50
Renal and Urologic Problems
Cynthia Ann Smith
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Elimination Infection
Fluids and Electrolytes Pain
LEARNING OUTCOMES
1. Discuss the pathophysiology, clinical manifestations, and 5. Distinguish the common causes and management of renal
interprofessional and nursing management of urinary tract trauma, renal vascular problems, and hereditary kidney
infections, cystitis, urethritis, and pyelonephritis. diseases.
2. Distinguish the etiology, clinical manifestations, and 6. Describe the clinical manifestations and nursing and
nursing and interprofessional management of acute interprofessional management of kidney and bladder
poststreptococcal glomerulonephritis, Goodpasture cancers.
syndrome, and chronic glomerulonephritis. 7. Describe the common causes and management of urinary
3. Describe the common causes, clinical manifestations, and incontinence and urinary retention.
interprofessional and nursing management of nephrotic 8. Distinguish among urethral, ureteral, suprapubic, and
syndrome. nephrostomy catheters regarding indications for use and
4. Compare and contrast the etiology, clinical manifestations, nursing responsibilities.
and interprofessional and nursing management of various 9. Explain the nursing management of the patient undergoing
types of urinary calculi. nephrectomy or urinary diversion surgery.
KEY TERMS
calculus polycystic kidney disease (PKD)
cystitis pyelonephritis
glomerulonephritis renal artery stenosis
hydronephrosis stricture
ileal conduit urethritis
interstitial cystitis (IC) urinary incontinence (UI)
lithotripsy urinary retention
nephrolithiasis urinary tract infection (UTI)
nephrosclerosis urosepsis
nephrotic syndrome
A wide range of renal and urologic problems contribute to INFECTIOUS AND INFLAMMATORY URINARY
impaired elimination. This chapter discusses problems of PROBLEMS
the upper urinary tract (kidneys and ureter) and lower uri-
nary tract (bladder and urethra). Many patients are at risk
URINARY TRACT INFECTION
for fluid, electrolyte, and acid-base imbalances because of Urinary tract infections (UTIs) are infections of the uri-
the kidneys’ vital role in homeostasis. The person may have nary tract. They are the most common outpatient infection.
discomfort, incontinence, disrupted sleep, and impaired skin Escherichia coli is the most common pathogen causing a
integrity. UTI. It causes 75% of cases without urinary tract structural
1195
,1196 SECTION 10 Problems of Urinary Function
TABLE 50.1 Common Causes of UTIs TABLE 50.2 Risk Factors for UTIs
• Candida species Anatomic Factors
• Enterobacter
• Congenital defects leading to obstruction or urinary stasis
• Enterococcus
• Fistula exposing urinary stream to skin, vagina, or fecal stream
• Escherichia coli
• Obesity
• Klebsiella pneumoniae
• Shorter female urethra and colonization from normal vaginal flora
• Proteus mirabilis
• Pseudomonas aeruginosa Factors Compromising Immune Response
• Serratia • Aging
• Staphylococcus aureus • Diabetes
• Streptococci, Group B • HIV infection
Factors Increasing Urinary Stasis
• Extrinsic obstruction (tumor, fibrosis compressing urinary tract)
• Intrinsic obstruction (stone, tumor of urinary tract, urethral stricture, BPH)
Pyelonephritis • Renal impairment
• Urinary retention (e.g., neurogenic bladder)
Upper tract Foreign Bodies
• Catheters (indwelling, external condom catheter, ureteral stent, nephros-
tomy tube, intermittent catheterization)
• Urinary tract instrumentation (cystoscopy)
• Urinary tract stones
Cystitis Functional Disorders
• Constipation
• Voiding dysfunction with detrusor sphincter muscle incoordination
Lower tract
Other Factors
• Habitual delay of urination (“nurse’s bladder,” “teacher’s bladder”)
Urethritis
• Pregnancy
• Menopause
Fig. 50.1 Sites of infections in the upper and lower urinary tracts. • Sexual activity (women)
• Poor personal hygiene
• Use of spermicidal agents, contraceptive diaphragm (women), bubble
abnormalities or stones and 65% of complicated UTIs baths, feminine sprays
(Table 50.1).1
Fungal and parasitic infections sometimes cause UTIs. These
are more common in patients who are immunosuppressed, have also occur when a person has developed antibiotic resistance, is
diabetes or kidney problems, or received multiple courses of immunocompromised, has pregnancy-induced changes, or has
antibiotic therapy. They may also occur in persons who live in recurrent infection. The person with a complicated infection is
or have traveled to certain developing countries. at risk for pyelonephritis, urosepsis, and renal damage.
Classification of Urinary Tract Infection Etiology and Pathophysiology
UTIs can be broadly described as an upper or lower UTI accord- The urinary tract above the urethra is normally sterile. Several
ing to its location within the urinary system (Fig. 50.1). We use mechanical and physiologic defense mechanisms aid in main-
specific terms to describe the location of a UTI. For example, taining sterility and preventing UTIs. These defenses include
pyelonephritis implies inflammation (usually caused by infec- normal voiding with complete bladder emptying, ureterovesical
tion) of the renal parenchyma and collecting system. Cystitis is junction (UVJ) competence, and ureteral peristaltic activity that
an inflammation of the bladder. Urethritis is an inflammation propels urine toward the bladder. The antibacterial properties
of the urethra. Urosepsis is a UTI that has spread systemically. It of urine are maintained by a slightly acidic pH (6.0 to 7.5) and
is a life-threatening condition requiring emergency treatment. abundant antimicrobial proteins and peptides that interfere
We also classify a UTI as complicated or uncomplicated. with the bacterial growth. A change in any of these defense
Uncomplicated UTIs occur in an otherwise normal urinary mechanisms increases the risk for a UTI (Table 50.2).
tract. They usually only involve the bladder. Complicated UTIs The organisms that usually cause UTIs originate in the
occur in a person with an underlying disease or with a structural perineum. They are introduced via the ascending route from
or functional problem in the urinary tract. Examples include the urethra. Most infections are caused by gram-negative bacilli
obstruction, stones, catheters, abnormal genitourinary (GU) normally found in the gastrointestinal (GI) tract. However,
tract, acute kidney injury (AKI), chronic kidney disease (CKD), gram-positive organisms, such as streptococci, enterococci, and
kidney transplant, diabetes, or neurologic disease. They can Staphylococcus saprophyticus, can also cause UTIs.
, CHAPTER 50 Renal and Urologic Problems 1197
TABLE 50.3 Lower Urinary Tract Symptoms blood (hematuria) or sediment, giving it a cloudy appearance.
(LUTS) Upper UTIs (involving the renal parenchyma, pelvis, and ure-
ters) typically causes fever, chills, and flank pain. A UTI con-
Symptoms Description
fined to the lower urinary tract does not usually have systemic
Emptying Symptoms
manifestations. People with significant bacteriuria may have no
Dysuria • Painful or difficult urination
symptoms or may have nonspecific symptoms, such as fatigue
Hesitancy • Difficulty starting urine stream
• Delay between initiation of urination (because
or anorexia.
of urethral sphincter relaxation) and beginning of Remember that the common manifestations of a UTI are
flow of urine often absent in older adults. Older adults tend to have general
• Diminished urinary stream abdominal discomfort rather than dysuria and suprapubic pain.
Intermittency • Interruption of urinary stream while voiding They may have impaired cognition or overall clinical deteriora-
Postvoid dribbling • Urine loss after completing voiding tion. Because older adults are less likely to have a fever with a
Urinary retention • Inability to empty urine from bladder UTI, temperature is an unreliable sign of a UTI.3
or incomplete • Caused by atonic bladder or obstruction of urethra Multiple problems may produce LUTS similar to the symp-
emptying • Can be acute or chronic toms of a UTI. For example, patients with bladder tumors or
Storage Symptoms
those receiving intravesical chemotherapy or pelvic radiation
Incontinence • Involuntary or accidental urine loss or leakage usually have urinary frequency, urgency, and dysuria. Interstitial
Nocturia • Awakened by urge to void 2 or more times during cystitis/painful bladder syndrome produces urinary symptoms
sleep that are similar to and sometimes confused with a UTI.
• May be diurnal or nocturnal depending on sleep A small number of healthy persons have some bacteria col-
schedule onizing the bladder. We call this asymptomatic bacteriuria.
Nocturnal enuresis • Adults: loss of urine during sleep It does not justify screening or treatment except in pregnant
Urgency • Sudden, strong, or intense desire to void immedi- women, those with a recent kidney transplant, or those having
ately a urologic procedure.
• Often accompanied by frequency
Urinary frequency • More than 8 times in 24-h period Diagnostic Studies
• Often <200 mL each voiding
In a patient suspected of having a UTI, first obtain a dipstick uri-
nalysis. This test can identify the presence of nitrites (indicating
A common factor contributing to ascending infection is bacteriuria), white blood cells (WBCs), and leukocyte esterase
urologic instrumentation (e.g., catheterization, cystoscopic (an enzyme present in WBCs, indicating pyuria). Microscopic
examinations). Instrumentation allows bacteria that are nor- urinalysis can confirm these findings. Bacterial counts of 105
mally present at the opening of the urethra to enter the urethra colony-forming units per milliliter (CFU/mL) or higher typi-
or bladder. Sexual intercourse promotes “milking” of bacteria cally indicate a clinically significant UTI. However, counts as
from the vagina and perineum. It may cause minor urethral low as 102 to 103 CFU/mL in a person with signs and symptoms
trauma that predisposes women to UTIs. are indicative of UTI.
UTIs can result from hematogenous transmission, in which After confirmation of bacteriuria and pyuria, we may do
blood-borne bacteria invade the kidneys, ureters, or bladder from a urine culture. A urine culture is needed in persistent bacteri-
elsewhere in the body. For a kidney infection to occur this way, uria, recurring UTIs (more than 2 or 3 per year), or complicated,
there must be prior injury to the urinary tract, such as obstruc- CAUTI, or HAI UTIs. We may culture urine when the infection is
tion of the ureter, damage caused by stones, or renal scars. not responsive to empiric therapy or the diagnosis is questionable.
UTIs are the most common health care–associated infection A voided midstream technique (clean-catch urine sample) is
(HAI). They are mainly due to the use of an indwelling cath- best for obtaining a urine culture in most circumstances (see
eter. Catheter-associated urinary tract infections (CAUTIs) are Table 49.8). When we cannot obtain an adequate clean-catch
often caused by E. coli and, less often, Pseudomonas organisms. specimen, we may do catheterization. A specimen from catheter-
CAUTIs lead to extended hospital stays, increased health care ization gives more accurate results than a clean-catch specimen.
costs, and increased mortality.2 A urine culture with sensitivity testing can determine the bac-
teria’s susceptibility to a variety of antibiotic drugs. The results
Clinical Manifestations allow the HCP to choose an antibiotic known to be capable of
Manifestations of UTIs range from painful urination in uncom- destroying the bacteria causing a UTI in a specific patient.
plicated urethritis or cystitis to severe systemic illness with Some patients need imaging studies of the urinary tract. An
abdominal or back pain, fever, and sepsis. ultrasound or CT scan may be done if we suspect an obstruction
Lower urinary tract symptoms (LUTS) occur in patients who or UTIs recur.
have UTIs of the upper urinary tract, as well as those confined to
the lower tract. Symptoms are related to either bladder storage Interprofessional Care
or bladder emptying (Table 50.3). These include dysuria, fre- The interprofessional care and drug therapy of UTIs are out-
quency (voiding more than every 2 hours), urgency, and supra- lined in Table 50.4. Once a UTI has been diagnosed, appropriate
pubic discomfort or pressure. The urine may have grossly visible antimicrobial therapy is started. An antibiotic may be chosen
, 1198 SECTION 10 Problems of Urinary Function
TABLE 50.4 Interprofessional Care Other antibiotics used in the treatment of uncomplicated
UTI include ampicillin, amoxicillin, and cephalosporins.
UTI Fluoroquinolones (e.g., levofloxacin, ciprofloxacin) are given to
treat complicated UTIs. E. coli resistance to TMP/SMX, β-lac-
Diagnostic Assessment
tams, and ciprofloxacin is an increasing problem in the United
• History and physical assessment
• Urinalysis (midstream, “clean-catch” voided specimen)
States. In patients with UTIs from fungi, fluconazole (Diflucan)
• Urine for culture and sensitivity (if indicated) is the preferred therapy.
• Imaging studies of urinary tract (if indicated): CT scan, ultrasound, cystoscopy A urinary analgesic, such as oral phenazopyridine, may
relieve discomfort caused by severe dysuria. Phenazopyridine is
Management an azo dye excreted in urine. There it exerts a topical analgesic
Uncomplicated UTI effect on the urinary tract mucosa. It is taken up to 2 concur-
• Patient teaching rent days. Teach patients that this drug causes the urine to turn
• Adequate fluid intake (8 to 9 8-oz glasses/day)
orange or red.
Drug Therapy Patients who have repeated UTIs may receive prophylactic
• Antibiotics or suppressive antibiotics. A low dose of TMP/SMX, nitrofu-
• fluconazole (in patients with fungal UTI) rantoin, or another antibiotic taken daily may prevent recur-
• fosfomycin (Monurol) ring UTIs. A single dose may be taken after an event likely to
• nitrofurantoin (Macrodantin, Macrobid) provoke a UTI, such as sexual intercourse. While suppressive
• TMP/SMX (Bactrim, Bactrim DS) therapy is often effective short term, use is limited because of
• trimethoprim alone (in patients with sulfa allergy) the risk for antibiotic resistance, which leads to breakthrough
• cephalexin
infections with increasingly virulent pathogens.
Recurrent UTI
• Repeat urinalysis
NURSING MANAGEMENT: URINARY TRACT
• Urine culture and sensitivity testing INFECTION
• Adequate fluid intake (8 to 9 8-oz glasses/day)
• Repeat patient teaching Assessment
• Imaging studies of urinary tract (if indicated): see above Subjective and objective data that you should obtain from a
patient with a UTI are shown in Table 50.5.
Drug Therapy
• Antibiotic: nitrofurantoin, TMP/SMX
• Sensitivity-guided antibiotic therapy: ampicillin, amoxicillin, 1st- or
Clinical Problems
2nd-generation cephalosporin, fluoroquinolones Clinical problems for the patient with a UTI may include:
• 3- to 6-month trial of suppressive or prophylactic antibiotic therapy • Impaired urinary elimination
• Postcoital antibiotic prophylaxis: cephalexin, nitrofurantoin, TMP/SMX, • Infection
fosfomycin, trimethoprim • Pain
• Deficient knowledge
More information on clinical problems and interventions for
based on the HCP’s best judgment (empiric therapy) or the the patient with a UTI is presented in eNursing Care Plan 50.1
results of sensitivity testing. (available on the website for this chapter).
Uncomplicated UTIs are treated with a short-term course of
antibiotics, typically for 3 days. In contrast, complicated UTIs Planning
need a longer period of treatment, lasting 7 to 14 days or more.4 The overall goals are that the patient with a UTI will have (1)
Many residents of long-term care facilities, especially women, relief from bothersome symptoms, (2) no upper urinary tract
have chronic asymptomatic bacteriuria. However, we usually involvement, and (3) no recurrence.
only treat symptomatic UTIs.
First-choice drugs to treat uncomplicated or initial UTIs are Implementation
trimethoprim/sulfamethoxazole (TMP/SMX), nitrofurantoin, Health Promotion
cephalexin, and fosfomycin.4 TMP/SMX has the advantages of It is important to recognize people who are at risk for a UTI.
being inexpensive and taken twice daily. Nitrofurantoin is taken These include debilitated persons, older adults, patients who
3 or 4 times daily, but a twice-daily formulation is available. are immunocompromised (e.g., cancer, diabetes), and patients
treated with immunosuppressive drugs or corticosteroids.
Health promotion measures can help decrease the frequency of
DRUG ALERT UTIs and support early detection of infection. These activities
Nitrofurantoin (Macrodantin) include teaching preventive measures, including (1) emptying
the bladder regularly and completely, (2) evacuating the bowel
• A void use if the creatinine clearance <30 mL/min.
regularly, (3) wiping the perineal area from front to back after
• Notify HCP at once if fever, chills, cough, chest pain, dyspnea, rash, or
voiding and defecation, and (4) drinking an adequate amount
numbness or tingling of fingers or toes develops.
of liquid each day.
Renal and Urologic Problems
Cynthia Ann Smith
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Elimination Infection
Fluids and Electrolytes Pain
LEARNING OUTCOMES
1. Discuss the pathophysiology, clinical manifestations, and 5. Distinguish the common causes and management of renal
interprofessional and nursing management of urinary tract trauma, renal vascular problems, and hereditary kidney
infections, cystitis, urethritis, and pyelonephritis. diseases.
2. Distinguish the etiology, clinical manifestations, and 6. Describe the clinical manifestations and nursing and
nursing and interprofessional management of acute interprofessional management of kidney and bladder
poststreptococcal glomerulonephritis, Goodpasture cancers.
syndrome, and chronic glomerulonephritis. 7. Describe the common causes and management of urinary
3. Describe the common causes, clinical manifestations, and incontinence and urinary retention.
interprofessional and nursing management of nephrotic 8. Distinguish among urethral, ureteral, suprapubic, and
syndrome. nephrostomy catheters regarding indications for use and
4. Compare and contrast the etiology, clinical manifestations, nursing responsibilities.
and interprofessional and nursing management of various 9. Explain the nursing management of the patient undergoing
types of urinary calculi. nephrectomy or urinary diversion surgery.
KEY TERMS
calculus polycystic kidney disease (PKD)
cystitis pyelonephritis
glomerulonephritis renal artery stenosis
hydronephrosis stricture
ileal conduit urethritis
interstitial cystitis (IC) urinary incontinence (UI)
lithotripsy urinary retention
nephrolithiasis urinary tract infection (UTI)
nephrosclerosis urosepsis
nephrotic syndrome
A wide range of renal and urologic problems contribute to INFECTIOUS AND INFLAMMATORY URINARY
impaired elimination. This chapter discusses problems of PROBLEMS
the upper urinary tract (kidneys and ureter) and lower uri-
nary tract (bladder and urethra). Many patients are at risk
URINARY TRACT INFECTION
for fluid, electrolyte, and acid-base imbalances because of Urinary tract infections (UTIs) are infections of the uri-
the kidneys’ vital role in homeostasis. The person may have nary tract. They are the most common outpatient infection.
discomfort, incontinence, disrupted sleep, and impaired skin Escherichia coli is the most common pathogen causing a
integrity. UTI. It causes 75% of cases without urinary tract structural
1195
,1196 SECTION 10 Problems of Urinary Function
TABLE 50.1 Common Causes of UTIs TABLE 50.2 Risk Factors for UTIs
• Candida species Anatomic Factors
• Enterobacter
• Congenital defects leading to obstruction or urinary stasis
• Enterococcus
• Fistula exposing urinary stream to skin, vagina, or fecal stream
• Escherichia coli
• Obesity
• Klebsiella pneumoniae
• Shorter female urethra and colonization from normal vaginal flora
• Proteus mirabilis
• Pseudomonas aeruginosa Factors Compromising Immune Response
• Serratia • Aging
• Staphylococcus aureus • Diabetes
• Streptococci, Group B • HIV infection
Factors Increasing Urinary Stasis
• Extrinsic obstruction (tumor, fibrosis compressing urinary tract)
• Intrinsic obstruction (stone, tumor of urinary tract, urethral stricture, BPH)
Pyelonephritis • Renal impairment
• Urinary retention (e.g., neurogenic bladder)
Upper tract Foreign Bodies
• Catheters (indwelling, external condom catheter, ureteral stent, nephros-
tomy tube, intermittent catheterization)
• Urinary tract instrumentation (cystoscopy)
• Urinary tract stones
Cystitis Functional Disorders
• Constipation
• Voiding dysfunction with detrusor sphincter muscle incoordination
Lower tract
Other Factors
• Habitual delay of urination (“nurse’s bladder,” “teacher’s bladder”)
Urethritis
• Pregnancy
• Menopause
Fig. 50.1 Sites of infections in the upper and lower urinary tracts. • Sexual activity (women)
• Poor personal hygiene
• Use of spermicidal agents, contraceptive diaphragm (women), bubble
abnormalities or stones and 65% of complicated UTIs baths, feminine sprays
(Table 50.1).1
Fungal and parasitic infections sometimes cause UTIs. These
are more common in patients who are immunosuppressed, have also occur when a person has developed antibiotic resistance, is
diabetes or kidney problems, or received multiple courses of immunocompromised, has pregnancy-induced changes, or has
antibiotic therapy. They may also occur in persons who live in recurrent infection. The person with a complicated infection is
or have traveled to certain developing countries. at risk for pyelonephritis, urosepsis, and renal damage.
Classification of Urinary Tract Infection Etiology and Pathophysiology
UTIs can be broadly described as an upper or lower UTI accord- The urinary tract above the urethra is normally sterile. Several
ing to its location within the urinary system (Fig. 50.1). We use mechanical and physiologic defense mechanisms aid in main-
specific terms to describe the location of a UTI. For example, taining sterility and preventing UTIs. These defenses include
pyelonephritis implies inflammation (usually caused by infec- normal voiding with complete bladder emptying, ureterovesical
tion) of the renal parenchyma and collecting system. Cystitis is junction (UVJ) competence, and ureteral peristaltic activity that
an inflammation of the bladder. Urethritis is an inflammation propels urine toward the bladder. The antibacterial properties
of the urethra. Urosepsis is a UTI that has spread systemically. It of urine are maintained by a slightly acidic pH (6.0 to 7.5) and
is a life-threatening condition requiring emergency treatment. abundant antimicrobial proteins and peptides that interfere
We also classify a UTI as complicated or uncomplicated. with the bacterial growth. A change in any of these defense
Uncomplicated UTIs occur in an otherwise normal urinary mechanisms increases the risk for a UTI (Table 50.2).
tract. They usually only involve the bladder. Complicated UTIs The organisms that usually cause UTIs originate in the
occur in a person with an underlying disease or with a structural perineum. They are introduced via the ascending route from
or functional problem in the urinary tract. Examples include the urethra. Most infections are caused by gram-negative bacilli
obstruction, stones, catheters, abnormal genitourinary (GU) normally found in the gastrointestinal (GI) tract. However,
tract, acute kidney injury (AKI), chronic kidney disease (CKD), gram-positive organisms, such as streptococci, enterococci, and
kidney transplant, diabetes, or neurologic disease. They can Staphylococcus saprophyticus, can also cause UTIs.
, CHAPTER 50 Renal and Urologic Problems 1197
TABLE 50.3 Lower Urinary Tract Symptoms blood (hematuria) or sediment, giving it a cloudy appearance.
(LUTS) Upper UTIs (involving the renal parenchyma, pelvis, and ure-
ters) typically causes fever, chills, and flank pain. A UTI con-
Symptoms Description
fined to the lower urinary tract does not usually have systemic
Emptying Symptoms
manifestations. People with significant bacteriuria may have no
Dysuria • Painful or difficult urination
symptoms or may have nonspecific symptoms, such as fatigue
Hesitancy • Difficulty starting urine stream
• Delay between initiation of urination (because
or anorexia.
of urethral sphincter relaxation) and beginning of Remember that the common manifestations of a UTI are
flow of urine often absent in older adults. Older adults tend to have general
• Diminished urinary stream abdominal discomfort rather than dysuria and suprapubic pain.
Intermittency • Interruption of urinary stream while voiding They may have impaired cognition or overall clinical deteriora-
Postvoid dribbling • Urine loss after completing voiding tion. Because older adults are less likely to have a fever with a
Urinary retention • Inability to empty urine from bladder UTI, temperature is an unreliable sign of a UTI.3
or incomplete • Caused by atonic bladder or obstruction of urethra Multiple problems may produce LUTS similar to the symp-
emptying • Can be acute or chronic toms of a UTI. For example, patients with bladder tumors or
Storage Symptoms
those receiving intravesical chemotherapy or pelvic radiation
Incontinence • Involuntary or accidental urine loss or leakage usually have urinary frequency, urgency, and dysuria. Interstitial
Nocturia • Awakened by urge to void 2 or more times during cystitis/painful bladder syndrome produces urinary symptoms
sleep that are similar to and sometimes confused with a UTI.
• May be diurnal or nocturnal depending on sleep A small number of healthy persons have some bacteria col-
schedule onizing the bladder. We call this asymptomatic bacteriuria.
Nocturnal enuresis • Adults: loss of urine during sleep It does not justify screening or treatment except in pregnant
Urgency • Sudden, strong, or intense desire to void immedi- women, those with a recent kidney transplant, or those having
ately a urologic procedure.
• Often accompanied by frequency
Urinary frequency • More than 8 times in 24-h period Diagnostic Studies
• Often <200 mL each voiding
In a patient suspected of having a UTI, first obtain a dipstick uri-
nalysis. This test can identify the presence of nitrites (indicating
A common factor contributing to ascending infection is bacteriuria), white blood cells (WBCs), and leukocyte esterase
urologic instrumentation (e.g., catheterization, cystoscopic (an enzyme present in WBCs, indicating pyuria). Microscopic
examinations). Instrumentation allows bacteria that are nor- urinalysis can confirm these findings. Bacterial counts of 105
mally present at the opening of the urethra to enter the urethra colony-forming units per milliliter (CFU/mL) or higher typi-
or bladder. Sexual intercourse promotes “milking” of bacteria cally indicate a clinically significant UTI. However, counts as
from the vagina and perineum. It may cause minor urethral low as 102 to 103 CFU/mL in a person with signs and symptoms
trauma that predisposes women to UTIs. are indicative of UTI.
UTIs can result from hematogenous transmission, in which After confirmation of bacteriuria and pyuria, we may do
blood-borne bacteria invade the kidneys, ureters, or bladder from a urine culture. A urine culture is needed in persistent bacteri-
elsewhere in the body. For a kidney infection to occur this way, uria, recurring UTIs (more than 2 or 3 per year), or complicated,
there must be prior injury to the urinary tract, such as obstruc- CAUTI, or HAI UTIs. We may culture urine when the infection is
tion of the ureter, damage caused by stones, or renal scars. not responsive to empiric therapy or the diagnosis is questionable.
UTIs are the most common health care–associated infection A voided midstream technique (clean-catch urine sample) is
(HAI). They are mainly due to the use of an indwelling cath- best for obtaining a urine culture in most circumstances (see
eter. Catheter-associated urinary tract infections (CAUTIs) are Table 49.8). When we cannot obtain an adequate clean-catch
often caused by E. coli and, less often, Pseudomonas organisms. specimen, we may do catheterization. A specimen from catheter-
CAUTIs lead to extended hospital stays, increased health care ization gives more accurate results than a clean-catch specimen.
costs, and increased mortality.2 A urine culture with sensitivity testing can determine the bac-
teria’s susceptibility to a variety of antibiotic drugs. The results
Clinical Manifestations allow the HCP to choose an antibiotic known to be capable of
Manifestations of UTIs range from painful urination in uncom- destroying the bacteria causing a UTI in a specific patient.
plicated urethritis or cystitis to severe systemic illness with Some patients need imaging studies of the urinary tract. An
abdominal or back pain, fever, and sepsis. ultrasound or CT scan may be done if we suspect an obstruction
Lower urinary tract symptoms (LUTS) occur in patients who or UTIs recur.
have UTIs of the upper urinary tract, as well as those confined to
the lower tract. Symptoms are related to either bladder storage Interprofessional Care
or bladder emptying (Table 50.3). These include dysuria, fre- The interprofessional care and drug therapy of UTIs are out-
quency (voiding more than every 2 hours), urgency, and supra- lined in Table 50.4. Once a UTI has been diagnosed, appropriate
pubic discomfort or pressure. The urine may have grossly visible antimicrobial therapy is started. An antibiotic may be chosen
, 1198 SECTION 10 Problems of Urinary Function
TABLE 50.4 Interprofessional Care Other antibiotics used in the treatment of uncomplicated
UTI include ampicillin, amoxicillin, and cephalosporins.
UTI Fluoroquinolones (e.g., levofloxacin, ciprofloxacin) are given to
treat complicated UTIs. E. coli resistance to TMP/SMX, β-lac-
Diagnostic Assessment
tams, and ciprofloxacin is an increasing problem in the United
• History and physical assessment
• Urinalysis (midstream, “clean-catch” voided specimen)
States. In patients with UTIs from fungi, fluconazole (Diflucan)
• Urine for culture and sensitivity (if indicated) is the preferred therapy.
• Imaging studies of urinary tract (if indicated): CT scan, ultrasound, cystoscopy A urinary analgesic, such as oral phenazopyridine, may
relieve discomfort caused by severe dysuria. Phenazopyridine is
Management an azo dye excreted in urine. There it exerts a topical analgesic
Uncomplicated UTI effect on the urinary tract mucosa. It is taken up to 2 concur-
• Patient teaching rent days. Teach patients that this drug causes the urine to turn
• Adequate fluid intake (8 to 9 8-oz glasses/day)
orange or red.
Drug Therapy Patients who have repeated UTIs may receive prophylactic
• Antibiotics or suppressive antibiotics. A low dose of TMP/SMX, nitrofu-
• fluconazole (in patients with fungal UTI) rantoin, or another antibiotic taken daily may prevent recur-
• fosfomycin (Monurol) ring UTIs. A single dose may be taken after an event likely to
• nitrofurantoin (Macrodantin, Macrobid) provoke a UTI, such as sexual intercourse. While suppressive
• TMP/SMX (Bactrim, Bactrim DS) therapy is often effective short term, use is limited because of
• trimethoprim alone (in patients with sulfa allergy) the risk for antibiotic resistance, which leads to breakthrough
• cephalexin
infections with increasingly virulent pathogens.
Recurrent UTI
• Repeat urinalysis
NURSING MANAGEMENT: URINARY TRACT
• Urine culture and sensitivity testing INFECTION
• Adequate fluid intake (8 to 9 8-oz glasses/day)
• Repeat patient teaching Assessment
• Imaging studies of urinary tract (if indicated): see above Subjective and objective data that you should obtain from a
patient with a UTI are shown in Table 50.5.
Drug Therapy
• Antibiotic: nitrofurantoin, TMP/SMX
• Sensitivity-guided antibiotic therapy: ampicillin, amoxicillin, 1st- or
Clinical Problems
2nd-generation cephalosporin, fluoroquinolones Clinical problems for the patient with a UTI may include:
• 3- to 6-month trial of suppressive or prophylactic antibiotic therapy • Impaired urinary elimination
• Postcoital antibiotic prophylaxis: cephalexin, nitrofurantoin, TMP/SMX, • Infection
fosfomycin, trimethoprim • Pain
• Deficient knowledge
More information on clinical problems and interventions for
based on the HCP’s best judgment (empiric therapy) or the the patient with a UTI is presented in eNursing Care Plan 50.1
results of sensitivity testing. (available on the website for this chapter).
Uncomplicated UTIs are treated with a short-term course of
antibiotics, typically for 3 days. In contrast, complicated UTIs Planning
need a longer period of treatment, lasting 7 to 14 days or more.4 The overall goals are that the patient with a UTI will have (1)
Many residents of long-term care facilities, especially women, relief from bothersome symptoms, (2) no upper urinary tract
have chronic asymptomatic bacteriuria. However, we usually involvement, and (3) no recurrence.
only treat symptomatic UTIs.
First-choice drugs to treat uncomplicated or initial UTIs are Implementation
trimethoprim/sulfamethoxazole (TMP/SMX), nitrofurantoin, Health Promotion
cephalexin, and fosfomycin.4 TMP/SMX has the advantages of It is important to recognize people who are at risk for a UTI.
being inexpensive and taken twice daily. Nitrofurantoin is taken These include debilitated persons, older adults, patients who
3 or 4 times daily, but a twice-daily formulation is available. are immunocompromised (e.g., cancer, diabetes), and patients
treated with immunosuppressive drugs or corticosteroids.
Health promotion measures can help decrease the frequency of
DRUG ALERT UTIs and support early detection of infection. These activities
Nitrofurantoin (Macrodantin) include teaching preventive measures, including (1) emptying
the bladder regularly and completely, (2) evacuating the bowel
• A void use if the creatinine clearance <30 mL/min.
regularly, (3) wiping the perineal area from front to back after
• Notify HCP at once if fever, chills, cough, chest pain, dyspnea, rash, or
voiding and defecation, and (4) drinking an adequate amount
numbness or tingling of fingers or toes develops.
of liquid each day.
