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

CHAPTER Genitourinary System Jaime C Paz CHAPTER OUTLINE CHAPTER OBJECTIVES 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 The objectives of this chapter are the following: Provide a basic understanding of the structure and function of the genitourinary system Provide information about the clinical evaluation of the genitourinary system, including physical examination and diagnostic studies Describe the various health conditions of the genitourinary system Provide information about the management of genitourinary disorders, including renal replacement therapy and surgical procedures 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 component 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 dysfunction from systemic dysfunction, 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 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 formation and micturition (voiding) • Regulation of blood volume by conserving or excreting fluids 225 226 CHAPTER 9    Genitourinary System Adrenal gland Transversus abdominis Abdominal aorta Kidney Quadratus lumborum Inferior vena cava Psoas major and minor Ureter Iliacus Bladder Urethra FIGURE 9-1  Schematic illustration of the genitourinary system, including trunk musculature TABLE 9-1  Segmental Innervation and Pain Referral Areas of the Urinary System Structure Segmental Innervation Kidney T10-L1 Ureter T11-L2, S2-S4 Urinary bladder T11-L2, S2-S4 Medulla Pyramid Cortex Possible Pain Referral Area Lumbar spine (ipsilateral flank) Upper abdomen Groin Upper and lower abdomen Suprapubic region Scrotum Medial and proximal thigh Thoracolumbar region Sacral apex Suprapubic region Thoracolumbar region From Boissonault WG, Bass C: Pathological origins of trunk and neck pain: part Pelvic and abdominal visceral disorders, J Orthop Phys Ther 12:194, 1990 • 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 vasoconstriction 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 Papilla Hilum Minor calyces Major calyx Renal pelvis Ureter FIGURE 9-2  Renal cross-section 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 CHAPTER 9    Genitourinary System 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 genitourinary 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 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)   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 hematuria 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 carefully 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 inflammation 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 227 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 specimen 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, urobilinogen, occult blood, red blood cells, white blood cells, crystals, casts, bacteria or other microorganisms Urine abnormalities are summarized in Table 9-2   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 collection “hat” placed on the toilet or commode for women If micturition occurs during a PT session, 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 *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 228 CHAPTER 9    Genitourinary System TABLE 9-2  Urine Abnormalities Abnormality Etiology Glycosuria (presence of glucose) Proteinuria (presence of proteins) Hyperglycemia and probable diabetes mellitus 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 Possible urinary tract bleeding or kidney diseases (calculi, cystitis, neoplasm, glomerulonephritis, or miliary tuberculosis) Generally indicates urinary tract infection Urine is generally cloudy in appearance, with the possible presence of white blood cells Can result from diabetes, fasting or starvation, a high-protein diet, and alcoholism Usually an early indicator of liver disease and hepatocellular jaundice Can occur with renal stones, gout, parathyroid or malabsorption abnormalities Hematuria (presence of blood and red blood cells) Bacteriuria (presence of bacteria) Ketonuria (presence of ketones)* Bilirubinuria (presence of bilirubin) Crystals (end products of food metabolism) 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 12411255; 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 *Ketones are formed from protein and fat metabolism, and trace amounts in the urine are normal 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, 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 dysfunction, 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 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 shrinkage (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 injection 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 cystoscope 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 genitourinary 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 CHAPTER 9    Genitourinary System suspected aneurysm, renal artery stenosis, renovascular hypertension and trauma, palpable renal masses, chronic pyelonephritis, renal abscesses, and determination of the suitability of a (donor) kidney for renal transplantation.9-12   CLINICAL TIP Patients who are scheduled for procedures involving contrast dye are generally restricted from eating or drinking hours before the procedure A patient who is scheduled for an afternoon 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 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   CLINICAL TIP Patients may experience urinary frequency or dysuria after cystoscopic procedures; therefore the therapist should be prepared for sudden interruptions during a therapy session that is conducted the same day after this diagnostic procedure Cystometry (Cystometrogram) Cystometry is used to evaluate motor and sensory function of the bladder in patients with incontinence or evidence of neurologic 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 position; (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 229 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, hematomas, 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 angiography (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 transplant A local anesthetic is provided during the procedure, and accuracy of biopsy location is improved when guided by ultrasound, fluoroscope, or CT scanning.6,9-11 Bladder, Prostate, and Urethral Biopsies.  Bladder, prostate, 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 removing 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 etiology: 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, 230 CHAPTER 9    Genitourinary System TABLE 9-3  Risk, Injury, Failure, Loss, End-Stage Kidney Disease (RIFLE) Classification Class Risk Injury Failure Loss End-stage kidney disease Glomerular Filtration Rate (GFR) Criteria Urine Output Criteria GFR decrease > 25% or serum creatinine × 1.5 GFR decrease > 50% or serum creatinine × GRF decrease 75% or serum creatinine × or serum creatinine ≥4 mg/dl with an acute rise > 0.5 mg/dl Complete loss of kidney function >4 weeks (persistent acute renal failure) End-stage kidney disease >3 months 0.5 mg/dl 6 hr 12 hr 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 • Peritoneal dialysis, hemodialysis, continuous renal replacement therapy as necessary (refer to the Renal Replacement 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 considerable 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 pyelonephritis, arthroembolic renal disease, and chronic urinary obstruction The two primary systemic diseases that are associated with CKD are type 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 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 CHAPTER 9    Genitourinary System • 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 preferred medication to use for venous thromboembolism prophylaxis 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 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 endoscope insertion, and female sexual trauma Women are more prone to acute pyelonephritis than men.17,22,25 Spontaneous resolution 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, ceftriaxone, trimethoprim/sulfamethoxazole (TMP-SMX), or ofloxacin • In complicated cases requiring hospitalization, bed rest, intravenous fluids, and antipyretic agents are also indicated.26 231   CLINICAL TIP Kidney infection (pyelonephritis) may be referred to as an “upper UTI” or urinary tract infection Chronic Pyelonephritis.  Chronic pyelonephritis is characterized by chronic interstitial inflammation and scarring resulting 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 glomerulonephritis will result in CKD Primary glomerulonephritis can include acute nephritic syndrome, postinfectious glomerulonephritis, and chronic glomerulonephritis Immunoglobulin 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 nitrogen 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 232 CHAPTER 9    Genitourinary System • • • • • • Oral ulcers or malar rash Dark urine Hypertension Heart murmurs Skin pallor Abdominal and/or back tenderness Management for acute glomerulonephritis can include nonpharmacological strategies, such as diet or fluid restrictions, or medical management including diuretics, electrolyte correction, antimicrobials, and/or immunosuppression.28 Acute Interstitial Nephritis A hypersensitivity reaction, commonly induced by medications (methicillin or nonsteroidal antiinflammatory drugs) or infections, 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 stoneforming 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, diabetes 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: • 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 not pass spontaneously Diabetic Nephropathy Approximately 40% of people with type or type 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 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 strategies (see Chapter 3) • Nutritional support • Renal replacement therapy Renal Artery Stenosis Renal artery stenosis (RAS) commonly results from atherosclerotic disease and concomitant risk factors for vascular disease such as advancing age, elevated cholesterol, smoking, and systemic 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 • 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 controlling blood pressure or recovery of renal function.41 Renal Vein Thrombosis Renal vein thrombosis (RVT) is an uncommon disorder, primarily 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 hypercoagulable 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, Klebsiella, and Enterobacter Urinary tract infections are also common causes of kidney infections (pyelonephritis) Prostatic enlargement, 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 suprapubic pain, urinary frequency, hematuria, and dysuria without evidence of infection.43 Signs and symptoms of acute cystitis include the following43,44: CHAPTER 9    Genitourinary System 233 • 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 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 composed 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 formation and clinical presentation 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 incontinence 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 selfcatheterization (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   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 234 CHAPTER 9    Genitourinary System 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 Leakage of urine because of inability to delay voiding after a sensation of bladder fullness is perceived Combination of stress and urge symptoms Leakage of urine from mechanical forces or urinary retention from an overdistended bladder Urethral sphincter dysfunction, or weakness in pelvic floor muscles Urge Mixed Overflow Functional The inability to void because of cognitive or physical impairments, psychological unwillingness, or environmental barriers Neurologic disorders, spinal cord injury, or detrusor overactivity Combination of stress and urge causes above Anatomic obstruction by prostate, stricture, or cystocele Diabetes mellitus or spinal cord injury Neurologic disorders, detrusor failure 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 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 Currently 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 hormones to the prostate, causing the gland to shrink over time Agents include finasteride (Proscar) and dutasteride (Avodart) • 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), transurethral 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) asymptomatic prostatitis Causative pathogens for acute and chronic bacterial 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 incomplete 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 dysmenorrhea 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 currently unknown Several theories are available: (1) direct endometrial implantation due to retrograde menstrual flow into the pelvic cavity from the uterus, (2) transformation of multipotential cells into endometrium-like cells, (3) transport of CHAPTER 9    Genitourinary System endometrial cells by uterine vascular and lymphatic systems to distant sites, and (4) disorder of immune surveillance allowing growth of endometrial implants Differential diagnosis of endometriosis may include pelvic inflammatory disease, ectopic pregnancy, appendicitis, hernia, irritable bowel syndrome, nerve entrapment, interstitial cystitis, or muscle strain Laparoscopic examination will confirm the diagnosis of endometriosis.53-55 Signs and symptoms of endometriosis include the following53-55: • Classic triad of dysmenorrhea, dyspareunia (pain with intercourse), and infertility • Pelvic pain (hypogastric and perineal regions) related to the menstrual cycle • Pain in the low back and lower extremities • Intermittent constipation/diarrhea, dysuria, hematuria, and urinary frequency • Abnormal bleeding (premenstrual spotting, menorrhagia) Management of endometriosis includes any of the following53-55: • Nonsteroidal antiinflammatory drugs for relief of symptoms associated with dysmenorrhea • Conservative therapies aimed at enhancing fertility (for those wishing to bear children) • Hormonal therapy aimed at reducing hormone levels and cyclic stimulation of ectopic endometrial tissue Agents used include estrogen-progesterone, progestins, and gonadotropinreleasing hormone (GnRH) agonists • Laparoscopic ablation of endometrial implants (ectopic tissue) with concurrent uterine nerve ablation to significantly reduce pain • Total abdominal hysterectomy and bilateral salpingooophorectomy (TAH-BSO) in women who no longer wish to bear children, followed by estrogen replacement therapy 235 or compartment.56,57 Continuous renal replacement therapy (CRRT) is generally implemented in the critical care setting in patients with AKI.58 Kidney transplantation is described in Chapter 14 Peritoneal Dialysis Peritoneal dialysis (PD) involves using the peritoneal cavity as a semipermeable membrane to exchange soluble substances and water between the dialysate fluid and the blood vessels in the abdominal cavity.18,56,57 Dialysate fluid is instilled into the peritoneal cavity through an indwelling catheter After the dialysate is instilled into the peritoneum, there is an equilibration period when water and solutes pass through the semipermeable membrane Once equilibration is finished, then the peritoneal cavity is drained of the excess fluid and solutes that the failing kidneys cannot remove Instillation, equilibration, and drainage constitute one exchange.56,57 The process of peritoneal dialysis can range from 45 minutes to hours, depending on the method of PD, and patients can have anywhere from to 24 exchanges per day.56 There are two types of PD: automated PD (APD) and continuous ambulatory PD (CAPD) APD uses an automatic cycling device to control the instillation, equilibration, and drainage phases CAPD is schematically represented in Figure 9-3.56 PD is indicated for patients with CKD, who may or may not be hospitalized The choice to use PD versus intermittent hemodialysis is dependent on whether there is a functioning peritoneal cavity as well as the ability for the patient or care providers to manage the exchanges In cases of AKI, intermittent hemodialysis or CRRT are preferable modalities.58,59 Management The specific management of various genitourinary disorders is discussed earlier in the respective health conditions sections This section expands on renal replacement therapy and surgical procedures Guidelines for physical therapy management for patients who have genitourinary dysfunction are also discussed Renal Replacement Therapy The primary methods of managing fluid and electrolyte balance in patients with AKI or CKD are peritoneal dialysis, intermittent hemodialysis, or continuous renal replacement therapy For either type of dialysis (peritoneal or intermittent), the principles of diffusion, osmosis, and ultrafiltration to balance fluid and electrolyte levels are used Diffusion is the movement of solutes, such as Cr, urea, or electrolytes, from an area of higher concentration to an area of lower concentration Osmosis is the movement of fluid from an area of lesser solute concentration to an area of greater solute concentration Ultrafiltration, the removal of water and fluid, is accomplished by creating pressure gradients between the arterial blood and the dialyzer membrane A B FIGURE 9-3  Schematic illustration of continuous ambulatory peritoneal dialysis A, Instillation of dialysate fluid B, Drainage of excess fluid and solutes 236 CHAPTER 9    Genitourinary System Intermittent Hemodialysis Kidney functions that are controlled by intermittent hemodialysis include (1) fluid volume, (2) electrolyte balance, (3) acidbase balance, and (4) filtration of nitrogenous wastes The patient’s arterial blood is mechanically circulated through semipermeable tubing that is surrounded by a dialysate solution in the dialyzer (artificial kidney) The dialysate fluid contains vital solutes to permit diffusion of electrolytes into or out of the patient’s blood As the patient’s arterial blood is being filtered through the dialyzer, “clean” blood is returned to the patient’s venous circulation.57,58 Figure 9-4 illustrates this process Vascular access is attained either through cannula insertion (usually for temporary dialysis) or through an internal arteriovenous fistula (for chronic dialysis use), which is surgically created in the forearm The arteriovenous fistula is created by performing a side-to-side, side-to-end, or end-to-end anastomosis between the radial or ulnar artery and the cephalic vein If a native fistula cannot be created, then a synthetic graft is surgically anastomosed between the arterial and venous circulation.56 Figure 9-5 illustrates these various types of vascular access Patients who require intermittent hemodialysis for AKI are generally required to replace to liters of fluid per dialysis session in order to fully achieve clear waste products and achieve osmotic balance This large amount of fluid exchange can promote hypotension and possible ischemia of nephrons in patients who are critically ill Therefore, in the more unstable patient, continuous renal replacement therapy may be more suitable.60 Patients who require chronic intermittent hemodialysis usually have it administered three to four times per week, with each exchange lasting approximately to hours The overall intent of this process is to extract up to days’ worth of excess fluid and solutes from the patient’s blood.18,61 Blood pump Pressure monitor Jugular vein Pressure monitor Infusion pump Subclavian vein Superior vena cava Temperature monitor Conductivity meter Dialyzer Purified water Blood leak detector Pressure monitor Air bubble detector Dialysate concentrate Drain Dialysate (negative) pressure pump FIGURE 9-4  Schematic representation of hemodialysis (From Thompson JM, McFarland GK, Hirsch JE, et al: Mosby’s clinical nursing, ed 3, St Louis, 1993, Mosby, p 938.) CHAPTER 9    Genitourinary System 237 A B C FIGURE 9-5  Methods of vascular access for hemodialysis A, Internal arteriovenous fistula B, Looped graft in forearm C, External cannula or shunt (From Lewis SM, Heitkemper MM, Dirksen SR, editors: Medical-surgical nursing: assessment and management of clinical problems, ed 6, St Louis, 2004, Mosby, p 1233.)   CLINICAL TIP Pulmonary hygiene treatments can be performed during dialysis; however, this depends on the hemodynamic stability of the patient and is at the discretion of the nurse or physician Extreme caution should be taken with the access site to prevent accidental disruption Continuous Renal Replacement Therapy The purpose of CRRT is to provide a continuous mechanism that balances fluid and electrolytes as well as small and medium solutes from the body in a manner that mimics the natural function of the patient’s native kidney Because of the process involved with CRRT, it is frequently used in the critical care setting to stabilize and manage patients without the adverse effects of hypotension that can occur with intermittent hemodialysis Predictable outcomes of CRRT include58: • Hemodynamic stability • Continuous control of fluid status • Control of acid-base status and electrolyte, calcium, and phosphate balance • Provision of protein-rich nutrition with excellent uremic control • Prevention of intracerebral water fluctuations • Minimal risk of infection There are several techniques to achieve CRRT, which are outlined in Table 9-6 Vascular access is dependent on the specific type of CRRT indicated for the patient Figure 9-6 provides an illustration of continuous venovenous hemofiltration   CLINICAL TIP The dialysis staff is generally nearby to monitor the procedure and is a valuable source of information regarding the patient’s hemodynamic stability Also, inquiring about the length of time for the hemodialysis may be helpful in scheduling therapy sessions 238 CHAPTER 9    Genitourinary System TABLE 9-6  Continuous Renal Replacement Therapy (CRRT) Techniques Types of CRRT Description Slow continuous ultrafiltration (SCUF) Used for fluid control only Can have arteriovenous or venovenous modes Convective blood purification through a high-permeability membrane Arteriovenous mode also available Diffusive purification of blood through a low-permeability dialyzer For small molecule clearance only Diffusive and convective blood purification with a highly permeable membrane Diffusive and convective blood purification with a highly permeable membrane and an accessory pump to control ultrafiltration A highly permeable plasma filter filters plasma, allowing it to pass through a bed of adsorbent material (carbon or resins) Fluid balance maintained throughout process Continuous venovenous hemofiltration (CVVH) Continuous venovenous hemodialysis Continuous venovenous hemodiafiltration (CVVHDF) Continuous high-flux dialysis (CVVHFD) Continuous plasma-filtration adsorption (CPFA) Data from Ronco C, Ricci Z, Bellomo R et al: Renal replacement therapy In Vincent JL, Abraham E, Moore FA et al, editors: Textbook of critical care, ed 6, Philadelphia, 2011, Saunders, pp 894-901 Controlled infusion fluid Infusion of substitution fluid, drugs, and nutrients Venous line Hemofilter Venous line Heparin infusion pump Closed graduated filtrate collection FIGURE 9-6  Schematic representation of continuous venovenous hemofiltration Surgical Interventions Surgical interventions for genitourinary system disorders can be categorized broadly as procedures that remove diseased portions of the genitourinary tract or procedures that restore urinary flow These interventions are briefly discussed in the following sections Refer to Chapter 20 for general anesthesia and postoperative considerations Nephrectomy There are three types of nephrectomy The primary indications for removing a part or all of the kidney include renal cell carcinoma, polycystic kidney disease, severe traumatic injury to the kidney, and organ donation, as well as removing a failing transplanted organ.62,63 Nephrectomy can be performed as an open or laparoscopic procedure.62-66 The types of nephrectomy and their definitions follow: • Radical nephrectomy—removal of the entire kidney, a section of the ureter, the adrenal gland, and the fatty tissue surrounding the kidney • Simple nephrectomy—removal of the entire kidney with a section of the ureter Generally performed when harvesting donor organs for kidney transplantation • Partial nephrectomy—only the infected or diseased portion of the kidney is removed Nephron-sparing surgery (NSS) is a term also used with partial nephrectomy and is indicated for patients with small, localized tumors Minimally invasive techniques include laparoscopic and robotic partial nephrectomies as well as cryoablation and radiofrequency ablation to target localized masses.66,67 Prostatectomy Prostatectomy is the surgical removal of a prostate gland with or without its capsule and is indicated for patients with acute urinary retention, recurrent or persistent urinary tract infections, significant bladder outlet obstruction that is not responsive to medical therapy, recurrent hematuria of prostatic origin, bladder calculi, and renal insufficiency secondary to obstruction The procedure can be performed via open approach or through transurethral resection of the prostate (TURP).68 Urinary Incontinence Procedures When conservative treatment of urinary stress incontinence is unsuccessful or not desired, surgical management is considered Stress incontinence has been reported in as many as 78% of women with 30% opting for surgery Procedures such as the Burch and Marshall-Marchetti-Kranz (MMK) retropubic urethropexies are aimed at reestablishing the anatomic support of the urethrovesical junction and proximal urethra in order to provide stability during increases in intraabdominal pressure Sling procedures involve placement of synthetic mesh acting as a dynamic support in the midurethral region and can be performed via retropubic or transobturator approaches Injection of urethral bulking agents, such as collagen and carbon beads, can also be performed to help support the urethra.69 Urinary Diversion Procedures aimed at diverting urine flow are indicated for patients who have undergone cystectomy or have a diseased bladder Obstructed ureters as well as total urinary incontinence are also indications Urinary diversion involves creating a conduit from either the small or large intestine.70 Figure 9-7 illustrates some methods of urinary diversion Physical Therapy Management The following are general goals and guidelines for the physical therapist when working with patients who have genitourinary dysfunction These guidelines should be adapted to a patient’s specific needs The primary physical therapy goals in this patient population are similar to those of other patients in the acute care setting These goals are to (1) optimize safe functional mobility, (2) maximize activity tolerance and endurance, and (3) prevent postoperative pulmonary complications General physical therapy management guidelines and considerations revolve around the normal functions of the genitourinary system that are disrupted by the various health conditions discussed earlier in this chapter These include, but are not limited to, the following: Evaluating laboratory values before examination or intervention can help the physical therapist decide which particular signs and symptoms to monitor as well as determine the parameters of the session.71 Refer to Chapter 15 for more information on fluid and electrolyte imbalance CHAPTER 9    Genitourinary System 239 The inability to regulate cellular waste products, blood volume, and electrolyte levels can result in: • Mental status changes from a buildup of ammonia, BUN, Cr, or a combination of these If this situation occurs, then the therapist may choose to modify or defer physical therapy intervention, particularly educational activities that require concentration • Disruption of excitable tissues such as peripheral nerves and skeletal, cardiac, and smooth muscle from altered levels of electrolytes.72 If this situation occurs, then the therapist may need to reduce exercise intensity during muscle-strengthening activities In addition, if peripheral neuropathy results in sensory deficits, then the therapist needs to take the appropriate precautions with the use of modalities and educate the patient on protective mechanisms to avoid skin breakdown • Peripheral or pulmonary edema from inability to excrete excess body fluids.72 Pulmonary edema can result in shortness of breath with activities and recumbent positioning Peripheral edema can result in range-of-motion limitations and skin breakdown Refer to Table 3-5 for a description of pitting edema, and see Chapter for a description of pulmonary edema • Fluid and electrolyte imbalance can also alter the hemodynamic responses to activity; therefore careful vital sign and symptom monitoring should always be performed Blood pressure regulation can be altered by the inability to excrete body fluids and activate the renin-angiotensin system.72 Activity tolerance can be reduced by the factors mentioned in this section, as well as anemia that can result from decreased erythropoietin secretion from kidneys, which is necessary for stimulating red blood cell production.72 Patients will likely demonstrate variable levels of fatigue when receiving RRT; some patients are more fatigued before a dialysis session, whereas others are more fatigued after a dialysis session Hemodialysis sessions typically occur three times per week but may have different schedules depending on the patient situation Patients with CKD may present with concurrent clinical manifestations of diabetes mellitus, as diabetes mellitus is a strong contributing factor to this disorder Refer to Chapter 10 for more information on diabetes mellitus As stated in the introduction to this chapter, patients with genitourinary dysfunction may have referred pain (see Table 9-1) Physical therapists can play a role in differentiating the source of a patient’s back pain as well as possibly providing symptomatic management of this referred pain Patients who have undergone surgical procedures with abdominal incisions are less likely to perform deep breathing and coughing because of incisional pain Diligent position changes, instruction on incisional splinting during deep breathing, and coughing, along with early mobilization, help prevent the development of pulmonary complications.73-77 240 CHAPTER 9    Genitourinary System A B C D FIGURE 9-7  Methods of urinary diversion A, Ureteroileosigmoidostomy B, Ileal loop (or ileal conduit) C, Ureterostomy (transcutaneous ureterostomy and bilateral cutaneous ureterostomies) D, Nephrostomy (From Lewis SM, Heitkemper MM, Dirksen SR, editors: Medical-surgical nursing: assessment and management of clinical problems, ed 6, St Louis, 2004, Mosby, p 1203.) For patients who are ambulatory and present with urinary urgency, possibly from diuretic therapy, the use of a bedside commode may be a beneficial recommendation to minimize the incidences of incontinence 10 Patients who are incontinent may benefit from a home exercise program, referral to a physical therapist who specializes in pelvic floor strengthening, or both on discharge from the hospital References The urinary system In Patton KT, Thibodeau GA, editors: Anatomy & physiology, ed 7, St Louis, 2010, Mosby Patton KT, Thibodeau GA, editors: Anatomy & physiology, ed 7, St Louis, 2010, Mosby Bullock BL: Normal renal and urinary excretory function In Bullock BL, editor: Pathophysiology: adaptations and alterations in function, ed 4, Philadelphia, 1996, Lippincott, p 616 Screening for urogenital disease In Goodman CC, Kelly Snyder TE, editors: Differential diagnosis for physical therapists, ed 5, St Louis, 2013, Elsevier, pp 384-386 McLinn DM, Boissonnault WG: Screening for male urogenital system disease In Boissonnault WG, editor: Examination in physical therapy practice: screening for medical disease, New York, 1991, Churchill Livingstone, p 121 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 Pyridium http://www.rxlist.com/pyridium-drug/patient-imagesside-effects.htm#sideeffects Accessed June 7, 2012 Abdomen In Seidel HM, Ball JW, Dains JE et al, editors: Mosby’s guide to physical examination, ed 5, St Louis, 2003, Mosby, pp 541-552 Malarkey LM, McMorrow ME: Nurse’s manual of laboratory tests and diagnostic procedures, ed 2, Philadelphia, 2000, Saunders, pp 38-48, 629-670 10 Pagana KD, Pagana TJ: Mosby’s diagnostic and laboratory test reference, ed 9, St Louis, 2009, Mosby 11 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 12 Thompson FD, Woodhouse CRJ: Disorders of the kidney and urinary tract, London, 1987, Edward Arnold 13 Cheng CM, Ponnusamy A, Anderton JG: Management of acute renal failure in the elderly patient, a clinician’s guide, Drugs Aging 25(6):455-476, 2008 14 Weigel KA, Potter CK, Green CJ: Kidney failure In Monahan FD, Neighbors M, Sands JK, editors: Phipps’ medical-surgical nursing: health and illness perspectives, ed 8, St Louis, 2008, Mosby, pp 1003-1039 15 Sharfuddin AA, Weisbord SD, Palevsky PM et al: Acute kidney injury In Taal MW, Chertow GM, Marsden PA et al, editors: Brenner and Rector’s the kidney, ed 9, Philadelphia, 2011, Saunders, pp 1044-1085 16 Renal system In Thompson JM, McFarland GK, Hirsch JE et al, editors: Mosby’s manual of clinical nursing practice, ed 2, St Louis, 1989, Mosby, p 1021 17 Huether SE: Alterations of renal and urinary tract function In McCance KL, Huether SE, editors: 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assessment and management of clinical problems, ed 5, St Louis, 2000, Mosby, pp 1310-1330 57 Urinary system disorders In Gould BE, Dyer RM, editors: Pathophysiology for the health professions, ed 4, Philadelphia, 2011, Saunders, p 448 58 Ronco C, Ricci Z, Bellomo R et al: Renal replacement therapy In Vincent JL, Abraham E, Moore FA et al, editors: Textbook of critical care, 6, Philadelphia, 2011, Saunders, pp 894-901 59 Chiu YW, Mehrotra R: The utilization and outcome of peritoneal dialysis In Himmelfarb J, Sayegh MH, editors: Chronic kidney disease, dialysis and transplantation, ed 3, Philadelphia, 2010, Saunders, pp 405-417 60 Dirkes S, Hodge K: Continuous renal replacement therapy in the adult intensive care unit: history and current trends, Crit Care Nurse 27(2):61-80, 2000 61 Noble H: An aging renal population—is dialysis always the answer? 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JAMA 284(20):2579, 2000 66 Delacroix SE, Wood CG, Jonasch E: Renal neoplasia In Taal MW, Chertow GM, Marsden PA et al, editors: Brenner and Rector’s the kidney, ed 9, Philadelphia, 2011, Saunders, pp 1508-1536 67 Kimura M, Baba S, Polasick TJ: Minimally invasive surgery using ablative modalities for localized renal mass, Int J Urol 17:215-227, 2010 68 Han M, Partin AW: Retropubic and suprapubic open prostatectomy In Wein AJ, Kavoussi LR, Novick AC et al, editors: Campbell-Walsh urology, ed 10, Philadelphia, 2011, Saunders, pp 2695-2705 69 Wai CY: Surgical treatment for stress and urge urinary incontinence, Obstet Gynecol Clin North Am 36:509-519, 2009 70 Dahl DM, McDougal WS: Use of intestinal segments in urinary diversion In Wein AJ, Kavoussi LR, Novick AC et al, editors: Campbell-Walsh urology, ed 10, Philadelphia, 2011, Saunders, pp 2435-2442 71 Lab values interpretation resource: update 2012 Acute Care Section, American Physical Therapy Association http:// www.acutept.org/associations/11622/files/labvalues.pdf Accessed March 21, 2013 72 Dean E: Oxygen transport deficits in systemic disease and implications for physical therapy, Phys Ther 77(2):187, 1997 73 Brooks-Brunn JA: Postoperative atelectasis and pneumonia, Heart Lung 24:94-115, 1995 74 Brooks-Brunn JA: Predictors of postoperative pulmonary complications following abdominal surgery, Chest 111:564-571, 1997 75 Basse L, Raskov HH, Jakobsen DH et al: Accelerated postoperative recovery programme after colonic resection improves physical performance, pulmonary function and body composition, Br J Surg 89:446-453, 2002 76 Olsén MF, Nordgren IH, Lönroth H et al: Randomized controlled trial of prophylactic chest physiotherapy in major abdominal surgery, Br J Surg 84:1535-1538, 1997 77 Olsén MF, Lönroth H, Bake B: Effects of breathing exercises on breathing patterns in obese and non-obese subjects, Clin Physiol 19(3):251-257, 1999  ... deficits in systemic disease and implications for physical therapy, Phys Ther 77(2):187, 199 7 73 Brooks-Brunn JA: Postoperative atelectasis and pneumonia, Heart Lung 24 :94 -1 15, 199 5 74 Brooks-Brunn... to Chapter 10 for more information on diabetes mellitus As stated in the introduction to this chapter, patients with genitourinary dysfunction may have referred pain (see Table 9- 1) Physical therapists. .. Campbell-Walsh urology, ed 10, Philadelphia, 2011, Saunders, pp 257 0-2 621 49 Paolone DR: Benign prostatic hyperplasia, Clin Geriatr Med 26(2):22 3-2 39, 2010 242 CHAPTER 9    Genitourinary System