GUT Disorder

Disorder of the
Genitourinary
System
By Mekasha G. (BSc,
MSc, MPH)
By Mekasha G.(MSc, MPH) 1

Learning objectives
• At the end of the course the students will be able
to: -
1. Revise the anatomy and physiology of GUT
2. Review the approach in pts. with GUT
disorders
3. Describe and identify the common GUT
disorders.
4. Develop a nursing care for a patient with a
GUT problems
Introduction
The term "genitourinary" actually refers to two
different systems.
 Urinary system -responsible for removal of
 Nitrogenous waste products of metabolism from
the bloodstream,
 Disposal of concentrated wastes (urine).
 Genito - the genital organs and the reproductive
system, which is responsible for production of
succeeding generations for perpetuation of the
species.
Anatomy and physiology review of
GUT
The renal and
urinary systems
include:
kidneys
Ureters
Bladder
Urethra

Kidneys
 Are a pair of bean-shaped, brownish-red
structures located retroperitoneally(behind
and outside the peritoneal cavity).
 The average adult kidney weighs
approximately 113 to 170 g and is 10 to 12
cm long.
 Each kidney has about 1 million nephrons.
 The kidneys receive 20% to 25% of the total
cardiac output.

Functions of the Kidney
Urine formation
Excretion of waste products
Regulation of electrolytes
Regulation of acid–base balance
Control of water balance
Control of blood pressure
Renal clearance
Regulation of red blood cell production
Synthesis of vitamin D to active form
Secretion of prostaglandins
Regulates calcium and
By Mekasha G.(MSc,phosphorus
MPH) balance6
Ureters
 Are long fibromuscular tubes that connect
each kidney to the bladder.
 Each tube is about 24 to 30 cm long.
 For passage of urine from each renal pelvis
into the bladder.
Urinary bladder
 Is a muscular, hollow sac located just behind
the pubic bone.
 It is the reservoir for urine.
 The capacity of the adult bladder is 400 to
500ml.
Urethra
Arises from the base of the bladder
In male
 It passes through the penis and
transports semen and urine from
the body.
In women
It opens just anterior to the
vagina and is used to carry urine
from the body.
APPROACH TO THE PHYSICAL
DIAGNOSIS OF THE
GENITOURINARY SYSTEM
(GUS)

Common symptoms
1. Urinary Tract
Renal pain:
 This is pain arising from the kidneys
 Is usually felt at or below the costal margin posteriorly
 May radiate Anteriorly towards the umbilicus
Ureteric pain:
 Results from sudden distention of the ureter and possibly
the renal pelvis.
 It is severe colicky pain that originates in the
costovertebral angle.
 It may radiate into the lower quadrant of the abdomen and
possibly to the upper thigh and testicle or labium
Renal vs. uretral pain
Kidney pain occurs in acute pyelonephritis.
 Ureteral colic is caused by sudden obstruction of a
ureter, as by urinary stones or blood clots.

Hematuria:
Is the presence of red blood cells in the urine.
Oliguria:
Denotes the passage of less than 400 ml of urine per
day.
Anuria:
Is the complete absence of urine output(50ml/day).
Polyuria:
Implies a high urine output.
Usually urine output of more than 3L per day.

Urinary frequency:
Is an abnormally frequent voiding.
Occurred in bladder irritation or inflammation.
Dysuria:
Is a specific form of discomfort arising from the
urinary tract in which there is pain immediately
before, during, or immediately after micturition.
Urgency:
Is the loss of the normal ability to postpone
micturation beyond the time when the desire to pass
urine is initially perceived.
Incontinence:
Refers to an involuntary loss of urine.
Hesitancy:
Is difficulty initiating the process of micturation.
Terminal dribbling
Is difficulty of completing micturation in a clean

stop fashion.

THE MALE GENITAL TRACT
URETHRAL DISCHARGE:
The color, amount, and duration of the discharge have
to be ascertained.
Commonest causes are sexually transmitted
infections.
Genital ulcer:
single or multiple, painful or painless.
OTHER COMPLAINTS
 History of sores, growths on the penis.
 History of swelling or pain in the scrotum.
THE FEMALE GENITAL TRACT
VAGINAL DISCHARGE
 Can be associated with itching.
The color, odor, and amount should be
characterized.
Menstrual History:
This part of history should be included to know
mainly the extent of bleeding, regularity, age at
menarche, Last menstrual period, length of time
between periods, How heavy is the flow, and
Bleeding between periods.
Dyspareunia: Pain during sexual intercourse.
Physical
Examination
THE KIDNEYS
Palpation of the Left Kidney.
Place your left hand behind the patient just below
and parallel to the 12th rib.
 Place your right hand gently in the right upper
quadrant
 Ask the patient to take a deep breath.
At the peak of inspiration, press your right hand
firmly and deeply , just below the costal margin, and
try to “capture” the kidney between your two hands.
If it is palpable, describe its size, shape, and any
tenderness. By Mekasha G.(MSc, MPH) 20
Palpating the right kidney

Percussion
 Assessing Kidney Tenderness.
 The costovertebral angle—the angle formed by the
lower border of the 12th rib and the transverse
processes of the upper lumbar vertebrae—defines
the region to assess for kidney tenderness.
 Place the ball of one hand in the costovertebral
angle and strike it with the ulnar surface of your fist.
 Direct percussion with the fist over the CVA is also
acceptable.
 Pain with pressure or fist percussion suggest
pyelonephritis, but may also have a musculoskeletal
cause. By Mekasha G.(MSc, MPH) 22
costovertebral angle

BLADDER
Palpate for enlarged bladder.
Palpate for tenderness, and distention.
GENITAL EXAMINATION
MALE
THE PENIS
Check the external meatus of the urethra for any
discharge.
Inspect for abnormal meatal opening.
Palpate the ventral and dorsal aspect of the shaft for
tenderness or lesions.
Diagnostic Procedures
Nursing responsibilities

Common procedures
 Urinalysis and urine culture
 Renal function tests
 X-ray and other imaging modalities
 Endo urological procedures
 Biopsy
 Uro-dynamic Tests
Diagnostic tests
Laboratory Tests
 Urine Tests
Urinalysis- give information
regarding kidney function and helps
to diagnose other diseases.
Urine culture- determines whether
bacteria are present in the urine, as
well as their strains and
concentration.
 Also used to identify the antimicrobial therapy
that is best suited Byfor the particular strains. 27
Mekasha G.(MSc, MPH)
Urinalysis and urine culture
 Clean catch/mid stream urine
 24 hrs urine collection

Renal Function Tests:
 Renal concentration tests
 Specific gravity
 Purpose:
 Evaluate ability of kidneys to
concentrate solutes in urine.
 NV: 1.010-1.025

 Urinary osmolality
 Concentrating ability is lost
early in kidney diseases,
hence these test findings
may disclose early defects
in renal function.
 NV: 300-900mmol/Kg/24hrs,
50-1200 mmol/Kg -Random
sample
Blood urea nitrogen (BUN)
 Urea forms in the liver, constitutes the final
product of protein metabolism.
 Amount of excreted urea varies directly with
dietary protein intake.
 The test for BUN which measures the nitrogen
portion of urea is used as an index of glomeruli
function in excretion of urea.
 Thus, serves as an index of renal functioning
 A marked increase in BUN = severe impaired
renal function.
BUN
 Serve as an index of renal function.
 Urea is a nitrogenous end product
of protein metabolism.
 Test values are affected by protein
intake, tissue breakdown, and fluid
volume changes
 NV:
 Adult: 7-18 mg/dl
 Elderly 8-20 mg/dl
Urine Creatinine
 Amino acid waste product derived from muscle
creatine (a product of protein metabolism)
 All creatinine filtered by kidneys in a certain

timeframe goes into the urine, creatinine levels
thus are equal to the glomeruli filtration rate.
 Disorders of the kidney interfere with normal

secretion of creatinine.
 Thus creatinine measures the effectiveness of

renal functioning (serum creatinine).
(Volume of urine [mL/min] urine creatinine [mg/dL])

Serum creatinine (mg/dL)
The adult GFR can vary from a normal of
approximately 125 mL/min (1.67 to 2.0
mL/sec) to a high of 200 mL/min.
Keep in mind that the rate normally
decreases as we age.
Urine creatinine men 0.8 -1.8
g/24h
Urine creatinine women 0.6 –
1.6 g/24h
Serum creatinine: 0.4-1.5 mg/dl
Sensitive indicator of renal
disease used to follow the
progression of renal disease.
BUN to Creatinine Ratio
 Evaluate the hydration status

of pts.
 An elevated ratio is seen in
hypovolemia.
 A normal ratio with an elevated
BUN and creatinine is seen in
intrinsic renal diseases.
 NV: about 10:1.
Creatinine Clearance
 Decreased
– Impaired kidney function
– Kidney Disease
– Shock & dehydration
– CHF
 Increased
– State of high cardiac output
– Pregnancy
– Burns
Dx cont
 KUB X-ray
– An abdominal plain X-ray film
that includes the kidneys,
ureters, and the bladder.
– Is an AP (anteroposterior)
abdominal x ray.
 Purpose to:
– Detect kidney stones.
– As a preliminary film for an IVP.
– As a follow-up x-ray after
ureteral stents.
Dx cont
 Precautions
 Pregnant women.
 Is a screening test for kidney
stones/should be followed by other
diagnostic tests [US/IVP/CT.
 Description
 A KUB is typically a single x-ray
procedure.
 Preparation
 No special preparation.
 Aftercare
 No special aftercare required.
Intravenous Pyelogram (IVP)
 Is an X-ray examination of the KUB using
contrast medium.
 The contrast injected travels through the

bloodstream and collects in the kidneys and
urinary tract, turning these areas bright
white.
 Allows to see and assess the anatomy and

function of the KUB.

IVP- Indications To:
 Assess abnormalities in the
urinary system.
 kidney stones.
 Enlarged prostate.
 Tumors in the kidney, ureters,
or urinary bladder.
 Diagnose symptoms such as
blood in the urine or flank
pain or lower back.
Pt preparation
 NPO after midnight on the night
before your exam.
 Mild laxative the evening before
the procedure.
 Assess for history of allergies.
 Remove jewelry, eyeglasses, and
any metal objects or clothing that
might interfere with the x-ray
images.
 Is a relatively comfortable
procedure.
 Pt may feel a minor sting as the
contrast material is injected.
 Some patients experience a
flush of warmth, a mild itching
sensation and a metallic taste.
 Usually disappear within a
minute or two and are harmless.
 Assess for allergic reaction.
 During the imaging pt may be
asked to turn from side to
side/different positions to capture
views from several angles.
 Pt may be asked to empty his
bladder so that an additional x-ray
can be taken after it empties.
 Benefits
–Minimally invasive imaging
procedure.
–Provides valuable, detailed
information to diagnose and
treat urinary tract conditions:
kidney stones/cancer.
–provide information on
obstructions to direct
treatment.
 Limitations of IVP studies
–Doesn’t show mainly
details of structural
problems of the tract;
kidneys, ureters, and
bladder.
–CT/MRI more valuable
functioning tissue of the
kidneys and surrounding
structures.
Endourological Diagnosis and
Treatment Procedures
 Visualization of the urinary

tract with an endoscope.
 Endo urological procedures
include:
 Cystoscopy (cysto)
 Ureterorenoscopy
Cystoscopy
 Is the procedure to
visualize the urethra and
urinary bladder with the
help of a Cystoscopy.
 It has a self-contained
optical lens system that
provides a magnified,
illuminated view of the
bladder. By Mekasha G.(MSc, MPH) 47
Indications
 Obstruction in the urethra
– Stone
– Tumors
– Stricture
 Enlargement of the prostate
– BPH
– Prostatitis
– Cancer
 Bladder changes
–Stones.
–Tumors.
–Inflammation.
–Neurogenic bladder.
–Congenital.

Cystoscopy
used to find the cause of :
 Frequent urinary tract
infections.
 Hematuria.
 Frequency and urgency.
 Unusual cells found in a
urine sample.
 Dysuria, chronic pelvic pain,
or cystitis.
Procedure/nursing responsibilities
 Informed Consent
 Position—dorsal/lithotomy
 Sedative may be administered
 A local topical anesthetic is
instilled into the urethra by the
urologist before the Cystoscopy is
inserted.
 IV diazepam (valium) in
combination with topical urethral
anesthesia may be administered.
 Alternative spinal (regional)
or general anesthesia may
be used.
 Assemble the instrument.
 Connect light to the source.
 Connect to the irrigating
can (distilled water).
 Lubricate the scope- KY
jelly/Lidocaine.
Rigid cystoscope (left) and semirigid uretero scope (right).

Ureterorenoscopy
 Procedure carried out on
any part of the ureter.
 Indications:
–Stones
–Stricture
–Tumors

 Procedure:
– Cystoscope is done 1st.
– Then guide wire is passed to
the ureter.
 Stone
– Removed intact if small
– Fragmented by litho if large
 Tumor
– Resected as indicated.
 Stricture
–Dilated/divided
 Stenting- based on the
ureter circumstance.
 Empty bladder by catheter

 Complications of
Ureterorenoscopy
 False placing
 Perforation
 Bleeding
 evulsions

 Aftercare
 Observe for complications
 Bleeding
 False spacing
 Injury to the surrounding
 Extravasations of fluid/urine into
the penis.
 Can occur if the division is
forceful and in the wrong plane.

Renal biopsy
 Is a tissue of a living kidney taken
for pathological or immunological
purposes.
 Indications
– Nephrotic syndrome
– Acutely progressing pyelonephritis
– Systemic vacuities
– Goodpature’s syndrome-progressive
glomerulonephritis, hemoptysis.
– Diabetic nephropathy.
Nursing Responsibilities Before
Procedure
 Bleeding time
 Platelet count (<
100,000/cm3)
thrombocytopenia.
 Low Hgb.
 Anemia
 Drugs- what drugs pt is on
(anti-platelet, Anticoagulant).
Nursing cont.
 Explain the procedure to the pt.
 Obtain the consent.
 Premedicate the pt.
 Always done US guided, CT scan
guided
 Done by nephrologists/radiologist

Nursing cont
 Pillow under the other side flank

 Local injection- lidocaine
 Right kidney is preferred for
convenience.
 Long kidney biopsy needle.
 Small skin cut and introduce the Bx
needle
 Needle is put into the kidney while
pt is allowed to take deep breath.
 Immediately deliver the Bx to the
lab. By Mekasha G.(MSc, MPH) 62
Post procedural Nursing care
 Keep the pt on the same position for
24hrs.
 Close observation-BP, pulse q
15minutes for 1hour
 Complete bed rest for 6hrs and 3
consecutive urine sample for
hematuria
 If hematuria is increasing report.

Complications
 Hemorrhage- because
kidney is highly
vascularized organ.
 Discharge pt after 24 hrs
if no complications.
 Instruct pt not to do any
exercise for 2-3 days.
Fluid and electrolyte disturbance
Approximately 60% of lean
body weight is water,
- 2/3 is intracellular and
- 1/3 is extracellular
compartments, mostly as
interstitial fluid.
Only 5% of total body water
is in blood plasma.
Fluid and electrolyte imbalance
Fluid volume deficit (hypovolemia)
 Lose of ECF exceeds the intake of fluid.
Contributing factors
Loss of water and electrolytes,
as in vomiting,
diarrhea,
fistulas, fever,
excess sweating,
burns, blood loss,
gastrointestinal suction, and third-space fluid shifts (from
the vascular system to other body spaces).
Decreased intake, as in anorexia, nausea, and
inability to gain access to fluid.
Diabetes insipidus and uncontrolled diabetes
mellitus also contribute to MPH)
By Mekasha G.(MSc, a depletion of 66
Clinical presentations
Acute weight loss
Decreased skin turgor
Oliguria, concentrated urine.
Postural hypotension, weak rapid pulse,
capillary filling time prolonged, low central
venous pressure , ↓ blood pressure.
Dizziness, weakness, thirst and confusion,
↑ pulse
Muscle cramps.

Labs indicate:
↑ hemoglobin and
hematocrit.
↑ serum and urine
osmolality and specific
gravity.
↓ urine sodium,↑ BUN
and creatinine.
Management
 If the deficit is not severe, the oral route is
preferred, provided the patient can drink.
 If fluid losses are acute or severe, the IV route
is required.
 Isotonic electrolyte solutions (e.g. lactated
Ringer’s solution, 0.9%Nacl) are frequently
used.
 As the patient becomes normotensive, a
hypotonic electrolyte solution (e.g 0.45% Nacl)
 Avoid fluid overload.
Fluid volume excess (hypervolemia)
Contributing factors:
Compromised regulatory mechanisms,
such as renal failure, heart failure, and
cirrhosis.
Consumption of excessive amounts of
table or other sodium salts.
Overzealous administration of sodium-
containing fluids.
Prolonged corticosteroid therapy,
severe stress, and hyperaldosteronism.
Clinical Manifestations
• Acute weight gain,
• Peripheral edema and
• Ascites, distended jugular veins,
• Crackles, shortness of breath and wheezing,
• Increased BP, and cough.
Labs indicate:
↓Hemoglobin and Hematocrit
↓Serum and urine osmolality
↓Urine sodium and specific gravity
Chest x-ray may reveal pulmonary
congestion
Management
Management is directed at the causes
Dietary restriction of sodium
Symptomatic treatment consists of
administering diuretics and restricting
fluids and sodium.
Potassium supplements can be
prescribed.
If renal function is so severely impaired
hemodialysis or peritoneal dialysis may be
used to remove nitrogenous wastes and
control potassium and acid-base balance,
and to remove sodium and fluid.
Electrolyte Imbalances
Hyponatremia
Refers to a serum sodium level that is < 135 mEq/L
Can be due to:
Loss of sodium, as in use of diuretics, loss of GI
fluids, renal disease, and adrenal insufficiency.
Gain of water, as in excessive administration of D5W.

Disease states associated with syndrome of
inappropriate secretion of ADH(SIADH) such as
head trauma.
Medications associated with water retention

(oxytocin and certain tranquilizers)
Hyperglycemia and Byheart failure cause a loss of Na.
Mekasha G.(MSc, MPH) 74
Clinical manifestations
Anorexia, nausea and vomiting

Dry skin, increase pulse,
decrease BP, weight gain, edema.
Headache, lethargy, dizziness,
confusion.
Muscle cramps and weakness,
muscular twitching, seizures,
papilledema.

Management
Administration of sodium by
mouth, nasogastric tube, or a
parenteral route
lactated Ringer’s solution or
isotonic saline (0.9% sodium
chloride) solution may be used.
In a patient with normal or excess
fluid volume, hyponatremia is
treated by restricting fluid.
Hypernatremia
Is a serum sodium level higher than
145 mEq/L.
Can be caused by:
Water deprivation in patients unable
to drink is a common cause.
Hypertonic tube feedings without
adequate water supplements.
Excess sodium bicarbonate, and
sodium chloride administration.
Salt water near-drowning victims.
 Thirst.
 Elevated body temperature.
 Swollen dry tongue and sticky mucous
membranes.
 Hallucinations, lethargy, restlessness,
irritability, seizures.
 Pulmonary edema.
 Hyperreflexia, twitching.
 Nausea, vomiting, anorexia.
 Increased pulse and BP.
Management
Gradual lowering of the serum sodium

level by the infusion of a hypotonic
electrolyte solution ( 0.3% sodium
chloride) or an isotonic solution (D5W).
The serum sodium level is reduced at a
rate no faster than 0.5 to 1 mEq/L/h.
Too-rapid reduction in the serum
sodium level renders the plasma
temporarily hypo osmotic to the fluid in
the brain tissue, causing movement of
fluid into brain cells and dangerous
cerebral edema.
Potassium deficit (hypokalemia)
Is when serum potassium <3.5 mEq/L.
Contributing factors:
Medications like thiazides and loop
diuretics, corticosteroids, and
amphotericin B.
GI loss of potassium- diarrhea, vomiting,
and gastric suction.
Metabolic alkalosis that promotes the
transcellular shift of potassium: hydrogen
ions move out of the cells in alkalotic
states to help correct the high pH, and
potassium ions move in to maintain an
electrically neutral
By Mekasha state.
G.(MSc, MPH) 80
…cont’d
Hyperaldosteronism increases
renal potassium wasting.
Patients with persistent insulin
hypersecretion (insulin
promotes the entry of
potassium into skeletal
muscle and hepatic cells).
Magnesium depletion causes
renal potassium loss.
Fatigue, anorexia, nausea, vomiting, muscle
weakness, leg cramps, decreased bowel
motility, paresthesias and dysrhythmias.
If prolonged, inability of the kidneys to
concentrate urine (resulting in polyuria,
nocturia) and excessive thirst.
Potassium depletion suppresses the release
of insulin and results in glucose intolerance.
Decreased muscle strength can be found on
physical assessment.
Severe hypokalemia can cause death
through cardiac or respiratory arrest.
Management
Increased intake in the daily diet or
by oral potassium supplements.
Foods high in potassium include
most fruits and vegetables, legumes,
whole grains, milk, and meat.
Cautiously IV replacement for
patients with severe hypokalemia
(e.g. serum level of 2mEq/L)
Monitor for signs of hyperkalemia;
smooth muscle hyperactivity can
lead to hyperactive bowel sounds.
Potassium excess (hyperkalemia)
Is when serum potassium >5.0 mEq/L
It is less common than hypokalemia but is
usually more dangerous because cardiac
arrest is more frequently associated
with high serum potassium levels.
Three major causes are:
Decreased renal excretion of potassium.
Rapid administration of potassium and
Movement of potassium from the ICF
compartment to the ECF compartment.

…cont’d
Medications commonly
implicated are potassium
chloride, heparin, ACE
inhibitors, NSAIDs, beta-
blockers, and potassium sparing
diuretics.
In acidosis, as hydrogen ions
enter the cells to buffer the pH
of the ECF. By Mekasha G.(MSc, MPH) 85
Muscle weakness,
tachycardia, dysrhythmias and
cardiac arrest.
Flaccid paralysis, paresthesia.
Nausea, Intestinal colic,
cramps, abdominal distention,
and diarrhea.
Irritability, anxiety.
Management
In nonacute situations, restriction of dietary
potassium and potassium-containing
medications may correct the imbalance.
If serum potassium levels are dangerously

elevated, administer IV calcium gluconate
(calcium antagonizes the action of
hyperkalemia on the heart, but it does not
reduce the serum potassium concentration).
Monitor the BP hence hypotension may result

from the rapid IV administration of calcium
gluconate. By Mekasha G.(MSc, MPH) 87
…magt cont’d
IV administration of sodium bicarbonate,
regular insulin, and a hypertonic
dextrose solution may be necessary to
alkalinize the plasma, cause a temporary
shift of potassium into the cells.
Loop diuretics increase excretion of
potassium.
Beta-2 agonists, such as albuterol are
highly effective in decreasing potassium
(move potassium into the cells).

Calcium deficit (hypocalcemia)
Occur when serum calcium level is
lower than 8.6 mg/dl.
Contributing factors:
Hypoparathyroidism (primary or
post-surgical(thyroidectomy or
Parathyroidectomy).
After radical neck dissection.
Excessive secretion of glucagon from
the inflamed pancreas, which results
in increased secretion of calcitonin.
…cont’d
Patients with renal failure, because
these patients frequently have
elevated serum phosphate levels
which causes a drop in the serum
calcium level.
Inadequate vitamin D consumption.
Medications like aluminum-
containing antacids,
aminoglycosides, caffeine, and
corticosteroids.
Tetany; a general muscle hypertonia
with:
Numbness and tingling in
extremities.
Stiffness of hands and feet.
Bronchospasm, laryngeal spasm,
carpopedal spasm,
Photophobia, cardiac
dysrhythmias, and seizures.
Hyperactive deep tendon reflexes.
…c/f cont’d
Positive:
Trousseau’s sign- carpopedal spasm is
induced by occluding the blood flow to the
arm for 3 minutes with a blood pressure
cuff.
Chvostek’s sign-when a sharp tapping
over the facial nerve just in front of the
parotid gland and anterior to the ear
causes spasms or twitching of the mouth,
nose, and eye.
Osteoporosis- a bone disease that develops
when bone mineral density and bone mass
decrease, or when the structure and
strength of bone change.
Management
Acute symptomatic hypocalcemia is
life-threatening and requires prompt
treatment with IV administration of a
calcium salt (calcium chloride, and
calcium gluconate).
Calcium should be diluted in D5W and
administered as a slow IV bolus or a
slow IV infusion.
0.9% sodium chloride solution should
not be used with calcium because it
increases renal calcium loss.
…magt cont’d
The patient is kept in bed during IV
infusion, and blood pressure should be
monitored.
Vitamin D therapy can increase calcium
absorption from the GI tract.
Aluminum hydroxide, calcium acetate, or
calcium carbonate antacids may be
prescribed to decrease elevated
phosphorus levels.
Increasing the dietary intake of calcium to
at least 1000 to 1500 mg/day in the adult is
recommended. By Mekasha G.(MSc, MPH) 95
Calcium excess (hypercalcemia)
Occurs when serum calcium level
is greater than 10.2 mg/dl.
Reduces neuromuscular
excitability because it suppresses
activity at the myoneural junction.
The most common causes are
malignancies and
hyperparathyroidism.

Other factors include:
Immobilization after severe
or multiple fractures or
spinal cord injury.
Thiazide diuretics reduce
urinary calcium excretion.
Prolonged period with milk
and alkaline antacids.
Vitamin A and D
intoxication.
Decreased tone in smooth and striated
muscle may cause symptoms such as
muscle weakness, incoordination,
anorexia, nausea, vomiting, constipation
and dehydration.
Patients with chronic hypercalcemia
may develop symptoms similar to those
of peptic ulcer disease because
hypercalcemia increases the secretion
of acid and pepsin by the stomach.

…s/s cont’d
Confusion, impaired memory, slurred
speech, lethargy, acute psychotic
behavior, or coma may occur.
Hypercalcemic crisis refers to an
acute rise in the serum calcium level to
17 mg/dl or higher.
Severe thirst and polyuria are
characteristically present.
Can result in life-threatening
neurologic, cardiovascular, and renal
symptoms. By Mekasha G.(MSc, MPH) 99
Management
Treating the underlying cause
(e.g.chemotherapy for a malignancy or partial
parathyroidectomy for hyperparathyroidism)
Administering fluids to dilute serum calcium
and promote its excretion by the kidneys.
Phosphate therapy to promote calcium deposition
in bone and reducing GI absorption of calcium.
Loop diuretics promote renal excretion of
calcium.
Calcitonin IM increases the deposit of calcium in
the bones and increases urinary excretion of
calcium.
Mobilizing the patient to promote bone retention
of calcium.
Restricting dietaryBy Mekasha
calcium intake.
G.(MSc, MPH) 100
Acid-base imbalance
 Results:-
 If either bicarbonate or
carbonic acid is increased or
decreased so that the 20:1
ratio is no longer
maintained.

Metabolic acidosis
(base bicarbonate deficit)
• Is characterized by a low pH (increased H+
concentration) and a low plasma bicarbonate
concentration.
Results from:
Direct loss of bicarbonate, as in diarrhea, lower
intestinal fistulas, and use of diuretics.
Administration of parenteral nutrition without
bicarbonate or bicarbonate-producing solutes
(e.g. lactate).
Excessive administration of chloride
Excessive accumulation of fixed acid occurs in
ketoacidosis, lactic acidosis, and the late phase
of salicylate poisoning.
Signs and symptoms vary with the severity of
the acidosis.
Headache, confusion, drowsiness, increased
respiratory rate, and depth.
Nausea and vomiting.
Peripheral vasodilation and decreased cardiac
output occur when the pH falls below 7.
Decreased BP, cold and clammy skin,
dysrhythmias, and shock.
The cardinal feature is a decrease in the
serum bicarbonate level(less than 22 mEq/L).
Low pH(less than 7.35).
Management
 Treatment is directed at correcting the
metabolic defect.
 e.g. If the problem results from excessive
intake of chloride, eliminating the source.
 Bicarbonate is administered if the pH is less
than 7.1 and the bicarbonate level is less
than 10 mEq/L.
 In chronic metabolic acidosis, hemodialysis
or peritoneal dialysis may also be included.
 Although hyperkalemia occurs with acidosis,
hypokalemia may occur with reversal of the
acidosis and subsequent movement of
potassium back into the cells.
 Therefore, the serum potassium
By Mekasha G.(MSc, MPH) level is 104
Metabolic alkalosis
(base bicarbonate excess)
Characterized by a high pH (decreased
H+ concentration) and a high plasma
bicarbonate concentration.
The most common cause is vomiting
or gastric suction with loss of hydrogen
and chloride ions (loss of this highly
acidic fluid increases the alkalinity of
body fluids).
Hypokalemia :
The kidneys conserve potassium, and
thus H+ excretion increases; and
…cont’d
 Cellular potassium moves out of

the cells into the ECF in an
attempt to maintain near-normal
serum levels thus, H+ must enter
to maintain electroneutrality.
Excessive alkali ingestion from
antacids containing bicarbonate.
Chronic ingestion of milk.
Long-term diuretic therapy.
Tingling of the fingers and toes, dizziness, and
hypertonic muscles.
Atrial tachycardia, respirations are depressed as
a compensatory action by the lungs.
As the pH increases >7.6 and hypokalemia
develops, ventricular disturbances may occur.
Evaluation of arterial blood gases reveals a PH
greater than 7.45 and a serum bicarbonate
concentration greater than 26 mEq/L.
Management
Treatment is aimed at reversing the
underlying disorder.
Chloride supplementation for the
kidney allows excretion of excess
bicarbonate.
Restoring normal fluid volume by
administering sodium chloride fluids.
Potassium is administered as KCl to
replace both K+ and Cl− losses
Monitor patient’s fluid intake and
output. By Mekasha G.(MSc, MPH) 108
Respiratory acidosis
(Carbonic acid excess)
Is a condition in which the pH is <7.35 and
the PaCO2 is >42 mm Hg.
Is always due to inadequate excretion of CO2
with inadequate ventilation, resulting in
elevated plasma CO2 levels and thus
elevated carbonic acid (H2CO3) levels and
a decrease in PaO2
It can also occur in diseases that impair
respiratory muscles, such as muscular
dystrophy, myasthenia gravis, and Guillain-
Barre syndrome.
Chronic respiratory acidosis
By Mekasha G.(MSc, MPH) occurs with 109
Increased PR, RR, and BP
Mental cloudiness, and feeling of fullness in
the head.
Cerebrovascular vasodilation and increased
cerebral blood flow.
In severe form ,sign of increased ICP
(papilledema and dilated conjunctival blood
vessels)
Cyanosis and tachypnea.
Hyperkalemia (shift of potassium out of the
cell).
Management
Treatment is directed at improving

ventilation
Bronchodilators to reduce bronchial
spasm.
Antibiotics for respiratory infections.
Anticoagulants for pulmonary emboli.
Pulmonary hygiene measures, to clear
the respiratory tract of mucus and
purulent drainage.
Hydration (2–3 L/day) to keep the
mucous membranes moist and thereby
facilitate the removal of secretions. 111
By Mekasha G.(MSc, MPH)
…magt cont’d
Supplemental oxygen.
Mechanical ventilation.
Placing the patient in a semi-
Fowler’s position facilitates
expansion of the chest wall.

Respiratory alkalosis
(Carbonic acid deficit)
 A condition in which the arterial pH is
>7.45 and the PaCO2 is less than
38 mm Hg.
 Is always due to hyperventilation,
which causes excessive “blowing off”
of CO2 and, hence, a decrease in the
plasma carbonic acid concentration.
 Causes can include extreme anxiety,
hypoxemia, the early phase of
salicylate intoxication, gram-negative
Lightheadedness due to
vasoconstriction and decreased
cerebral blood flow.
Numbness and tingling from
decreased calcium ionization.
Tinnitus, Inability to concentrate,
at times loss of consciousness.
Tachycardia and ventricular and
atrial dysrhythmias.
Management
Treatment is directed at correcting

the underlying problem.
If the cause is anxiety, the patient is
instructed to breathe more slowly to
allow CO2 to accumulate or to
breathe into a closed system (such as
a paper bag).
A sedative may be required to
relieve hyperventilation in very
anxious patients.
Reading assignment
Magnesium imbalance
Phosphorus imbalance
Chloride imbalance

URINARY TRACT
IFECTIONS

Terminologies
Frequency-frequent voiding(more than every 3
hrs).
Urgency-Strong desire to void.
Dysuria-Painful or difficult voiding.
Hesitancy-Delay, difficulty in initiating voiding.
Nocturia-Excessive urination at night.
Incontinence-Involuntary loss of urine.
Enuresis- Involuntary voiding during sleep.
Polyuria- Increased volume of urine voided
Oliguria- Urine output less than 500mL/day
Anuria-Urine output less than 50 mL/day
Hematuria-Red blood cells in the urine
Pyuria: white blood cells
By Mekasha G.(MSc,in
MPH)the urine 118
…terms cont’d
Proteinuria- Abnormal amounts of protein in the
urine.
Uremia: an excess of urea and other nitrogenous
wastes in the blood.
Bacteriuria: more than 105colonies of bacteria/ ml
of urine
Cystitis: inflammation of the urinary bladder
Prostatitis: inflammation of the prostate gland
Pyelonephritis: inflammation of the renal pelvis
Urethritis : inflammation of the urethra
Pyonephrosis: pus accumulation around the kidney
Urinary casts: microscopic particles formed in the
kidney from abnormal constituents in the urine
such as WBCs, RBCs, or G.(MSc,
By Mekasha pus. MPH) 119
Introduction
Urinary tract infection(UTI) is a general term
that refers to invasion of the urinary tract by
bacteria; commonly Escherichia coli which
found in stool.
classification
Lower UTIs include:
bacterial cystitis
bacterial prostatitis
bacterial urethritis
Upper UTIs-much less common and they
includes:
Pyelonephritis
Interstitial nephritis
Predisposing Factors for UTIs
Stasis of urine in the bladder serves as a
culture medium for bacterial growth.
Contamination in the perineal and urethral
areas.
Instrumentation, the most common cause is
urinary catheterization.
Reflux of urine from the urethra to the
bladder or the bladder to the ureter because
of faulty valves to maintain one-way flow.
(congenital, or result of previous infections).
Previous history of UTIs.
Decreased natural host defenses or
immunosuppression. By Mekasha G.(MSc, MPH) 121
Urethritis
• Is inflammation of the urethra that may be

due to:
A chemical irritant (detergents or
lotions, spermicidal agents) or
Infectious causes (typically sexually
transmitted)
Gonococcal urethritis (GCU) -
Neisseria gonorrhea
Nongonococcal urethritis (NGU) -
Chlamydia trachomatis, or
Trichomonas vaginalis.
Clinical features
Urinary frequency, urgency,

and dysuria.
In male, purulent
discharge(GCU) and clear
discharge(NGU) from the
penis.
It is difficult to diagnose in
women (discharge may not
be present).
Diagnosis
Urinalysis- 5 or
more granulocytes per High
Power Field.
Urine culture.
DRE to inspect the prostate
gland for swelling or infection.
Tests to check for sexually
transmitted diseases.

Management
Removal of the cause if it is caused by
a chemical irritant.
If bacteria, an antibiotic is prescribed
based on the results of a culture.
Analgesics.
Sex partners should be referred for
appropriate evaluation and treatment.
Proper perineal hygiene should be
stressed.
Cystitis
Is bladder inflammation, usually

caused by a bladder infection
(commonly by Escherichia coli).
Other causes include radiotherapy
and certain chemicals.
It may also occur as a complication
of another illness.
Cystitis can be simple or
complicated type.
Uncomplicated (Simple) cystitis
– In healthy adult woman
– Non-pregnant
– No signs of systemic disease(fever,
nausea, vomiting, flank pain)
Complicated cystitis
– Females with comorbid medical conditions
– All male patients
– Indwelling foley catheters
– Urosepsis/hospitalization
– Repeated infection

Signs and Symptoms
Burning or pain when

passing urine.
Needing to pass urine a lot.
A constant, dull ache in the
lower abdomen.
Urine that smells, or
contains blood or is cloudy.

Diagnosis
Clinical presentations
Urinalysis-for uncomplicated
cloudy urine and the
presence of WBCs,
bacteria, RBCs
Urine culture and sensitivity-
For the complicated UTI.
Management
Uncomplicated cystitis
sulfamethoxazole and trimethoprim
(Bactrim). about 80% of cases are
cured after 3 days of treatment.
Complicated cystitis is often treated
with ciprofloxacin or other broad-
spectrum antibiotic.
Other antibiotics may be prescribed
depending on the results of the urine
culture and sensitivity.
Cephalosporins and penicillins are
recommended in pregnancy.
Pyelonephritis
Is an inflammation of the renal
parenchyma, calyces, and pelvis.
It is commonly caused by a bacterial
infection that has spread up the
urinary tract or traveled through
the bloodstream to the kidneys.
Almost always caused by Bacteria
found in stool (such as E. coli or
Klebsiella)
Maybe acute or chronic
Acute pyelonephritis
Results from bacterial

invasion of the renal
parenchyma.
Patients with acute
pyelonephritis usually have
enlarged kidneys with
interstitial infiltrations of
inflammatory cells.
Sign and symptoms
Patient will become

acutely ill,
Chills, fever, malaise, and
flank pain.
Dysuria and frequency.
CVA tenderness to
percussion is a common
finding. By Mekasha G.(MSc, MPH) 133
Diagnosis
Hx ad P/E.
Urine test to check for bacteria.
The urine will also be checked for
concentration, blood, pus, and
casts.
Urine culture and sensitivity.
X-rays or an ultrasound to look
for cysts or tumors in the urinary
tract. By Mekasha G.(MSc, MPH) 134
Management
Pt with mild signs and symptoms may be
treated on an outpatient basis with
antibiotics for 14 to 21 days.
Other patients, including all pregnant
women, may be hospitalized for at least 2 or
3 days of parenteral antibiotic therapy.
Antibiotics are selected according to results
of urinalysis, culture, and sensitivity and
may include broad-spectrum medications.
A follow-up urine culture is done 2 weeks
after completion of antibiotic therapy to
document clearing of the infection.
Chronic Pyelonephritis
Implies recurrent kidney
infections, and can result
in scarring of the renal
parenchyma and impaired
function.
The kidneys become scarred,
contracted, and nonfunctioning.
It may develop in association with
other renal disease unrelated to
infection processes.
Patient usually has no symptoms of
infection unless an acute exacerbation
occurs.
Noticeable signs and symptoms may
include fatigue, headache, poor
appetite, polyuria, excessive thirst, and
weight loss.
A perinephric abscess and/or pyonephrosis
may develop in severe cases.
Persistent and recurring infection may
produce progressive scarring of the kidney,
which may result in renal failure(ESRD).
Diagnosis
Intravenous urogram.
Measurements of
creatinine clearance.
BUN and serum
creatinine levels.

Management
Antibiotic therapy for acute infections.
Antibiotic prophylaxis for prevention
of recurrent infections.
Close monitoring of patients.
Investigation and management as
appropriate for underlying structural
abnormalities.
Management of renal impairment as
indicated by the degree of impairment.
Obstruction of
Urinary
system

Urethral Strictures
Is a narrowing of the lumen of the
urethra caused by scar tissue.
A common cause of stricture is:
Urethral injury resulting from
insertion of catheters or surgical
instruments.
Direct application of force to the
perineal area.
Sexually transmitted infections
(untreated gonorrhea).
Congenital abnormalities.
Signs and symptoms
Diminished force and volume of

the urinary stream.
Inability to fully empty the
bladder.
Symptoms of urinary infection
and retention occur.
Hydronephrosis (distension and
dilation of the renal pelvis
and calyces).
Treatment
Urethral dilatation and drainage of the
urinary bladder with metal
sounds(bougies) or surgery (internal
urethrotomy)
Insertion of a suprapubic catheter.
After dilation
Hot sitz baths and nonopioid
analgesic agents to control pain.
Antibiotic for several days.
Surgery (urethroplasty) -the repair of
an injury or defect within the walls of
the urethra. By Mekasha G.(MSc, MPH) 143
Urolithiasis
Refers to stones (calculi)any were
in the urinary tract.
Are formed when there is a high
concentration of mineral(s);i.e.
calcium (hypercalciuria), oxalate
(hyperoxaluria), or uric acid
(hyperuricosuria) in the urine.
They may vary in size from
minute granular deposits, called
sand or gravel, to bladder stones
as large as an orange.
...cont’d
Calcium oxalate is a major
constituent of most urinary
stones.
Stones can be classified by
their location or by their
chemical composition.
80% of those with kidney
stones are men, commonly
b/n 20-30 years of age.
Risk factors
Early onset of urolithiasis
Familial stone formation
Genetic predisposition
Fluid intake pattern
Dehydration
High doses of vitamin C-result in high levels
of oxalate in the urine
A low level of citrate
Gout (excessive uric acid in the blood)
Infection-provide nucleus for stone
formation
Only one functioning kidney

…risk factors cont’d
Disease associated with stone formation:
e.g. - hyperparathyroidism
- renal tubular acidosis
- malabsorptive conditions
Medication associated with stone
formation:
e.g. - calcium supplements
- vitamin D supplements
- acetazolamide
Anatomical abnormalities associated with
stone formation:
e.g - pelvo-ureteral junction obstruction
- ureteral stricture
- vesico-ureteral reflux
Location of stones
Nephrolithiasis (renal calculus) -stones in
the kidney
Ureterolithiasis-stones in the ureter.
Cystolithiasis-refers to stones which form
or have passed into the urinary bladder.

Pathophysiology
For precipitation of crystals in urine to
occur, the urine must be "supersaturated“.
Urine normally contains chemicals citrate,
magnesium, and pyrophosphate that
prevent the formation of crystals.
Low levels of these inhibitors can contribute
to the formation of kidney stones.
Citrate is thought to be the most important.
Insufficient water in the kidneys to dissolve
waste products is also an other contributing
factor.
….cont’d
The chemical composition of stones

depends on the chemical imbalance in the
urine.
The four most common types of stones are
comprised of calcium, uric acid, struvite,
and cystine.

Calcium Stones
Approximately 85% of stones are composed
predominantly of calcium compounds.
The most common cause of calcium stone
production is excess calcium in the urine
(hypercalciuria).
Excess calcium builds up in the kidneys and
urine, where it combines with other waste
products to form stones.
Low levels of citrate, high levels of oxalate
and inadequate urinary volume may also
contribute.
Calcium stones are composed of calcium
oxalate or calcium phosphate.
…cont’d
These stones come in 2 different types -
monohydrate and dihydrate.
Calcium oxalate dihydrate stones usually
break easily with lithotripsy.
Monohydrate stones are among the most
difficult stones to fragment.

Uric Acid Stones
 Approximately 10% of patients with kidney stone
disease develop this type of stone.
 Digestion produces uric acid.
 If the acid level in the urine is high or too much
acid is excreted, the uric acid may not dissolve
and uric acid stones may form.
 Patients with gout often develop these stones.
 Genetics may play a role in the development of
uric acid stones, which are more common in
men.
 They are not visible on X-rays.
 Uric acid stones form in acidic urine and often
dissolve when the urine is alkalinized.
Struvite Stones
Also called an infection stone
Develops when a urinary tract infection
affects the chemical balance of the urine.
Bacteria in the urinary tract release
chemicals that neutralize acid in the urine,
which enables bacteria to grow more
quickly.
They are capable of splitting urea into
ammonia, decreasing the acidity of the
urine and resulting in favorable conditions
for the formation of struvite stones.
Struvite stones are more common in
women.
Accounts about 15% of urinary calculi
Cystine Stones
Some people inherit a rare, congenital
condition that results in large amounts of
cystine in the urine.
This condition (called cystinuria) causes
cystine stones.
They are difficult to treat and requires life-
long therapy.
1% to 2% of all stones.

Manifestations depend on obstruction,
infection, and edema.
Stones in the renal pelvis may be associated
with:
Intense, deep ache in the CVA region
that radiates anteriorly and downward
to the bladder in female and testis in
male.
Hematuria, pyuria
Nausea and vomiting
Diarrhea and abdominal discomfort
may also occur.
…s/s cont’d
Stones lodged in the ureter cause :
Acute, colicky, wavelike pain,
radiating down the thigh and
genitalia.
Desire to void, but little urine is
passed, and it usually contains
blood because of the abrasive
action of the stone.
This group of symptoms is called
ureteral colic.
…s/s cont’d
Stones lodged in the bladder

usually produce symptoms of
irritation and may be associated
with UTI and hematuria.
If the stone obstructs the bladder
neck, urinary retention occurs.
If infection is associated with a
stone, the condition is far more
serious, with sepsis threatening the
patient’s life.
Diagnosis
Diagnosis of is often made on the basis of
clinical symptoms alone, although
confirmatory tests are usually performed.
Hx including assessing risk factors
Physical findings
Laboratory tests
Microscopic urinalysis
Serum creatinine level
Serum electrolyte level
Serum and urinary pH level
Radiology
X-ray studies-most stones are
radiopaque.
Ultrasonography

Management
Patients can urinate stones if they are 5 mm
or smaller; larger stones do not pass.
IV hydration
Po/IV narcotic analgesics (e.g, codeine,
morphine sulfate)
NSAIDS- in addition to relieving pain, inhibit
the synthesis of prostaglandin E, reducing
swelling and facilitating passage of the stone.
Hot baths or moist heat to the flank areas
Encouraged fluids -to keep the urine dilute
Antiemetics (e.g. metoclopramide)
Antibiotics (e.g. ampicillin, gentamicin,
ciprofloxacin)
…mag’t cont’d
Uricosuric agents (eg, allopurinol)

Alkalinizing agents (eg, potassium citrate,
sodium bicarbonate): for uric acid and cystine
calculi.
Nutritional Therapy
E.g for uric acid stones, the patient is
placed on a low-purine diet to reduce the
excretion of uric acid in the urine.
Lithotripsy-is used to break the stones into
smaller parts that can then be removed or
urinated out.
Surgery-if the stone does not respond to
other forms of treatment
Surgical procedures
 Nephrolithotomy -incision into the kidney
with removal of the stone .
 Nephrectomy- if the kidney is
nonfunctional secondary to infection or
hydronephrosis.
 Stones in the kidney pelvis are removed
by a pyelolithotomy, those in the ureter by
ureterolithotomy, and those in the bladder
by cystotomy.

Lithotripsy

Preventing Kidney Stones
Restriction of protein intake
Reducing sodium intake hence, sodium
competes with calcium for reabsorption in
the kidneys.
Low-calcium diets are not generally
recommended, except for true absorptive
hypercalciuria. limiting calcium, especially
in women, can lead to osteoporosis and does
not prevent renal stones.
Avoiding intake of oxalate-containing foods.
During the day, drink fluids (ideally water)
every 1 to 2 hours.
…prev. cont’d
Drink two glasses of water at bedtime and
an additional glass at each nighttime.
Avoid activities leading to sudden increases
in environmental temperatures that may
cause excessive sweating and dehydration.
Contact your primary health care provider
at the first sign of a urinary tract infection.

BENIGN PROSTATIC HYPERPLASIA
(BPH)
BPH is a progressive adenomatous
enlargement of the prostate gland that
occurs with aging.
It is also called benign enlargement of
the prostate (BEP),
adenofibromyomatous hyperplasia and
benign prostatic hypertrophy.
The gland enlarges, extending upward
into the bladder and obstructing the
outflow of urine
Affects half of men over age 50 and 90%
of men over ageBy 80.
Causes of BPH
 The cause is not completely understood
 BPH is part of the natural aging process
 Dihydrotestosterone (DHT), a metabolite of
testosterone, is a critical mediator of
prostatic growth.
 DHT is synthesized in the prostate from
circulating testosterone by the action of the
enzyme 5α-reductase, type 2.
 This enzyme is localized principally in the
stromal cells; hence, those cells are the main
site for the synthesis of DHT.
Facts about BPH
Castrated boys do not develop BPH when
they are aged.
BPH cannot be prevented.
BPH can be treated.
BPH does not predispose to the
development of prostate cancer.

Pathophysiology

Symptoms are classified as storage or voiding.
Storage symptoms include urinary
frequency, urgency, incontinence, and
nocturia.
Voiding symptoms include hesitancy,
intermittency, straining to void, and
dribbling.
This symptoms can be evaluated using the
IPSS questionnaire
Frequent UTIs
Gradual dilation of the ureters (hydroureter)
and kidneys (hydronephrosis)
Diagnostic tests
Medical history
Validated symptom questionnaire
Physical examination (DRE)
Urinalysis
CBC –to monitor post op complications
PSA test (3-10ng/ml)
Transrectal Ultrasound of Prostate
Biopsy

DRE: Possible findings
 Symmetrical enlargement of the gland
 Marked protrusion into the rectal lumen
 Smooth with no nodularity
 Median sulcus may be indistinguishable
 Consistency is slightly elastic
 Non tender

International prostate symptom score (IPSS)
questions Less
than 1
Less
than
About
More
than
Almost Your
Not at all half the half
time half the always score
time the
in 5 time
time
INCOMPLETE EMPTYING
OVER THE PAST MONTH, HOW OFTEN HAVE YOU HAD A 0 1 2 3 4 5
SENSATION OF NOT EMPTYING YOUR BLADDER
COMPLETELY AFTER YOU FINISH URINATING?
FREQUENCY
OVER THE PAST MONTH, HOW OFTEN HAVE YOU HAD TO 0 1 2 3 4 5
URINATE AGAIN LESS THAN TWO HOURS AFTER YOU
FINISHED URINATING?
INTERMITTENCY
OVER THE PAST MONTH, HOW OFTEN HAVE YOU FOUND 0 1 2 3 4 5
YOU STOPPED AND STARTED AGAIN SEVERAL TIMES WHEN
YOU URINATED?
URGENCY
OVER THE LAST MONTH, HOW DIFFICULT HAVE YOU 0 1 2 3 4 5
FOUND IT TO POSTPONE URINATION?
Weak stream
Over the past month, how often have you had a weak urinary stream? 0 1 2 3 4 5
Straining None 1 time 2 times 3 times

4 5 times Your
Over the past month, how often have you had to push or strain to begin urination? 0 1 2 3 4
times 5
or more score
Nocturia
Over the past month, many times did you most typically get up to urinate from
the time you went to bed until the time you got up in the morning? 0 1 2 3 4 5
Total score: 0-7 Mildly symptomatic;

By Mekasha G.(MSc, 8-19
MPH) moderately symptomatic;
175
20-35 severely symptomatic.
Management
Mild symptoms managed with watchful

waiting.
Moderate to Severe symptoms needs:
Watchful waiting
Medical management
and
Surgical treatment.

Watchful Waiting and Behavioral
Modification
Decrease caffeine, alcohol consumption.
Avoid taking large amounts of fluid over a
short period of time.
Void whenever the urge is present, every 2-3
hours
Maintain normal fluid intake, do not restrict
fluid
Avoid bladder irritants.
Limit nighttime fluid consumption.
Patients will be examined yearly for the need
of additional treatment.
Medical
Management
Foley’s catheter (stylet, metal catheters)
Drug therapy
alpha blockers – relax the smooth muscles
along urinary tract which improves urine
flow (doxazosin, terazosin, tamsulosin)
5-alpha reductase inhabitors -
antiandrogen agents; shrink the prostate
gland (finasteride, dutasteride)
narcotic analgesic – relieve post-op pain

(morphine, codeine)

Surgical treatment
Indicated for IPSS of >16
TURP(closed procedure)
Gold Standard” of care for BPH
Uses an electrical “knife” to surgically
cut and remove excess prostate tissue
Long lasting and effective in relieving
symptoms and restoring urine flow

…surgery cont’d
Prostatectomy
Perineal prostectomy –incision between
the scrotum and anus(rare)
Suprapubic resection – lower abdomen –
incision through the bladder.
Retropubic –midline abd. incision– does
not go through the bladder.
Laparoscopic prostatectomy

Complications of BPH
Urinary retention
UTI
Residual urine
Sepsis secondary to UTI
Calculi
Hematuria
Renal failure

Care of prostate surgery
 Relieving pain
 Monitoring V/S, I&O
 Continuous irrigation & maintain catheter
patency( three lumen system of catheterization)
 Blood clots and hematuria are expected for the
first 24-36 hours.
 After catheter is removed – check for urinary
retention and urinary stream.
 Encourage Kegal exercise pelvic muscle floor
technique hourly.
 Stool softeners to avoid straining
 Sitting and walking for long periods should be
avoided By Mekasha G.(MSc, MPH) 182
….care cont’d
 Reduce anxiety
 Monitoring and managing potential
complications
Bleeding
Infection
Clot formation
Erectile dysfunction(damage to the
pudendal nerves)
Retrograde ejaculation
Urinary incontinency or dribbling

Three-Way System for Bladder
Irrigation

Diseases of the
Kidney

Acute glomerulonephritis
Glomerulonephritis is an inflammation of
the glomerular capillaries.
Acute glomerulonephritis is primarily a
disease of children older than 2 years of
age, but it can occur at nearly any age.
It occurs over days or weeks
It is not infection of the kidney but, rather untoward
side effects of the defense mechanism of the body.

Causes
A group A beta-hemolytic streptococcal
infection of the throat precedes the onset of
glomerulonephritis by 2 to 3 weeks.
Impetigo (infection of the skin) and acute
viral infections (uris, mumps, hbv, hiv
infection).
Antigens outside the body (eg, medications,
foreign serum) initiate the process,
resulting in antigen-antibody complexes
being deposited in the glomeruli.
In other patients, the kidney tissue itself
serves as the inciting antigen.
Pathophysiology

hematuria, which may be microscopic or
macroscopic
cola-colored Urine because of RBCs and
protein plugs or casts. (RBC casts indicate
glomerular injury.)
Proteinuria-due to the increased
permeability of the glomerular membrane.
hypoalbuminemia
BUN and serum creatinine levels may rise
as urine output drops.
The patient may be anemic.
Edema and hypertension in 75% of patients
…c/f cont’d
In the more severe form:
The patient has ARF with oliguria
headache, malaise, and flank pain
circulatory overload
Confusion and seizures

Diagnostic Findings
kidneys become large, edematous, and
congested
Lab test
Urinalysis test-Look for protein, RBCs,
WBCs, casts
 Blood tests may show anemia,
abnormal albumin levels, abnormal
BUN, and high creatinine levels.

Management
Most cases resolve spontaneously in about a
week, but some progress to renal failure.
Treatment is primarily symptomatic and
treat complications promptly.
Corticosteroids, managing hypertension
Sodium and fluid restrictions may be
ordered along with diuretics when the
patient has hypertension, edema, and heart
failure.
If associated with a streptococcus infection,
antibiotics are given (penicillin is the agent
of choice).
Complications
Majority of children recover completely.
Adults who develop glomerulonephritis may
recover renal function or progress to
chronic glomerulonephritis.
Hypertensive encephalopathy
Heart failure and
Pulmonary edema
Without treatment, ESRD develops in a
matter of weeks or months

Chronic glomerulonephritis
Characterized by irreversible and
progressive glomerular and
tubulointerstitial fibrosis, ultimately
leading to a reduction in the glomerular
filtration rate (GFR) and retention of
uremic toxins.
Caused by slow, cumulative damage and
scarring of the tiny blood filters in the
kidneys.
May lead to gradual loss of renal function,
and eventual renal failure.
Causes
The specific cause of most cases of chronic
glomerulonephritis is unknown.
Viral infections, such as hepatitis B or C
and AIDS.
Autoimmune disorders, such as systemic
lupus erythematosus, or other causes of
vasculitis
May be due to repeated episodes of acute
glomerulonephritis.

May develop silently (without symptoms)
over several years.
Early signs and symptoms may include:
Blood or protein in the urine (hematuria,
proteinuria)
High blood pressure
Swelling of ankles or face (edema)
Frequent nighttime urination
Very bubbly or foamy urine

…c/f cont’d
As the disease progresses, signs and
symptoms of renal insufficiency and chronic
renal failure may develop
Loss of appetite, nausea and vomiting
Periorbital and peripheral (dependent)
edema
Dry and itchy skin
Sign of anemia, heart failure
Peripheral neuropath
Reversal in sleep pattern
Nighttime muscle cramps
Seizures, tremors
Diagnostic Findings
History and physical examination
Laboratory studies-Blood and urine tests
Chest x-ray- to show fluid overload.
Ultrasound study of the kidneys may be
performed to evaluate the size of the
kidneys.
kidneys are reduced to as little as one-
fifth their normal size (consisting largely
of fibrous tissue).
A kidney biopsy may be performed.

Management
Symptomatic management
If the patient has hypertension, the blood
pressure is reduced with sodium and water
restriction, antihypertensive agents, or both
Weight is monitored daily
Medications are prescribed to treat fluid
overload
Treat UTIs to prevent further renal damage.
Initiation of dialysis is considered early in the
course of the disease to keep the patient in
optimal physical condition.

Nephrotic syndrome
Is a glomerular disease characterized by:
Marked increase in protein in the urine
(proteinuria)
Decrease in albumin in the blood
(hypoalbuminemia)
Edema
High serum cholesterol and low-density
lipoproteins (hyperlipidemia)
It is characterized by an increase in
permeability of the capillary walls of
the glomerulus.
It is most commonByin children but can affect200
Mekasha G.(MSc, MPH)
Causes
• Most commonly, it is primary or idiopathic.
• Primary causes include:
Minimal-change nephropathy
Focal glomerulosclerosis
Membranous nephropathy
Hereditary nephropathies
• Secondary causes include
Diabetes mellitus
Lupus erythematosus
Amyloidosis and paraproteinemia
Multiple myeloma
Viral infections (eg, hepatitis B, hepatitis C,
HIV)
P
a
t
h
o
p
h
y
s
i
o
l
o
g
y By Mekasha G.(MSc, MPH) 202
Soft and pitting edema that commonly
occurs around the eyes (periorbital), in
dependent areas (sacrum, ankles, and
hands), and in the abdomen (ascites).
Malaise, headache, irritability, and fatigue
Poor appetite
Unintentional weight gain
Foamy urine

Diagnostic Findings
Urinary protein measurement
Proteinuria exceeding 3 to 3.5 g/day is
sufficient for the diagnosis of nephrotic
syndrome
Serum albumin
hypoalbuminemia: albumin levels of ≤2.5
g/dl
Renal function tests
Lipid profile- elevated LDL, VLDL
Renal ultrasonography
Renal biopsy
Management
Treatment can be symptomatic or can
directly address the injuries caused to the
kidney.
Diuretic agents may be prescribed for the
patient with severe edema.
The use of ACE inhibitors in combination
with diuretics often reduces the degree of
proteinuria but may take 4 to 6 weeks to be
effective.
Antineoplastic agents or
immunosuppressant medications.
No data to show that lipid-lowering drugs
improve renal or Bypatient outcomes.
…magt cont’d
low-sodium, liberal-potassium diet to
enhance the sodium/potassium pump
mechanism, thereby assisting in elimination
of sodium to reduce edema.
Protein intake should be about 0.8 g/kg/day,
with emphasis on high biologic proteins
(dairy products, eggs, meats), and the diet
should be low in saturated fats (not
consume more than 1 g of protein/kg body
weight/ day).
Ongoing activity, rather than bed rest, will
reduce the risk of blood clots.
Complications
Infection
Renal vein thrombosis
Atherosclerosis and related heart diseases
Acute renal failure
Chronic kidney disease
Fluid overload, CHF, pulmonary edema
Malnutrition

Renal Failure
Also called kidney failure, is diagnosed
when the kidneys cannot remove the body’s
metabolic wastes or perform their
regulatory functions.
Results in dysfunction in almost all other
parts of the body as a result of imbalances
in fluid, electrolytes, and calcium levels, as
well as impaired RBC formation and
decreased elimination of waste products.
It can be acute or chronic

Acute renal failure (ARF)
• Is a rapid loss of renal function due to
damage to the kidneys.
• In ARF, rapid damage to the kidney causes
waste products to accumulate in the
bloodstream, resulting in the symptoms of
renal failure.
• Has a high mortality rate that ranges from
25% to 90%.

Causes
• Prerenal Failure (hypoperfusion of kidney)
• Occurs in 60% to 70% of cases
Volume depletion resulting from:
 Hemorrhage, Renal losses (diuretics,
osmotic diuresis),GI losses (vomiting,
diarrhea, nasogastric suction)
Impaired cardiac efficiency resulting from:
 MI, HF, dysrhythmias, cardiogenic shock
Vasodilation resulting from:
 Sepsis, anaphylaxis, medications like
antihypertensive or others
…cause cont’d
• Intrarenal Failure (actual damage to kidney
tissue)
Prolonged renal ischemia resulting from:
 Pigment nephropathy, myoglobinuria,
hemoglobinuria
Nephrotoxic agents such as:
 Certain antibiotics (aminoglycosides,
tetracyclines), NSAIDs, ACE inhibitors, contrast
agents, Heavy metals (lead, mercury),
chemicals (carbon tetrachloride, arsenic),
Infectious processes such as:
 acute pyelonephritis, acute glomerulonephritis
…cause cont’d
• Postrenal Failure (obstruction to urine
flow)
Urinary tract obstruction, including:
Calculi (stones)
Tumors
Benign prostatic hyperplasia
Strictures
Blood clots
 In this case the blood supply to the kidneys
and nephron function initially may be
normal, but resulting in impaired nephron
function. By Mekasha G.(MSc, MPH) 212
Phases of Acute Renal Failure
• There are four phases of ARF:
Initiation
Oliguria
Diuresis and
Recovery

…Phases cont’d
Initiation period begins with the initial insult
and ends when oliguria develops.
Oliguria period is accompanied by an increase
in the the serum concentration of substances
excreted by the kidneys .
In phase uremic symptoms first appear and life-
threatening conditions such as hyperkalemia
develop.
Diuresis period is marked by a gradual
increase in urine output, which signals that
glomerular filtration has started to recover.
Uremic symptoms may still be present. The
patient must be observed closely for dehydration
during this phase. By Mekasha G.(MSc, MPH) 214
…Phases cont’d
Recovery period signals the improvement
of renal function and may take 3 to 12
months.
Laboratory values return to the patient’s
normal level.
Although a permanent 1% to 3% reduction
in the GFR is common, it is not clinically
significant.

Almost every system of the body is affected
with failure of the normal renal regulatory
mechanisms.
The patient may appear critically ill and
lethargic.
The skin and mucous membranes are dry
from dehydration.
CNS symptoms; drowsiness, headache,
muscle twitching, and seizures.
Sign of metabolic acidosis and electrolyte
imbalance.
Diagnostic Findings
Common laboratory finding
A widely accepted criterion for ARF is a
50% or greater increase in serum
creatinine above baseline (normal is < 1.0
mg/dl)
Evaluation for changes in the urine
Urine volume may be normal, or changes
may occur. Oliguria (<500 mL/day),
nonoliguria (>800 mL/day), or anuria(<50
mL/day)
Hematuria may be present, and the urine
has a low specificBy Mekasha
gravity.
G.(MSc, MPH) 217
…dx cont’d
Serum electrolyte levels
Anemia
X-ray examination of the kidneys, ureters,
and bladder to diagnose causes of
postrenal failure
Ultrasonography

Management
The objectives of treatment are:
to restore normal chemical balance and
prevent complications
Management includes:
Eliminating the underlying cause
Maintaining fluid balance; and
Providing renal replacement therapy
(when indicated)

…magt cont’d
 Prerenal azotemia is treated by optimizing
renal perfusion
 Intrarenal azotemia is treated with
supportive therapy
 Postrenal failure is treated by relieving the
obstruction.
 Adequate renal blood flow in patients with
prerenal causes of ARF may be restored by IV
fluids or transfusions of blood products.
 Dialysis may be initiated to prevent
complications of ARF, such as hyperkalemia,
metabolic acidosis, pericarditis, and
pulmonary edema.By Mekasha G.(MSc, MPH) 220
Methods to replace normal kidney
• Continuous renal replacement
therapies (CRRTs)-function by circulating
the patient’s blood through a hemofilter.
• Hemodialysis- is a procedure that
circulates the patient’s blood through a
dialyzer to remove waste products and
excess fluid
• Peritoneal dialysis- a procedure that uses
the patient’s peritoneal membrane as the
semipermeable membrane to exchange
fluid and solutes

Prevention of ARF
Provide adequate hydration to patients at risk
for dehydration
Prevent and treat shock promptly with blood
and fluid replacement.
Monitor central venous and arterial pressures
and hourly urine output of critically ill
patients to detect the onset of renal failure as
early as possible.
Continually assess renal function (urine
output, laboratory values) when appropriate.
Appropriately administer blood in order to
avoid severe transfusion reactions, which can
precipitate renal failure.
…prev cont’d
Prevent and treat infections promptly.
Pay special attention to wounds, burns, and
other precursors of sepsis.
Give meticulous care to patients with
indwelling catheters. Remove catheters as
soon as possible.
Closely monitor dosage, duration of use,
and blood levels of all medication
metabolized or excreted by the kidneys.

Chronic Renal Failure or ESRD
It occurs with a gradual decrease in the
function of the kidneys over time.
This loss of function is not reversible.
The causes of chronic renal failure are
numerous; common ones include:
Diabetic nephropathy
Chronic hypertension causing
nephrosclerosis
Glomerulonephritis, and
Autoimmune diseases

Every body system is affected in ESRD,
patients exhibit a number of signs and
symptoms.
Uremia develops and adversely affects every
system in the body.
In the early, or silent, stage the patient is
usually without symptoms, even though up to
50% of nephron function may have been lost.
The renal insufficiency stage occurs when the
patient has lost 75 % of nephron function and
some signs of mild renal failure are present.
Anemia and the inability to concentrate urine
may occur. The BUN and creatinine levels are
slightly elevated. By Mekasha G.(MSc, MPH) 225
….s/s cont’d
ESRD occurs when 90% of the nephrons are
lost. Patients at this stage experience
chronic and persistent abnormal kidney
function.
The BUN and creatinine levels are always
elevated.
These patients may make urine but not filter
out the waste products, or urine production
may cease.

Diagnostic Findings
Decreased GFR
Sodium and Water Retention
Metabolic acidosis
Anemia
Serum electrolyte disturbance (see what
happens)

Management
Complications can be prevented or delayed by
administering prescribed phosphate-binding
agents, calcium supplements, antihypertensive
and cardiac medications, antiseizure
medications, and erythropoietin.
Dietary intervention-Protein is restricted. The
allowed protein must be of high biologic value.
Calories are supplied by carbohydrates and fat
to prevent wasting.
Vitamin supplementation is necessary because
a protein-restricted diet does not provide the
necessary complement of vitamins

…magt cont’d
Hyperkalemia is usually prevented by
ensuring adequate dialysis treatments with
potassium removal and careful monitoring
of diet, medications, and fluids for their
potassium content.
The patient with increasing symptoms of
renal failure is referred to a dialysis and
transplantation center early in the course
of progressive renal disease.

Complications
Hyperkalemia
Acidosis
Pericarditis, pericardial effusion, and
pericardial tamponade
Hypertension
Anemia
Irritating during hemodialysis
Bone disease and metastatic and vascular
calcifications

End of chapter
Thank you !!!

GUT Disorder

Uploaded by

Copyright:

Available Formats

GUT Disorder

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

GUT Disorder

Uploaded by

Copyright:

Available Formats

Disorder of the

By Mekasha G.(MSc, MPH) 1

By Mekasha G.(MSc, MPH) 4

By Mekasha G.(MSc, MPH) 5

By Mekasha G.(MSc, MPH) 11

By Mekasha G.(MSc, MPH) 13

By Mekasha G.(MSc, MPH) 14

Refers to an involuntary loss of urine.

Is difficulty initiating the process of micturation.

Is difficulty of completing micturation in a clean

By Mekasha G.(MSc, MPH) 16

By Mekasha G.(MSc, MPH) 21

By Mekasha G.(MSc, MPH) 23

By Mekasha G.(MSc, MPH) 25

 Urinalysis and urine culture

 Renal function tests

 X-ray and other imaging modalities

 Endo urological procedures

 Clean catch/mid stream urine

 24 hrs urine collection

By Mekasha G.(MSc, MPH) 28

By Mekasha G.(MSc, MPH) 29

 All creatinine filtered by kidneys in a certain

 Disorders of the kidney interfere with normal

 Thus creatinine measures the effectiveness of

(Volume of urine [mL/min] urine creatinine [mg/dL])

 Evaluate the hydration status

 The contrast injected travels through the

 Allows to see and assess the anatomy and

By Mekasha G.(MSc, MPH) 39

 Visualization of the urinary

By Mekasha G.(MSc, MPH) 49

By Mekasha G.(MSc, MPH) 53

By Mekasha G.(MSc, MPH) 54

By Mekasha G.(MSc, MPH) 56

By Mekasha G.(MSc, MPH) 57

By Mekasha G.(MSc, MPH) 58

By Mekasha G.(MSc, MPH) 61

 Pillow under the other side flank

By Mekasha G.(MSc, MPH) 63

By Mekasha G.(MSc, MPH) 67

Gain of water, as in excessive administration of D5W.

Medications associated with water retention

Anorexia, nausea and vomiting

By Mekasha G.(MSc, MPH) 75

Gradual lowering of the serum sodium

By Mekasha G.(MSc, MPH) 84

If serum potassium levels are dangerously

Monitor the BP hence hypotension may result

By Mekasha G.(MSc, MPH) 88

By Mekasha G.(MSc, MPH) 96

By Mekasha G.(MSc, MPH) 98

By Mekasha G.(MSc, MPH) 101

 Cellular potassium moves out of

Treatment is directed at improving

By Mekasha G.(MSc, MPH) 112

Treatment is directed at correcting

By Mekasha G.(MSc, MPH) 116

By Mekasha G.(MSc, MPH) 117

• Is inflammation of the urethra that may be