Brief Information regarding the disorders of the genitourinary system. This presentation involves the disorders of the urinary system including Chronic Kidney Disease, Congenital problems related to the urinary system, and renal cancers.

1. Nursing management of
patient with Genito-urinary
problems 2
Mr Sushil Sudarshan Humane
MSN, RN

2. Cronic kidney disease
When the patient has
sustained enough kidney dama
ge to require renal
replacement therapy on a
permanent basis, the patient
has moved into the fifth or
final stage of CKD, also referred
to as chronic renal failure.

3. Chronic kidney disease
• Chronic renal failure (CRF) is the end result of a gradual,
progressive loss of kidney function.
• Causes include chronic infections
(glomerulonephritis, pyelonephritis), vascular diseases
(hypertension, nephrosclerosis), obstructive processes
(renal calculi), collagen diseases (systemic lupus),
nephrotoxic agents (drugs, such as aminoglycosides), and
endocrine diseases (diabetes, hyperparathyroidism).
• This syndrome is generally progressive and produces major
changes in all body systems.

4. Chronic kidney disease
• The final stage of renal dysfunction, end-stage renal disease
(ESRD), is demonstrated by a glomerular filtration rate
(GFR) of 15%–20% of normal or less.
• Renal failure results when the kidneys cannot remove the
body’s metabolic wastes or perform their regulatory
functions.
• The substances normally eliminated in the urine
accumulate in the body fluids as a result of impaired renal
excretion, affecting endocrine and metabolic functions as
well as fluid, electrolyte, and acid-base disturbances.

6. Chronic
kidney
disease
Predisposing factors
• Diabetes, which is the most common risk factor
for chronic kidney failure in the United States
• Age 60 or older
• Kidney disease present at birth (congenital)
• Family history of kidney disease
• Autoimmune Disorder (Lupus erythematosus)
• Bladder outlet obstruction (BPH and Prostatitis)
• Race (Sickle cell disease

7. Chronic kidney disease
Precipitating Factors
• Occupational Hazard (overexposure to toxins and to some
medications)
• Sedentary Lifestyle (hypertension, atherosclerosis)
• Diet (High residue diet)

9. Chronic kidney disease
Complications
• Hyperkalemia. Hyperkalemia due to decreased excretion, metabolic
acidosis, catabolism, and excessive intake (diet, medications, fluids).
• Pericarditis. Pericarditis due to retention of uremic waste products and
inadequate dialysis.
• Hypertension. Hypertension due to sodium and water retention and the
malfunction of the renin-angiotensin-aldosterone system.
• Anemia. Anemia due to decreased erythropoietin production decreased
RBC lifespan, bleeding in the GI tract from irritating toxins
and ulcer formation, and blood loss during hemodialysis.
• Bone disease. Bone disease and metastatic and vascular calcifications due
to retention of phosphorus, low serum calcium levels, abnormal vitamin D
metabolism, and elevated aluminum levels.

10. Chronic kidney disease
Clinical manifestations
Because virtually every body system is affected
in ESRD, patients exhibit a number of signs and
symptoms.
• Peripheral neuropathy. Peripheral neuropathy,
a disorder of the peripheral nervous system, is
present in some patients.
• Severe pain. Patients complain of severe pain
and discomfort.
• Restless leg syndrome. Restless leg syndrome
and burning feet can occur in the early stage
of uremic peripheral neuropathy.

11. Chronic kidney disease
Diagnostic findings
• Glomerular filtration rate. GFR and creatinine clearance decrease while
serum creatinine (more sensitive indicator of renal function) and BUN
levels increase.
• Sodium and water retention. Some patients retain sodium and water,
increasing the risk for edema, heart failure, and hypertension.
• Acidosis. Metabolic acidosis occurs in ESRD because the kidneys are unable
to excrete increased loads of acid.
• Anemia. In ESRD, erythropoietin production decreases and
profound anemia results, producing fatigue, angina, and shortness of
breath.

12. Chronic kidney disease
Diagnostic findings
• Urine
• Volume: Usually less than 400 mL/24 hr (oliguria) or urine is
absent (anuria).
• Color: Abnormally cloudy urine may be caused by pus,
bacteria, fat, colloidal particles, phosphates, or urates. Dirty,
brown sediment indicates presence of RBCs, hemoglobin,
myoglobin, porphyrins.
• Specific gravity: Less than 1.015 (fixed at 1.010 reflects severe
renal damage).
• Osmolality: Less than 350 mOsm/kg is indicative of tubular
damage, and urine/serum ratio is often 1:1.
• Creatinine clearance: May be significantly decreased (less
than 80 mL/min in early failure; less than 10 mL/min in ESRD).
• Sodium: More than 40 mEq/L because kidney is not able to
reabsorb sodium.
• Protein: High-grade proteinuria (3–4+) strongly indicates
glomerular damage when RBCs and casts are also present.
Blood
• BUN/Cr: Elevated, usually in proportion. Creatinine level of 12
mg/dL suggests ESRD. A BUN of >25 mg/dL is indicative of renal
damage.
• CBC: Hb decreased because of anemia, usually less than 7–8 g/dL.
• RBCs: Life span decreased because of erythropoietin deficiency,
and azotemia.
• ABGs: pH decreased. Metabolic acidosis (less than 7.2) occurs
because of loss of renal ability to excrete hydrogen and ammonia
or end products of protein catabolism. Bicarbonate and PCO2
Decreased.
• Serum sodium: May be low (if kidney “wastes sodium”) or normal
(reflecting dilutional state of hypernatremia).
• Potassium: Elevated related to retention and cellular shifts
(acidosis) or tissue release (RBC hemolysis). In ESRD, ECG changes
may not occur until potassium is 6.5 mEq or higher. Potassium
may also be decreased if patient is on potassium-
wasting diuretics or when patient is receiving dialysis treatment.
• Magnesium, phosphorus: Elevated

13. Chronic kidney disease
Diagnostic findings
• Proteins (especially albumin): Decreased serum level may reflect protein loss via urine, fluid shifts,
decreased intake, or decreased synthesis because of lack of essential amino acids.
• Serum osmolality: Higher than 285 mOsm/kg; often equal to urine.
• KUB x-rays: Demonstrates size of kidneys/ureters/bladder and presence of obstruction (stones).
• Retrograde pyelogram: Outlines abnormalities of renal pelvis and ureters.
• Renal arteriogram: Assesses renal circulation and identifies extravascularities, masses.
• Voiding cystourethrogram: Shows bladder size, reflux into ureters, retention.
• Renal ultrasound: Determines kidney size and presence of masses, cysts, obstruction in upper urinary tract.
• Renal biopsy: May be done endoscopically to examine tissue cells for histological diagnosis.
• Renal endoscopy, nephroscopy: Done to examine renal pelvis; flush out calculi, hematuria; and remove
selected tumors.
• ECG: May be abnormal, reflecting electrolyte and acid-base imbalances.
• X-ray of feet, skull, spinal column, and hands: May reveal demineralization/calcifications resulting from
electrolyte shifts associated with CRF

14. Chronic kidney disease
Treatment
• The goal of management is to maintain kidney function and homeostasis for as
long as possible.
• Pharmacologic therapy:
• Calcium and phosphorus binders treat hyperphosphatemia and hypocalcemia;
• Antihypertensive and cardiovascular agents (digoxin and dobutamine) manage
hypertension;
• Anti-seizure agents (IV diazepam or phenytoin) are used for seizures, and;
• Erythropoietin (Epogen) is used to treat anemia associated ESRD.
• Nutritional therapy. Dietary intervention includes careful regulation of protein
intake, fluid intake to balance fluid losses, sodium intake to balance sodium
losses, and some restriction of potassium.
• Dialysis. Dialysis is usually initiated if the patient cannot maintain a reasonable
lifestyle with conservative treatment.
• ssion.

15. Chronic kidney disease
Nursing management
Assessment of a patient with ESRD includes the following:
• Assess fluid status (daily weight, intake and output, skin turgor, distention
of neck veins, vital signs, and respiratory effort).
• Assess nutritional dietary patterns (diet history, food preference, and
calorie counts).
• Assess nutritional status (weight changes, laboratory values).
• Assess understanding of cause of renal failure, its consequences and its
treatment.
• Assess patient’s and family’s responses and reactions to illness and
treatment.
• Assess for signs of hyperkalemia.

16. Chronic kidney disease
Nursing management
Based on the assessment data, the following nursing diagnoses for a patient
with chronic renal failure were developed:
• Excess fluid volume related to decreased urine output, dietary excesses,
and retention of sodium and water.
• Imbalanced nutrition less than body requirements related
to anorexia, nausea, vomiting, dietary restrictions, and altered oral mucous
membranes.
• Activity intolerance related to fatigue, anemia, retention of waste
products, and dialysis procedure.
• Risk for situational low self-esteem related to dependency, role changes,
changes in body image, and change in sexual function.

17. Chronic kidney disease
Nursing management
Nursing care is directed towards the following:
• Fluid status. Assess fluid status and identify potential sources of imbalance.
• Nutritional intake. Implement a dietary program to ensure proper
nutritional intake within the limits of the treatment regimen.
• Independence. Promote positive feelings by encouraging increased self-
care and greater independence.
• Protein. Promote intake of high-biologic –value protein foods: eggs, dairy
products, meats.
• Medications. Alter schedule of medications so that they are not given
immediately before meals.
• Rest. Encourage alternating activity with rest.

18. Congenital Disorders of
Genitourinary system
Mr Sushil Sudarshan Humane
MSN, RN

19. Congenital Disorders of
Genitourinary system
Common Renal anomalies
• Abnormal number: agenesis
• Abnormal form or position: horseshoe kidney.
Common ureteral & renal pelvis anomalies
• UPJ obstruction.
• Vesico-uretral reflux.
• Duplication.
• Uretrocele.
• Ectopic ureter.

20. Congenital Disorders
of Genitourinary
system
Common Bladder anomalies
• Bladder Extrophy.
Common Urethral & penile
anomalies
• Hypospadias. • Epispadias.

21. 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.

22. 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.

23. 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.

24. 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.

25. 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.

26. Congenital Disorders of Genitourinary system
Pelviureteric junction obstruction
• Management- alternative techniques: 1.Antegrade endopyelotomy .
2.Laparoscopic pyeloplasty

27. 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 -

28. 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.

29. 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.

30. 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.

31. 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.

32. 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.

33. 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

34. 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.

35. 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).

36. 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).

37. Cancer of Kidney
Mr Sushil Sudarshan Humane
MSN, RN

38. Cancer of kidney
• 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.

39. 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;

40. 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

41. Cancer 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.

42. Cancer of Kidney
Diagnostic Findings- The diagnosis of a renal tumor may
require
• intravenous urography,
• cystoscopic examination,
• nephrotomograms,
• renal angiograms, ultrasonography,
• CT scan.

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

44. Cancer 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

45. Cancer 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.

46. Cancer 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.

47. Cancer 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.

48. Cancer 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

49. Cancer 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.

50. Cancer 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

51. Cancer 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.

52. Cancer 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

53. Cancer of
Bladder
Management- radiation therapy
• Radiation of the tumor may be
performed preoperatively to
reduce microextension of the
neoplasm and viability of tumor
cells,

54. Cancer 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

55. Cancer of ureter
Risk factors-
• Increased age
• Treatment of bladder cancer
• Tobacco smoking
• Analgesics nephropathy
• Industrial exposures

56. Cancer 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.

57. Cancer of ureter
Diagnostic evaluation- Diagnosis may include-
• computed tomography urography (CTU),
• magnetic resonance urography(MRU),
• intravenous pyelography (IVP)
• x-ray,
• Ureteroscopy
• biopsy

58. Cancer of ureter
Management- Treatment methods include -
• surgery
• Chemotherapy
• radiation therapy
• medication.

59. Cancer 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 u
rethra.
• Being 60 or older.
• Being a white female.

60. Cancer 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

61. Cancer of urethra
Diagnostic evaluation-Diagnosis is established by transurethral biopsy
Types-
• transitional cell carcinoma
• squamous cell carcinoma
• adenocarcinoma
• melanoma

62. Cancer 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.

63. Cancer of urethra
Management- chemotherapy
• Chemotherapy involves using drugs to destroy urethral cancer cells.
• It is a systemic urethral cancer treatment (i.e., destroys urethral canc
er cells throughout the body) that is administered orally or intra
venously (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