FACTOR	MECHANISM
Obstruction	Incomplete bladder emptying creates a continuous pool of urine in which bacteria can grow, prevents flushing out of bacteria, and allows bacteria to ascend more easily to higher structures. Bacteria have a greater chance of multiplying the longer they remain in residual urine. Overdistention of the bladder damages the mucosa and allows bacteria to invade the bladder wall.
Stones (calculi)	Large stones can obstruct urine flow. The rough surface of a stone irritates mucosal surfaces and creates a spot where bacteria can establish and grow. Bacteria can live within stones and cause re-infection.
Vesicoureteral reflux	Bacteria-laden urine is forced backward from the bladder up into the ureters and kidneys, where pyelonephritis can develop. Reflux of sterile urine can cause kidney scarring, which may promote kidney dysfunction.
Diabetes mellitus	Excess glucose in urine provides a rich medium for bacterial growth. Peripheral neuropathy affects bladder innervation and leads to a flaccid bladder and incomplete bladder emptying.
Characteristics of urine	Alkalotic urine promotes bacterial growth. Concentrated urine promotes bacterial growth.
Gender	Women are susceptible to periurethral colonization with coliform bacteria. Use of diaphragms, frequency of intercourse, and a new partner within the past year are associated with urinary tract infection (UTI) in women. Bladder displacement during pregnancy predisposes women to cystitis and the development of pyelonephritis. A diaphragm or pessary that is too large can obstruct urine flow or traumatize the urethra.
Age	Urinary stasis may be caused by incomplete bladder emptying as a result of an enlarged prostate in men and cystocele and prolapse in women. Neuromuscular conditions that cause incomplete bladder emptying, such as Parkinson disease and strokes, affect older adults more frequently. The use of anticholinergic drugs in older adults contributes to delayed bladder emptying. Fecal incontinence contributes to poor perineal hygiene. Hypoestrogenism in older women adversely affects the cells of the vagina and urethra, making them more susceptible to infections.
Sexual activity	Irritation of the perineum and urethra during intercourse can promote migration of bacteria from the perineal area to the urinary tract in some women. Spermicides can alter vaginal pH, increasing potential numbers of pathogens. Inadequate vaginal lubrication may exacerbate potential urethral irritation. Bacteria may be introduced into the man’s urethra during anal intercourse or during vaginal intercourse with a woman who has a bacterial vaginitis.
Recent use of antibiotics	Antibiotics change normal protective flora, providing opportunity for pathogenic bacterial overgrowth and colonization.

Cystitis

Pathophysiology

Cystitis is an inflammation of the bladder. It can be caused by irritation or, more commonly, by infection from bacteria, viruses, fungi, or parasites. Infectious cystitis is the most common of the UTIs. Noninfectious cystitis is caused by irritation from chemicals or radiation. Interstitial cystitis is an inflammatory disease that has no known cause.

Infectious agents, most commonly bacteria, move up the urinary tract from the external urethra to the bladder. Less common, spread of infection through the blood and lymph fluid can occur. Once bacteria enter the urinary tract, several factors influence the outcome (Table 69-2).

TABLE 69-2 IMPORTANT FACTORS INFLUENCING THE OUTCOME OF URINARY TRACT INFECTION

FACILITATING ASPECTS	PROTECTIVE ASPECTS
Anatomy
Females: Short length of the urethra and its proximity to the vagina and rectum facilitate colonization of coliform bacteria.
Males: With age, the prostate enlarges and may obstruct the normal flow of urine, producing stasis.	Males: Long length of the urethra and its distance from the rectum provide protection from colonization with coliform bacteria.
Physiology
Females: Pregnancy predisposes a woman to ureteral reflux and subsequent pyelonephritis; with age, the decline in estrogen facilitates colonization of Escherichia coli. In addition, vaginal atrophy can alter urethral competency. Males: With age, prostatic secretions lose their antibacterial characteristics and predispose to bacterial proliferation in the urine.	Females: Well-estrogenized mucosa in the urethra and trigone may inhibit bacterial colonization and enhance urogenital blood flow. Males: Normal prostatic secretions inhibit bacterial growth. Both males and females: Mucin is produced by urothelial cells lining the bladder—this helps maintain mucosal integrity and prevent cellular damage; mucin may also prevent bacteria from adhering to urothelial cells.
Trauma
Females: Vaginal penetration with sexual intercourse may traumatize the urethra and bladder base, leading to postcoital (or “honeymoon”) cystitis; a vaginal diaphragm that is too large can place pressure on the urethra, causing trauma; vaginal childbirth can cause permanent damage to the urethra. Males: Sexually transmitted diseases may cause urethral strictures that obstruct the flow of urine and predispose to urinary stasis. Both males and females: Urethral instrumentation (e.g., catheterization) may disturb the urothelial surface and predispose to adherence of bacteria that would ordinarily not be pathogenic.	Females: Adequate lubrication, either natural or artificial, with intercourse may prevent any trauma.
Infectious Agent
Some organisms are better able to adhere to host cells and secrete substances that induce inflammation.	A small inoculum (number of microorganisms introduced into the body) is more easily flushed away by the flow of urine.

The presence of bacteria in the urine is bacteriuria and can occur with any urologic infection. When bacteriuria is without symptoms of infection, it is called colonization. Colonization, asymptomatic bacteriuria, is more common in older adults. This problem does not appear to progress to acute infection or kidney impairment unless the patient has other pathologic problems, and then it requires treatment.

Etiology and Genetic Risk

UTIs, like other infections, are the result of interactions between a pathogen and the host. Usually, a high bacterial virulence (ability to invade and infect) is needed to overcome normal strong host resistance. However, a compromised host is more likely to become infected even with bacteria that have low virulence. Genetically, invading bacteria with special adhesions are more likely to cause ascending UTIs that start in the urethra or bladder and move up into the ureter and kidney. Patient-specific genetic factors such as blood type and ability to produce bladder surface biofilms that protect bacteria may influence the risk for UTI (Bowen & Hellstrom, 2007).

Infectious cystitis is most commonly caused by organisms from the intestinal tract. About 90% of UTIs are caused by Escherichia coli. Less common organisms include Staphylococcus saprophyticus, Klebsiella pneumoniae, and organisms from the Proteus and Enterobacter species (Bowen & Hellstrom, 2007).

In most cases, organisms first grow in the perineal area, then move into the urethra as a result of irritation, trauma, or catheterization of the urinary tract, and finally ascend to the bladder. Catheters are the most common factor placing patients at risk for UTIs in the hospital setting. Within 48 hours of catheter insertion, bacterial colonization begins. About 50% of patients with indwelling catheters become infected within 1 week of catheter insertion.

How a catheter-related infection occurs varies between genders. Bacteria from a woman’s perineal area are more likely to ascend to the bladder by moving along the outside of the catheter. In men, bacteria tend to gain access to the bladder from inside the lumen of the catheter. Any break in the closed urinary drainage system allows bacteria to move through the urinary tract. Best practices to reduce the risk for catheter contamination and catheter-related UTIs are listed in Chart 69-1.

Chart 69-1

Best Practice for Patient Safety & Quality Care

Minimizing Catheter-Related Infection

• Assess patients daily for those who no longer need indwelling catheters.

• Consider appropriate alternatives to an indwelling catheter.

• Use aseptic routine when handling catheter devices; manipulation can promote an environment favorable to pathogens.

• Select a small-size catheter (14 to 18 Fr with a 5-mL balloon).

• Use strict sterile technique to insert the catheter (in the hospital setting); a break in technique can introduce pathogens into the urinary tract.

• Do not inject more than 10 mL into the balloon.

• Maintain a closed-system irrigation by ensuring that catheter tubing connections are sealed securely; disconnections can introduce pathogens into the urinary tract.

• Avoid routine catheter irrigation.

• Keep urine collection bags below the level of the bladder at all times; elevating the collection bag above the bladder causes reflux of pathogens from the bag into the urinary tract.

• Secure the catheter to the patient’s thigh (women) or lower abdomen (men); catheter movement can cause urethral friction and irritation.

• Perform daily catheter care by washing the perineum and proximal portion of the catheter with soap and water and drying gently (removes pathogens and reduces pathogenic population).

• Consider the use of coated catheters for patients requiring indwelling catheters for more than 3 to 5 days. This coating reduces bacterial colonization along the catheter.

Application of antiseptic solutions or antibiotic ointments to the perineal area of catheterized patients has not been demonstrated to have any beneficial effect.

Data from Smith, J. (2003). Indwelling catheter management: From habit to evidence-based practice. Ostomy and Wound Management, 49(12), 34-45.

Organisms other than bacteria also can cause cystitis. Fungal infections, such as those caused by Candida, can occur during long-term antibiotic therapy, because antibiotics reduce normal protective flora. Patients who are severely immunosuppressed, are receiving corticosteroids or other immunosuppressive agents, or have diabetes mellitus or acquired immune deficiency syndrome (AIDS) are at higher risk for fungal UTIs.

Viral and parasitic infections are rare and usually are transferred to the urinary tract from an infection at another body site. For example, Trichomonas, a parasite found in the vagina, can also be found in the urine. Treatment of the vaginal infection (see Chapter 74) also resolves the UTI.

Noninfectious cystitis may result from chemical exposure, such as to drugs (e.g., cyclophosphamide [Cytoxan, Procytox ]), from radiation therapy, and from immunologic responses, as with systemic lupus erythematosus (SLE).

Interstitial cystitis is a rare, chronic inflammation of the bladder, urethra, and adjacent pelvic muscles that is not a result of infection. The condition affects women ten times more often than men, and the diagnosis is difficult to make. Manifestations are similar to those of infectious cystitis with voiding occurring as often as 60 times daily, more intense urgency preceding urination, and suprapubic or pelvic pain, sometimes radiating to the groin, vulva or rectum, that is relieved by voiding. Results from urinalysis and urine culture are negative for infection (Evans & Sant, 2007; Siegel et al., 2008).

Although cystitis is not life threatening, infectious cystitis can lead to life-threatening complications, including pyelonephritis and sepsis. Severe kidney damage is a rare complication unless the patient also has other predisposing factors, such as anatomic abnormalities, pregnancy, obstruction, reflux, calculi, or diabetes.

The spread of the infection from the urinary tract to the bloodstream is termed urosepsis and is more common among older adults (Kessenich, 2010). Sepsis from any source is a systemic infection that can lead to overwhelming organ failure, shock, and death. The most common cause of sepsis in the hospitalized patient is a UTI (CDC, 2009). Sepsis has a high mortality and prolongs hospital stays (see Chapter 39).

Incidence/Prevalence

The incidence of UTI is second only to that of upper respiratory infections in primary care. Patients who have frequency (an urge to urinate frequently in small amounts), dysuria (pain or burning with urination), and urgency (the feeling that urination will occur immediately) account for more than 5 million health care visits annually. About 50% of these patients will have a confirmed UTI (U.S. Renal Data Systems, 2010).

Considerations for Older Adults

The prevalence of UTIs varies with age and gender. Women of any age are more commonly affected with UTIs than are men. In men, the incidence of UTI greatly increases after 73 years of age. In women, the prevalence of UTIs increases from 20% among all women to 50% in those older than 80 years (U.S. Renal Data Systems, 2010). Skin and mucous membrane changes from a lack of estrogen appear to account for much of the increased risk in older women. Prostate disease increases risk for UTIs in men.

Health Promotion and Maintenance

Although cystitis is common, in many cases it is preventable. In the health care setting, reducing the use of indwelling urinary catheters is a major prevention strategy (Gray, 2010). When catheters must be used, strict attention to sterile technique during insertion can reduce the risk for UTIs as can consistent and adequate perineal and catheter care (see Chart 69-1).

Nursing Safety Priority

Action Alert

Ensuring that urinary catheters are used appropriately and discontinued as early as possible is everyone’s responsibility. Do not allow catheters to remain in place for staff convenience.

Changes in fluid intake patterns, urinary elimination patterns, and hygiene patterns can help prevent or reduce cystitis in the general population. Teach all people to have a minimum fluid intake of 1.5 to 2.5 L daily unless fluid restriction is required for other health problems. Another strategy is to have sufficient fluid intake to cause 2 to 2.5 L of urine daily. Encourage people to drink more water rather than sugar-containing drinks. Teach people to avoid urinary stasis by urinating every 3 to 4 hours rather than waiting until the bladder is greatly distended. Encourage everyone either to shower daily or to wash the perineal and urethral areas daily with mild soap and a water rinse. Teach women to avoid the use of vaginal washes. Other hygiene measures that specifically reduce the risk for cystitis and other UTIs are listed in Chart 69-2.

Chart 69-2 Patient and Family Education

Preparing for Self-Management: Preventing a Urinary Tract Infection

• Drink at least 2 to 3 L of sugarless fluid every day.

• Be sure to get enough sleep, rest, and nutrition daily.

• [For women] Clean your perineum (the area between your legs) from front to back.

• [For women] Avoid using or wearing irritating substances, such as bubble bath, nylon underwear, and scented toilet tissue. Wear loose-fitting cotton underwear.

• [For women] Empty your bladder before and after intercourse.

• For both women and men, gently wash the perineal area before intercourse.

• Avoid the use of scented or flavored lubricants.

• If you experience burning when you urinate, if you have to urinate frequently, or if you find it difficult to begin urinating, notify your physician or other health care provider right away, especially if you have a chronic medical condition (e.g., diabetes) or are pregnant.

• Empty your bladder as soon as you feel the urge to urinate.

• Empty your bladder regularly (every 4 hours), even if you do not feel the urge to urinate.

• You may try these home therapies:

• Cranberry juice (pure), 50 mL daily

• Apple cider vinegar, 2 tablespoons three times daily in juice

• Vitamin C, 500 mg daily to acidify the urine

• To prevent recurrent infection:

• Take your prescribed antibiotic or other drug as directed, even after the symptoms go away.

• Schedule a follow-up appointment for 10 to 14 days after you finish taking the drug. At your follow-up visit, another urine sample may be taken for analysis or culture.

Patient-Centered Collaborative Care

Assessment

Physical Assessment/Clinical Manifestations

Frequency, urgency, and dysuria are the common manifestations of a urinary tract infection (UTI), but other manifestations may be present (Chart 69-3). Urine may be cloudy, foul smelling, or blood tinged. Ask the patient about risk factors for UTI during the assessment (see Table 69-1). For noninfectious cystitis, the Pelvic Pain and Urgency/Frequency (PUF) Patient Symptom Scale can identify patients with interstitial cystitis.

Chart 69-3 Key Features

Urinary Tract Infection

Common Clinical Manifestations

Rare Clinical Manifestations

Clinical Manifestations that May Occur in the Older Adult

• The only symptom may be something as vague as increasing mental confusion or frequent, unexplained falls.

• A sudden onset of incontinence or a worsening of incontinence may be the only symptom of an early UTI.

• Fever, tachycardia, tachypnea, and hypotension, even without any urinary symptoms, may be signs of urosepsis.

• Loss of appetite, nocturia, and dysuria are common symptoms.

UTI, Urinary tract infection.

Before performing the physical assessment, ask the patient to void so that the urine can be examined and the bladder emptied before palpation. Assess vital signs to help rule out sepsis. Inspect the lower abdomen, and palpate the urinary bladder. Distention after voiding indicates incomplete bladder emptying.

Using Standard Precautions, examine any lesions around the urethral meatus and vaginal opening. To help differentiate between a vaginal and a urinary tract infection, note whether there is any vaginal discharge (vaginal discharge and irritation are more indicative of vaginal infection). Women often report burning with urination when normal acidic urine touches labial tissues that are inflamed or ulcerated by vaginal infections or sexually transmitted diseases (STDs). Maintain privacy with drapes during the examination.

The prostate is palpated by digital rectal examination (DRE) for size, change in shape or consistency, and tenderness. The physician or advanced practice nurse performs the DRE.

Laboratory assessment for a UTI is a urinalysis with testing for leukocyte esterase and nitrate. The combination of a positive leukocyte esterase and nitrate is 68% to 88% sensitive in the diagnosis of a UTI (Bowen & Hellstrom, 2007). Although a urinalysis can include a microscopic count of bacteria, white blood cells (WBCs), and red blood cells (RBCs), this additional testing is more expensive, is time consuming, and may not improve diagnostic accuracy. The presence of more than 20 epithelial cells/high power field (hpf) suggests contamination. The presence of 100,000 colonies/mL or the presence of three or more WBCs (pyuria) with RBCs (hematuria) indicates infection.

A urinalysis is performed on a clean-catch midstream specimen. If the patient cannot produce a clean-catch specimen, you may need to obtain the specimen with a small-diameter (6 Fr) catheter. For a routine urinalysis, 10 mL of urine is needed; smaller quantities are sufficient for culture.

A urine culture confirms the type of organism and the number of colonies. Urine culture is expensive, and results take at least 48 hours. It is indicated when the UTI is complicated or does not respond to usual therapy or the diagnosis is uncertain. A UTI is confirmed when more than 10⁵ colony-forming units are in the urine from any patient. In patients who also have symptoms of UTI, as few as 10³ colony-forming units may allow the diagnosis to be made. The presence of many different types of organisms in low colony counts usually indicates that the specimen is contaminated. Sensitivity testing follows culture results when complicating factors are present (e.g., stones or recurrent infection), when the patient is older, or to ensure the appropriate antibiotics are prescribed.

Occasionally the serum WBC count may be elevated, with the differential WBC count showing a “left shift” (see Chapter 19). This shift indicates that the number of immature WBCs is increasing in response to the infection. As a result, the number of bands, or immature WBCs, is elevated. Left shift most often occurs with urosepsis and rarely occurs with uncomplicated cystitis, which is a local rather than a systemic infection.

Other Diagnostic Assessment

The diagnosis of cystitis is based on the history, physical examination, and laboratory data. If urinary retention and obstruction of urine outflow are suspected, urography, abdominal sonography, or computed tomography (CT) may be needed to locate the site of obstruction or the presence of calculi. Voiding cystourethrography (see Chapter 68) is needed when ureteral reflux is suspected.

Cystoscopy (see Chapter 68) may be performed when the patient has recurrent UTIs (more than three or four a year). A urine culture is performed first to ensure that no infection is present. If infection is present, the urine is sterilized with antibiotic therapy before the procedure to reduce the risk for sepsis. Cystoscopy identifies abnormalities that increase the risk for cystitis. Such abnormalities include bladder calculi, bladder diverticula, urethral strictures, foreign bodies (e.g., sutures from previous surgery), and trabeculation (an abnormal thickening of the bladder wall caused by urinary retention and obstruction). Retrograde pyelography, along with the cystoscopic examination, shows outlines and images of the drainage tract. Areas of obstruction or malformation and the presence of reflux are then identified early.

Cystoscopy is needed to accurately diagnose interstitial cystitis. A urinalysis usually shows WBCs and RBCs but no bacteria. Common findings in interstitial cystitis are a small-capacity bladder, the presence of Hunner’s ulcers (a type of bladder lesion), and small hemorrhages after bladder distention.

Interventions

Nonsurgical Management

The expected outcome is to maintain an optimal urinary elimination pattern. Nursing interventions for the management of cystitis focus on comfort and teaching about drug therapy, nutrition therapy, and prevention measures.

Drug Therapy

Drugs used to treat bacteriuria and promote patient comfort include urinary antiseptics or antibiotics, analgesics, and antispasmodics. Cure of a UTI depends on the antibiotic levels achieved in the urine (Chart 69-4). Oral antifungal agents are usually prescribed for fungal infections. When oral antifungal therapy is not sufficient, amphotericin B is most often given in daily bladder instillations. Antispasmodic drugs decrease bladder spasm and promote complete bladder emptying.

Chart 69-4 Common Examples of Drug Therapy

Urinary Tract Infections

Antibiotic therapy is used for bacterial UTIs (see Chart 69-4). Guidelines indicate that a 3-day, high-dose course of trimethoprim/sulfamethoxazole or a fluoroquinolone is effective in treating uncomplicated, community-acquired UTIs in women (Bowen & Hellstrom, 2007). Fluoroquinolones cannot be used to treat UTIs during pregnancy because of the potential for birth defects. The shorter courses increase adherence and reduce cost. Longer antibiotic treatment (7 to 21 days) and/or different agents are required for hospitalized patients; those with complicating factors, such as pregnancy, indwelling catheters, or stones; and those with diabetes or immunosuppression.

Nursing Safety Priority

Drug Alert

Two of the fluoroquinolone antibiotics, Tequin and Noroxin, are designated as sound-alike, look-alike agents with other drugs and could easily be administered in error. Take care to not confuse Tequin with Tegretol, an oral anticonvulsant, or with Ticlid, a platelet inhibitor. Take care to not confuse Noroxin with Neurontin, an oral anticonvulsant.

NCLEX Examination Challenge

Safe and Effective Care Environment

The client prescribed cephalexin (Keflex) for cystitis reports that she has had a severe allergic reaction to penicillin in the past. What is the nurse’s best action?

A. Reassure the client that Keflex is not penicillin.

B. Place an allergy alert band on the client’s wrist.

C. Notify the prescriber before administering the first Keflex dose.

D. Highlight this important information in the client’s medical record.

Long-term, low-dose antibiotic therapy is used for chronic, recurring infections caused by structural abnormalities or stones. Trimethoprim 100 mg daily may be used for long-term management of the older patient with frequent UTIs. For women who have recurrent UTIs after intercourse, one low-dose tablet of trimethoprim (TMP) (Proloprim, Trimpex) or TMP/sulfamethoxazole (half or single-strength Bactrim, Cotrim, Septra) or nitrofurantoin (Macrodantin, Nephronex , Novofuran ) after intercourse is often prescribed. Estrogen used as an intravaginal cream may prevent recurrent UTIs in the postmenopausal woman, although this therapy is controversial.

Women’s Health Considerations

Pregnant women with a bacterial UTI require prompt and aggressive treatment because simple cystitis can lead to acute pyelonephritis during pregnancy. Pyelonephritis in pregnancy can cause preterm labor and adversely affect the fetus.

Patients may associate symptoms of discomfort with sexual activities and have feelings of guilt and embarrassment. Open and sensitive discussions with a woman who has recurrences of UTI after sexual intercourse can help her find techniques to handle the problem (see Chart 69-2). Explore with her the factors that contribute to her infections, such as sexual penetration when the bladder is full, diaphragm use, and her general resistance to infection. Some positions during intercourse may reduce urethral irritation and subsequent cystitis. Remind the patient that although perineal washing before intercourse is helpful, vigorous cleaning of the perineum with harsh soaps and vaginal douching may irritate the perineal tissues and increase the risk for UTI. At the patient’s request, discuss the problem with her and her partner to help them find ways of maintaining their intimate relationship.

Decision-Making Challenge

Patient-Centered Care; Evidence-Based Practice

The 26-year-old female patient with recurrent cystitis tells you that she now “holds” her urine all day and drinks very little to prevent the need to use the public toilet while at work. She is convinced that the toilet is the source of her repeated bladder infections.

1. Is this patient’s understanding of the cause of recurrent cystitis correct? Why or why not?

2. What other assessment data should you obtain and why?

3. What will you tell her about the effectiveness of her actions to reduce the need to urinate at a public toilet?

4. What techniques could you suggest for her to use a public toilet for urination?

Urethritis

Pathophysiology

Urethritis is an inflammation of the urethra that causes symptoms similar to urinary tract infection (UTI). In men, manifestations include burning or difficulty urinating and a discharge from the urethral meatus. The most common cause of urethritis in men is sexually transmitted diseases (STDs). These include gonorrhea or nonspecific urethritis caused by Ureaplasma (a gram-negative bacterium), Chlamydia (a sexually transmitted gram-negative bacterium), or Trichomonas vaginalis (a protozoan found in both the male and female genital tract).

In women, urethritis causes manifestations similar to those of bacterial cystitis. Urethritis is known by several other terms: pyuria-dysuria syndrome, frequency-dysuria syndrome, trigonitis syndrome, and urethral syndrome. Urethritis is most common in postmenopausal women and appears to be caused by tissue changes related to low estrogen levels.

Patient-Centered Collaborative Care

Ask the patient about a history of STD, painful or difficult urination, discharge from the penis or vagina, and discomfort in the lower abdomen. Urinalysis may show pyuria (white blood cells [WBCs] in the urine) without a large number of bacteria. However, results of urethral culture may indicate an STD. In women, the diagnosis may be made by excluding cystitis when urinalysis and urethral culture are negative for bacteria but symptoms persist. In such cases, pelvic examination may reveal tissue changes from low estrogen levels in the vagina. Urethroscopy may show low estrogen changes with inflammation of urethral tissues.

STDs and infection are treated with antibiotic therapy. More information on STDs can be found in Chapter 76.

Postmenopausal women often have improvement in their urethral symptoms with the use of estrogen vaginal cream. Estrogen cream applied locally to the vagina increases the amount of estrogen in the urethra as well, and irritating symptoms are reduced.

Noninfectious Disorders

Urethral Strictures

Urethral strictures are narrowed areas of the urethra. These problems may be caused by complications of an STD (usually gonorrhea) and by trauma during catheterization, urologic procedures, or childbirth. About one third of urethral strictures have no obvious cause. Strictures occur more often in men than in women. They may be a factor in other urologic problems, such as recurrent UTIs, urinary incontinence, and urinary retention.

The most common symptom of urethral stricture is obstruction of urine flow. Strictures rarely cause pain. Because urine stasis can result when flow is obstructed, the patient with a stricture is at risk for developing a UTI and may have overflow incontinence. Overflow incontinence is the involuntary loss of urine when the bladder is overdistended. Assess the patient for these two problems.

A urethral stricture is treated surgically. Dilation of the urethra (using a local anesthetic) is only a temporary measure, not a curative one. Stent placement can be used in some patients. The best chance of long-term cure is with urethroplasty, which is the surgical removal of the affected area with or without grafting to create a larger opening. The recurrence rate after surgery is still high, and most patients need repeated procedures. The urethral stricture location and length are the most important factors affecting choice of interventions and recovery.

Urinary Incontinence

Pathophysiology

Continence is the control over the time and place of urination and is unique to humans and some domestic animals. It is a learned behavior in which a person can suppress the urge to urinate until a socially appropriate location is available (e.g., a toilet). Efficient bladder emptying (i.e., coordination between bladder contraction and urethral relaxation) is needed for continence.

Incontinence is an involuntary loss of urine severe enough to cause social or hygienic problems. It is not a normal consequence of aging or childbirth and often is a stigmatizing and an underreported health problem. Many people suffer in silence, are socially isolated, and may be unaware that treatment is available. In addition, the cost of incontinence can be enormous.

Continence occurs when pressure in the urethra is greater than pressure in the bladder. For normal voiding to occur, the urethra must relax and the bladder must contract with enough pressure and duration to empty completely. Voiding should occur in a smooth and coordinated manner under a person’s conscious control. Incontinence has several possible causes and can be either temporary or chronic (Table 69-3). Temporary causes usually do not involve a disorder of the urinary tract. The most common forms of adult urinary incontinence are stress incontinence, urge incontinence, overflow incontinence, functional incontinence, and a mixed form.

TABLE 69-3 TYPES OF URINARY INCONTINENCE

Stress incontinence is the most common type. Its main feature is the loss of small amounts of urine during coughing, sneezing, jogging, or lifting. In the continent person, the urethra can be relaxed and tightened under conscious control because skeletal muscles of the pelvic floor surround it. When a person feels the urge to urinate, the conscious contraction of the urethra can override a bladder contraction if the urethral contraction is strong enough.

Patients with stress incontinence cannot tighten the urethra enough to overcome the increased bladder pressure caused by contraction of the detrusor muscle. This is common after childbirth, when the pelvic muscles are stretched and weakened. The weakened pelvic floor allows the urethra to move during exertion. If the pelvic muscles are not strengthened, this condition continues. Low estrogen levels after menopause also contribute to stress incontinence. Vaginal, urethral, and pelvic floor muscles become thin and weak without estrogen.

Urge incontinence is the perception of an urgent need to urinate as a result of bladder contractions regardless of the volume of urine in the bladder. Normally when the bladder is full, contraction of the smooth muscle fibers of the bladder detrusor muscle signals the brain that it is time to urinate. Continent persons override that signal and relax the detrusor muscle for the time it takes to locate a toilet. Those who suffer from urge incontinence cannot suppress the signal and have a sudden strong urge to void and often leak large amounts of urine at this time. Urge incontinence is also known as an overactive bladder (OAB). Overactivity may have no known cause or may be the result of abnormal detrusor contractions related to other problems. Such problems include stroke and other neurologic problems, other urinary tract problems, and irritation from concentrated urine or artificial sweeteners, caffeine, alcohol, and citric intake. Drugs, such as diuretics, and nicotine can also irritate the bladder.

Mixed incontinence is the presence of more than one type of incontinence. Often urine loss is related to both stress and urge incontinence. The manifestations mimic more than one subtype. This category is more common in older women.

Overflow incontinence occurs when the detrusor muscle fails to contract and the bladder becomes overdistended. This type of incontinence (also known as reflex incontinence) occurs when the bladder has reached its maximum capacity and some urine must leak out to prevent bladder rupture. Causes for the underactive (acontractile) bladder may or may not be determined.

The urethra can be obstructed and fail to relax enough to allow urine flow. Incomplete bladder emptying or urinary retention from urethral obstruction results in overflow incontinence.

Functional incontinence is incontinence occurring as a result of factors other than the abnormal function of the bladder and urethra. A common factor is the loss of cognitive function in patients affected by dementia. To maintain continence, a person must be aware that urination needs to occur in a socially acceptable place. Patients with dementia may not have that awareness.

Etiology and Genetic Risk

Incontinence may have temporary or permanent causes. Evaluation of the incontinent patient means considering all possible causes, beginning with those that are temporary and correctable. Surgical and traumatic causes of urinary incontinence are related to procedures or surgery in the lower pelvic structures, areas that contain complex nerve pathways. Radical urologic, prostatic, and gynecologic procedures for treatment of pelvic cancers may result in urinary incontinence. Injury to segments S2 to S4 of the spinal cord may cause incontinence from impairment of normal nerve pathways.

Inappropriate bladder contraction may result from disorders of the brain and nervous system or from bladder irritation due to chronic infection, stones, chemotherapy, or radiation therapy. Failure of bladder contraction occurs with neuropathy of diabetes mellitus and syphilis.

Considerations for Older Adults

Many factors contribute to urinary incontinence in older adults (Chart 69-5). An older person may have decreased mobility from many causes. In inpatient settings, mobility is limited when the older patient is restrained or placed on bedrest. Vision and hearing impairments may also prevent the patient from locating a call light to notify the nurse or assistive personnel of the need to void. Assess for these factors, and minimize them to prevent urinary incontinence. Getting out of bed to urinate is a common cause of falls among older adults.