1. KIDNEYS - are bean-shaped, reddish brown paired organs normally located high in the abdominal cavity and against its back wall.
Excretion of waste products
Parts of the Kidney
2. URETERS - are muscular ducts that propel urine from the kidneys to the urinary bladder. In the adult, the ureters are usually 25–30 cm (10–12 in) long.
Ureterovesical valves – prevents the urine from backing up and returning to the ureter.
3. URINARY BLADDER - is a solid, muscular, and distensible (or elastic) organ that sits on the pelvic floor.
Serves as storage of urine.
4. URETHRA - is a tube which connects the urinary bladder to the outside of the body.
female – 1.5-2 inches (3-5 cm) long
male – 8 inches (17.5 cm) long
derived from the Greek word “ nephros ” meaning kidney.
Is the basic structural unit and functional unit of the kidney.
Kidney contains 800, 000 to one million nephrons.
Inter tubular capillaries
Proximal convoluted tubules
Descending Limb Loop of Henle
Ascending Limb Loop of Henle
Distal convoluted tubules
water and electrolytes reabsorption renal calyces renal pelvis bladder ureters urethra
Benign Prostatic Hyperplasia
The prostate is the urologic organ most frequently affected by benign and malignant neoplasms. BPH or hyperplasia is a common nonmalignant condition. It is estimated that by age 50 to 60, 80% of men have some degree of BPH which increases to over 95% in men over age 70.
It is characterized by hyperplasia of prostatic stromal and epithelial cells, resulting in the formation of large, fairly discrete nodules in the periurethral region of the prostate.
When sufficiently large, the nodules compress the urethral canal to cause partial, or sometimes virtually complete, obstruction of the urethra which interferes the normal flow of urine.
Abnormal changes in the size of the prostate are important because its closeness to the neck of the bladder, where urine is stored, and the urethra, through which urine passes. can effect the transport of urine.
The capsule surrounding the prostate gland restricts the multiplying cells of the prostate from spreading outward. Therefore, as the prostate enlarges, it may squeeze the urethra, which passes through it, and may also constrict the neck of the bladder. Both actions reduce the flow of urine.
BPH is assessed by:
general physical, including rectal examination
laboratory examination of blood, urine, and renal function
x ray examination including intravenous pyelography (IVP and cystography
instrumental examination, including catheterization and and cystoscopy
Signs and symptoms:
Increased frequency of urination
Abdominal straining with urination
- is a type of x-ray examination specifically designed to study the kidneys, bladder, and ureters (the tubes which carry urine from the kidneys to the bladder).
Urine culture-clean catch
- is a method of collecting a urine sample for various tests, including urinalysis and urine culture.
- is a procedure to see the inside of the bladder and urethra. Cystoscopy is performed with a cystoscope -- a specialized tube with a small camera on the end (endoscope).
Potential Complications of prostatic enlargement include:
impeded urine outflow
urinary reflux or backward flow because of decompensation of the ureterovesical junction.
Potential for Alteration n Nutrition and Potential Fluid Volume Deficit Due to Symptoms of BPH, Self-Imposed Fluid Restriction, and Anticipated Stress of Surgery
Alteration in Patterns of Urinary Elimination
Fluid Volume Deficit Due to Postoperative Hemorrhage
Alteration in Comfort: Pain Due to Surgical Intervention, Clots in Bladder, or Bladder Spasms
Disturbance in Self-Concept Due to Major “Intimate Surgery Compounded by the Aging Process
Medication approaches include those aimed at androgen deprivation, in efforts to inhibit prostatic hypertrophy, such as prescribing estrogen, cyproterone acetate, or the nonsteroidal effects. Hence, they are usually reserved for men with prostatic cancer.
Antibiotics may relieve acute symptoms and possibly delay surgery. Sympathomimetic drugs like phenylpropanolamine and phenylephrine, which are found in common cold and cough remedies, worsen BPH. Warn patient not to take any of these.
Surgery is the most common means of relieving urinary obstruction due to BPH. The part of the prostate gland causing obstruction is removed. Indications for prostatectomy include:
Upper urinary tract dilatation(hydroureter, hydronephrosis) and impaired renal function
Severe discomfort and inconvenience for the person
Total urinary obstruction
Vesical(urinary bladder)calculus, indicative of long-standing obstruction associated with BPH and infection
Long-standing urinary obstruction that impairs renal function
Includes activities such as screening (e.g., assessing large numbers of healthy people for hypertension and self-examination.
Since there is no known cause for bph, and it affects men by age 50, to 60, and there is increased risk over age 70, living a healthy lifestyle and regualry visits to a physician for checkups may be necessary to confirm signs and symptoms, for assessment, and fir diagnosis. : in general, the primary prevention include activities such as genetic counselling, immunization against infectious diseases, good nutrition, careful genital hygiene, healthy sexual practices, use of condoms to prevent STDs, sticking to one partner only, and avoiding oral or anal sex with a person who has genital lesions.
Provided by most health professionals who provide care for people experiencing acute and chronic illness. Medications for BPH such as antibiotics, and those aimed at androgen deprivation such as estrogen, cyproterone acetate, or flutamide.
Surgery may include prostatectomy, and transurethral resection of the prostate
Self-care- learning /teaching opportunities for the person and significant others are important. Explain to the patient that if his bladder is distended rapidly, it can increase his discomfort, and precipitate acute retention. Advise patient to:
void whenever the urge to do so is felt, and not put it off.
Avoid taking large amounts of fluid over a short period of time
Totally avoid alcohol, since its diuretic effects along with the volume of fluid increases bladder distention
is an ascending urinary tract infection that has reached the pyelum (pelvis) of the kidney.
Signs and symptoms:
Abdominal pain(radiating to the back on the affected side).
Tenderness of the bladder area
Vomiting and other GI disturbances
Dipstick test – to determine of there is presence of pus in the urine.
Urine Culture – to determine what type of microorganisms are present so that appropriate antimicrobial agents can be prescribed..
KUB x-rays – to identify if radio opaque stones are present in the kidney, ureter and bladder.
Ultrasonography (Urology) or CT scan – to locate any obstruction in the urinary tract.
End-stage renal disease (ESRD)
Formation of kidney stones
Acute pain related to inflammation and irritation of urinary tract
Disturbed sleep pattern related to urinary frequency
Impaired comfort related to chills and fever
Impaired urinary elimination related to irritation of urinary tract
Ineffective health maintenance related to deficient knowledge regarding self-care, treatment of disease, prevention of further urinary tract infection
- for out patients, a 2week course of antibiotics (ciprofloxacin, gentamicin with or without ampicillin, or a 3 rd generation cephalosporin.
- for recurring infection, the patient may need antibiotic therapy for 6 weeks.
- follow-up urine culture obtained 2 weeks after completion of antibiotic therapy.
- oral or parenteral fluids for hydration.
Eat a balanced diet
Drink adequate fluid
Maintain regular bowel habits
Monitoring VS every 4 hours.
Consuming adequate fluids – 3-4 L of fluids a day to dilute urine, decrease burning on urination, and prevent dehydration.
Emptying the bladder regularly and timely.
Performing recommended perineal hygiene.
Administer antipyretic and antibiotic agents as prescribed.
Monitor effectiveness and side effects of the drugs given.
Follow-up appointments to evaluate effectiveness of therapy.
A. General Information
The most common type of UTI, is an inflammation of the bladder wall, usually caused by ascending bacteria or obstructive voiding patterns that leads to decreased flow or stasis of urine.
Understanding How the Bladder Works
The bladder is a balloon-like sac that sits in the lower part of the abdomen in front of the bowel. It stores the urine that the kidneys produce as they filter out waste products from the bloodstream
As urine forms in the kidneys, it travels down the ureters, which are the tubes that connect the kidneys to the bladder.
The urine is stored in the bladder until the person feels the urge to urinate.
Going to the bathroom to urinate causes the bladder to contract.
This releases the urine, which passes down a tube called the urethra.
The urethra connects the bladder to the outside of the body.
Urinating allows the body to continually remove certain waste products from its system.
Particularly common among females, as they have a shorter urethra than males and it is situated relatively close to their anus (back passage).
For infection to occur, bacteria must gain access to the bladder, attach to and colonize the epithelium of the urinary tract to avoid being washed out with voiding, evade host defense mechanisms, and initiate inflammation.
Everyone with a catheter (to drain urine) will have bacteria in their bladder, usually without symptoms. During the change of catheter, small lesions (damaged areas) may appear, which may increase the danger of infection (cystitis) and possible blood infection.
frequency(voiding more than every 3 hours)
Acute pain related to inflammation and infection within the urinary tract
Deficient knowledge related to factors predisposing the patient to infection and recurrence, and pharmacologic therapy
Impaired urinary elimination related to irritation and inflammation of the bladder mucosa
Chronic or recurrent urinary tract infection
Complicated UTI (pyelonephritis)
Acute renal failure
Medical Management: Antispasmodics These prescription-only medicines help decrease the muscle spasms that cause urgency to urinate. Painkillers Pain-relieving drugs help treat symptoms of burning and urgency. They may be available over-the-counter (often called OTC drugs) or by prescription only . Cystitis is almost always treated with medication. These medications include: • O ral antibiotics • P ainkillers • A ntispasmodics Oral Antibiotics Oral antibiotics are the most common medications used to treat cystitis. They kill the bacteria that are causing the infection.
Fulguration and resection of ulcers —can be done with instruments inserted through the urethra. Fulguration involves burning Hunner’s ulcers with electricity or a laser. When the area heals, the dead tissue and the ulcer fall off, leaving new, healthy tissue behind. Resection involves cutting around and removing the ulcers. Both treatments are done under anesthesia and use special instruments inserted into the bladder through a cystoscope.
Augmentation, which makes the bladder larger. In most of these procedures, scarred, ulcerated, and inflamed sections of the patient’s bladder are removed, leaving only the base of the bladder and healthy tissue.
Bladder removal , called a cystectomy, is another, infrequently used surgical option. Once the bladder has been removed, different methods can be used to reroute the urine. In most cases, ureters are attached to a piece of colon that opens onto the skin of the abdomen.
encourage client to maintain the diet indicated
female clients should learn the risks associated with chemical irritants
remind client to void every 2-3 hours
review of correct hygienic practices
avoid alcohol, caffeinated beverages, spicy foods and tomatoes
drink 10oz of cranberry juice daily to acidify urine
urination immediately after sexual intercourse will flush out most bacteria from the urethra.
clean carefully after a bowel movement
antispasmodic agents may also be useful in relieving bladder irritability and pain.
drink 10oz of cranberry juice daily to acidify urine
using strict aseptic technique during insertion of catheter
monitor blood culture and other examination results
using strict aseptic technique during insertion of catheter
daily perineal care
teach patient to maintain proper hygienic practices
Wilms' tumor or nephroblastoma is a tumor of the kidneys that typically occurs in children, rarely in adults. Its common name is an eponym, referring to Dr. Max Wilms, the German surgeon (1867–1918) who first described this kind of tumor.
Wilm’s tumor is the most common type of kidney cancer in children and is very different from adult kidney cancer. Although Wilm’s tumor can develop in both kidneys (called bilateral), it usually occurs in only one (unilateral). Rarely, Wilm’s tumor develops in one kidney first and then the other.
There are 2 main types of Wilm’s tumors. The type depends on how the cells look under a microscope (histology).
1.Wilm’s tumor of unfavorable appearance (histology) under the microscope.
2.Wilm’s tumor of favorable appearance (histology) under the microscope.
Wilm's' tumors generally are categorized by five stages as well as recurrent disease.
Stage I -- Cancer is found only in the kidney and can be completely removed by surgery.
Stage II -- Cancer has spread to areas near the kidney, such as to fat or soft tissue, to blood vessels or to the renal sinus, a large part of the kidney through which blood and fluid enter and exit the kidney. The cancer can be completely removed by surgery.
Stage III -- Cancer has spread to areas near the kidney, but cannot be completely removed by surgery. The cancer may have spread to important blood vessels or organs near the kidney. It also may have spread throughout the abdomen, making it difficult to remove all cancer. Cancer may have spread to lymph nodes, the small bean-shaped structures found throughout the body that produce and store infection-fighting cells, near the kidney.
Stage IV -- Cancer has spread to organs further away from the kidney, such as the lungs, liver, bone and brain.
Stage V -- Cancer cells are found in both kidneys.
Recurrent -- Recurrent disease means that the cancer has come back or recurred after it has been treated. It may come back where it started or in another part of the body.
Mass or lump, which causes no tenderness, in the abdomen
Pain in the abdomen from pressure on other organs near the tumor
Swelling of the abdomen
Veins that appear distended or large across the abdomen
Blood in the urine
High blood pressure
Weakness or tiredness
Anemia (low levels of red blood cells)
Pre-procedure Nursing Care:
Patent IV line
Insert foley catheter
CXR or U/S prior to procedure
Abdominal CT scan or Bone scan or MRI prior to procedure
- use of drugs to kill cancer cells. Usually the drugs are given into a vein, by mouth, or through a venous access device. Once the drugs enter the bloodstream, they go throughout the whole body. This makes chemo especially useful for cancer that has spread beyond the kidney.
Radiation therapy - treatment with high energy rays (such as x-rays) to kill or shrink cancer cells. - external beam radiation is given in a way much like the x-rays used to find broken bones. - this type of radiation is often used along with surgery for more advanced Wilms tumors (stages III, IV, and V) and for some earlier stage tumors with unfavorable histology.
Surgery is a common treatment for all stages of Wilms tumor:
Radical nephrectomy - A radical nephrectomy is the removal of the whole kidney and some surrounding tissue and nearby lymph nodes (called a lymph node dissection).
Partial nephrectomy - A partial nephrectomy is the removal of the tumor and some of the surrounding kidney, preserving as much of the kidney as possible.
Eat a balanced diet
Drink adequate fluid
Maintain regular bowel habits
Annual physical examination
Assess understanding of the patient for recurrence of renal calculi
Teach patient about causes of kidney stones and recommendations to prevent recurrence
Encourage increased mobility
Increase fluid intake
Acute pain related to pressure from tumor
Constipation related to obstruction associated with presence of tumor
Ineffective airway clearance related to pain of abdominal discomfort
Less than body requirements related to side effects of chemotherapy
Risk for impaired skin integrity related to irradiation effects
- refers to the condition where urinary calculi (stones) are formed in the urinary tract (kidney, ureter, bladder and urethra).
- urinary calculi occurs in both sexes, but calculi causing urinary obstruction occurs more commonly in males due to the smaller diameter and increased length of the urethra.
- accretion of hard, solid, nonmetallic minerals in the urinary tract.
fever and chills
pain in costovertebral region
diarrhea and abdominal discomfort
nausea and vomiting
Dietary and medication histories and family history of renal stones
Radiographs or ultrasonography is needed for definitive diagnosis.
Blood chemistries and a 24-hour urine test for measurement of calcium, uric acid, creatinine. Sodium, pH, and total volume are part of the diagnostic workup.
Bacterial urine culture and sensitivity testing should be performed to properly treat any concurrent urinary tract infections (UTI).
When stones are recovered, chemical analysis is carried out to determine their composition.
Kidney stones , also called renal calculi, are solid concretions (crystal aggregations) of dissolved minerals in urine;
Calculi typically form inside the kidneys or bladder.
Some of the substances found in urine are able to crystalize, and in a concentrated form these chemicals can precipitate into a solid deposit attached to the kidney walls which grows in the process of accretion to form into a kidney stone.
An 8 mm kidney stone
Fever and chills.
frequency in micturation
dribbling of urine
loss of appetite
loss of weight
X-rays- The relatively dense calcium renders these stones radio-opaque and they can be detected by a traditional X-ray of the abdomen that includes the Kidneys, Ureters and Bladder—KUB.
Computed tomography without contrast is considered the gold-standard diagnostic test for the detection of kidney stones.
Ultrasound imaging is useful as it gives details about the presence of hydronephrosis .
Culture of a urine sample to exclude urine infection.
24 hour urine collection to measure total daily urinary volume, magnesium, sodium, uric acid, calcium, citrate, oxalate and phosphate.
Infection and Urosepsis
Obstruction of the urinary tract by a stone or edema with subsequent acute renal failure
Acute pain related to inflammation, obstruction, and abrasion of the urinary tract
Deficient knowledge regarding prevention of recurrence of renal stones.
Deficient knowledge related to requirements and dietary restrictions.
Impaired urinary elimination related to anatomical obstruction and irritation caused by stone
Risk for infection related to obstruction of urinary tract with stasis of urine.
Opioid analgesics are administered to prevent shock and syncope that amy result from excruciating pain.
NSAIDs are effective in treating renal stone pain because they provide specific pain relief.
Increase fluid intake unless contraindicated.
For patients with calcium-based renal stones, they are advised to restrict calcium in their diet.
A low-protein diet is prescribed for those with Cystine stones.
Chemolysis – stone dissolution using infusions of chemical solutions for the purpose of dissolving the stone.
During a cystoscopy , which is used for removing small stones located in the ureter close to the bladder, a ureteroscope is inserted into the ureter to visualize the stone. The stone is then fragmented or captured and removed.
ESWL- Extracorporeal Shock Wave Lithotripsy
- is used for most symptomatic, non passable upper urinary tract stones. Electromagnetically generated shock waves are focused over the area of the renal stone. The high-energy dry shock waves pass through the skin and fragment the stone.
- is used to treat larger stones. A percutaneous tract is formed and a nephroscope is inserted through it. Then the stone is extracted and pulverized.
to provide immediate relief of a blocked kidney. This is especially useful in saving a failing kidney due to swelling and infection from the stone .
three-dimensional reconstructed CT scan image of a ureteral stent in the left kidney (indicated by yellow arrow). There is a kidney stone in the pyelum of the lower pole of the kidney (highest red arrow) and one in the ureter beside the stent (lower red arrow).
Ureteral (double-J) stents
Nursing Management after surgery:
Maintaining airway clearance and breathing patterns
Promoting urinary elimination
Urinary incontinence (UI) is the accidental leakage of urine. It is a disorder in which a person experiences involuntary loss of urine from the bladder.
any conditions or disease that can cause nerve damage like diabetes, Parkinson’s, multiple sclerosis.
Spinal cord injury
- Detailed description of the problem and a history of medication use.
Patient’s voiding history
A diary of fluid intake and output.
Physical Examination (digital rectal exam – to check for prostate enlargement; check for nerve damage)
Urodynamic test - involves measuring pressure in the bladder as it is filled with fluid through a small catheter. This test can help identify limited bladder capacity, bladder overactivity or underactivity, weak sphincter muscles, or urinary obstruction.
Urinalysis and urine culture
EEG and EMG – to check for brain dysfunction and to measure nerve activity of muscles related to loss of bladder control.
Risk for impaired skin integrity
Self care deficit related to toileting needs
Functional Incontinence related to altered environment; sensory. Cognitive or mobility deficits
Low Self Esteem related to inability to control passage of urine