CONDITIONS RESULTING IN ALTERED URINARY ELIMINATION
Story, L (2024). Pathophysiology: A Practical Approach Madeleine El Hajj, MSN, RN
(5th. edition) Jones and Bartlett learning, Ch 7 NUR 310, Fall 2024
Lebanese American University
LEARNING OUTCOMES
By the end of this course, the learner will be able to:
- Describe and compare renal alterations that alter urinary
elimination.
ANATOMY AND PHYSIOLOGY REVIEW
ANATOMY AND PHYSIOLOGY REVIEW (CONT’D)
ANATOMY AND PHYSIOLOGY REVIEW (CONT’D)
ANATOMY AND PHYSIOLOGY REVIEW (CONT’D)
ANATOMY AND PHYSIOLOGY REVIEW (CONT’D)
ANATOMY AND PHYSIOLOGY REVIEW (CONT’D)
Effects of antidiuretic
hormone on the
kidneys.
ANATOMY AND PHYSIOLOGY REVIEW (CONT’D)
Effects of
antidiuretic
aldosterone on the
kidneys.
ANATOMY AND PHYSIOLOGY REVIEW (CONT’D)
ANATOMY AND PHYSIOLOGY REVIEW (CONT’D)
CONDITIONS RESULTING IN
ALTERED URINARY ELIMINATION
URINARY ELIMINATION
Urination requires:
1- a functioning bladder with stretch receptors
that can sense the filling of the bladder
2- an intact parasympathetic pelvic nerve to
transmit the signal,
3- working detrusor muscles to initiate bladder
contractions to expel the urine
Urination is voluntary to a certain extent
URINARY INCONTINENCE
In children up to 3 years of age, urination is completely
reflexive
Urinary incontinence: when older children and adults lose
control over urination,
Urinary incontinence is not just a medical issue; it can affect
emotional, psychological, and social health.
Complications: Skin problems, recurrent UTIs, psychological
problems, changes in the individual’s usual activities (e.g.,
work and exercise).
URINARY INCONTINENCE (CONT’D)
Enuresis: involuntary urination by a child after 4 to 5 years of
age
Nocturnal enuresis, can be genetic
Primary enuresis: never achieved bladder control at night but
no incontinence during the day)
Secondary enuresis (not bedwetting for more than 6 months and
then start wetting)
Secondary is usually related to a stressful event (birth of a
sibling, divorce, …)
Causes: psychological, structural (e.g., smaller than normal
bladder), nighttime polyuria, sleep disorder, constipation
URINARY INCONTINENCE (CONT’D)
Stress incontinence
• Loss of urine from pressure exerted on the
bladder by coughing, sneezing, laughing,
exercising, or lifting something heavy
• Occurs when the sphincter muscle of the
bladder is weakened
• Contributing factors: pregnancy, childbirth,
menopause, prostate removal, obesity, and
chronic coughing
URINARY INCONTINENCE (CONT’D)
Overactive bladder: (previously urge incontinence)
• Sudden, intense urge to urinate, followed by an
involuntary loss of urines
• Needs felt often, including throughout the night
• Causes: menopause, prostatic issues, UTI, smoking,
Parkinson’s disease, Alzheimer’s disease, stroke,
nervous system damage
URINARY INCONTINENCE (CONT’D)
Reflex incontinence
• Urinary incontinence caused by trauma or damage to
the nervous system (e.g., that caused by spinal cord
injury above the second to fourth sacral vertebrae,
multiple sclerosis, and diabetes melitus).
• Detrusor hyperreflexia - increased detrusor muscle
contractility that occurs even though there is no
sensation to void
• With reflex incontinence, urgency is generally
absent.
URINARY INCONTINENCE (CONT’D)
Overflow incontinence
• Inability to empty the bladder, or retention
• Other indications include dribbling urine and a
weak urine stream
• Causes: bladder damage, urethral blockage, nerve
damage, and prostate conditions
• Chronic overdistension occurs because of a
perceived inability to interrupt work to void that
results in detrusor muscle areflexia and overflow
incontinence (nurse’s bladder or teacher’s bladder)
NEUROGENIC BLADDER
Bladder dysfunction caused by an interruption
of normal bladder nerve innervation, causing
the bladder to be spastic or flaccid
Flaccid: urine volume is large, bladder pressure
is low, contractions are absent
Spastic: urines volume normal or low,
involuntary contractions occur
Some patients experience both conditions
NEUROGENIC BLADDER (CONT’D)
Causes:
Brain or spinal cord injury / tumors / infection
•Dementia •Parkinson’s disease • Spina bifida •DM
•Stroke •Medications •Vaginal childbirth •Multiple
sclerosis •Alcoholism •SLE •Herpes zoster
Clinical manifestations:
include symptoms of an overactive bladder (e.g.,
frequency and urgency) and an underactive bladder
(e.g., hesitancy and retention).
Complications: UTI, renal calculi, incontinence,
hydronephrosis, autonomic dysreflexia
INTERSTITIAL CYSTITIS /BLADDER PAIN SYNDROME
Chronic noninfectious inflammation
Non-ulcerative / Ulcerative
Complications: bladder hardens, its capacity is
low, and pain worsens
Risk factors: being female, age, autoimmune
diseases, family history, smoking, bladder tissue
defect
Manifestations: pain in the suprapubic area,
pelvic, and abdominal area, urinary frequency,
urgency, nocturia, sexual dysfunction, pain is worse
during ovulation and menstruation, sexual
dysfunction. May affect sleep and work
URINARY TRACT INFECTIONS (UTI)
Any infection that begins in the UT (extremely
common)
The UT is typically sterile despite frequent
contamination that is washed out
Urine is an excellent medium for bacterial
proliferation due to protein content
Urinary system mechanisms to prevent infection:
one-way valves between the ureters and the bladder;
urination; prostate secretions; and the immune system.
Bacteria form a biofilm that adheres to and invades
nearby structures
URINARY TRACT INFECTIONS (UTI) (CONT’D)
Cross contamination from perineal area>invasion of the
urethra from meatus>ascend to the bladder (cystitis) >move
long to kidneys (pyelonephritis)
Occasionally bacteria may invade kidneys from the blood
In pyelonephritis: edema, abscesses & necrosis can develop
Severe untreated UTI leads to sepsis
E. Coli 75-95%
UTI (CONT’D)
Risk factors: female, benign prostatic hypertrophy, congenital
urinary tract abnormalities, immobility, urinary or bowel
incontinence, renal calculi, reflux, decreased cognition,
pregnancy, impaired immune response, urinary catheterization,
and improper personal hygiene
Clinical manifestations: urgency, dysuria, frequency, urethral
discharge, nocturia, hematuria, cloudy, foul-smelling urines,
fever, fatigue, pain in suprapubic, lower back or flank, confusion
(older adults), increased blood pressure (with pyelonephritis)
URINARY TRACT
OBSTRUCTIONS
UT OBSTRUCTIONS-UROLITHIASIS
Presence of renal calculi, vary in size at any point in the
urinary tract
Hard crystals composed of minerals that the kidneys normally
excrete
Calculi can form in the renal pelvis (nephrolithiasis), ureters,
and bladder
The most frequent type of calculi contains calcium in
combination with either oxalate or phosphate
Other types: uric acid, magnesium ammonium phosphate
(struvite), & cystine stones
UT OBSTRUCTIONS-UROLITHIASIS (CONT’D)
Risk factors: pH changes, excessive concentration of insoluble
salts in the urine, urinary stasis, family history, obesity,
hypertension, and diet (high-protein, high-sodium, or low-
calcium diet).
Complications: hydronephrosis. The movement of calculi is
painful, causes irritation. In addition to urine stagnation this
increases the risk for a UTI
Clinical manifestations of nephrolithiasis:
Colicky pain in the flank area that radiates to the lower abdomen
and groin, Bloody, cloudy, or foul-smelling urine, Dysuria,
Frequency, Genital discharge, Nausea and vomiting, Fever and
chills
UT OBSTRUCTIVE- HYDRONEPHROSIS
Abnormal dilation of the renal pelvis and calyces
of one or both kidneys secondary to obstruction
Partial obstruction: mild, may be asymptomatic
Complete obstruction: severe, compression of
tissues & blood vessels > atrophy & necrosis >
glomerular filtration cessation
Manifestations: Colicky flank pain or pressure,
Bloody, cloudy, or foul-smelling urine, Dysuria,
Decreased urine output, Frequency, Urgency,
Nausea and vomiting, Abdominal distension,
Palpable mass, UTIs
TUMORS - RENAL CELL CARCINOMA
Most frequently occurring kidney cancer in adults (50–70
years of age).
Risk factors: being male, obesity, dialysis treatment,
family history, hypertension, other kidney disease,
certain chemicals, smoking.
Complications: Metastasis to the liver, lungs, bone, or
nervous system is common at the time of diagnosis.
Thrombus formation.
Asymptomatic in its early stages.
Clinical manifestations: flank pain, Palpable mass,
fever, hematuria, Abnormal urine color, Urinary
retention, Unexplained weight loss, Anemia,
Polycythemia, Hypertension, Paraneoplastic syndromes
such as hypercalcemia or Cushing’s syndrome
TUMORS-BLADDER CANCER
Types: transitional cell carcinoma (begins in cells that normally
make up inner bladder lining), squamous cell carcinoma (thin flat
cells), and adenocarcinoma (cancer beginning in the cells that
make and release mucus), small-cell carcinoma (cancer
beginning as nerve-like called neuroendocrine cells), and
sarcoma (in the muscle cells of the bladder)
The cells that form squamous cell carcinoma and adenocarcinoma
develop in the inner lining of the bladder because of chronic
irritation and inflammation
Metastasis to the pelvic lymph nodes, liver, and bones is common
Recurrence 40% of cases
TUMORS-BLADDER CANCER (CONT’D)
Risk factors: smoking, working with chemicals
(hairdresser, …), excessive use of analgesics,
recurrent UTI, recurrent irritation (long-term
catheter, calculi), chemotherapy, radiation
Clinical manifestations: • Painless hematuria
(gross or microscopic) • Abnormal urine color
(dark, rusty, or brown) • Frequency • Dysuria • Urge
incontinence • UTIs • Back or abdominal pain
BENIGN PROSTATIC HYPERPLASIA/ HYPERTROPHY (BPH)
A common, nonmalignant enlargement of the prostate
gland. Usually by the age of 50
BPH does not increase prostate cancer risk
The exact cause is unknown
• Declining testosterone and increasing estrogen
levels enlarge prostatic cell proliferation, enlarging
the prostate
• Or stem cells in the prostate do not mature and die
as programmed, enlarging the prostate
As the prostate expands, it presses against the urethra
and obstructs urine flow
BPH (CONT’D)
Risk factors: age, family history, obesity, cardiovascular
disease, type 2 DM, physical inactivity, erectile
dysfunction
Complications: UTI, bladder calculi, bladder damage,
hydronephrosis, renal impairment
Clinical manifestations:
Frequency, Urgency, Urinary retention, Difficulty initiating
urination, Weak urinary stream, Dribbling urine, Nocturia,
Bladder distension, Overflow incontinence, Erectile
dysfunction
