Acute care handbook for physical therapists (fourth edition) chapter 9 genitourinary system

Acute care handbook for physical therapists (fourth edition) chapter 9 genitourinary system Acute care handbook for physical therapists (fourth edition) chapter 9 genitourinary system Acute care handbook for physical therapists (fourth edition) chapter 9 genitourinary system Acute care handbook for physical therapists (fourth edition) chapter 9 genitourinary system Acute care handbook for physical therapists (fourth edition) chapter 9 genitourinary system

Genitourinary System

CHAPTER

9

Jaime C Paz

CHAPTER OBJECTIVES

The objectives of this chapter are the following:

1 Provide a basic understanding of the structure and function of the genitourinary system

2 Provide information about the clinical evaluation of the genitourinary system, including physical examina-tion and diagnostic studies

3 Describe the various health conditions of the genitourinary system

4 Provide information about the management of genitourinary disorders, including renal replacement therapy and surgical procedures

5 Give guidelines for physical therapy management in patients with genitourinary diseases and disorders

PREFERRED PRACTICE PATTERNS

The most relevant practice patterns for the diagnoses discussed in this chapter, based on the

American Physical Therapy Association’s Guide to Physical Therapist Practice, second edition,

are as follows:

• Primary Prevention/Risk Reduction for Skeletal Demineralization: 4A

• Impaired Aerobic Capacity/Endurance Associated with Deconditioning: 6B

• Primary Prevention/Risk Reduction for Integumentary Disorders: 7A Please refer to Appendix A for a complete list of the preferred practice patterns, as individual patient conditions are highly variable and other practice patterns may be applicable

The regulation of fluid and electrolyte levels by the genitourinary system is an essential com-ponent of cellular and cardiovascular function Imbalance of fluids, electrolytes, or both can lead to blood pressure changes or impaired metabolism that can ultimately influence the patient’s activity tolerance (see Chapter 15) Genitourinary structures can also cause pain that

is referred to the abdomen and back To help differentiate neuromuscular and skeletal dysfunc-tion from systemic dysfuncdysfunc-tion, physical therapists need to be aware of pain referral patterns from these structures (Table 9-1)

Body Structure and Function The genitourinary system consists of two kidneys, two ureters, one urinary bladder, and one urethra The genitourinary system also includes the reproductive organs: the prostate gland, testicles, and epididymis in men, and the uterus, fallopian tubes, ovaries, vagina, external genitalia, and perineum in women Of these reproductive organs, only the prostate gland and uterus are discussed in this chapter

The anatomy of the genitourinary system is shown in Figure 9-1 An expanded, frontal view of the kidney is shown in Figure 9-2 The functional unit of the kidney is the

nephron, with approximately 1 million nephrons in each kidney Urine is formed in the nephron

through a process consisting of glomerular filtration, tubular reabsorption, and tubular secretion.1

The following are the primary functions of the genitourinary system2:

• Excretion of cellular waste products (e.g., urea and creatinine [Cr],) through urine forma-tion and micturiforma-tion (voiding)

• Regulation of blood volume by conserving or excreting fluids

CHAPTER OUTLINE

Body Structure and Function

Clinical Evaluation

Physical Examination

Diagnostic Tests

Health Conditions

Renal System Dysfunction

Lower Urinary Tract Dysfunction

Prostate Disorders

Endometriosis

Management

Renal Replacement Therapy

Surgical Interventions

Physical Therapy Management

TABLE 9-1 Segmental Innervation and Pain Referral

Areas of the Urinary System

Structure Segmental Innervation Possible Pain Referral Area

Upper abdomen

S2-S4 GroinUpper and lower abdomen

Suprapubic region Scrotum

Medial and proximal thigh Thoracolumbar region Urinary

bladder T11-L2, S2-S4 Sacral apexSuprapubic region

Thoracolumbar region

From Boissonault WG, Bass C: Pathological origins of trunk and neck pain:

part 1 Pelvic and abdominal visceral disorders, J Orthop Phys Ther 12:194,

1990.

FIGURE 9-1 Schematic illustration of the genitourinary system, including trunk musculature

Adrenal gland

Kidney

Ureter Inferior vena cava

Abdominal aorta

Bladder Urethra

Transversus abdominis

Quadratus lumborum Psoas major and minor Iliacus

FIGURE 9-2 Renal cross-section

Papilla Cortex

Minor calyces Major calyx Hilum

Renal pelvis Ureter

Medulla Pyramid

• Electrolyte regulation by conserving or excreting minerals

• Acid-base balance regulation (H+ [acid] and HCO3 − [base]

ions are reabsorbed or excreted to maintain homeostasis)

• Arterial blood pressure regulation Sodium excretion and

renin secretion maintain homeostasis Renin is secreted from

the kidneys during states of hypotension, which results in

formation of angiotensin I and II Angiotensin causes

vaso-constriction to help increase blood pressure Angiotensin also

triggers the release of aldosterone, resulting in conservation

of water by the kidney

• Erythropoietin secretion (necessary for stimulating red blood

cell production)

The brain stem controls micturition through the autonomic

nervous system Parasympathetic fibers stimulate voiding,

whereas sympathetic fibers inhibit it The internal urethral

sphincter of the bladder and the external urethral sphincter of the urethra control flow of urine.3

Clinical Evaluation Evaluation of the genitourinary system involves the integration

of patient history, physical findings, and laboratory data

Physical Examination

History Patients with suspected genitourinary pathology often present with characteristic complaints or subjective reports Therefore

kidney disease Fist percussion is performed by placing one hand along the costovertebral angle of the patient and striking the dorsal surface of that hand with a closed fist of the examiner’s other hand.6 Direct percussion with a closed fist may also be performed over the costovertebral angles The patient should feel a “thud” but not pain or tenderness.8

Auscultation Auscultation is performed to examine the blood flow to the kidneys from the abdominal aorta and the renal arteries The presence of bruits (murmurs) can indicate impaired perfusion

to the kidneys, which can lead to renal dysfunction Placement

of the stethoscope is generally in the area of the costovertebral angles and the four abdominal quadrants Refer to Chapter 8, Figure 8-2, for a diagram of the abdominal quadrants.6,8

Diagnostic Tests*

Urinalysis Urinalysis is a very common diagnostic tool used not only to examine the genitourinary system, but also to help evaluate for the presence of other systemic diseases Urine specimens can be collected by bladder catheterization or suprapubic aspiration of bladder urine, or by having the patient void into a sterile speci-men container Urinalysis is performed to examine6,9,10:

• Urine color, appearance, and odor

• Specific gravity, osmolarity, or both (concentration of urine ranges from 1.005 to 1.030)

• pH (4.6 to 8.0)

• Presence of glucose, ketones, proteins, bilirubin, urobilino-gen, occult blood, red blood cells, white blood cells, crystals, casts, bacteria or other microorganisms

Urine abnormalities are summarized in Table 9-2

a detailed history, thorough patient interview, review of the

patient’s medical record, or a combination of these provides a

good beginning to the diagnostic process for possible

genito-urinary system pathology The description of pain can offer clues

as to its source: renal pain can be described as aching and dull

in nature, whereas urinary pain is generally described as colicky

(occurring in wavelike spasms) and/or intermittent.4

Changes in voiding habits or a description of micturition

patterns are also noted during patient history and are listed

here4-6:

• Dysuria (painful burning or discomfort during urination)

• Nocturia (urinary frequency, more than once, at night)

• Incomplete bladder emptying

• Difficulty initiating urinary stream

• Hematuria (blood in urine)

• Frequency (greater than every 2 hours)

• Hesitancy (weak or interrupted stream)

• Proteinuria (urine appears foamy)

• Oliguria (very low urine output, such as less than 400 ml in

a 24-hour period)

*The reference range of various laboratory values can vary among different facilities Be sure to verify the reference values located in the laboratory test section of the medical record.

CLINICAL TIP

As a side effect of the medication phenazopyridine (Pyridium),

a patient’s urine may turn rust-colored and be misinterpreted as

hematuria.7 Pyridium is prescribed in the treatment of urinary

pain and urgency However, any new onset of possible hematu-ria should always be alerted to the medical team for proper

delineation of the cause

Observation

The presence of abdominal or pelvic distention, peripheral

edema, incisions, scars, tubes, drains, and catheters should be

noted when performing patient inspection, because these may

reflect current pathology and recent interventions Refer to

Chapter 18 for more information on medical equipment The

physical therapist must handle external tubes and drains

care-fully during positioning or functional mobility treatments

CLINICAL TIP

Patients with genitourinary disorders may also present with skin

changes, such as pallor or rough, dry skin.6 Take caution in

handling patients with skin changes from dehydration to

prevent any skin tears that can lead to infection formation

Palpation

The kidneys and a distended bladder are the only palpable

structures of the genitourinary system Distention or

inflamma-tion of the kidneys results in sharp or dull pain (depending on

severity) with palpation.6,8

Percussion

Pain and tenderness that are present with fist percussion of the

kidneys can be indicative of kidney infection or polycystic

CLINICAL TIP

If the patient is having his or her urine collected (to measure hormone and metabolite levels), the physical therapist should have the patient use the predesignated receptacle in situations when the patient needs to urinate during a physical therapy session: this will ensure that the collection is not interrupted The predesignated receptacle can be a urinal for men or a col-lection “hat” placed on the toilet or commode for women If micturition occurs during a PT session, do not discard the urine,

as it may be necessary to record or process the sample Urine output (UO) may also be collected throughout the day to measure the patient’s urine output relative to the patient’s fluid intake (input) This provides a general estimate of the patient’s renal function Measurements of the patient’s input and output are often abbreviated I/Os

ethnicity, and serum (blood) creatinine with a reference value of greater than 60 ml/min/1.73 m2.10

Blood Urea Nitrogen

As an end product of protein and amino acid metabolism, increased blood urea nitrogen (BUN) levels can be indicative of any of the following: decreased renal function or fluid intake, increased muscle (protein) catabolism, increased protein intake, congestive heart failure, or acute infection Levels of BUN need

to be correlated with plasma Cr levels to implicate renal dys-function, because BUN level can be affected by decreased fluid intake, increased muscle catabolism, increased protein intake, and acute infection Alterations in BUN and Cr level can also lead to an alteration in the patient’s mental status The reference range of BUN is 10 to 20 mg/dl in adults.6,9,10

CLINICAL TIP

Noting BUN and Cr levels on a daily basis for any changes may help explain changes in the patient’s mental status, participation

in physical therapy sessions, or both

Creatinine Tests

Two measurements of Cr (end product of muscle metabolism)

are performed: measurements of plasma Cr and Cr clearance

Plasma Cr is measured by drawing a sample of venous blood

Increased levels are indicative of decreased renal function The

reference range of plasma Cr is 0.5 to 1.2 mg/dl.10

Cr clearance, also called a 24-hour urine test, specifically

measures glomerular filtration rate Decreased clearance

(indicated by elevated levels of plasma creatinine relative

to creatinine levels in the urine) indicates decreased renal

function The reference range of Cr clearance is 87 to 139 ml

per minute.10

Estimated Glomerular Filtration Rate

The 24-hour urine collection necessary to measure creatinine

clearance has become time consuming and expensive to perform,

resulting in a prediction equation for glomerular filtration rate

(eGFR) This estimate includes the patient’s age, gender,

Radiographic Examination

Kidneys, Ureters, and Bladder X-Ray An x-ray of the

kidneys, ureters, and bladder (a procedure often abbreviated as

“KUB”) is generally performed as an initial screening tool for genitourinary disorders The size, shape, and position of the renal, ureteral, and bladder structures are delineated to help identify renal calculi (kidney stones), tumor growth or shrink-age (chronic pyelonephritis), and calcifications in the bladder wall A KUB can also be performed when internal hemorrhage

is suspected after major traumatic incidents Identification of any of these disorders requires further evaluation.6,9,11

Pyelography Radiopaque dyes are used to radiographically

examine the urinary system Two types of tests are performed: intravenous pyelography (IVP) and retrograde urography Intravenous pyelography consists of (1) taking a baseline radiograph of the genitourinary system, (2) intravenous injec-tion of contrast dye, and (3) sequential radiographs to evaluate the size, shape, and location of urinary tract structures and to evaluate renal excretory function The location of urinary obstruction or cause of nontraumatic hematuria may be also be identified with this procedure.6,9,11

Retrograde urography consists of passing a catheter or cys-toscope into the bladder and then proximally into the ureters before injecting the contrast dye This procedure is usually performed in conjunction with a cystoscopic examination and

is indicated when urinary obstruction or trauma to the genito-urinary system is suspected Evaluation of urethral stent

or catheter placement can also be performed with this procedure.5,6,9,11

Renal Arteriography Renal arteriography consists of

injecting radiopaque dye into the renal artery (arteriography) through a catheter that is inserted into the femoral or brachial artery Arterial blood supply to the kidneys can then be examined radiographically Indications for arteriography include

TABLE 9-2 Urine Abnormalities

Abnormality Etiology

Glycosuria (presence of

glucose) Hyperglycemia and probable diabetes mellitus.

Proteinuria (presence

of proteins) Proteins are usually too large to be filtered; therefore permeability

has abnormally increased.

Can occur with diabetes, acute or chronic kidney disease, nephrotic syndrome, congestive heart failure, systemic lupus erythematosus.

Hematuria (presence of

blood and red

blood cells)

Possible urinary tract bleeding or kidney diseases (calculi, cystitis, neoplasm, glomerulonephritis, or miliary tuberculosis).

Bacteriuria (presence

of bacteria) Generally indicates urinary tract infection.

Urine is generally cloudy in appearance, with the possible presence of white blood cells.

Ketonuria (presence of

ketones) * Can result from diabetes, fasting or starvation, a high-protein diet,

and alcoholism.

Bilirubinuria (presence

of bilirubin) Usually an early indicator of liver disease and hepatocellular

jaundice.

Crystals (end products

of food

metabolism)

Can occur with renal stones, gout, parathyroid or malabsorption abnormalities.

*Ketones are formed from protein and fat metabolism, and trace amounts in

the urine are normal.

Data from Bates P: Nursing assessment: urinary system In Lewis SM,

Heitkemper MM, Dirksen SR, editors: Medical-surgical nursing: assessment

and management of clinical problems, ed 5, St Louis, 2000, Mosby, pp

1241-1255; Abdomen In Seidel HM, Ball JW, Dains JE, et al, editors: Mosby’s guide

to physical examination, ed 5, St Louis, 2003, Mosby, p 551; Weigel KA, Potter

CK: Assessment of the renal system In Monahan FD, Neighbors M, Sands JK,

editors: Phipps’ medical-surgical nursing: health and illness perspectives, ed 8,

St Louis, 2008, Mosby, pp 943-960; Pagana KD, Pagana TJ: Mosby’s diagnostic

and laboratory test reference, ed 9, St Louis, 2009, Mosby.

differentiating solid mass densities as cystic or hemorrhagic Kidney size and shape, as well as the presence of cysts, abscesses, tumors, calculi, congenital abnormalities, infections, hemato-mas, and collecting system dilation, can also be assessed with CT.5,9-11

Magnetic Resonance Imaging and Angiography Multiple uses for magnetic resonance imaging (MRI) and angi-ography (MRA) include imaging the renal vascular system, staging of renal cell carcinoma, identifying bladder tumors and their local metastases, and distinguishing between benign and malignant prostate tumors.9,10

Biopsies

Renal Biopsy A renal biopsy consists of examining a small

portion of renal tissue that is obtained percutaneously with a needle to determine the pathologic state and diagnosis of a renal disorder, monitor kidney disease progression, evaluate response

to medical treatment, and assess for rejection of a renal trans-plant A local anesthetic is provided during the procedure, and accuracy of biopsy location is improved when guided by ultra-sound, fluoroscope, or CT scanning.6,9-11

Bladder, Prostate, and Urethral Biopsies Bladder,

pros-tate, and urethral biopsies involve taking tissue specimens from the bladder, prostate, and urethra with a cystoscope, or needle aspiration via the transrectal or transperineal approach Biopsy

of the prostate can also be performed through an open biopsy procedure, which involves incising the perineal area and remov-ing a wedge of prostate tissue Examination for pain, hematuria, and suspected neoplasm are indications for these biopsies.9

Health Conditions

Renal System Dysfunction

Acute Kidney Injury Acute kidney injury (AKI) (formerly known as acute renal failure [ARF]) can result from a variety of causes and is defined

as an abrupt or rapid deterioration in renal function that results

in a rise in serum creatinine levels or blood urea nitrogen with

or without decreased urine output occurring over hours or days.13 There are three types of AKI, categorized by their etiol-ogy: prerenal, intrinsic, and postrenal.13-15

Prerenal AKI is caused by a decrease in renal blood flow from reduced cardiac output, dehydration, hemorrhage, shock, burns,

or trauma.13,14 Intrinsic AKI involves primary damage to kidneys and is caused by acute tubular necrosis (ATN), glomerulonephritis, acute pyelonephritis, atheroembolic renal disease, malignant hypertension, nephrotoxic substances (e.g., aminoglycoside antibiotics or contrast dye), or blood transfusion reactions.13 Postrenal AKI involves obstruction distal to the kidney and can be caused by urinary tract obstruction by renal stones, obstructive tumors, or benign prostatic hypertrophy.13,14,16-19 Two primary classification criteria have been developed to monitor the progression and severity of AKI: Risk, Injury,

CLINICAL TIP

Patients who are scheduled for procedures involving contrast

dye are generally restricted from eating or drinking 8 hours

before the procedure A patient who is scheduled for an after-noon procedure may therefore be fatigued earlier in the day

and may want to defer a scheduled therapy session Modifying

the intended therapy session and respecting the person’s wishes

at this time are both suitable alternatives

CLINICAL TIP

Patients may experience urinary frequency or dysuria after cys-toscopic procedures; therefore the therapist should be prepared

for sudden interruptions during a therapy session that is con-ducted the same day after this diagnostic procedure

suspected aneurysm, renal artery stenosis, renovascular

hyper-tension and trauma, palpable renal masses, chronic

pyelonephri-tis, renal abscesses, and determination of the suitability of a

(donor) kidney for renal transplantation.9-12

Bladder Examination: Cystoscopy

Cystoscopy consists of passing a flexible, fiberoptic scope

through the urethra into the bladder to examine the bladder

neck, urothelial lining, and ureteral orifices The patient is

generally placed under general or local anesthesia during this

procedure Cystoscopy is performed to directly examine the

prostate in men, bladder, urethra, and ureters, as well as to

examine the causes of urinary dysfunction and for removal of

small tumors.9,10

Cystometry (Cystometrogram)

Cystometry is used to evaluate motor and sensory function of

the bladder in patients with incontinence or evidence of

neuro-logic bladder dysfunction The procedure consists of inserting

a catheter into the bladder, followed by saline instillation and

pressure measurements of the bladder wall.6,10,11

Renal Scanning

The structure, function, and perfusion of the kidneys can be

examined with a nuclear scan using different radioisotopes for

different testing procedures and structures.10

Ultrasonography Studies

Ultrasound is used to (1) evaluate kidney size, shape, and

posi-tion; (2) determine the presence of kidney stones, cysts, and

prerenal collections of blood, pus, lymph, urine, and solid

masses; (3) identify the presence of a dilated collecting system;

and (4) help guide needle placement for biopsy or drainage of

a renal abscess or for placement of a nephrostomy tube.9 It is

the test of choice to help rule out urinary tract obstruction.11

Computed Tomography Scan

Indications for computed tomography (CT) of the genitourinary

system include defining renal parenchyma abnormalities and

• Peritoneal dialysis, hemodialysis, continuous renal replace-ment therapy as necessary (refer to the Renal Replacereplace-ment Therapy section)

• Transfusions and blood products

• Nutritional support Chronic Kidney Disease Chronic kidney disease (CKD) is an irreversible reduction in renal function that occurs as a slow, insidious process from a large number of systemic diseases that injure the kidney or from intrinsic disorders of the kidney The renal system has consider-able functional reserve, and as many as 50% of the nephrons can be destroyed before symptoms occur Progression of CKD

to complete renal failure is termed end-stage kidney disease

(ESKD) At this point, renal replacement therapy (RRT) is required for patient survival.14,20

CKD can result from primary renal disease or other systemic diseases Primary renal diseases that cause CKD are polycystic kidney disease, chronic glomerulonephritis, chronic pyelone-phritis, arthroembolic renal disease, and chronic urinary obstruction The two primary systemic diseases that are associ-ated with CKD are type 2 diabetes and hypertension.21 Other systemic diseases that can result in CKD include gout, systemic lupus erythematosus, amyloidosis, nephrocalcinosis, sickle cell anemia, scleroderma, and human immunodeficiency virus.14 Complications of CKD are similar to those of AKI, including anemia and hypertension, but can also include bone pain and extraosseous calcification.20 Patients with CKD are staged based

on the severity of their disease (as measured by GFR), from the United States Kidney Disease Outcomes Quality Initiative (KDOQI) Stage 1 is normal kidney function, whereas renal replacement therapy (RRT) is recommended in stage 5.21 Management of CRF includes conservative management

or RRT.21,22 Conservative management includes the following16,17,22,23:

• Nutritional support, dietary modifications (salt and protein restrictions)

• Smoking cessation

• Calcium carbonate and vitamin supplements

• Erythropoietin for anemia

Failure, Loss, End-Stage Kidney Disease (RIFLE) (Table 9-3)

and Acute Kidney Injury Network (AKIN) classification

(Table 9-4)

Clinical manifestations of AKI are based upon the specific

type and can include the following13-19:

• Hypovolemic symptoms of thirst, hypotension, and decreased

urine output

• Acid-base imbalance

• Electrolyte imbalance

• Infection

• Anemia

• Peripheral edema

• Pulmonary vascular congestion, pleural effusion

• Cardiomegaly, gallop rhythms, elevated jugular venous

pressure

• Hepatic congestion

Management of AKI includes any of the following:

• Treatment of the primary etiology, including antimicrobial

agents if applicable

• Treatment of life-threatening conditions associated with

AKI

• Optimize hemodynamics and fluid status

• Balance acid-base and electrolytes, particularly potassium

levels

CLINICAL TIP

Patients who have AKI may have the phrase “due to void” used

when the medical team is awaiting urine output after Foley

catheterization Voluntary voiding in sufficient amounts may

contribute to discharge planning

TABLE 9-3 Risk, Injury, Failure, Loss, End-Stage

Kidney Disease (RIFLE) Classification

Class Glomerular Filtration Rate (GFR) Criteria Urine Output Criteria

serum creatinine × 1.5 <0.5 ml/kg/hr × 6 hr

serum creatinine × 2 <0.5 ml/kg/hr × 12 hr

serum creatinine × 3

or serum creatinine

≥4 mg/dl with an acute rise > 0.5 mg/dl

<0.3 ml/kg ×

24 hr or anuria ×

12 hr

function >4 weeks (persistent acute renal failure)

End-stage

kidney

disease

End-stage kidney disease

>3 months

Data from Bellomo R, Ronco C, Kellum JA et al: Acute renal failure—

definition, outcome measures, animal models, fluid therapy and information

technology needs: the Second International Consensus Conference of the Acute

Dialysis Quality Initiative (ADQI) Group, Crit Care 8:R204-R212, 2004.

TABLE 9-4 Acute Kidney Injury Network (AKIN)

Classification

Classes Serum Creatinine (sCr) Criteria Urinary Output Criteria

increase > 0.3 mg/dl from baseline

<0.5 ml/kg/hr >6 hr

12 hr

increase > 4 mg/dl with

an acute increase

> 0.5 mg/dl

<0.5 ml/kg > 24 hr

or anuria × 12 hr

Data from Mehta RL, Kellum JA, Shah SV et al: Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury, Crit Care 11:R31, 2007.

Chronic Pyelonephritis Chronic pyelonephritis is

charac-terized by chronic interstitial inflammation and scarring result-ing in destruction of nephrons Chronic pyelonephritis is a cause

of CKD and is categorized into two forms, reflux-associated and obstructive Reflux-associated is the most common form and occurs when there is a reflux of urine from the bladder resulting

in kidney scarring Obstructive chronic pyelonephritis occurs from recurrent episodes of kidney infection that result from distal obstruction.27

Signs and symptoms of chronic pyelonephritis will not be present without renal insufficiency Once renal insufficiency occurs, the patient will be symptomatic and similar to those described earlier in the AKD and CKD sections If recurrent bouts of acute pyelonephritis are present, then a history of intermittent symptoms of fever, flank pain, and dysuria may be reported.26

Management of chronic pyelonephritis includes any of the following26:

• Treatment of primary etiology and preserving renal function

• Prolonged antimicrobial therapy to maximize effectiveness Glomerular Diseases

Injury to the glomeruli with subsequent inflammation can result from a variety of situations, either from primary kidney disorders or as a secondary consequence of systemic diseases such as systemic lupus erythematosus, amyloidosis, Wegener’s granulomatosis, diabetes mellitus, or hypertension Primary glomerulonephritis may be idiopathic, be drug induced, or result from streptococcal infection Approximately 25% of glo-merulonephritis will result in CKD Primary glomerulonephri-tis can include acute nephritic syndrome, postinfectious glomerulonephritis, and chronic glomerulonephritis Immuno-globulin A (IgA) nephropathy or Berger’s disease is a form of idiopathic glomerulonephritis and is the most common type worldwide.28,29

Glomerular diseases can result in any of these five major syndromes29:

• Nephritic syndrome, manifested by hematuria, azotemia, proteinuria, oliguria, edema, and hypertension

• Rapidly progressive glomerulonephritis, manifested by acute nephritis, proteinuria, and acute kidney failure

• Nephrotic syndrome, manifested by proteinuria (>3.5 g/ day), hypoalbuminemia, hyperlipidemia, lipiduria

• Chronic kidney failure, manifested by azotemia (high nitro-gen levels) and uremia progressing for months to years

• Isolated urinary abnormalities, manifested by subnephrotic proteinuria and/or glomerular hematuria

Regardless of the type of glomerulonephritis, common signs and symptoms may include28,29:

• Edema

• Joint pain

• Allopurinol therapy

• Hyperkalemia correction

• Avoiding use of nonsteroidal antiinflammatory drugs,

acetaminophen, bisphosphonates, oral estrogens or herbal

therapies

Renal replacement therapy includes the following:

• Peritoneal dialysis or hemodialysis to maintain fluid and

electrolyte balance

• Renal transplantation (see Chapter 14)

CLINICAL TIP

Patients who are on bed rest or have yet to begin consistently

ambulating are likely to be put on anticoagulants For patients

with chronic renal disease, unfractionated heparin is the

pre-

ferred medication to use for venous thromboembolism prophy-laxis Because most medicines, including anticoagulants, are

eliminated through the kidneys, patients with renal disease may

have a higher likelihood of bleeding if anticoagulant dosing is

not titrated closely.24 Therefore monitor the patients’ clotting

times before moving them

CLINICAL TIP

Kidney infection (pyelonephritis) may be referred to as an

“upper UTI” or urinary tract infection

Pyelonephritis

Pyelonephritis is an acute or chronic inflammatory response in

the kidney, particularly the renal pelvis, from bacterial, fungal,

or viral infection It can be classified as acute or chronic

Acute Pyelonephritis Acute pyelonephritis is frequently

associated with concurrent cystitis (bladder infection) The

common causative agents are bacterial, including Escherichia

coli, Proteus, Klebsiella, Enterobacter, Pseudomonas, Serratia, and

Citrobacter Predisposing factors for acute pyelonephritis include

urine reflux from the ureter to the kidney (vesicoureteral reflux),

kidney stones, pregnancy, neurogenic bladder, catheter or

endo-scope insertion, and female sexual trauma Women are more

prone to acute pyelonephritis than men.17,22,25 Spontaneous

reso-lution of acute pyelonephritis may occur in some cases without

intervention

Signs and symptoms of acute pyelonephritis include any of

the following26:

• Sudden onset of fever and chills

• Pain and/or tenderness with deep palpatory pressure of one

or both costovertebral (flank) areas

• Urinary frequency, dysuria and urgency

• Possible hematuria, pyuria (presence of white blood cells

[leukocytes])

• Nausea, vomiting, and diarrhea

Management of acute pyelonephritis includes any of the

following26:

• Antibiotic therapy commonly includes ciprofloxacin

(Cipro), ampicillin (Omnipen), levofloxacin, norfloxacin,

cef-triaxone, trimethoprim/sulfamethoxazole (TMP-SMX), or

ofloxacin

• In complicated cases requiring hospitalization, bed

rest, intravenous fluids, and antipyretic agents are also

indicated.26

• Analgesics (NSAIDs) and fluids.

• Reduction in dietary consumption of predisposing factors described earlier

• Alpha1 antagonists and calcium channel blockers may enhance passage of stones

• Ureteroscopic stone manipulation or in situ extracorporeal shock wave lithotripsy (ECSWL) in cases where stones do not pass spontaneously

Diabetic Nephropathy Approximately 40% of people with type 1 or type 2 diabetes will develop diabetic nephropathy, which is the primary cause

of patients starting renal replacement therapy.34 The presence

of proteinuria (>0.5 g/24 hr) defines diabetic neuropathy, and, ideally, screening for kidney dysfunction should occur at the time of diagnosis for type 2 diabetes Microalbuminuria levels help to establish the diagnosis of nephropathy with random urine samples, a technique recommended by the American Diabetes Association Risk factors include sustained hyperglycemia, hypertension, smoking, dyslipidemia, and diets high in protein and fat Patients with diabetic nephropathy are also at high risk for cardiovascular disease, and therefore routine screening for coronary heart disease, carotid disease, peripheral artery disease, and atherosclerotic renal-artery stenosis should occur.34

Signs and symptoms of diabetic nephropathy include the following34:

• Microalbuminuria

• Decreased glomerular filtration rate

• Retinopathy

• Manifestations of AKI or CKD as noted in earlier sections Management of diabetic nephropathy includes any of the following16,35,36:

• Strict glycemic control (refer to the Diabetes Mellitus section

in Chapter 10)

• Management of risk factors including hypertension, smoking, and dyslipidemia including behavioral and medical strate-gies (see Chapter 3)

• Nutritional support

• Renal replacement therapy Renal Artery Stenosis Renal artery stenosis (RAS) commonly results from atheroscle-rotic disease and concomitant risk factors for vascular disease such as advancing age, elevated cholesterol, smoking, and sys-temic hypertension.37 Population-based studies in the United States report that more than 70% of older patients with 60% occlusion of the renal artery have clinical manifestations of cardiovascular disease.38 Additional but less common causes of RAS include fibromuscular dysplasia or systemic disease Decreased renal perfusion results in renovascular hypertension, which can worsen preexisting systemic hypertension.37

Signs and symptoms of renal artery stenosis include the following37,39:

• Unexplained hypertension

• Flank or upper abdominal pain

• Abdominal bruits

• Oral ulcers or malar rash

• Dark urine

• Hypertension

• Heart murmurs

• Skin pallor

• Abdominal and/or back tenderness

Management for acute glomerulonephritis can include

non-pharmacological strategies, such as diet or fluid restrictions, or

medical management including diuretics, electrolyte

correc-tion, antimicrobials, and/or immunosuppression.28

Acute Interstitial Nephritis

A hypersensitivity reaction, commonly induced by medications

(methicillin or nonsteroidal antiinflammatory drugs) or

infec-tions, can result in inflammation of the renal interstitium and

tubules, which is referred to as acute interstitial nephritis (AIN)

or acute tubulointerstitial nephritis Physical findings of AIN

include the following30:

• Leukocyturia

• Mild hematuria

• Mild proteinuria

Management of interstitial nephritis includes any of the

following16,30,31:

• Fluid and nutritional support

• Removal of causative medications while treating primary

infection (as indicated)

• Renal replacement therapy (as indicated)

Nephrolithiasis

Nephrolithiasis is characterized by renal calculi (kidney stones)

that form in the renal pelvis There are four primary types of

kidney stones, which are categorized according to the

stone-forming substances: (1) calcium, (2) struvite (composed of

magnesium, ammonium, and phosphate), (3) uric acid, and

(4) cystine.32 Many factors contribute to stone formation and

include the following33:

• Dietary factors (high protein, organ meats, salt, spinach,

rhubarb, beet, black tea intake)

• Hyperparathyroidism, sarcoidosis, metabolic syndrome,

dia-betes mellitus

• Medications (carbonic anhydrase inhibitors, triamterene,

indinavir, and vitamin C or D)

Signs and symptoms of kidney stones include the

following33:

• Colicky pain in the flank and/or lower abdominal region,

with possible radiation into the groin, depending on the

stone location (Pain increases greatly as the stone passes

through the ureters.)

• Hematuria, urinary frequency

• Nausea and vomiting

• Fever

• Variable urine pH

• Variable levels of serum calcium, chloride, phosphate, carbon

dioxide, uric acid, and Cr

After identification of the stones by noncontrast CT

scan, management of kidney stones includes any of the

following32,33:

• Urinary frequency and urgency (as often as every 15 to 20 minutes)

• Dysuria

• Lower abdominal or suprapubic pain

• Urinalysis may reveal pyuria, hematuria, and bacteriuria Management of cystitis includes antimicrobial treatment for approximately 3 days or less depending on the exact agent prescribed.44

Urinary Calculi Urinary calculi are stones (urolithiasis) that can form anywhere

in the urinary tract outside of the kidneys and are mostly com-posed of calcium oxalate and phosphate.27 Formation of stones, symptoms, and management are similar to that of kidney stones (see the Nephrolithiasis section for further details on the forma-tion and clinical presentaforma-tion of kidney stones)

Neurogenic Bladder

A neurogenic bladder is characterized by dysfunctional voiding

as a result of neurologic injury that interferes with urine storage

or voluntary coordinated voiding.45 Control of the bladder occurs at multiple levels throughout the central nervous system, and consequently injury at one or more of these levels can result

in voiding dysfunction The range of symptoms of neurogenic bladder can include suprapubic or pelvic pain, urinary inconti-nence to urinary retention, incomplete voiding, paroxysmal hypertension with diaphoresis (autonomic dysreflexia), urinary tract infection, and occult decline in kidney function.45 Management consists of addressing the primary neurologic disturbance (as able) and providing antimicrobial agents for any associated infection in order to preserve kidney function.45 A progressive approach also includes46:

• Bladder retraining, fluid regulation, and pelvic floor exercises

• Antimuscarinic agents (desmopressin)

• Antimuscarinic agents plus clean intermittent self-catheterization (CISC)

• Antimuscarinic agents plus CISC and botulinum toxin (BoNT/A)

• Indwelling catheterization with or without antimuscarinic agents, BoNT/A, and/or possible surgery

Urinary Incontinence Incontinence of urine can be transient or acute and can result from situations such as fluid imbalance, stool impaction, impaired mobility, delirium, and side effects of medications Inadequate resolution of these factors and/or repeated episodes

• Peripheral or pulmonary edema

• Acute kidney injury after initiating angiotensin-converting

enzyme (ACE) inhibitor or angiotensin receptor blocker

therapy40,41

Diagnosis can be established by renal duplex

ultraso-nography, MRA, CT angiography, and invasive digital

sub-traction renal angiography (which is the gold standard for

diagnosis).40,41

Management of renal artery stenosis includes any of the

following39:

• Antihypertensive agents (ACE inhibitors or angiotensin

receptor blockers, in appropriate cases)

• Antiplatelet therapy with aspirin

• Glycemic and lipid control

• Renal replacement therapy as indicated

• Surgery: Angioplasty with stent placement has not been

shown to have better results than medical therapy in

control-ling blood pressure or recovery of renal function.41

Renal Vein Thrombosis

Renal vein thrombosis (RVT) is an uncommon disorder,

primar-ily seen in children, that is caused by severe dehydration In

adults who are postoperative or have sustained trauma are also

at risk for RVT, along with adults who may have a

hypercoagu-lable state, renal tumors extending into the renal vein, or

nephrotic syndrome Renal vein occlusion can increase renal

vein pressure, creating a decrease in renal artery blood flow.42

Diagnosis is confirmed with renal Doppler ultrasound, CT scan,

or MRI

Signs and symptoms of renal vein thrombosis include the

following42:

• Flank or loin pain

• Fever

• Manifestations of acute kidney injury, including oliguria

• Gross hematuria

RVT can be managed with systemic anticoagulants or

catheter-directed thrombolytic therapy with urokinase or tissue

plasminogen activator.42

Lower Urinary Tract Dysfunction

Cystitis

Inflammation of the urinary bladder may occur acutely or

extend to a chronic situation Acute cystitis commonly occurs

from urinary tract infections (UTIs) resulting from pathogens

such as Escherichia coli, Staphylococcus saprophyticus, Proteus,

Kleb-siella, and Enterobacter Urinary tract infections are also common

causes of kidney infections (pyelonephritis) Prostatic

enlarge-ment, cystocele of the bladder, calculi (stones), or tumors can

also result in cystitis.43,44

A variant of cystitis is chronic pelvic pain syndrome, which

occurs predominantly in women and results in severe

suprapu-bic pain, urinary frequency, hematuria, and dysuria without

evidence of infection.43

Signs and symptoms of acute cystitis include the

following43,44:

CLINICAL TIP

If patients are incontinent of urine, observe whether bed linens and/or the hospital gown is soiled before a physical therapy session, as these need to be changed in order to minimize skin breakdown A condom catheter (for men) or adult incontinence undergarments (for men and women) can be applied before mobility treatment to aid in completion of the session

• Antiinfective agents (if there is associated infection).

• Intermittent catheterization (as necessary)

Surgical options include transurethral incision of the prostate (TUIP), transurethral resection of the prostate (TURP), trans-urethral needle ablation of the prostate (TUNA), or open prostatectomy

Prostatitis Prostatitis is an inflammation of the prostate gland It can be divided into four categories: (1) acute bacterial, (2) chronic bacterial, (3) chronic pelvic pain syndrome, and (4) asymptom-atic prostatitis Causative pathogens for acute and chronic

bacte-rial prostatitis can include E coli, Pseudomonas aeruginosa, Klebsiella, Proteus, and Enteroccocus.52

Signs and symptoms of prostatitis include the following52:

• Suprapubic, perineal, or low back pain

• Fever, chills, malaise, nausea and vomiting

• Increased urinary frequency or urgency to void

• Painful urination (dysuria)

• Difficulty initiating a stream, interrupted voiding, or incom-plete emptying

• Sexual dysfunction Management of prostatitis includes any of the following52:

• Antimicrobial agents (for bacterial prostatitis)

• Alpha1-adrenergic blocking agents or antiinflammatory agents

• Antipyretics

• Invasive management as a last resort

Endometriosis

Endometriosis is the second most common cause of dysmenor-rhea and can be a confounding source of musculoskeletal pain Aberrant growth of endometrial tissue occurs outside of the uterus, particularly in the dependent parts of the pelvis and ovaries The incidence is greatest between the ages of 25 and

29 The exact nature of the pathogenesis and etiology are cur-rently unknown Several theories are available: (1) direct endo-metrial implantation due to retrograde menstrual flow into the pelvic cavity from the uterus, (2) transformation of multi-potential cells into endometrium-like cells, (3) transport of

can contribute to chronic urinary incontinence.47 Table 9-5

provides a summary of the different types of chronic urinary

incontinence Management of the various types of chronic

incontinence may include scheduled voiding, pelvic floor

exercises, antimuscarinic drugs, surgical intervention, and

catheterization.47

Prostate Disorders

Benign Prostatic Hyperplasia

Benign prostatic hyperplasia (BPH) is characterized by an

increased number of epithelial and stromal cells in the prostate

gland and may contribute to lower urinary tract symptoms

(LUTS) in men over the age of 40.48 Digital rectal examination

can detect benign enlargement or abnormalities that may be

associated with prostate cancer In the presence of microscopic

hematuria, CT urogram and cystoscopy is recommended, along

with laboratory tests such as measurement of serum prostate

antigen (PSA).49 Enlargement of the prostate from BPH can

result in urinary tract obstruction; however, factors such as those

described in Table 9-5 are also contributing issues to LUTS in

both men and women.48 Thus there are overlapping signs and

symptoms of BPH and LUTS, including48,50:

• Frequency of micturition, urgency

• Urge incontinence

• Decreased force and caliber of urinary stream

• Straining to void, hesitancy

• Postvoid dribble

• Nocturia, dysuria and hematuria

Management of BPH includes any of the following48,51:

• Alpha1-adrenergic blocking agents act to relax the smooth

muscle in the neck of the bladder to facilitate voiding

Cur-rently prescribed agents include tamsulosin (Flomax) and

prazosin (Minipress) Other medications include doxazosin

(Cardura), terazosin (Hytrin), and alfuzosin (Uroxatral)

• 5α-Reductase enzyme inhibitor used to inhibit male

hor-mones to the prostate, causing the gland to shrink over

time Agents include finasteride (Proscar) and dutasteride

(Avodart)

TABLE 9-5 Types of Chronic Urinary Incontinence

Type Description Common Causes

Stress Loss of urine that occurs involuntarily in situations

associated with increased intraabdominal pressure, such as with laughing, coughing, or exercise

Urethral sphincter dysfunction, or weakness in pelvic floor muscles

after a sensation of bladder fullness is perceived Neurologic disorders, spinal cord injury, or detrusor overactivity

Overflow Leakage of urine from mechanical forces or urinary

retention from an overdistended bladder Anatomic obstruction by prostate, stricture, or cystoceleDiabetes mellitus or spinal cord injury

Neurologic disorders, detrusor failure Functional The inability to void because of cognitive or physical

impairments, psychological unwillingness, or environmental barriers

Mobility and/or cognitive impairment(s)

Adapted from Stiles M, Walsh: Care of the elderly patient In Rakel RE, Rakel DP, editors: Textbook of family medicine, ed 8, Philadelphia, 2011, Saunders, p 49.