INFECTIONS OF THE URINARY TRACT

INTRODUCTION

Urinary tract infections (UTIs) are the infections caused by pathogenic microorganisms in the urinary tract with or without signs and symptoms lower urinary symptoms may predominate at the bladder or urethra

DEFINITION

infections involving the upper urinary truct

acute or chronic pyelonephritis (inflammation of the renal pelvis)

interstitial nephritis (inflammation of the kidney)

renal abscesses

CLASSIFICATION

bacterial cystitis (inflammation of the urinary bladder)

bacterial prostatitis (inflammation of the prostate gland),

bacterial urethritis (inflammation of the urethra).

infections lower urinary tract

uncomplicated community acquired complicated, occurs in people with urologic abnormalities occurs due to recent catheterisation nosocomial

Other classifications are

pyelonephritis -inflammation of renal parenchyma

cystitis - inflammation of bladder wall urethritis - inflammation of urethra urosepsis -UTI spread into systemic

circulation

ANOTHER CLASSIFICATION

The incidence rises to 50% in women over the age of 80 .A UTI is one of the most common reasons patients seek healthcare. Most cases occur in women, with one of every five women

INCIDENCE

Epidemiologically, UTIs are subdivided into catheter associated(or nosocomial) infections and non-catheter-associate(orcommunity acquired)infection symptomatic or asymptomatic

EPIDEMIOLOGY

Many different microorganisms can infect the urinary tract,but the most common agents are the gram-negative bacilli. Escherichiacoli causes 80% of acute infections in patients without catheters,urologic abnormalities, or calculi. Other gram-negative rods, especially Proteus and Klebsiella and occasionally Enterobacter,staphylococcus aureus,shigella ,proteus etc

ETIOLOGY

the physical barrier of the urethra, urine flow, ureterovesical junction competence, various antibacterial enzymes antibodies, anti adherent effects mediated by the

mucosal cells

mechanisms maintain the sterility of the bladder

For infection to occur, bacteria must gain access to the bladder, attach to it and colonize the epithelium of the urinary tract to avoid being washed out with voiding, evade host defence mechanisms, and initiate inflammation. Most UTIs result from focal organisms that ascend from the perineum to the urethra and the bladder and then adhere to the mucosal surfaces

Pathophysiology

increasing the normal slow shedding of bladder epithelial cells Glycosaminoglycan (GAG) The normal bacterial flora of the vagina and

urethra Urinary immunoglobulin (IgA)

BACTERIAL INVASION OF THE URINARY TRACT

Urethrovesicalreflux- which is the reflux (backward flow) of urine from the urethra into the bladder With coughing, sneezing, or straining, the bladder pressure rises, which may force urine from the bladder into the urethra. When the pressure returns to normal, the urine flows back into the bladder,

REFLUX

Bacteriuria is generally defined as more than 105 colonies of bacteria per millilitre of urine. Because urine samples (especially in women) are commonly contaminated by the bacteria normally present in the urethral area, a bacterial count exceeding105 colonies/mL of clean-catch midstream urine is the measure that distinguishes true bacteriuria from contamination. In men, contamination of the collected urine sample occurs less frequently; hence, bacteriuria can be defined as 104 colonies/mL urine

UROPATHOGENIC BACTERIA

Infection can ascend up the urethra (ascending infection),

through the blood stream, (haematogenous spread), By means of a fistula colonize the periurethral area and subsequently enter

the bladder by means of the urethra. In women, the short urethra offers little resistance to the movement of uro pathogenic bacteria. Sexual intercourse . (haematogenous spread) from a distant site of infection . through direct extension by way of a fistula from the

intestinal

ROUTES OF INFECTION

no symptoms. pain at the urethra burning on urination, frequency, urgency nocturia,incontinence suprapubic or pelvic pain. Hematuria and back pain may also be present. In older individuals, these typical symptoms are seldom

noticed Signs and symptoms of upper UTI (pyelonephritis) include

fever, chills, flank or low back pain, nausea and vomiting, headache, malaise, and painful urination.

Clinical Manifestations

1. Physical examination 2. pain and tenderness in the area of the

costovertebral angles

3. urine dipstick may react positively for blood ,white blood cells nitrates

4. indicating infection5. urine microscopy shows red blood cells and many

white blood cells per field 6. without epithelial cells 7. urine culture is used to detect presence of bacteria

and for antimicrobial 8. sensitivity testing9. USG and CT studies

Diagnostic finding

. A colony count of at least 105 colony-forming units (CFU) per millilitre of urine on clean-catch midstream or catheterized specimen is a major criterion for infection

About one third of women with symptoms of acute infections have negative midstream

COLONY COUNTS

Microscopic Hematuria (greater than 4 red blood cells [RBCs] per high- powerfield

Pyuria (greater than 4 white blood cells [WBCs] per high-power field)

CELLULAR STUDIES

gold standard in documenting a UTI

URINE CULTURES

pharmacologic therapy patient education.

Medical Management

cephalosporin ampicillin aminoglycoside trimethoprim sulfamethoxazole other choices are bacterim ,septrin, ampicillin or amoxicillin fluoroquinolone or ciprofloxacin Levofloxacin Ciprofloxacin and norfloxacin

Commonly used antibiotics

Pyridium Sodabicarb power-to make urine alkaline

urinary analgesic

In females with recurrent uti is treated with long term antibiotic prophylaxis Usually continued for 6months or more

LONG-TERM PHARMACOLOGIC THERAPY

Assessment History Symptoms Habits Hygiene Urine assessment

NURSING PROCESS

1. Acute pain related to inflammation and infection of the urethra, bladder, and other urinary tract structures as evidenced by positive urine culture results

2. Deficient knowledge related to factors predisposing the patientto infection and recurrence, detection and prevention of recurrence, and pharmacologic therapy

NURSING DIAGNOSES

relieving pain monitoring and managing potential

complications measures to prevent catheter associated

infection promoting home and community-based care teaching patients self-care

Nursing Interventions

INTRODUCTION

CANCER OF THE BLADDER

Anatomy and physiology

Transitional cell (urothelial) carcinoma Urothelial cells also line other parts of the

urinary tract, such as the lining of the kidney (called the renal pelvis), the ureters, and the urethra, so transitional cell cancers can also occur in these places. In fact, patients with bladder cancer sometimes have other tumors in the lining of the kidneys, ureters, or urethra. If someone has a cancer in one part of their urinary system, the entire urinary tract needs to be checked for tumors

TYPES OF BLADDER CANCER

Non-invasive bladder cancers are still in the inner layer of cells (the transitional

epithelium) but have not grown into the deeper layers.

 Invasive cancers grow into the lamina

propria or even deeper into the muscle layer.

Invasive cancers are more likely to spread and are harder to treat.

Discription of bladder cancer

Papillary carcinomas They grow in slender, finger-like

projections from the inner surface of the bladder toward the hollow center. Papillary tumors often grow toward the center of the bladder without growing into the deeper bladder layers. These tumors are called non invasive papillary cancers. Very low-grade, non-invasive papillary cancer is sometimes called papillary neoplasm of low-malignant potential and tends to have a very good outcome.

Transitional cell carcinomas

Flat carcinomas They do not grow toward the hollow part of

the bladder at all. If a flat tumor is only in the inner layer of bladder cells, it is known as a non-invasive flat carcinoma or a flat carcinoma in situ (CIS).If either a papillary or flat tumor grows into deeper layers of the bladder, it is called an invasive transitional cell (or urothelial) carcinoma.

Cigerette smoking Exposure with chemical dyes Exposure with cytoxan Radiation therapy Chronic irritation of the bladder Excessive use of phenacetin

ETIOLOGY

The tumour usually starts in the epithelium of the inner bladder the tumour gradualy invades the muscular layer followed by serous layer at his stage their can be local lymph node involvement the next stage is extensive local spread tumour can spread to peritoneum prostate ,or uterus in females ,patient will present with haemorrhagic symptoms and tumour related pressure effect . the next stage is distant metastasis in which tumour spreads to bones lungs ,brain etc

Pathophysiology

Painless Hematuria ,either gross or microscopic

Dysuria Frequency Urgency Pelvic flank pain Leg oedema

Clinical Manifestations

1. cystoscopy 2. bladder washed cytology3. urine for flow cytometry4. IVP5. MRI scan6. Chest x ray7. excretory urography, 8. CT scan,9. ultrasonography,10. bimanual examination 11. Biopsies of the tumour and adjacent mucus

Assessment and Diagnostic Findings

Urine tests for tumor markers: UroVysion: BTA tests: Immunocyt: NMP22 BladderChek:

Newer diagnostic methods

American Joint Committee on Cancer Also called the TNM system.

TNM staging system for bladder cancer

T category( tumour ) letter T is followed by numbers and/or

letters to describe how far the main (primary)

tumor has grown through the bladder wall and whether it has grown into nearby tissues.

Higher T numbers mean more extensive growth.

 

N category( node ) The letter N is followed by a number from 0

to 3 to indicate any cancer spread to lymph nodes near the bladder. Lymph nodes are

bean-sized collections of immune system cells,

to which cancers often spread first.

M category (metastasis) The letter M is followed by 0 or 1 to

indicate whether or not the cancer has spread

(metastasized) to distant sites, such as other organs or lymph nodes that are not near the

bladder.

Has minimal role, concentrates on symptom management and supportive in nature Treatment of bladder cancer depends on the grade of the tumour

Medical Management

T categories for bladder cancer The T category describes the main tumor. of TX: Main tumor cannot be assessed due to

lack of information T0: No evidence of a primary tumor Ta: Non-invasive papillary carcinoma Tis: Non-invasive flat carcinoma (flat

carcinoma in situ, or CIS)

T1: The tumor has grown from the layer of cells lining the bladder into the connective tissue

below. It has not grown into the muscle layer of the bladder.

T2: The tumor has grown into the muscle layer.

T2a: The tumor has grown only into the inner half of the muscle layer.

T2b: The tumor has grown into the outer half of the muscle layer

T3: The tumor has grown through the muscle layer of the bladder and into the fatty tissue

layer that surrounds it. T3a: The spread to fatty tissue can only be

seen by using a microscope. T3b: The spread to fatty tissue is large

enough to be seen on imaging tests or to be seen

or felt by the surgeon.

T4: The tumor has spread beyond the fatty tissue and into nearby organs or structures. It may

be growing into any of the following: the stroma (main tissue) of the prostate, the seminal

vesicles, uterus, vagina, pelvic wall, or abdominal wall.

T4a: The tumor has spread to the stroma of the prostate (in men), or to the uterus and/or

vagina (in women). T4b: The tumor has spread to the pelvic wall or

the abdominal wall

NX: Regional lymph nodes cannot be assessed due to lack of information.

N0: There is no regional lymph node spread. N1: The cancer has spread to a single lymph

node in the true pelvis. N2: The cancer has spread to 2 or more

lymph nodes in the true pelvis. N3: The cancer has spread to lymph nodes

along the common iliac artery.  

M0: There are no signs of distant spread. M1: The cancer has spread to distant parts

of the body  

cystoscopy bladder washed cytology urine for flow cytometry IVP MRI scan Chest x ray excretory urography, CT scan, ultrasonography,

◦ bimanual examination ◦ Biopsies of the tumour and adjacent mucus

Assessment and Diagnostic Findings

Transurethral resection with fulguration (electrocautery)

Laser photocoagulation Open loop resection Segmental cystectomy Partial cystectomy Radical cystectomy

SURGICAL MANAGEMENT

methotrexate, 5 fluorouracil,vinblastine, doxorubicin (Adriamycin), and cisplatin

gemcitabine and the taxanes Topical chemotherapy-thiotepa, doxorubicin

mitomycin, ethoglucid, and BCG) to the tumor to promote tumor destruction.

PHARMACOLOGIC THERAPY

Radiation of the tumour may be performed preoperatively to reduce micro extension of the neoplasm and viability of tumour cells thus reducing the chances that the cancer may recur in the immediate area or spread through the circulatory or lymphatic systems

RADIATION THERAPY

External beam radiation Intensity modulated radiotherapy Brachytherapy

Types

The use of photodynamic techniques in treating superficial bladder cancer is under investigation. This procedure involves systemic injection of a photosensitizing material (hematoporphyrin), which the cancer cell picks up. A laser-generated light then changes the hematoporphyrin in the cancer cell into a toxic medication. This process is being investigated for patients in whom Intravesicalchemotherapy or immunotherapy has failed

INVESTIGATIONAL THERAPY

Ileal Conduit (Ileal Loop) The Ileal conduit, the oldest of the urinary diversion

procedures ,is considered the gold standard because of the low number of complications and surgeons’ familiarity with the procedure. In an Ileal conduit, the urine is diverted by implanting the ureter into a 12-cm loop of ileum that is led out through the abdominal wall

Utreostomy Directing ureters into skin Nephrostomy Urine to drainage bag directly through a catheter 

URINARY DIVERSIONS

Continent Ileal Urinary Reservoir (Indiana Pouch) The most common continent urinary diversion is the Indiana

pouch, created for patients whose bladder is removed or can no longer function (neurogenic bladder). The Indiana pouch uses a segment of the ileum and cecum to form the reservoir for urine The ureters are tunnelled through the muscular bands of the intestinal pouch and anastomosed. The reservoir is made continent by narrowing the dfferent portion of the ileum and sewing the terminal ileum to the subcutaneous tissue, forming a continent stoma flush with the skin. The pouch is sewn to the anterior abdominal wall around a cecostomy tube. Urine can collect in the pouch until a catheter is inserted and the urine is drained.

CONTINENT URINARY DIVERSIONS

Ureterosigmoidostomy, another form of continent urinary diversion,

is an implantation of the ureters into the sigmoid colon It is usually performed in patients who have had extensive pelvic irradiation, previous small bowel resection, or coexisting small bowel disease.

 

Ureterosigmoidostomy

Anxiety related to anticipated losses associated with the surgical procedure

Imbalanced nutrition, less than body requirements related to inadequate nutritional intake

Deficient knowledge about the surgical procedure and postoperative care

Preoperative Nursing Diagnoses

RELIEVING ANXIETY ENSURING ADEQUATE NUTRITION EXPLAINING SURGERY AND ITS EFFECTS

Interventions

MAINTAINING PERISTOMAL SKIN INTEGRITY RELIEVING PAIN IMPROVING BODY IMAGE EXPLORING SEXUALITY ISSUES MONITORING AND MANAGING POTENTIAL

COMPLICATIONS

Postoperative Nursing Interventions

Peritonitis Stomal Ischemia and Necrosis Stomal Retraction and Separation

Complications

Continuing Care

Teaching Patients Self-Care

Evidence based practice

Conclusion 

BIBLIOGRAPHY

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