Chapter 46: Renal and Urologic Problems
URINARY TRACT INFECTIONS
Urinary tract infections (UTIs) are the second most common bacterial disease, and the
most common bacterial infection in women.
UTIs include cystitis, pyelonephritis, and urethritis.
Risk factors for UTIs include pregnancy, menopause, instrumentation, and sexual
intercourse. Escherichia coli (E. coli) is the most common pathogen causing a UTI.
UTIs that are hospital-acquired are called nosocomial infections.
UTI symptoms include dysuria, frequent urination (more than every 2 hours), urgency,
and suprapubic discomfort or pressure. Flank pain, chills, and the presence of a fever
indicate an infection involving the upper urinary tract (pyelonephritis).
UTIs are diagnosed by dipstick urinalysis to identify the presence of nitrites (indicating
bacteriuria), WBCs, and leukocyte esterase (an enzyme present in WBCs indicating
pyuria). A voided midstream technique yielding a clean-catch urine sample is preferred.
Trimethoprim-sulfamethoxazole (TMP-SMX) or nitrofurantoin (Macrodantin) is often
used to empirically treat uncomplicated or initial UTIs. Additional drugs may be used to
Health promotion activities include teaching preventive measures such as (1) emptying
the bladder regularly and completely, (2) evacuating the bowel regularly, (3) wiping the
perineal area from front to back after urination and defecation, and (4) drinking an
adequate amount of liquid each day.
Pyelonephritis is an inflammation of the renal parenchyma and collecting system
(including the renal pelvis). The most common cause is bacterial infection which begins
in the lower urinary tract. Recurring infection can result in chronic pyelonephritis.
Clinical manifestations vary from mild fatigue to the sudden onset of chills, fever,
vomiting, malaise, flank pain, and the lower UTI characteristics.
Interventions include teaching about the disease process with emphasis on (1) the need to
continue drugs as prescribed, (2) the need for a follow-up urine culture to ensure proper
management, and (3) identification of risk for recurrence or relapse.
Interstitial cystitis (IC) is a chronic, painful inflammatory disease of the bladder
characterized by symptoms of urgency/frequency and pain in the bladder and/or pelvis. IMMUNOLOGIC DISORDERS OF THE KIDNEY
Immunologic processes involving the urinary tract predominantly affect the renal
Clinical manifestations of glomerulonephritis include varying degrees of hematuria
(ranging from microscopic to gross) and urinary excretion of various formed elements,
including RBCs, WBCs, proteins, and casts.
Acute poststreptococcal glomerulonephritis (APSGN) develops 5 to 21 days after an
infection of the tonsils, pharynx, or skin (e.g., streptococcal sore throat, impetigo) by
nephrotoxic strains of group A -hemolytic streptococci. Manifestations include
generalized body edema, hypertension, oliguria, hematuria with a smoky or rusty
appearance, and proteinuria.
APSGN management focuses on symptomatic relief. This includes rest, edema and
hypertension management, and dietary protein restriction when an increase in
nitrogenous wastes (e.g., elevated BUN value) is present.
One of the most important ways to prevent the development of APSGN is to encourage
early diagnosis and treatment of sore throats and skin lesions.
Goodpasture syndrome is a rare autoimmune disease characterized by the presence of
circulating antibodies against glomerular and alveolar basement membrane.
Rapidly progressive glomerulonephritis (RPGN) is glomerular disease associated with
acute renal failure where there is rapid, progressive loss of renal function over days to
Chronic glomerulonephritis is a syndrome that reflects the end stage of glomerular
inflammatory disease. It is characterized by proteinuria, hematuria, and development of
uremia. Treatment is supportive and symptomatic.
Nephrotic syndrome results when the glomerulus is excessively permeable to plasma
protein, causing proteinuria that leads to low plasma albumin and tissue edema.
o Nephrotic syndrome is associated with systemic illness such as diabetes or systemic
o Treatment is focused on symptom management.
o The major nursing interventions for a patient with nephrotic syndrome are related to
edema. Edema is assessed by weighing the patient daily, accurately recording intake
and output, and measuring abdominal girth or extremity size.
Urinary Stones Factors involved in the development of urinary stones include metabolic, dietary, genetic,
climatic, lifestyle, and occupational influences. Other factors are obstruction with urinary
stasis and urinary tract infection.
The five major categories of stones (lithiasis) are (1) calcium phosphate, (2) calcium
oxalate, (3) uric acid, (4) cystine, and (5) struvite.
Urinary stones cause clinical manifestations when they obstruct urinary flow. Common
sites of complete obstruction are at the UPJ (the point where the ureter crosses the iliac
vessels) and at the ureterovesical junction (UVJ).
Management of a patient with renal lithiasis consists of treating the symptoms of pain,
infection, or obstruction.
Lithotripsy is used to eliminate calculi from the urinary tract. Outcome for lithotripsy is
based on stone size, stone location, and stone composition.
The goals are that the patient with urinary tract calculi will have (1) relief of pain, (2) no
urinary tract obstruction, and (3) an understanding of measures to prevent further
recurrence of stones.
To prevent stone recurrence, the patient should consume an adequate fluid intake to
produce a urine output of approximately 2 L/day. Additional preventive measures focus
on reducing metabolic or secondary risk factors.
A stricture is a narrowing of the lumen of the ureter or urethra. Ureteral strictures can
affect the entire length of the ureter.
A urethral stricture is the result of fibrosis or inflammation of the urethral lume