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genitourinary disorders (medical surgical nursing)

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covers most of the nursing management of the renal or genito urinary disorders

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genitourinary disorders (medical surgical nursing)

  1. 1. Aashish Parihar Nursing Tutor College of Nursing AIIMS, Jodhpur
  2. 2. 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
  3. 3. 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
  4. 4. 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
  5. 5. anatomy and physiology of genitourinary system
  6. 6. anatomy and physiology of genitourinary system
  7. 7. anatomy and physiology of genitourinary system
  8. 8. anatomy and physiology of genitourinary system
  9. 9. physiology of genitourinary system
  10. 10. anatomy and 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.
  11. 11. anatomy and physiology of genitourinary system Ureters, Bladder, and Urethra - 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
  12. 12. anatomy and physiology of genitourinary system Ureters, Bladder, and Urethra - 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
  13. 13. anatomy and physiology of genitourinary system 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.
  14. 14. anatomy and physiology of genitourinary system Nursing assessment: history, and physical examination  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
  15. 15. anatomy and physiology of genitourinary system Nursing assessment: history, and physical examination  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
  16. 16. anatomy and physiology of genitourinary system Nursing assessment: history, and physical examination  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)
  17. 17. anatomy and physiology of genitourinary system Nursing assessment: history, and physical examination 
  18. 18. anatomy and physiology of genitourinary system Nursing assessment: history, and physical examination 
  19. 19. anatomy and physiology of genitourinary system 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
  20. 20. anatomy and physiology of genitourinary system Nursing assessment: history, and physical examination  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.
  21. 21. anatomy and physiology of genitourinary system Nursing assessment: history, and physical examination  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.
  22. 22. anatomy and physiology of genitourinary system Nursing assessment: history, and physical examination
  23. 23. anatomy and physiology of genitourinary system Nursing assessment: history, and physical examination  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)
  24. 24. anatomy and physiology of genitourinary system Nursing assessment: history, and physical examination  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.
  25. 25. 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.
  26. 26. Anatomy of the Male Reproductive System urological obstructions
  27. 27. urological obstructions 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.
  28. 28. urological obstructions 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.
  29. 29. urological obstructions 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.
  30. 30. urological obstructions 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.
  31. 31. urological obstructions 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.
  32. 32. Normal Urethrogram Obstructive Urethrogram urological obstructions urethral strictures
  33. 33. urological obstructions 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).
  34. 34. urological obstructions 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.
  35. 35. urological obstructions 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.
  36. 36. urological obstructions 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
  37. 37. urological obstructions renal calculi Types of stone- Calcium stone Oxalate stone Cystiene stone Struvite stone
  38. 38. urological obstructions 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:
  39. 39. urological obstructions 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
  40. 40. urological obstructions 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
  41. 41. urological obstructions 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.
  42. 42. urological obstructions 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).
  43. 43. 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
  44. 44. Urological obstrUctions renal calcUli Location of stones- Kidney Ureter Bladder Urethra
  45. 45. Urological obstrUctions renal calcUli Site of obstruction-
  46. 46. Urological obstrUctions renal calcUli Clinical features- Pain Heamturia Dysuria Oedema Pyuria Associated symptoms- Nausea, vomiting, diarrhea, abdominal discomfort Chills and fever (may)
  47. 47. Urological obstrUctions 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
  48. 48. Urological obstrUctions 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
  49. 49. Urological obstrUctions 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.
  50. 50. Urological obstrUctions 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.
  51. 51. Urological obstrUctions 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.
  52. 52. Urological obstrUctions renal calcUli Diagnostic evaluation- History Physical examination Urinanalysis Blood studies Stone chemistry Radiographic studies
  53. 53. Urological obstrUctions 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
  54. 54. Urological obstrUctions renal calcUli Diagnostic evaluation Physical examination - Locate, nature and characteristics of pain Assess the level of pain ,tenderness etc. Observe for the associated symptoms.
  55. 55. Urological obstrUctions renal calcUli Diagnostic evaluation 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
  56. 56. Urological obstrUctions renal calcUli Diagnostic evaluation Blood studies- Hyperuracemia Hypercalcemia Neutrophilia Elevated serum parathyroid hormone
  57. 57. Urological obstrUctions renal calcUli Diagnostic evaluation Stone chemistry- Collection of stone through a strainer is useful. Analyze the stone chemically to find out the composition which helps in therapeutic management.
  58. 58. Urological obstrUctions renal calcUli Diagnostic evaluation 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
  59. 59. Urological obstrUctions 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
  60. 60. Urological obstrUctions renal calcUli Management Medical 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
  61. 61. Urological obstrUctions renal calcUli Management Medical 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.
  62. 62. Urological obstrUctions renal calcUli Management Medical 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.
  63. 63. Urological obstrUctions renal calcUli Management Medical 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
  64. 64. Urological obstrUctions renal calcUli Management Medical 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
  65. 65. Urological obstrUctions renal calcUli Management Medical management Cystine stone - Low-protein diet Penicillamine is administered to reduce the amount of cystine in the urine urine is alkalinized.
  66. 66. Urological obstrUctions renal calcUli Management Medical management Oxalate stone - Encourage the increased fluid intake Avoid the food contains oxalate such as- spinach, strawberries, tea, peanuts, wheat bran
  67. 67. Urological obstrUctions renal calcUli Management Non surgical management- Ureteroscopy ESWL (Extra Corporeal Shock wave lithotripsy) Endoscopic procedures Electrohydrolic lithotripsy Chemolysis
  68. 68. Urological obstrUctions renal calcUli Management Non surgical 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
  69. 69. Urological obstrUctions renal calcUli Management Non surgical 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.
  70. 70. Urological obstrUctions renal calcUli Management Non surgical management- ESWL-
  71. 71. Urological obstrUctions renal calcUli Management Non surgical 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.
  72. 72. Urological obstrUctions renal calcUli Management Non surgical 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.
  73. 73. Urological obstrUctions renal calcUli Management Non surgical 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.
  74. 74. Urological obstrUctions 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
  75. 75. 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
  76. 76. DisorDers of kiDney glomerUlonephritis , acUte (acUte nephritic synDrome ) 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.
  77. 77. DisorDers of kiDney glomerUlonephritis , acUte (acUte nephritic synDrome ) 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
  78. 78. DisorDers of kiDney glomerUlonephritis , acUte (acUte nephritic synDrome ) 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
  79. 79. DisorDers of kiDney glomerUlonephritis , acUte (acUte nephritic synDrome)
  80. 80. DisorDers of kiDney glomerUlonephritis , acUte (acUte nephritic synDrome) Clinical features- Hematuria - The urine may appear cola-colored be- cause 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
  81. 81. DisorDers of kiDney glomerUlonephritis , acUte (acUte nephritic synDrome) 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
  82. 82. DisorDers of kiDney glomerUlonephritis , acUte (acUte nephritic synDrome) Diagnostic evaluation- 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.
  83. 83. DisorDers of kiDney glomerUlonephritis , acUte (acUte nephritic synDrome) Complications- Hypertensive Encephalopathy Heart Failure Pulmonary Edema ESRD
  84. 84. DisorDers of kiDney glomerUlonephritis , acUte (acUte nephritic synDrome) Management- Goal- To conserve renal function To treat complication adequately Types of management- Non pharmacological management Dietary management Pharmacological management Nursing management
  85. 85. DisorDers of kiDney glomerUlonephritis , acUte (acUte nephritic synDrome) 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.
  86. 86. DisorDers of kiDney glomerUlonephritis , acUte (acUte nephritic synDrome) 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.
  87. 87. 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).
  88. 88. DisorDers of kiDney Glomerulonephritis , acute (acute nephritic synDrome) 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).
  89. 89. DisorDers of kiDney Glomerulonephritis , acute (acute nephritic synDrome) 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.
  90. 90. DisorDers of kiDney Glomerulonephritis , acute (acute nephritic synDrome) 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.
  91. 91. DisorDers of kiDney acute pyelonephritis Definition- Pyelonephritis is a bacterial infection of the renal pelvis, tubules, and interstitial tissue of one or both kidneys.
  92. 92. DisorDers of kiDney acute pyelonephritis 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
  93. 93. DisorDers of kiDney acute pyelonephritis 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
  94. 94. DisorDers of kiDney acute pyelonephritis Pathophysiology-
  95. 95. DisorDers of kiDney acute pyelonephritis 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
  96. 96. DisorDers of kiDney acute pyelonephritis Diagnostic evaluation- 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
  97. 97. DisorDers of kiDney acute pyelonephritis 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.
  98. 98. DisorDers of kiDney acute pyelonephritis 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.
  99. 99. DisorDers of kiDney acute pyelonephritis 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
  100. 100. DisorDers of kiDney acute pyelonephritis 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.
  101. 101. DisorDers of kiDney acute pyelonephritis 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.
  102. 102. 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.
  103. 103. 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)
  104. 104. 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)
  105. 105. 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
  106. 106. DisorDers of kiDney nephrotic synDrome pathophysiology-
  107. 107. 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.
  108. 108. DisorDers of kiDney nephrotic synDrome Diagnostic evaluation- 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,
  109. 109. 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)
  110. 110. 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
  111. 111. 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.
  112. 112. 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.
  113. 113. 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)
  114. 114. DisorDers of kiDney acute renal failure Etiology- Pre – renal Volume depetion Hemorrhage Renal loses GI losses Impaired cardiac efficiency Vasodilation sepsis Anaphylaxis
  115. 115. 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
  116. 116. DisorDers of kiDney acute renal failure Etiology- Post – renal Urinary tract obstructions Renal calculi Tumors BPH Blood clots Strictutres
  117. 117. 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
  118. 118. 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
  119. 119. DisorDers of kiDney acute renal failure PHASES OF ARF  Initiating phase Oliguric phase Diuretic phase Recovery phase
  120. 120. 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
  121. 121. 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.
  122. 122. 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.
  123. 123. 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)
  124. 124. DisorDers of kiDney acute renal failure Diagnostic evaluation- 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
  125. 125. 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
  126. 126. 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.
  127. 127. 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
  128. 128. DisorDers of kiDney acute renal failure Management-  To correct fluid and electrolyte balance.  To correct dehydration.  To Keep other body systems working properly
  129. 129. 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.
  130. 130. DisorDers of kiDney conGenital DisorDers of Genitourinary system Common Bladder anomalies • Bladder Extrophy. Common Urethral & penile anomalies • Hypospadias. • Epispadias.
  131. 131. DisorDers of kiDney Congenital DisorDers of genitourinary system 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.
  132. 132. 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.
  133. 133. DisorDers of kiDney Congenital DisorDers of genitourinary system 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.
  134. 134. DisorDers of kiDney Congenital DisorDers of genitourinary system Pelviureteric junction obstruction 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. Diagnostic evaluation- IVU - shows delay in appearance of contrast and dilated renal pelvis and calices. Renal scan -shows differential renal function and confirms obstruction.
  135. 135. DisorDers of kiDney Congenital DisorDers of genitourinary system Pelviureteric junction obstruction 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.
  136. 136. DisorDers of kiDney Congenital DisorDers of genitourinary system Pelviureteric junction obstruction Management- alternative techniques: 1.Antegrade endopyelotomy . 2.Laparoscopic pyeloplasty
  137. 137. DisorDers of kiDney Congenital DisorDers of genitourinary system 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 -
  138. 138. DisorDers of kiDney Congenital DisorDers of genitourinary system Vesicoureteric junction reflux • 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.
  139. 139. DisorDers of kiDney Congenital DisorDers of genitourinary system Vesicoureteric junction reflux 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.
  140. 140. DisorDers of kiDney Congenital DisorDers of genitourinary system 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.
  141. 141. DisorDers of kiDney Congenital DisorDers of genitourinary system 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.
  142. 142. DisorDers of kiDney Congenital DisorDers of genitourinary system 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.
  143. 143. DisorDers of kiDney Congenital DisorDers of genitourinary system 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
  144. 144. DisorDers of kiDney Congenital DisorDers of genitourinary system Hypospadias • Site Of the meatus
  145. 145. DisorDers of kiDney Congenital DisorDers of genitourinary system Hypospadias Treatment • The child should be referred for urological assessment and surgical treatment. • The ideal age for surgery is 6–12 months.
  146. 146. DisorDers of kiDney Congenital DisorDers of genitourinary system Epispadias • Congenital condition in which the urethra opens on dorsal surface of penis.. • Usually associated with bladder extrophy (ectopia vesicae).
  147. 147. DisorDers of kiDney Congenital DisorDers of genitourinary system 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).
  148. 148. 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.
  149. 149. 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; 
  150. 150. 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
  151. 151. 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 pain- less 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.
  152. 152. DisorDers of kiDneyCanCer of kiDney Assessment and Diagnostic Findings- The diagnosis of a renal tumor may require intravenous urography, cystoscopic examination, nephrotomograms, renal angiograms, ultrasonography, CT scan.
  153. 153. DisorDers of kiDneyCanCer of kiDney Management- Goal- The goal of management is to eradicate the tumor before metastasis occurs.
  154. 154. DisorDers of kiDneyCanCer of kiDney 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
  155. 155. DisorDers of kiDneyCanCer of kiDney 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.
  156. 156. DisorDers of kiDneyCanCer of kiDney 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.
  157. 157. 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.
  158. 158. DisorDers of kiDneyCanCer of blaDDer 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
  159. 159. DisorDers of kiDneyCanCer of blaDDer 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.
  160. 160. DisorDers of kiDneyCanCer of blaDDer 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
  161. 161. DisorDers of kiDneyCanCer of blaDDer 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.
  162. 162. DisorDers of kiDneyCanCer of blaDDer 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
  163. 163. DisorDers of kiDneyCanCer of blaDDer Management- radiation therapy Radiation of the tumor may be performed preoperatively to reduce microextension of the neoplasm and viability of tumor cells,
  164. 164. 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
  165. 165. DisorDers of kiDneyCanCer of ureter Risk factors- Increased age Treatment of bladder cancer Tobacco smoking Analgesics nephropathy Industrial exposures
  166. 166. DisorDers of kiDneyCanCer of ureter 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.
  167. 167. DisorDers of kiDneyCanCer of ureter Diagnostic evaluation- Diagnosis may include-   computed tomography urography (CTU),  magnetic resonance urography(MRU),  intravenous pyelography (IVP)  x-ray,  Ureteroscopy  biopsy
  168. 168. DisorDers of kiDneyCanCer of ureter Management- Treatment methods include - surgery  Chemotherapy  radiation therapy  medication.
  169. 169. 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.
  170. 170. DisorDers of kiDneyCanCer of urethra 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
  171. 171. DisorDers of kiDneyCanCer of urethra Diagnostic evaluation- Diagnosis is established by transurethral biopsy Types- transitional cell carcinoma  squamous cell carcinoma  adenocarcinoma  melanoma
  172. 172. DisorDers of kiDneyCanCer of urethra 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.
  173. 173. DisorDers of kiDneyCanCer of urethra 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

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