GENITOUNARY Anatomy and Physiology Urinary system (illustration 1.

) Kidney

a.

structure (illustration ) i. cortex (outer layer): glomeruli, proximal and distal tubules ii. medulla (middle layer): about eight renal pyramids formed by collecting ducts and tubules iii. renal pelvis (innermost layer): composed of calyces where papillae move urine into the ureter by peristalsis

iv.

nephron:

functional unit that filters, concentrates, reabsorbs and

b.

secretes to produce urine (illustration 1 illustration 2 ) v. glomerulus: filters fluid wastes out of the blood (plural: glomeruli) vi. tubules (proximal, Henle's loop, distal): here fluid is made into urine functions i. fluid and electrolyte balance ii. acid-base balance: HPO4 buffer system, NH3 buffer system iii. to regulate arterial blood pressure: renin, aldosterone

iv.
2. Ureters a. b.

to excrete waste products: urea, creatinine production of erythropoietin

convey urine from pelvis of the kidneys to the bladder consists of smooth muscle, moves by peristalsis ) )

3.
4.

Bladder - stores urine (illustration Urethra

B.

Reproductive system - male (illustration

1.
2.

Testes: main male sex glands (illustration ) Each testis is encased in a fibrous capsule which has partitions into the inner gland Seminiferous tubules form spermatozoa (illustration ) Interstitial cells secrete testosterone Accessory glands a. seminal vesicles b. prostate gland c. bulbourethral glands secrete lubrication prior to ejaculation Ducts a. epididymis conducts semen from testes to vas deferens

3. 4.
5.

6.

b. c. d. 7.
8. Scrotum Penis

vas deferens conduct semen from each epididymis to an ejaculatory duct (illustration ) ejaculatory ducts urethra

C.

Reproductive system - female (illustration 1 illustration 2 illustration 3 1. Ovaries a. consist of graafian follicles in which ova develop b. functions of ovaries: ovulation (illustration ) iii. secretion of progesterone and estrogen Fallopian tubes - conduct ova from ovaries to uterus Uterus functions in menstruation and pregnancy Vagina (illustration )

)

i. ii.

oogenesis (illustration

)

2. 3. 4.

5.
6.

Vulva (illustration Breasts

)

II.

Prostate Disorders A. Benign prostatic hyperplasia (BPH) 1. Definition - enlargement of the prostate gland 2. Etiology a. occurs as men age b. associated with circulating androgens c. as prostate enlarges, prostatic tissue forms nodules d. prostate becomes spongy and thick e. prostatic urethra narrows via compression f. impedes passage of urine B. Findings 1. early stages often asymptomatic as enlargement occurs 2. changes in micturition C.

D.

3. nocturia Diagnostics 1. rectal examination 2. urinalysis 3. serum creatinine and BUN studies 4. serum PSA Management 1. if asymptomatic, follow annually 2. use the following medications as indicated: a. beta blockers I. prazosin (Minipress) - to decrease findings of prostatic hyperplasia urinary urgency, hesitancy, nocturia II. doxazosin (Cardura)- management of the findings of BPH b. hormonal manipulation I. finasteride (Proscar) - decrease prostate size with associated decrease in urinary findings II. terazosin (Hytrin) - management of outflow obstruction in clients with BPH; decreases findings c. to relieve symptoms temporarily, use balloon dilation d. surgery if indicated: I. TURP transurethral resection of prostate II. open prostatectomy III. laser surgery IV. insertion of prostatic stent Complications a. acute urinary retention b. involuntary bladder spasms (contractions) c. hydronephrosis d. urinary tract infection (see below) e. gross hematuria Nursing interventions a. assessment I. history of current signs and symptoms II. assess abdomen for distention of the bladder III. measure postvoid residual (if needed) IV. assess for infection, hematuria V. if beta blockers are used check sitting and standing blood pressures weekly while titrating dose b.
c. d. facilitate urinary elimination (illustration provide privacy for patient monitor intake and output, wieghts )

3.

4.

E.

e. maintain catheter patency (if in use) f. medicate as prescribed by health care provider Prostate cancer 1. Definition: malignant neoplasm, usually adenocarcinoma, of prostate gland 2. Etiology a. more prevalent in African American men b. most appear on the peripheral zone of the gland c. most are palpable on rectal examination d. spreads via lymphatics, bloodstream or by local extension e. specific etiology unknown; familial history increases risk 3. Findings usually asymptomatic in early stages obstruction of urinary flow pain represents location of metastases I. lumbosacral II. hips III. lower legs d. rectal discomfort e. weight loss f. anemia g. edema of lower extremities Diagnostics a. digital rectal examination b. needle biopsy c. transrectal ultrasonography d. serologic markers I. PSA II. prostatic acid phosphatase III. descending urography e. metastatic evaluation: I. chest x-ray II. IVP III. CT scan IV. MRI Management a. conservative approach I. usually no treatment for men over 70 due to slow progression II. analgesics and narcotics to manage pain III. short course of radiotherapy (site-specific) IV. IV administration of strontium chloride 89 (beta emitter agent) V. TURP in cases of bladder obstruction VI. placement of suprapubic catheter b. surgical approach I. radical prostatectomy b. c. cryosurgery curative approach I. external beam radiation II. interstitial radiation d. palliative approach I. hormone manipulation I. estrogen therapy diethylstilbestrol (DES) II. luteinizing hormone-releasing hormone (LHRH) II. bilateral orchiectomy (removal of the testes) III. use of anti-androgen drugs I. megestrol acetate (Megace) - antineoplastic decreases the growth of prostate carcinoma, an androgen-sensitive tumor II. flutamide (Eulexin) III. drugs are often used in combination therapy Complications c.

a.

4.

5.

II. III.

laparoscopic dissection of pelvic lymph node

6.

7.

bone metastases complications of hormone manipulation I. nausea and vomiting II. gynecomastia III. sexual dysfunction IV. hot flashes Nursing interventions a. assessment I. history of current symptoms II. examine abdomen for palpable nodes III. flank pain IV. bladder distention b. control pain c. reduce anxiety d. discuss potential changes re: sexual functioning

a. b.

III.

Female Reproductive Disorders A. Cystocele 1. Definition - bladder herniates into vagina 2. Etiology a. associated with obstetrical trauma b. may be due to a congenital defect c. findings may appear after hysterectomy d. may appear as genitalia atrophy with age Findings a. in early stages, asymptomatic b. pelvic pressure c. changes in micturition

3.

Don't be confused by the names: Cystocele is a hernia, but Endometriosis is cysts. Cystocele - hernia (bladder into vagina) Endometriosis - cysts of uterine tissue 4. 5. Diagnostics a. pelvic examination b. urinalysis and culture Management a. in postmenopausal client, estrogen therapy b. insertion of vaginal pessary to support pelvic organs c. surgical Intervention (if indicated) i. to restore bladder function ii. repair of anterior vaginal wall Complications a. infection b. urinary incontinence Nursing interventions a. assessment i. history of obstetrical trauma, abdominal surgery, menopause, and estrogen therapy ii. changes in micturition iii. pain level iv. bulge from vagina while standing upright

6. 7.

2.

v. bulge from perineum when patient bears down (illustration ) b. provide pain management as ordered c. control incontinence d. prevent urinary retention Pelvic inflammatory disease (PID) 4. Definition - infection of the cervix ascending to the fallopian tubes and broad ligaments 5. Etiology

a. b.

6.

c. d. e. f. Findings a. b. c. d.

increased incidence due to reinfection causative agents: i. neisseria gonorrhoeae ii. C. trachomatis iii. mycoplasma hominis history of multiple sexual partners use of IUD's (intrauterine device) history of therapeutic abortion history of caesarean section(s) pelvic pain fever, cervical discharge cervical motion tenderness irregular bleeding nausea, vomiting, acute abdomen dysuria, frequency

7.

8.

chlamydia (see STDs on page 30 of this lesson) Diagnostics a. endocervical culture b. CBC c. laparoscopy to view fallopian tubes Management a. medications (may be used in combination therapy) i. tetracyclines ii. penicillins iii. quinolones iv. cephalosporins b. potential surgical intervention to drain abscess ) Definition - endometrium tissue grows in cysts at various sites throughout the pelvis and/or abdominal wall Etiology a. occurs at any age; most commonly 25 to 45 b. higher incidence in white women than in African American women c. responds to ovarian hormonal stimulation i. progestins decrease it ii. estrogens increase it Findings a. may be asymptomatic b. may be present with pelvic pain c. dyspareunia d. painful defecation e. abnormal uterine bleeding f. persistent infertility g. hematuria, dysuria and flank pain if bladder is involved Diagnostics a. pelvic examination b. rectal examination c. laparoscopy

e. f. g.

3.

Endometriosis (illustration

4.
5.

6.

7.

8.

d. ultrasound, CT scan, barium studies Management a. medical: i. danazol (Cyclomen) - atrophy of ectopic endometrial tissue ii. leuprolide acetate (Lupron) - reduction of pain/lesions in endometriosis iii. progestins - decreases endometriosis iv. oral contraceptives b. surgical: i. laparoscopic surgery

ii.

iii.
iv.

CO2 laser laparoscopy laparotomy presacral neurectomy

4.

v. hysterectomy (illustration ) 9. Complications - infertility 10. Nursing interventions a. assess i. history of current signs and symptoms ii. pain level iii. impact of infertility (especially in child-bearing age group) b. reduce pain c. increase self-esteem Cervical cancer 4. Definition - three types: a. dysplasia
5. carcinoma in situ c. invasive carcinoma Etiology/epidemiology a. 35 to 55 years of age is the most common age group b. higher incidence in African Americans c. higher incidence among low socioeconomic populations d. risk factors include: i. multiple sexual partners ii. history of STD's iii. early sexual activity Findings a. usually asymptomatic in early stages b. postcoital bleeding, irregular vaginal bleeding c. spotting between periods d. spotting after menopause e. evidence of discharge f. pain with radiation to buttocks and legs g. anemia h. weight loss i. fever Diagnostics a. Papanicolaou test b. staging laparotomy c. metastatic evaluation: i. IVP ii. cystoscopy

b.

6.

7.

8.

iii. sigmoidoscopy Management a. radiotherapy i. used in all stages ii. internal - radium via applicator iii. external - via linear accelerator or cobalt b. surgery
hysterectomy (illustration ) 1. if childbearing is no longer wanted 2. if carcinoma in situ or invasive carcinoma, combine with radiotherapy 3. complication: impairment of the bladder not uncommon ii. pelvic exenteration iii. conization chemotherapy i. used as an adjunct with surgery or radiation if indicated ii. specific agents are dependent on diagnosis and often used in combination therapy

i.

c.

9.

Complications include metastasis to: a. lungs b. mediastinum c. bones d. liver, and subsequent spread to rectum and bladder 10. Nursing interventions a. assessment i. history of pap smears, sexual history and past STD's ii. history of current symptoms iii. client's understanding of the disease b. reduce anxiety c. enhance body image

5.

Breast cancer (illustration ) 4. Types of breast cancer a. in situ ductal b. in situ lobular c. invasive ductal d. invasive lobular e. inflammatory f. Paget's Disease of the nipple g. tubular h. medullary i. mucinous j. papillary 5.

k. sarcoma Etiology a. in women, begins in lining of milk duct b.
c. higher risk if family history risk may increase with use of hormones

6.

7.

Findings (illustration ) a. painless firm lump b. painless thickening in breast c. enlargement of axillary nodes or supraclavicular nodes d. nipple discharge e. scaliness or retraction of nipple (seen more in Paget's Disease) f. pain, ulceration, edema, orange-peel skin (usually late findings) Diagnostics a. mammography biopsy or aspiration c. tumor cell tests d. lab tests to determine metastases Management a. surgical approach (will depend on lymph node biopsies and tumor staging): i. lumpectomy ii. partial mastectomy iii. modified radical mastectomy iv. radical mastectomy v. simple mastectomy vi. axillary dissection b. radiation therapy c. chemotherapy: i. cyclophosphamide (Cytoxan) ii. methotrexate (Mexate) iii. doxorubicin HCL (Adriamycin) iv. paclitaxel (Taxol) d. endocrine therapy i. bone marrow transplant

b.

8.

ii.

oophorectomy

2.

iii. adrenalectomy hormone therapy i. use of tamoxifen (Nolvadex) 1. to block the effects of estrogen 2. for post-menopausal women with positive nodes 3. course of treatment a minimum of two years ii. use of other hormones in advanced disease: 1. estrogens (DES) or ethinyl estradiol (Estinyl) to suppress FSH and LH 2. progestins may decrease estrogen receptors 3. androgens may suppress FSH and estrogen production 4. aminoglutethimide blocks estrogen by blocking adrenal steroids 5. corticosteroids suppress secretion estrogen and progesterone from the adrenal glands 9. Complications of breast cancer a. metastases b. bone pain, neurologic changes, weight loss, anemia c. shortness of breath, cough, pleuritic pain, nonspecific chest discomfort 10. Nursing interventions: assess a. health history b. type of education needed c. level of anxiety and fear d. coping ability e. available support systems i. reduce anxiety ii. provide education iii. enhance coping strategies 11. Issues for male patient with breast cancer a. resembles cancer of the breast in women b. greater incidence in men in their 60's c. accounts for 1% of all cases d. prognosis is poor because men delay seeking treatment e. gynecomastia can be a contributing factor Genitourinary Disorders 1. Urinary tract infections (UTI) 4. Infections, by various agents, of parts of the urinary system 5. Etiology a. causative agent enters via urinary meatus b. women are more susceptible c. can be caused by poor voiding habits d. in women, acute infection caused most often by Escherichia coli e. in men, cause is usually obstructive abnormalities 6. Findings a. dysuria, frequency, urgency, nocturia
e. 7. Findings of hematuria Diagnostics a. urine dipstick b. urine microscopy c. urine culture Management a. antimicrobial therapy as indicated: b. in uncomplicated infection: i. co-trimoxazole (Bactrim) ii. ofloxacin (Floxin) iii. nitrofurantoin (Macrodantin) c. in complicated infection: i. oral antimicrobials as ordered ii. IV antimicrobials may be indicated

b. c.

suprapubic pain

8.

9.

Complications a. pyelonephritis

b. sepsis 10. Nursing interventions a. assess: i. history of urinary tract infections (UTIs) ii. voiding habits, personal hygiene, contraceptive methods iii. history of vaginal discharges, itching, irritation, dysuria b. manage pain: i. systemic analgesics and ii. urinary analgesics/antispasmodics
client teaching i. preventive measures 1. in the female client, discuss voiding after intercourse ii. nutritional considerations 1. increase water intake 2. avoid coffee, tea, alcohol, and colas (carbonated and noncarbonated) Sexually transmitted diseases (STDs) and genital lesions 4. Definition of STDs: diseases resulting from sexual intercourse with an infected individual 5. Etiologies

c.

2.

6.

condyloma acuminatum (genital warts) - subtype of human papillomavirus (HPV) Findings (see table on page 30 of this lesson) genital herpes: clustered painful vesicles and ulcers, mild lymphadenopathy; can be reactivated as a result of stress, infection, pregnancy, sunburn b. syphilis i. primary type: non-tender, painless, shallow, indurated clean ulcer, mild regional lymphadenopathy ii. secondary type: maculopapular rash, mucous patches, fever, generalized lymphadenopathy (flu-like illness) iii. chancroid: well circumscribed, painful ulcers with ragged borders, purulent exudate, tender inguinal nodes in 50% of patients iv. lvg: small, transient, non-tender papule ulcer which precedes firm, unilateral inguinal and femoral lymph nodes (buboes) with a characteristic groove in between v. condyloma acuminatum: single or multiple soft, fleshy, vegetating growth(s); may occur on penis Diagnostics (for lab tests, see table on page 30 of this lesson) a. genital herpes:Tzank smear, viral culture b. syphilis: VDRL, rapid plasma reagin (RPR) chancroid: gram, gimesa, or Wright stain d. LGV: microimmunofluorescence testing of aspirate from bubo e. condyloma acuminatum: Papanicolaou test and/or biopsy Management and pharmacology - common agents in the treatment of STDs (choice depends on diagnosis): a. acyclovir sodium (Zovirax) b. penicillin (Megacillin) c. doxycycline hyclate (Vibramycin) d. tetracycline HCL (Achromycin) e. ceftriaxone sodium (Rocephin) f. topical therapies:

a. b. c. d. e. a.

genital herpes - herpes simplex virus (illustration syphilis - treponema pallidum (illustration chancroid - haemophilus ducreyi (illustration ) )

)

lymphogranuloma venereum (LVG) - sub type of C. trachomatis

7.

c.

8.

9.

i. podofilox (Condylox) ii. podophylum resin (Podoben) Nursing interventions a. assess i. history of current lesions ii. history of other sexually transmitted diseases b. reduce fear and anxiety c. discuss coping with altered body image

C.

Renal calculi 1. Definition - presence of stones in the kidneys 2. Etiology a. causes: i. hypercalcemia

ii.
iii.

b.

chronic infections (proteus vulgaris) vii. chronic obstruction with urinary stasis viii. environmental factor: living in a warm, humid climate epidemiology i. more prevalent in men ii. can be anywhere in the urinary system iii. peak age of onset is 20 to 30 years of age iv. spontaneous passage occurs in 80% of patients v. calculi can lodge and cause obstruction. Common sites are: • bladder neck • renal pelvis • ureters vi. often recur in patients with history of two or more stones

iv. v. vi.

hypercalciuria chronic dehydration high purine diet (organ meats, yeast, etc.) cystinuria (genetic disorder)

3.

Findings a. pain - site dependent on location of obstruction b. increased hydrostatic pressure renal colic urethral colic e. findings can mimic cystitis f. with obstruction: when stones (calculi) block urine flow, client will show findings of UTI with fever and chills g. gastrointestinal findings i. nausea and vomiting ii. diarrhea iii. abdominal discomfort Diagnostics a. IVP to determine site and degree of obstruction b. retrograde or antegrade pyelography c. analysis of stone material d. urinalysis d.

c.

4.

5.

e. urine culture and sensitivity Management a. extracorporeal shock wave lithotripsy (ESWL) b. percutaneous nephrolithotomy (PCNL) c. percutaneous stone dissolution (Chemolysis) i. introduce a solvent (depending on the composition of the stone) ii. give broad-spectrum antimicrobials before, during and after the procedure to maintain sterile urine d. ureteroscopy

6.

7.

pyelolithotomy, nephrolithotomy, ureterolithotomy, f. cystolithotomy g. nephrectomy (surgical removal of a kidney) Complications a. obstruction from residual stone material (fragments) b. infection resulting from bacteria or spread of fragments from infected stone c. impaired renal function û may be chronic if stones obstructed tubes long before removal and treatment Nursing interventions a. assess i. history of UTI's, dietary habits, and family history of stones ii. pain and location iii. for findings of UTI iv. for findings of obstruction b. manage pain c. maintain urine flow d. control infection

e.

e.

client teaching

Client Teaching: Diet To Prevent Kidney Stones A. B. Decrease sodium intake Avoid the following: 1. Foods enriched with Vitamin D (Vitamin D increases calcium reabsorption) 2. Dairy: cheeses, milk, sour cream 3. Meat and fowl: brain, heart, liver, kidneys 4. Vegetables: beets, collards, mustard greens, spinach, peas, soybeans, endive, celery 5. Fruits: all berries, currants, figs, Concord grapes 6. Breads: whole grain breads, cereals etc, all breads made with self-rising flower, wheat germ, all grits 7. Drinks: any made from milk or milk products; draft beer; carbonated drinks 8. Other: chocolate, nuts, peanut butter, all foods made from milk or milk products, such as cakes, cookies 9. Acute renal failure A. Definition: kidneys fail to function B. Etiology A. causes; pathophysiology A. prerenal - decreased renal blood flow B. postrenal - stops or slows urine flow anywhere in the urinary tract C. intrarenal - injury to renal tissue due to toxins, intrarenal ischemia, vascular disorders and immunologic processes B. stages A. begins when kidney is injured B. oliguric/anuric phase (less than 500 ml of output in 24hrs) C. diuretic phase: 24-hr. urine exceeds 500 ml and there is no longer a rise in serum BUN and creatinine levels D. recovery phase: A. several months to one year B. more likely to leave scar tissue remnants C. functional loss usually not clinically significant C. Diagnostics A. urinalysis B. serum creatinine and BUN levels rise C. urine chemistry evaluation to distinguish phase and form D. renal ultrasonography D. Management A. preventive

E.

patient education re: use of analgesics, proper hydration, exposure to nephrotoxins B. monitor intake and output C. avoid infection; if present, use only prescribed medications which will be specific to patient needs B. supportive A. improve renal perfusion B. monitor intake and output C. correct and control hyperkalemia D. maintain adequate blood pressure E. maintain nutritional intake F. if indicated, initiate hemodialysis or peritoneal dialysis Complications: A. infection B. arrhythmias secondary to hyperkalemia

A.

GI bleeding due to stress ulcer E. multiple organ and system failure F. Nursing interventions A. assess: A. history of cardiac disease, malignancy, sepsis or recent infection B. exposure to nephrotoxic drugs: A. NSAIDs B. antibiotics C. chemical solvents D. contrast media C. urine volume B. achieve fluid and electrolyte balance C. prevent infection D. monitor serum electrolytes E. prevent GI bleeding F. maintain neurologic function G. maintain adequate nutrition: A. regulate protein intake B. offer high-carbohydrate feedings C. weigh daily D. restrict (as needed) foods high in sodium, potassium and phosphorus E. give total parenteral nutrition (TPN) if indicated and ordered 10. Chronic renal failure A. Definition - a progressive, irreversible deterioration in renal function: body cannot balance metabolism and fluid/electrolytes; result: uremia. B. Etiologies A. hypertension, severe and prolonged B. diabetes mellitus interstitial nephritis polycystic disease (hereditary) F. obstructive uropathy G. congenital disorder Findings of chronic renal failure (by system): E.

C. D.

electrolyte imbalances

C. D.

glomerulopathy

C.

4.

Diagnostics a. arterial blood gases

2. 3.

decreased serum levels of bicarbonate, calcium, proteins (albumin) Management a. control diabetes b. treat hypertension c. maintain renal function for as long as possible d. regulate diet: i. maintain low protein intake ii. prevent malnutrition iii. restrict dietary potassium iv. restrict dietary phosphorus by reducing intake of chicken, milk, legumes, carbonated drinks e. treat anemia with epoetin (Erythropoietin) f. treat acidosis with oral sodium bicarbonate g. dialysis when necessary 6. Complication: death 7. Nursing interventions a. assess i. history of chronic disorders ii. degree of renal impairment iii. effect on other body systems iv. how client is responding to illness v. support systems b. maintain fluid and electrolyte balance c. maintain adequate nutrition d. maintain skin integrity e. prevent constipation f. maintain safe level of activity g. determine how much client understands and how well client will comply with treatment After a urinary catheter is removed, the client may have some burning on urination, frequency and dribbling. These symptoms should subside. After a TUR (transurethral resection), tell the client that, because the three-way foley catheter has a large diameter, he will continuously feel the urge to void. 5.

b. c. d.

elevated serum BUN, creatinine, phosphorus CBC to detect anemia

4. 5. 6. 7.

After prostatic surgery, it is normal for the client's urine to be blood tinged and for him to pass blood clots and tissue debris. Because the prostate gland receives a rich blood supply, it is important to observe the client undergoing a prostatectomy for bleeding and shock. Breast cancer starts with the alteration of a single cell and takes a minimum of two years to become palpable. At the time of diagnosis, about one-half of clients with breast cancer have regional or distant metastasis.

Bacteriuria Cryptorchidism Dysmenorrhea Enuresis Epididymitis Incontinence Lymphedema Nephrotic Syndrome Pessary Polyuria Prostatitis Rectocele Strangury Stress Incontinence Toxic shock syndrome Urge Incontinence Urgency Vasectomy Genitourinary

• • • • • •

Breast cancer Breast self examination Catheterization of urinary bladder Chancre Ectopic pregnancy Endometriosis Female genital organs Formation of urine Genital herpes Human ovum Hysterectomy Kidney Male genital organs Nephron and blood vessels Oogenesis Perinium Spermatozoon Syphillis Testis Urinary bladder Urinary system Vagina Vas deferens Vulva

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