps the ureterovesical junction closed and keeps urine within
the ureters. As soon as micturition is completed, intravesical
pressure returns to its normal low baseline value, allowing efflux
of urine to resume.
Therefore, the only time that the bladder is completely empty is
in the last seconds of micturition before efflux of urine resumes.
The three areas of narrowing within the ureters have a
propensity toward obstruction because of renal calculi
(kidney stones) or stricture.
Obstruction of the ureteropelvic junction is the most serious
because of its close proximity to the kidney and the risk of
associated kidney dysfunction

During voiding (micturition), increased intravesical pressure
keeps the ureterovesical junction closed and keeps urine within
the ureters. As soon as micturition is completed, intravesical
pressure returns to its normal low baseline value, allowing efflux
of urine to resume.
Therefore, the only time that the bladder is completely empty is
in the last seconds of micturition before efflux of urine resumes.
The three areas of narrowing within the ureters have a propensity
toward obstruction because of renal calculi (kidney stones) or
stricture.
Obstruction of the ureteropelvic junction is the most serious
because of its close proximity to the kidney and the risk of
associated kidney dysfunction

Nursing assessment: history, and physical examination
 Multiparous women delivering their children vaginally are
at high risk for stress urinary incontinence
Elderly women and persons with neurologic disorders such
as diabetic neuropathy, multiple sclerosis, or Parkinson’s
disease often have incomplete emptying of the bladder with
urinary stasis, which may result in-
urinary tract infection
increasing bladder pressure leading to overﬂow
incontinence,
hydronephrosis,
pyelonephritis,
renal insufﬁciency.

 The patient’s chief concern or reason for seeking health
care, the onset of the problem, and its effect on the patient’s
quality of life
The location, character, and duration of pain, if present, and
its relationship to voiding
Factors that precipitate pain, and those that relieve it
History of urinary tract infections, including past treatment
or hospitalization for urinary tract infection
Fever or chills
Previous renal or urinary diagnostic tests or use of
indwelling urinary catheters

 Dysuria and when it occurs during voiding (at initiation or
termination of voiding)
Hesitancy, straining, or pain during or after urination
Urinary incontinence (stress incontinence, urge
incontinence, overﬂow incontinence, or functional
incontinence)
Hematuria or change in color or volume of urine
Nocturia and its date of onset
Renal calculi (kidney stones), passage of stones or gravel in
urine

 Female patients: number and type (vaginal or cesarean) of
deliveries; use of forceps; vaginal infection, discharge, or
irritation; contraceptive practices
Presence or history of genital lesions or sexually transmitted
diseases
Habits: use of tobacco, alcohol, or recreational drugs
Any prescription and over-the-counter medications
(including those prescribed for renal or urinary problems)



Nursing assessment: history,
and physical examination
 During physical examination
for genitourinary dysfunction
areas of emphasis include the
abdomen, suprapubic region,
genitalia and lower back, and
lower extremities.
Direct palpation of the
kidneys may help determine
their size and mobility
 The right kidney is easier to
feel because it is somewhat
lower than the left one

 Renal dysfunction may produce tenderness over the
costovertebral angle, which is the angle formed by the lower
border of the 12th, or bottom, rib and the spine.
 The abdomen is auscultated to assess for bruits (low-
pitched murmurs that indicate renal artery stenosis or an
aortic aneurysm).
The abdomen is also assessed for the presence of peritoneal
ﬂuid, which may occur with kidney dysfunction.

 The bladder should be percussed after the patient voids to
check for residual urine
 Percussion of the bladder begins at the midline just above
the umbilicus and proceeds downward.
The sound changes from tympanic to dull when percussing
over the bladder.
The bladder, which can be palpated only if it is moderately
distended, feels like a smooth, ﬁrm, round mass rising out of
the abdomen, usually at midline
Dullness to percussion of the bladder following voiding
indicates incomplete bladder emptying.

 The prostate gland is palpated by digital rectal examination
(DRE)
 Blood is drawn for PSA before the DRE because
manipulation of the prostate can cause the PSA level to rise
temporarily.
The inguinal area is examined for enlarged nodes, an
inguinal or femoral hernia, or varicocele (varicose veins of
the spermatic cord)

 In female, the vulva, urethral meatus, and vagina are
examined
The patient is assessed for edema and changes in body
weight. Edema may be observed, particularly in the face and
dependent parts of the body, such as the ankles and sacral
areas
 An increase in body weight commonly accompanies edema.
A 1-kg weight gain equals approximately 1,000 mL of ﬂuid.

urological obstructions
urethral strictures
A urethral stricture is a scar in or around
the urethra, which can block the flow of
urine, and is a result of inflammation,
injury or infection.

Anatomy of the Male Reproductive System

urethral strictures
Risk factors-
Urethral strictures are more common in men because
their urethras are longer than those in women.
Thus men's urethras are more susceptible to disease
or injury.
 A person is rarely born with urethral strictures and
women rarely develop urethral strictures.

urethral strictures
Etiology -
Stricture disease may occur anywhere from the
bladder to the tip of the penis.
 The common causes of stricture are trauma to the
urethra and infections such as sexually transmitted
diseases and damage from instrumentation.
Trauma such as straddle injuries, direct trauma to
the penis and catheterization can result in strictures
of the anterior part of the urethra.

urethral strictures
Etiology -
In adults, urethral strictures from instrumentation
trauma may occur after prostate surgery and urinary
catheterization.
 In children, urethral strictures most often follow
reconstructive surgery for congenital abnormalities
of the penis and urethra, cystoscopy and
occasionally may be congenital.

urethral strictures
Clinical features -
painful urination.
slow urine stream.
decreased urine output.
spraying of the urine stream.
blood in the urine.
abdominal pain.
urethral discharge.
urinary tract infections in men.
infertility in men.

urethral strictures
Diagnostic evaluation-
Evaluation of patients with urethral stricture
includes a physical examination.
Urethral imaging (X-rays or ultrasound).
The retrograde urethrogram is an invaluable test
to evaluate and document the stricture and
define the stricture recurrence. Combined with
antegrade urethrogram, length of the stricture
can be determined.

Normal Urethrogram Obstructive Urethrogram
urethral strictures

urethral strictures
Treatment-
Treatment options for urethral stricture disease are
varied and selection depends upon the length,
location and degree of scar tissue associated with the
stricture.
 The main treatment options include enlarging the
stricture by gradual stretching (dilation).

urethral strictures
Treatment-
Cutting the stricture with a endoscopic equipment
(urethrotomy) and surgical repair of the stricture
with reconnection and reconstruction called
urethroplasty.
Urethral Stents where a biocompatible hollow tube
is placed on the inside of the stricture to allow for
free passage of urine.

renal calculi
Urolithiasis refers to stones (calculi) in the urinary
tract.
Stones are formed in the urinary tract when urinary
concentrations of substances such as calcium
oxalate, calcium phosphate, and uric acid increase.
This is referred to as supersaturation and is depen-
dent on the amount of the substance, ionic strength,
and pH of the urine.

renal calculi
Incidence-
The occurrence of urinary stones occurs predomi-
nantly in the third to ﬁfth decades of life and
Affects men more than women.
About half of patients with a single renal stone have
another episode within 5 years.
Most stones contain calcium or magnesium in
combination with phosphorus or oxalate.
Most stones are radiopaque and can be detected by
x-ray studies

renal calculi
Types of stone-
Calcium stone
Oxalate stone
Cystiene stone
Struvite stone

renal calculi
Types of stone-
Calcium stone
Most stones (75%) are composed mainly of calcium
oxalate crystals.
Increased calcium concentrations in blood and urine
promote precipitation of calcium and formation of
stones.
Causes of hypercalcemia (high serum calcium) and
hypercalciuria (high urine calcium) include the
following:

renal calculi
Types of stone-
Calcium stone
 Hyperparathyroidism
 Renal tubular acidosis
Cancers
Granulomatous diseases (sarcoidosis, tuberculosis), which
may cause increased vitamin D production by the
granulomatous tissue
Excessive intake of vitamin D
Excessive intake of milk and alkali
Myeloproliferative diseases (leukemia, polycythemia vera,
multiple myeloma), which produce an unusual proliferation of
blood cells from the bone marrow

renal calculi
Types of stone-
Uric acid stones
5% to 10% of all stones
gout
myeloproliferative disorders
Diet high in purines and abnormal purine
metabolism

renal calculi
Types of stone-
Struvite stones
15% of urinary calculi
form in persistently alkaline, ammonia-rich urine
caused by the presence of urease splitting bacteria
such as Proteus, Pseudomonas, Klebsiella, Staphy-
lococcus, or Mycoplasma species.
Predisposing factors for struvite stones (commonly
called infection stones) include neurogenic bladder,
foreign bodies, and recurrent UTIs.

renal calculi
Types of stone-
Cystine stones
1% to 2% of all stones
occur in patients with a rare inherited defect in renal
absorption of cystine (an amino acid).

Urological obstrUctions
renal calcUli
Causes and predisposing factors:
Chronic dehydration, poor fluid intake, and immobility
Living in mountainous, desert, or tropical areas
Infection, urinary stasis, and periods of immobility
Inﬂammatory bowel disease and in patients with an
ileostomy or bowel resection because these patients
absorb more oxalate.
Medications- antacids, acetazolamide (Diamox),
vitamin D, laxatives, and high doses of aspirin

renal calcUli
Location of stones-
Kidney
Ureter
Bladder
Urethra

renal calcUli
Site of obstruction-

renal calcUli
Clinical features-
Pain
Heamturia
Dysuria
Oedema
Pyuria
Associated symptoms-
Nausea, vomiting, diarrhea, abdominal discomfort
Chills and fever (may)

renal calcUli
Clinical features-
Pain-
 Stones in the renal pelvis may be associated with an
intense, deep ache in the costovertebral region
 Pain originating in the renal area radiates anteriorly
and downward toward the bladder in the female and
toward the testis in the male.
 If the pain suddenly becomes acute, with tenderness
over the costovertebral area, and nausea and
vomiting appear termed as renal colic

renal calcUli
Clinical features-
Pain-
 Stones lodged in the ureter (ureteral obstruction) cause
acute, excruciating, colicky, wavelike pain, radiating
down the thigh and to the genitalia
 It is called ureteral colic
 Colic is mediated by prostaglandin E, a substance that
increases ureteral contractility and renal blood ﬂow and
that leads to increased intraureteral pressure and pain
 If the stone present in the bladder and obstruct he urine
flow, produces the pain at suprapubic region along with
bladder distension

renal calcUli
Clinical features-
Hematuria-
 Hematuria is often present because of the abrasive
action of the stone.
Dysuria-
 Painful micturition is termed as dysuria.
 Obstruction in urine flow tend to cause the dysuria.

renal calcUli
Clinical features-
Oedema-
 When the stones block the ﬂow of urine, obstruction
develops, producing an increase in hydrostatic pressure
and distending the renal pelvis and proximal ureter.
 Thereby GFR decreases leads to sodium and water
retetion and gives rise to oedema.
Pyuria-
 Obstruction in urine flow, urinary retention and urinary
stasis may cause the UTI and featured as pyuria.

renal calcUli
Clinical features-
Associated symptoms-
Nausea, vomiting, diarrhea, abdominal discomfort
 due to renointestinal reflexes and shared nerve supply
(celiac ganglion) between the ureters and intestine.
 and the anatomic proximity of the kidneys to the stomach,
pancreas, and large intestine.
Features of infection-
 Due to UTI.
 These features may be chill, high grade fever dysuria
etc.

renal calcUli
History
Physical examination
Urinanalysis
Blood studies
Stone chemistry
Radiographic studies

renal calcUli
Diagnostic evaluation
History -
Diet
Water
Occupation
 medication
Past and recent medical history
Collect the informations regarding the reasons for
seeking health care services

renal calcUli
Physical examination -
Locate, nature and characteristics of pain
Assess the level of pain ,tenderness etc.
Observe for the associated symptoms.

renal calcUli
Urinanalysis-
hematuria and pyuria
pH < 5.5 indicates uric acid stone
pH > 7.5 indicates struvite stone
urine culture and drug sensitivity studies to detect
infection.
24-hour urine test for measurement of calcium, uric
acid, creatinine, sodium,citrate and oxalate

renal calcUli
Blood studies-
Hyperuracemia
Hypercalcemia
Neutrophilia
Elevated serum parathyroid hormone

renal calcUli
Stone chemistry-
Collection of stone through a strainer is useful.
Analyze the stone chemically to find out the
composition which helps in therapeutic
management.

renal calcUli
Radiographic studies-
Kidney, ureters, and bladder radiography may show
stone.
Intra venous urogram (intravenous pyelogram) to
determine site and evaluate degree of obstruction
 Retrograde pyelography
Ultrasound
Helical or axial CAT Scan

renal calcUli
Management
General Principles
If small stone (< 4 mm) and able to treat as outpatient,
80% will pass stone spontaneously with hydration, pain
control, and reassurance.
Hospitalized for intractable pain, persistent vomiting,
high-grade fever, obstruction with infection, and solitary
kidney with obstruction.
Medical management
Surgical management
Nursing management

renal calcUli
Management
Goal-
Immediate goal-
 To relieve the pain until its causes can be eliminated.
Long term goal (basic goal)-
To eradicate the stone
To determine the stone type
To prevent nephron destruction
To control infection
To relieve any obstruction

renal calcUli
Management
 Opioid analgesics or NSAIDs are administered to
prevent shock and syncope that may result from the
excruciating pain.
NSAIDs provide speciﬁc pain relief because they
inhibit the synthesis of prostaglandin E.
Hot baths or moist heat to the ﬂank areas may also
be useful.

renal calcUli
Management
Fluids are encouraged. This increases the
hydrostatic pressure behind the stone, assisting it in
its downward passage.
A high, around-the-clock ﬂuid intake reduces the
concentration of urinary crystalloids, dilutes the
urine, and ensures a high urine output.

renal calcUli
Management
Calcium stone-
Cellulose sodium phosphate (Calcibind) may be effective in
preventing calcium stones.
It binds calcium from food in the intestinal tract, reducing the
amount of calcium absorbed into the circulation.
 restrict calcium in diet
Therapy with thiazide diuretics may be beneﬁcial in reducing the
calcium loss in the urine and lowering the elevated paratharmone
levels.
The urine may be acidiﬁed by use of medications such as
ammonium chloride or acetohydroxamic acid
Sodium and protein restriction diet

renal calcUli
Management
Uric acid stone-
low-purine diet such as shellﬁsh, anchovies,
asparagus, mushrooms, and organ meats are avoided
Allopurinol may be prescribed to reduce serum uric
acid levels and urinary uric acid excretion.
Proteins may be limited in diet

renal calcUli
Management
Cystine stone -
Low-protein diet
Penicillamine is administered to reduce the amount
of cystine in the urine
urine is alkalinized.

renal calcUli
Management
Oxalate stone -
Encourage the increased fluid intake
Avoid the food contains oxalate such as- spinach,
strawberries, tea, peanuts, wheat bran

renal calcUli
Management
Non surgical management-
Ureteroscopy
ESWL (Extra Corporeal Shock wave lithotripsy)
Endoscopic procedures
Electrohydrolic lithotripsy
Chemolysis

renal calcUli
Management
Ureteroscopy
 Ureteroscopy involves visualizing the stone and then destroying it.
 Access to the stone is accomplished by inserting a ureteroscope into the
ureter and then inserting a laser, electrohydraulic lithotriptor, or ultrasound
device through the ureteroscope to fragment and remove the stones.
 A stent may be inserted and left in place for 48 hours or more after the
procedure to keep the ureter patent

renal calcUli
Management
ESWL-
ESWL is a noninvasive procedure used to break up stones in
the calyx of the kidney
In ESWL, a high-energy amplitude of pressure, or shock wave,
is generated by the abrupt release of energy and transmitted
through water and soft tissues.
When the shock wave encounters a substance of different
intensity (a renal stone), a compression wave causes the
surface of the stone to fragment.
Repeated shock waves focused on the stone eventually
reduce it to many small pieces. These small pieces are excreted
in the urine, usually without difficulty.

renal calcUli
Management
ESWL-

renal calcUli
Management
Endoscopic procedures-
A percutaneous nephrostomy or a percutaneous nephrolithotomy
may be performed, and a nephroscope is introduced through the
dilated percutaneous tract into the renal parenchyma.
Depending on its size, the stone may be extracted with forceps or by
a stone retrieval basket. Alternatively, an ultrasound probe may be
introduced through the nephrostomy tube.

renal calcUli
Management
Electrohydraulic lithotripsy-
an electrical discharge is used to create a hydraulic
shock wave to break up the stone.
A probe is passed through the cystoscope, and the
tip of the lithotriptor is placed near the stone
This procedure is performed under topical
anesthesia.

renal calcUli
Management
Chemolysis-
Chemolysis, stone dissolution using infusions of
chemical solutions (eg, alkylating agents, acidifying
agents)
A percutaneous nephrostomy is performed, and the
warm irrigating solution is allowed to ﬂow
continuously onto the stone.

renal calcUli
Management
Surgical management-
 Nephrolithotomy - Incision into the kidney with
removal of the stone
 Nephrectomy – removal of kidney
 Pyelolithotomy - removal of stone from renal pelvis
Ureterolithotomy - removal of stone from ureter
Cystostomy – removal of stone from bladder
Cystolitholapaxy - an instrument is inserted through
the urethra into the bladder, and the stone is crushed in
the jaws of this instrument

DisorDers of kiDney
glomerUlonephritis ,acUte
(acUte nephritic synDrome )
Definition –
Acute glomerulonephritis refers to a group of
kidney diseases in which there is an
inflammatory reaction in the glomeruli.
It is not an infection of the kidney, but rather
the result of the immune mechanisms of the
body

DisorDers of kiDney
glomerUlonephritis , acUte
Risk factors –
Group A beta- hemolytic streptococcal infection of the
throat
Impetigo (infection of the skin)
Acute viral infections- upper respiratory tract infections,
mumps, varicella zoster virus, Epstein-Barr virus, hepatitis
B, and human immunodeﬁciency virus [HIV] infection).
Antigens outside the body (eg, medications, foreign serum)
In other patients, the kidney tissue itself serves as the
inciting antigen.

DisorDers of kiDney
Categories –
Primary: Disease is mainly in glomeruli
Secondary: Glomerular diseases that are the
consequence of systemic disease
Idiopathic: Cause is unknown
Acute: Occurs over days or weeks
Chronic: Occurs over months or years
Rapidly progressing: Constant loss of renal function
with minimal chance of recovery

DisorDers of kiDney
Categories –
Diffuse: Involves all glomeruli
Focal: Involves some glomeruli
Segmental: Involves portions of individual
glomeruli
Membranous: Evidence of thickened glomerular
capillary walls
Proliferative: Number of glomerular cells involved

DisorDers of kiDney
(acUte nephritic synDrome)

DisorDers of kiDney
Clinical features-
Hematuria - The urine may appear cola-colored because of
red blood cells (RBCs) and protein plugs or casts; RBC casts
indicate glomerular injury.
Edema and hypertension
Oliguria
Anemia from loss of RBCs into the urine

DisorDers of kiDney
Clinical features-
In the more severe form of the disease, patients also
complain of headache, malaise, and ﬂank pain.
 Elderly patients may experience circulatory overload
with dyspnea, engorged neck veins, cardiomegaly, and
pulmonary edema.
Atypical symptoms include confusion, somnolence, and
seizures, which are often confused with the symptoms of
a primary neurologic disorder

DisorDers of kiDney
History
On examination- kidney is large, tender, edematous and congested
Urinanalysis- protienuria, hematuria , oliguria
Blood studies-
Serum creatinine, BUN increased
Hypoalbuminemia, hyperlipidemia
Elevated serum IgA level
Antistreptolysin O titers are usually elevated in post streptococcal
glomerulonephritis
Electron microscopy and immunoﬂuorescent analysis help identify the
nature of the lesion
Kidney biopsy may be needed for deﬁnitive diagnosis.

DisorDers of kiDney
Complications-
Hypertensive Encephalopathy
Heart Failure
Pulmonary Edema
ESRD

DisorDers of kiDney
Management-
Goal-
To conserve renal function
To treat complication adequately
Types of management-
Non pharmacological management
Dietary management
Pharmacological management
Nursing management

DisorDers of kiDney
Non pharmacological management-
Complete bed rest – as excessive activity may increase the
protienuria and hematuria. It should be encouraged until the
urine clears and BUN, creatinine and BP return to normal.
Strict intake out put charting.
Fluid restrictions
Plasmapheresis to decrease the serum anti body level
Dialysis if, uremic symptoms are severe.

DisorDers of kiDney
Dietary management-
Protein restricted diet as the level of BUN and creatinine is
high in blood
Low fat diet due to hyperlipidemia
Sodium restriction if hypertension, edema or congestive
heart failure are present.
Increased carbohydrate diet to provide energy and to
prevent the catabolism of protein.

DisorDers of kiDney
Glomerulonephritis , acute
(acute nephritic synDrome)
Pharmacological management-
Residual streptococcal infection is suspected, penicillin is
the agent of choice.
Diuretics and antihypertensive agents may be given to
control hypertension.
Corticosteroids and cytotoxic agents are used to reduce
the inflammation.
H2 blockers (to prevent stress ulcers)
Phosphate binding agents (to reduce phosphate and
elevate calcium).

DisorDers of kiDney
Nursing management-
Monitor vital signs, intake and output, and maintain dietary
restrictions during acute phase.
Encourage rest during the acute phase as directed until the
urine clears and BUN, creatinine, and blood pressure
normalize. (Rest also facilitates diuresis.)
Administer medications as ordered, and evaluate patient's
response to antihypertensives, diuretics, H2 blockers,
phosphate-binding agents, and antibiotics (if indicated).

DisorDers of kiDney
Nursing management-
Carefully monitor fluid balance
Replace fluids according to the patient's fluid losses (urine,
respiration, feces)
Daily body weight as prescribed.
Monitor pulmonary artery pressure and CVP, if indicated.
Monitor for signs and symptoms of heart failure: distended neck
veins, tachycardia, gallop rhythm, enlarged and tender liver,
crackles at bases of lungs.
Observe for hypertensive encephalopathy, any evidence of
seizure activity.

DisorDers of kiDney
Nursing management-
Regular monitoring of blood pressure, urinary
protein, and BUN concentrations to determine if
there is exacerbation of disease activity.
Encourage patient to treat any infection promptly.
Tell patient to report any signs of decreasing renal
function and to obtain treatment immediately.

DisorDers of kiDney
acute pyelonephritis
Definition-
Pyelonephritis is a bacterial infection of the renal
pelvis, tubules, and interstitial tissue of one or both
kidneys.

DisorDers of kiDney
Etiology-
 upward spread of bacteria from the bladder or spread from
systemic sources reaching the kidney via the bloodstream.
Systemic infections (such as tuberculosis) can spread to the
kidneys and result in abscesses.
Pyelonephritis can result from urinary obstruction such as
vesicoureteral reflux (incompetence of ureterovesical valve,
which allows urine to regurgitate into ureters, usually at time
of voiding), other renal disease, trauma, or pregnancy

DisorDers of kiDney
Commonest microorganism-
Enteric bacteria, such as E. coli, is most common pathogen
other gram-negative pathogens include Proteus species,
Klebsiella, and Pseudomonas.
Gram-positive bacteria are less common, but include
Enterococcus and Staphylococcus aureus

DisorDers of kiDney
Pathophysiology-

DisorDers of kiDney
Clinical features-
Fever, chills, headache, malaise
Flank pain (with or without radiation to groin)
Nausea, vomiting, anorexia
Costovertebral angle tenderness
Urgency, frequency, and dysuria may be present

DisorDers of kiDney
History – urinary obstruction, systemic infection
Physical examination- pain and tenderness in the area of the
costovertebral angle
Urinalysis- pyuria, bactriuria, RBCs and WBCs in urine
Hematology- elevated WBC count
An ultrasound study or a CT scan may be performed to
locate any obstruction in the urinary tract.
 An IV pyelogram may be indicated with pyelonephritis if
functional and structural renal abnormalities are suspected

DisorDers of kiDney
Management-
For severe infections (dehydrated, cannot tolerate oral
intake) or complicating factors (suspected obstruction,
pregnancy, advanced age), inpatient antibiotic therapy is
recommended.
Usually immediate treatment is started with a penicillin or
aminoglycoside I.V. to cover the prevalent gram-negative
pathogens; subsequently adjusted according to culture
results.
An oral antibiotic may be started 24 hours after fever has
resolved and oral therapy continued for 3 weeks.

DisorDers of kiDney
Management-
Oral therapy antibiotic therapy is acceptable for
outpatient treatment.
Co-trimoxazole (Bactrim, Septran) or a
fluoroquinolone is used; 10 to 14 days is the usual
length of treatment.
Repeat urine cultures should be performed after the
completion of therapy.
Supportive therapy is given for fever and pain
control and hydration.

DisorDers of kiDney
Complication-
Bacteremia with sepsis
Papillary necrosis leading to renal failure
Renal abscess requiring treatment by percutaneous
drainage or prolonged antibiotic therapy
Perinephric abscess
Paralytic ileus

DisorDers of kiDney
Nursing Management-
Administer or teach self-administration of
antibiotics as prescribed, and monitor for
effectiveness and adverse effects.
Assess vital signs frequently, and monitor intake
and output; administer antiemetic medications to
control nausea and vomiting.
Administer antipyretic medications as prescribed
and according to temperature.

DisorDers of kiDney
Nursing Management-
Report fever that persists beyond 72 hours after initiating
antibiotic therapy; further testing for complicating factors
will be ordered.
Use measures to decrease body temperature if indicated;
cooling blanket, application of ice to armpits and groins, and
so forth.
Correct dehydration by replacing fluids, orally if possible,
or I.V.
Monitor CBC, blood cultures, and urine studies for
resolving infection.

DisorDers of kiDney
nephrotic synDrome
Definition-
Nephrotic syndrome is a clinical disorder characterized by
marked increase of protein in the urine (proteinuria),
decrease in albumin in the blood (hypoalbuminemia),
edema, and excess lipids in the blood (hyperlipidemia).
These occur because of increased permeability of the
glomerular capillary membrane.

DisorDers of kiDney
nephrotic synDrome
Classification of nephrotic syndrome-
ETOLOGICAL CLASSIFICATION
Primary NEPHROTIC syndrome.
Disease limited to kidney
Secondary NEPHROTIC syndrome.
Other systems involved
HISTOLOGICAL CLASISIFICATION
MCD (Minimal change disease )
FSGN (Focal segmental glomerulosclerosis )
MN (Membranous nephropathy)
MPGN (membranous proliferative glomerulonephrosclerosis)

DisorDers of kiDney
nephrotic synDrome
Etiology-
Membranous nephropathy (MN)
Hepatitis B
Sjogren's syndrome
Systemic lupus erythematosus (SLE)
Diabetes mellitus
Sarcoidosis
Syphilis
Drugs
Malignancy (cancer)

DisorDers of kiDney
nephrotic synDrome
Etiology-
Focal segmental glomerulosclerosis (FSGS)
Hypertensive Nephrosclerosis
Human immunodeficiency virus (HIV)
Diabetes mellitus
Obesity
Kidney loss
Minimal change disease (MCD)
Drugs
Malignancy, especially Hodgkin's lymphoma

DisorDers of kiDney
nephrotic synDrome
pathophysiology-

DisorDers of kiDney
nephrotic synDrome
Clinical features-
The major manifestation of nephrotic syndrome is
edema.
It is usually soft and pitting and commonly occurs
around the eyes (periorbital), in dependent areas
(sacrum, ankles, and hands), and in the abdomen
(ascites).
Patients may also exhibit irritability, headache, and
malaise.

DisorDers of kiDney
nephrotic synDrome
Urinalysis- marked proteinuria, microscopic hematuria,
24-hour urine for protein (increased) and creatinine
clearance (decreased)
Protein electrophoresis and immunoelectrophoresis of
the urine to categorize the proteinuria
Needle biopsy of kidney for histologic examination of
renal tissue to confirm diagnosis
Serum chemistry- decreased total protein and albumin,
normal or increased creatinine, increased triglycerides,

DisorDers of kiDney
nephrotic synDrome
Complications-
Complications of nephrotic syndrome include-
Infection (due to a deﬁcient immune response)
Thromboembolism (especially of the renal vein)
Pulmonary emboli
ARF(due to hypovolemia)
Accelerated atherosclerosis (due to hyperlipidemia)

DisorDers of kiDney
nephrotic synDrome
Management-
Treatment of causative glomerular disease
Diuretics (used cautiously) and angiotensin converting
enzyme inhibitors to control proteinuria
Corticosteroids or immunosuppressant agents to decrease
proteinuria
General management of edema
Sodium and fluid restriction; liberal potassium
Infusion of salt-poor albumin
Dietary protein supplements
Low-saturated-fat diet

DisorDers of kiDney
nephrotic synDrome
Nursing Management-
Monitor daily weight, intake and output, and urine specific
gravity.
Monitor CVP (if indicated), vital signs, orthostatic blood
pressure, and heart rate to detect hypovolemia.
Monitor serum BUN and creatinine to assess renal function.
Administer diuretics or immunosuppressants as prescribed,
and evaluate patient's response.
Infuse I.V. albumin as ordered.
Encourage bed rest for a few days to help mobilize edema;
however, some ambulation is necessary to reduce risk of
thromboembolic complications.

DisorDers of kiDney
acute renal failure
Definition-
Acute renal failure is a sudden and almost complete
loss of kidney function caused by failure of renal
circulation or by glomerular or tubular dysfunction.

DisorDers of kiDney
acute renal failure
Etiology-
Pre – renal (hypoperfusion of kidney)
Intra – renal (actual damage to the kidney tissue)
Post – renal (obstruction to urine flow)

DisorDers of kiDney
acute renal failure
Etiology-
Pre – renal
Volume depetion
Hemorrhage
Renal loses
GI losses
Impaired cardiac efficiency
Vasodilation
sepsis
Anaphylaxis

DisorDers of kiDney
acute renal failure
Etiology-
Intra – renal
Prolonged renal ischemia
Pigment nephropathy
Myoglobinuria
Hemoglobinuria
Nephrotoxic agents
Aminoglycosides agents
Radiopaque contrast agents
Heavy metals

DisorDers of kiDney
acute renal failure
Etiology-
Post – renal
Urinary tract obstructions
Renal calculi
Tumors
BPH
Blood clots
Strictutres

DisorDers of kiDney
acute renal failure
RISK FACTORS
Advanced age
Blockages in the blood vessels in your arms or legs
Diabetes
High blood pressure
Heart failure
Kidney diseases
Liver disease

DisorDers of kiDney
acute renal failure
PHASES OF ARF
Initiating phase
Oliguric phase
Diuretic phase
Recovery phase

DisorDers of kiDney
acute renal failure
PHASES OF ARF
Initiating phase
Begins with the initial insult and ends when oliguria develops
Oliguric phase
Urine output less than 400 ml/day
Diuretic phase
Urine out put become normal but nitrogenous waste products
still remain elevated in blood
Recovery phase
It signifies the improvement of renal function
It takes 3-12 months to return normal

DisorDers of kiDney
acute renal failure
Clinical features-
Vomiting and/or diarrhea, which may lead to dehydration.
Nausea.
Weight loss.
Nocturnal urination.
pale urine.
Less frequent urination, or in smaller amounts than usual,
with dark coloured urine
Haematuria.
Pressure, or difficulty urinating.
Itching.

DisorDers of kiDney
acute renal failure
Clinical features-
Bone damage.
Non-union in broken bones.
Muscle cramps (caused by low levels of calcium which can
cause hypocalcaemia)
Abnormal heart rhythms.
Muscle paralysis.
Swelling of the legs, ankles, feet, face and/or hands.
Shortness of breath due to extra fluid on the lungs
Pain in the back or side
Feeling tired and/or weak.

DisorDers of kiDney
acute renal failure
Clinical features-
Memory problems.
Difficulty concentrating.
Dizziness.
Low blood pressure.
Anorexia
Pruritus
Seizures (if blood urea nitrogen level is very high)

DisorDers of kiDney
acute renal failure
History regarding the etiological factors and risk factors.
Physical symptoms
Urine out put – scanty, bloody, and low specific gravity
Increased BUN and creatinine level in blood
Hyperkalemia
Metabolic acidosis
Hyperphoshatemia
Hypocalcemia
Anemia

DisorDers of kiDney
acute renal failure
Prevention-
Provide adequate hydration to patient at high risk
for dehydration
Prevent and treat shock with blood and fluid
replacement therapy
Manage hypotension
Monitor critically ill patient for central venous and
arterial pressures and hourly urine output to detect
the onset of renal failure as early as possible.
Continuously assess the renal function

DisorDers of kiDney
acute renal failure
Prevention-
Prevent and treat infections
Cautiously administer the blood
Closely monitor the all medications that
metabolized and excreted by the kidney for dosage
and blood levels for the toxic effects.
Pay special attention to wound, burns and other
precursors of sepsis.

DisorDers of kiDney
acute renal failure
COMPLICATIONS
ARF can affect the entire body in the form of –
Infection
Hyperkalaemia, Hyperphosphataemia, Hyponatraemia
Water overload
Pericarditis
Pulmonary oedema.
Reduced level of consciousness.
Immune deficiency

DisorDers of kiDney
acute renal failure
Management-
 To correct fluid and electrolyte balance.
 To correct dehydration.
 To Keep other body systems working properly

DisorDers of kiDney
conGenital DisorDers of Genitourinary system
Common Renal anomalies
• Abnormal number: agenesis
• Abnormal form or position: horseshoe kid.
Common ureteral & renal pelvis anomalies
• UPJ obstruction.
• Vesico-uretral reflux.
• Duplication.
• Uretrocele.
• Ectopic ureter.

DisorDers of kiDney
conGenital DisorDers of Genitourinary system
Common Bladder anomalies
• Bladder Extrophy.
Common Urethral & penile anomalies
• Hypospadias.
• Epispadias.

DisorDers of kiDney
Congenital DisorDers of
Renal agenesis
Bilateral renal agenesis
• both mesonephric ducts fail to
develop.
• Incompatible with life.
Unilateral renal agenesis
• the mesonephric duct fails to develop.
• Usually there is absent ureter, trigone,
kidney and (in boys) vas deferens.

DisorDers of kiDney
Congenital DisorDers of genitourinary system
Horseshoe kidney
• both metanephros are fused together.
• both kidneys rotated & their lower poles are joined in the
shape of a horseshoe.
• As the fetus grows, the joined kidneys are held up by the
inferior or superior mesenteric arteries at L3.

DisorDers of kiDney
Pelviureteric junction obstruction
Obstruction of the junction between the
renal pelvis & ureter.
Aetiology
• aperistaltic segment of ureter due to
absent muscles.
or
• crossing vessels over UPJ.

DisorDers of kiDney
Clinical features-
may present at any time (before birth, in childhood, or in adulthood)
by:
• abdominal mass.
• abdominal pain.
• Haematuria after fairly minor abdominal trauma.
IVU - shows delay in appearance of contrast and dilated renal
pelvis and calices.
Renal scan -shows differential renal function and confirms
obstruction.

DisorDers of kiDney
Management-
Surgery is indicated for:
1. obstructive symptoms,
2. stone formation,
3. recurrent urinary infection,
4. progressive renal impairment.
• Pyeloplasty is the treatment of choice
• Nephrectomy is performed if the affected kidney is <10% of
total renal function.

DisorDers of kiDney
Management-
alternative techniques:
1.Antegrade endopyelotomy .
2.Laparoscopic pyeloplasty

DisorDers of kiDney
Vesicoureteric junction reflux
• Reflux can be defined as the retrograde flow of urine into
upper urinary tract.
• incidence of reflux is equal in both sexes.
• Reflux can be classified into 5 grades -

DisorDers of kiDney
• Evaluation
•Micturating cystourethrography is the gold standard for
diagnosis and evaluation of VUR grade.
•Diuretic Renal scan (DMSA) is used to visualize scarring and
quantify differential renal function.

DisorDers of kiDney
Management
•antibiotic prophylaxis is recommended for children with
reflux of grades I-II.
•Surgery (uretro - vesical reimplantation or endoscopic
injection) is recommended in reflux of grades III-V and
persistent reflux despite a trial of antibiotics.

DisorDers of kiDney
Duplication of urinary system
• Ureteral duplication is the most frequent anomaly of urinary
tract
• Female: male = 2 : 1
• The orifice draining the upper segment is often obstructed.
• The orifice of the lower segment generally refluxes.
• Duplication is usually discovered on an IVU .
• Management is according to segment affected and its
function.

DisorDers of kiDney
Ectopic ureter
• An ectopic ureter is one that opens in some
location other than the bladder.
80% associated with duplicated system.
20% associated with single system.
• Most common sites (in female): urethra,
vestibule, and vagina
• In female present as urinary incontinence.
• Most common sites (in male): posterior
urethra and seminal vesicles.

DisorDers of kiDney
Uretrocele
• A congenital cystic ballooning of the
terminal submucosal ureter.
• It is classified as simple or ectopic.
• Simple ( Orthotopic ) Ureterocele :
in trigone.
•Ectopic Ureterocele : can obstruct
bladder neck or even prolapse from
female urethra.

DisorDers of kiDney
Hypospadias
• It is a condition in which the opening of the urethra is on
the underside of the penis, instead of at the tip.
• congenital condition results in underdevelopment of urethra.
• affects 3 per 1000 male infants.
• Consists of 3 anomalies:
( 1 ) Abnormal ventral opening of the urethral meatus.
( 2 ) Ventral curvature of the penis ( chordee ).
( 3 ) Deficient prepuce ventrally

DisorDers of kiDney
Hypospadias
• Site Of the meatus

DisorDers of kiDney
Hypospadias
Treatment
• The child should be referred for urological assessment and
surgical treatment.
• The ideal age for surgery is 6–12 months.

DisorDers of kiDney
Epispadias
• Congenital condition in which the urethra opens on dorsal
surface of penis..
• Usually associated with bladder extrophy (ectopia vesicae).

DisorDers of kiDney
Bladder Extrophy (Ectopia vesicae)
• Failure of development of the lower abdominal wall.
• Anomaly include defect in anterior abdominal wall, defect in
anterior bladder wall and epispadias (dorsal penile opening).

DisorDers of kiDney
CanCer of kiDney
Incidence-
Cancer of the kidney accounts for about 3.7% of all cancers
in adults.
It affects almost twice as many men as women.
The most common type of renal tumor is renal cell or renal
adenocarcinoma, accounting for more than 85% of all kid-
ney tumors.
These tumors may metastasize early to the lungs, bone,
liver, brain, and contralateral kidney.
The incidence of all stages of kidney cancer has increased in
last two decades.

DisorDers of kiDney
CanCer of kiDney
Risk factors-
Gender: Affects men more than women
Tobacco use
Occupational exposure to industrial chemicals, such as petroleum products,
heavy metals, and asbestos
Obesity
Unopposed estrogen therapy
Polycystic kidney disease
regular use of NSAIDs such as ibuprofen and naproxen,
faulty genes;
a family history of kidney cancer;
having kidney disease that needs dialysis;
being infected with hepatitis C;

DisorDers of kiDney
CanCer of kiDney
Types-
Most ocuuring renal cancer are renal cell carcinoma and renal pelvis
carcinoma, other, less common types of kidney cancer include:
Squamous cell carcinoma
Juxtaglomerular cell tumors (reninoma)
angiomyolipoma
Renal ancocytoma
Bellini duct carcinoma
Clear cell sarcoma of the kidney
Mesoblastic nephroma
Wilm’s tumor, usually is reported in children under the age of 5.
Mixed epithilial stromal cell tumors

DisorDers of kiDneyCanCer of kiDney
Clinical features-
Many renal tumors produce no symptoms and are discovered on a
routine physical examination as a palpable abdominal mass.
The classic triad of signs and symptoms, comprises hematuria, pain,
and a mass in the ﬂank.
The usual sign that ﬁrst calls attention to the tumor is painless
hematuria, which may be either intermittent and microscopic or
continuous and gross.
There may be a dull pain in the back from the pressure produced by
compression of the ureter, extension of the tumor into the perirenal
area, or hemorrhage into the kidney tissue.
Colicky pains occur if a clot or mass of tumor cells passes down the
ureter.
weight loss, increasing weakness, and anemia.

Assessment and Diagnostic Findings-
The diagnosis of a renal tumor may require
intravenous urography,
cystoscopic examination,
nephrotomograms,
renal angiograms, ultrasonography,
CT scan.

Management-
Goal-
The goal of management is to eradicate the tumor before
metastasis occurs.

Management-
Surgical management-
A radical nephrectomy is the preferred treatment if the
tumor can be removed. This includes removal of the kidney
(and tumor), adrenal gland, surrounding perinephric fat and
Gerota’s fascia, and lymph nodes.
 Radiation therapy, hormonal therapy, or chemotherapy may
be used along with surgery.
 Immunotherapy
Nephron-sparing surgery

Management-
pharmacological management-
use of biologic response modiﬁers such as interleukin-2 (IL-
2) and topical instillation of bacillus Calmette-Guerin (BCG)
Patients may be treated with IL-2, a protein that regulates
cell growth. This may be used alone or in combination with
lymphokine-activated killer cells
Interferon, another biologic response modiﬁer, appears to
have a direct antiproliferative effect on renal tumors.

Management-
Renal Artery Embolization-
In patients with metastatic renal carcinoma, the renal artery
may be occluded to impede the blood supply to the tumor
and thus kill the tumor cells.

DisorDers of kiDneyCanCer of blaDDer
Cancer of the urinary bladder is more common in people
aged 50 to 70 years.
It affects men more than women (3:1)
There are two forms of bladder cancer: superﬁcial (which
tends to recur) and invasive. About 80% to 90% of all
bladder cancers are transitional cell (which means they arise
from the transitional cells of the bladder);
the remaining types of tumors are squamous cell and ade-
nocarcinoma.

Risk factors-
 Cigarette smoking: risk proportional to number of packs
smoked daily and number of years of smoking
Environmental carcinogens: dyes, rubber, leather, ink, or
paint
Recurrent or chronic bacterial infection of the urinary tract
Bladder stones
 High urinary pH
High cholesterol intake
Pelvic radiation therapy
Cancers arising from the prostate, colon, and rectum in

Clinical Manifestations
Bladder tumors usually arise at the base of the bladder and
involve the ureteral oriﬁces and bladder neck.
Visible, painless hematuria is the most common symptom of
bladder cancer.
Infection of the urinary tract is a common complication,
producing frequency, urgency, and dysuria.
Any alteration in voiding or change in the urine, however,
may indicate cancer of the bladder.
Pelvic or back pain may occur with metastasis.

Assessment and Diagnostic Findings
The diagnostic evaluation includes –
cystoscopy (the mainstay of diagnosis),
excretory urography,
a CT scan,
ultrasonography,
bimanual examination with the patient anesthetized.
Biopsies of the tumor and adjacent mucosa

Management- surgical
Transurethral resection or fulguration (cauterization) may be per-
formed for simple papillomas (benign epithelial tumors).
eradicate the tumors through surgical incision or electrical
current with the use of instruments inserted through the urethra.
After this bladder-sparing surgery, intravesical administration of
BCG is the treatment of choice.
A simple cystectomy (removal of the bladder) or a radical
cystectomy is performed for invasive or multifocal bladder
cancer.
Radical cystectomy in men involves removal of the bladder,
prostate, and seminal vesicles and immediate adjacent perivesical
tissues.

Management- pharmacological
Chemotherapy with a combination of methotrexate, 5-ﬂuorouracil,
vinblastine, doxorubicin (Adriamycin), and cisplatin
Intravenous chemotherapy may be accompanied by radiation therapy.
Topical chemotherapy (intravesical chemotherapy or instillation of
antineoplastic agents into the bladder, resulting in contact of the agent
with the bladder wall) is considered when there is a high risk for
recurrence, when cancer in situ is present, or when tumor resection has
been incomplete.
Topical chemotherapy de- livers a high concentration of medication
(doxorubicin, mitomycin, ethoglucid, and BCG) to the tumor to promote
tumor destruction.
BCG is now considered the most effective intravesical agent for recurrent
bladder cancer because it enhances the body’s immune response to

Management- radiation therapy
Radiation of the tumor may be performed preoperatively to reduce
microextension of the neoplasm and viability of tumor cells,

DisorDers of kiDneyCanCer of ureter
Ureteral cancer is usually transitional cell carcinoma.
Transitional cell carcinoma is "a common cause of ureter
cancer and other urinary (renal pelvic) tract cancers.“
Cancer of the ureter begins in the cells that line the inside of
the tubes (ureters) that connect your kidneys to your bladder.
Cancer of the ureter is uncommon.
It occurs most often in older adults and in people who have
previously been treated for bladder cancer.
Men>women
Whitish>black

Risk factors-
Increased age
Treatment of bladder cancer
Tobacco smoking
Analgesics nephropathy
Industrial exposures

Clinical features-
Symptoms of ureteral cancer may include –
blood in the urine (hematuria);
diminished urine stream and straining to void (caused by urethral
stricture);
frequent urination and increased nighttime urination (nocturia);
hardening of tissue in the perineum, labia, or penis;
itching;
incontinence;
pain during or after sexual intercourse (dyspareunia);
 painful urination (dysuria);
recurrent urinary tract infection;
urethral discharge and swelling.

Diagnosis may include-
computed tomography urography (CTU),
magnetic resonance urography(MRU),
intravenous pyelography (IVP)
x-ray,
Ureteroscopy
biopsy

Management-
Treatment methods include -
surgery
Chemotherapy
 radiation therapy
 medication.

DisorDers of kiDneyCanCer of urethra
Urethral cancer is cancer originating from the urethra.
 Cancer in this location is rare, and the most common
type is papillary transitional cell carcinoma
Having a history of bladder cancer
Having conditions that cause chronic, swollen,
reddened part in the urethra.
Being 60 or older.
Being a white female.

Clinical features-
Bleeding from the urethra or blood in the urine.
Weak or interrupted flow of urine.
Urination occurs often.
A lump or thickness in the perineum or penis.
Discharge from the urethra.
Enlarged lymph nodes in the groin area.
Most common site being bulbomembranous urethra

Diagnosis is established by transurethral biopsy
Types-
transitional cell carcinoma
squamous cell carcinoma
adenocarcinoma
melanoma

Management-
Surgery-
Open excision surgery.
Electro-resection with flash surgery.
Laser surgery
Cystourethrectomy surgery.
Cystoprostatectomy surgery.
Anterior body cavity surgery.
Incomplete or basic penectomy surgery.

Management-
chemotherapy-
Chemotherapy involves using drugs to destroy urethral
cancer cells.
It is a systemic urethral cancer treatment (i.e., destroys
urethral cancer cells throughout the body) that is
administered orally or intravenously (through a vein;
IV).
 Medications are often used in combination to destroy
urethral cancer that has metastasized.
Commonly used drugs include vincristine, cisplatin and
methotrexate

genitourinary disorders (medical surgical nursing)

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