1. Adult Voiding Dysfunction Urinary incontinence Is involuntary loss of urine from the bladder common in older multiparous women; could affect nulliparous Risk factors: age, gender, number of vaginal deliveries Types of incontinence  Stress incontinence: loss of urine through intact urethra as a result of sneezing, coughing Affects women of vaginal deliveries In men after prostatectomy; because of  Loss of uretheral compression  Irritable bladder

2. Types of incontinence  Urge incontinence: involuntary loss of urine that Associates a strong urge to void, that can not be suppressed An uninhibited detrusor contraction is the precipitating factor; occurs in neurologic dysfunction that impairs inhibition of bladder contraction  Functional: intact system but have cognitive impairment, Alzheimer’s dementia or physical disability  Iatrogenic: because of extrinsic factors, medications, alpha- adrenergic agents  Mixed urinary incontinence Encompasses several types of incontinence Is involuntary leakage associated with urgency And with exertion, effort, sneezing, coughing. Chart 45-7, P1368

3. Types of incontinence  Reflex incontinence: Loss of urine due to hyperreflexia in the absence of normal sensations Most common in patients with spinal cord injury  Over flow incontinence: loss of urine that associates over distention of the bladder Results from the bladder inability to empty normally Common causes: spinal cord lesions; factors obstructing the flow of urine, tumors, stricture, prostatic hyperplasia

4. Medical Management Behavioral therapy The cornerstone is pelvic floor muscle exercise; Kegel exercises Other behavioral treatments include: Voiding diary; verbal instructions; Biofeedback  Fluid management: Adequate fluid intake, 1500-1600 ML Taken as small increments between breakfast & evening Reduces urgency related to Concentrated urine Decreases UTIs Maintains bowel functioning The best fluid is water Avoid soft drinks, sweeteners -irritate bladder walls

5. Behavioral therapy  Standardized voiding frequency Time voiding: establish voiding program: every 2 hours Bladder retraining: urinary urge inhibition exercises to inhibit voiding or leaking  Pelvic muscle exercises, Kegel: Tighten muscle used to stop flatus or stream of urine 5-10 seconds followed by 10 seconds rest; 2-3 times a day for 6 weeks 10-30 times at each session  Read chart 45-, P. 1582

6. Urinary incontinence pharmacological management Drugs: works best with behavioural interventions Anticholinergic, inhibit bladder contraction—for urge incontinence Antidepressant: Amitriptyline, Amoxapine decreases bladder contraction, and increases bladder neck resistance Sudafed, act on alpha-Adrenergic receptors—for stress incontinence; causes urinary retention; given with caution in prostatic hyperplasia Estrogen for postmenopausal women: restores mucosal, vascular, muscular integrity of the urethra

7. Urinary incontinence surgical therapy Periuretheral bulking: for those not benefit from behavioral interventions and drugs Artificial collagen are placed within the wall of the urethra to enhance the closing pressure of the urethra A 10-20 minutes procedure; under local anesthesia A cytoscope is used to place the collagen An artificial urinary sphincter, used to close urethra and promote continence 2 types of sphincter: periurethral cuff; cuff inflation pump

8. UI Nursing Management Incontinence is not inevitable with illness; but irreversible & treatable Provide support and encouragement to promote behavioural therapy Patient teaching, oral and in writing, behavioural therapy; read chart 45-6, P. 1583 Encourage the patient to develop and use a diary to record timing of pelvic exercises; frequency of voiding; changes in bladder function Explain the purpose of the medications; surgery

9. Urinary retention UR Inability to empty bladder completely during an attempt to void UR often leads to overflow incontinence from the pressure of retained urine in the bladder Residual urine: urine that remains in the bladder after voiding, In less than 60 years of age, complete emptying should occur over 60 years of age, 50-100 ml remain after each void because of decreased contractility of detrusor muscle UR occurs postoperatively; particularly if surgery affects perineal or anal regions-reflex spasm of the sphincters Effect of anesthesia: impede bladder emptying

10. UR  Predisposing factors Health conditions—DM, prostate enlargement, uretheral pathology (infection, tumor, calculus), pregnancy, neurological, spinal cord injury; multiple sclerosis Medications: Anticholinergic, Atropine, Dicyclomine hydrochlorid, is inhibiting bladder contractility Adrenergic blocking(ephedrine, propranolol)—causing bladder outlet resistance:

11. UR  Assessment Attention to an awareness of bladder fullness S & S of UTI; hematuria, urgency, dysuria Voiding diary Post-void residual volume using ultrasound bladder scanner  Complications: Infection, chronic infection can lead to calculi Kidney deterioration with large amount of urine retained leading to hydronephrosis Urine leakage-irritate skin

12. Nursing management UR Teaching to monitor urine out put closely Reassurance about the temporary nature of the problem Measures to promote urinary elimination: Providing privacy, natural setting as possible standing—in males Warmth applications to relax the sphincter (sitz bath, warm compresses) Other measures: provision of hot tea, turning on water faucet Stroking the abdomen or inner thighs Catheterization: to prevent over-distention of the bladder; superaubic Bladder retraining Home modifications

13. Urolithiasis & neprolithiasis  stones calculi in the kidneys & urinary tract  Pathophysiology: Formed when urinary concentration of substances (Ca Oxylate, Ca phsophate, Uric Acid) increases Formed any where; size, from sands in kidney to a size of orange in the bladder Theories explaining stones formation: Deficiency of substances that prevent crystallization: citrate, magnesium, nephrocalcin Fluid status, stones tend to occur in dehydrated patients

14. Pathophysiology Factors promoting stones formation: infection, stasis, immobility, that slow renal drainage and alter calcium metabolism Increased Ca concentrations in blood & urine also promote stone formation Ca-based stones = 75% of all renal stones 5-10% are uric acids stones; in patients with gout 15% are struvite stones: formed in persistently alkaline, ammonia-rich urine—caused by urease-splitting bacteria. Predisposing factors: neurogenic bladder, recurrent UTIs 1-2% cystine stones; occur in patients with a defect in renal absorption of cystine, an amino acid

15. Health assessment Clinical manifestations: S & S depends on the presence of obstruction, infection and edema Stone-obstruction-increased hydrostatic pressure—distending renal pelvis & proximal ureter Infection with chills, fever, dysuria can be a contributing factor with struvite stones Stone in the renal pelvis: Intense deep ache in costovertebral region Hematuria and pyuria may be present Pain radiate towards tests in male and bladder in female Diarrhea and abdominal discomfort

16. Health assessment Ureter stones cause acute severe colicky with desire to void, but little urine is passed amount Stones lodged in bladder causes irritation, hematuria, infection  Diagnostic procedures KUB, ultrasongraphy, IV urography, retrograde pyelography Blood tests and 24-hour urine for calcium, uric acid, creatinine, sodium, Ph Dietary and family history

17. Medical Management  Objectives: Eradicate stone and prevent nephron destruction Control infection and relieve obstruction  Relieve colic pain: Opioids to prevent shock& syncope Non-steriodal anti-inflammatory drugs  Reduce swelling that facilitates passage of the stone  Inhibiting synthesis of prostglandin E Hot application to the flank region; moist heat Fluids are encouraged unless restricted because of other illnesses

18. Nutritional therapy Encourage fluid intake unless contraindicated; 8-10 ounce glasses; urine output exceeding 2 L is advisable Restrict calcium; is questionable; in Ca-related stones Restrict sodium and protein intake with liberal fluids Thiazide diuretics to lower serum parathormone In uric acid stone; restrict food high in purine; shellfish, asparagus, mushrooms, organ meats In oxalate stones: maintain urine diluted; limit intake of spinach, strawberries, chocolate, peanuts, tea In cystine stone; low protein diet with increased fluid intake

19. Interventional procedures Ureteroscopy: Visualizing the stone then destroying it A ureteroscope is inserted in the ureter; then Inserting a laser, electrohydrualic lithotriptor to fragment stone A stent for 48 hrs is inserted to maintain patency of the ureter Extracorporeal shock wave lithotripsy: A non-invasive procedure, used to break stones in the calyx of the kidney A high shock wave is generated by release of energy; then transmitted by water & soft tissues Stones are fragmented then voided discomfort may occur; observe for obstruction and infection

20. Interventional procedures Endourologic methods of stone removal: Percutaneous nephrostomy or nephrolithotomy Nephroscopy is introduced into the renal parenchyma Stone is extracted with forceps or basket Chemolysis: Through nephrostomy Warm chemical solution flows onto the stone The solution is removed through ureter or nephrostomy tube. pressure inside renal pelvis should be monitored

21. Interventional procedures Surgical management, currently is rare; in 1-2% of the patients Nephrolithotomy-incision in the kidney Nephrectomy—removal of the kidney Pyelolithotomy—removal of stones from pelvis Cystotomy; Uretrolithotomy

22. Nursing management of patients with renal stones Relieving pain: Opioid with NSAID for rapid relieve of pain Comfort position; assess for pain level; ambulation if brings pain relief Monitoring and managing potential complications: Encourage fluid intake to prevent dehydration and increases hydrostatic pressure to facilitate stone passage Monitor urine out put and voiding pattern Encourage mobility Strain urine through gauze; inspect blood clot for stones Instruct patient to report decreased urine volume, bloody or cloudy urine. Observe stone passage, monitor for signs of infection