Outcomes (NOC)	Interventions (NIC) and Rationales
Urinary Elimination • Pain with urination _____ • Burning with urination _____ • Urinary frequency _____ • Urgency with urination _____ • Nocturia _____ • Visible blood in urine _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None	Urinary Elimination Management • Monitor urinary elimination including frequency, consistency, odor, volume, and color to evaluate elimination status. • Obtain midstream voided specimen for urinalysis (as appropriate) to determine pathogen causing UTI or to monitor effectiveness of treatment. • Instruct patient to monitor for signs and symptoms of urinary infection to obtain early treatment of recurrence. • Teach patient to drink 8 oz of liquid with meals, between meals, and in early evening to prevent dehydration, relieve bladder irritability, and decrease bacterial colonization. Infection Control • Instruct patient to take antibiotics as prescribed to alleviate infection and prevent development of antibiotic resistance. • Teach patient and family members how to avoid infections.

Outcomes (NOC)

Interventions (NIC) and Rationales

Urinary Elimination

• Pain with urination _____

• Burning with urination _____

• Urinary frequency _____

• Urgency with urination _____

• Nocturia _____

• Visible blood in urine _____

Urinary Elimination Management

• Monitor urinary elimination including frequency, consistency, odor, volume, and color to evaluate elimination status.

• Obtain midstream voided specimen for urinalysis (as appropriate) to determine pathogen causing UTI or to monitor effectiveness of treatment.

• Instruct patient to monitor for signs and symptoms of urinary infection to obtain early treatment of recurrence.

• Teach patient to drink 8 oz of liquid with meals, between meals, and in early evening to prevent dehydration, relieve bladder irritability, and decrease bacterial colonization.

Infection Control

• Instruct patient to take antibiotics as prescribed to alleviate infection and prevent development of antibiotic resistance.

• Teach patient and family members how to avoid infections.

Nursing Diagnosis

Readiness for enhanced self-health management as evidenced by verbalization of desire to manage treatment of illness and prevent recurrence

Patient Goals

1. Verbalizes knowledge of treatment regimen

2. Expresses intent to carry out treatment regimen

Outcomes (NOC)	Interventions (NIC) and Rationales
Knowledge: Treatment Regimen • Specific disease process _____ • Rationale for treatment regimen _____ • Self-care responsibilities for ongoing treatment _____ • Expected effects of treatment _____ • Prescribed medication regimen _____ Measurement Scale 1 = No knowledge 2 = Limited knowledge 3 = Moderate knowledge 4 = Substantial knowledge 5 = Extensive knowledge	Teaching: Disease Process • Appraise patient’s current level of knowledge related to specific disease process to plan individualized teaching. • Explain pathophysiology of the disease and how it relates to anatomy and physiology. • Describe rationale behind management/therapy/treatment recommendations to promote compliance with treatment. • Describe possible chronic complications to emphasize the need for completion of treatment. Teaching: Prescribed Medication • Instruct patient on the purpose and action of each medication. • Instruct patient on possible adverse effects of each medication so patient can identify problems. • Instruct patient on appropriate actions to take if side effects occur to prevent serious problems.

Outcomes (NOC)

Interventions (NIC) and Rationales

Knowledge: Treatment Regimen

• Specific disease process _____

• Rationale for treatment regimen _____

• Self-care responsibilities for ongoing treatment _____

• Expected effects of treatment _____

• Prescribed medication regimen _____

Measurement Scale

1 = No knowledge

2 = Limited knowledge

3 = Moderate knowledge

4 = Substantial knowledge

5 = Extensive knowledge

Teaching: Disease Process

• Appraise patient’s current level of knowledge related to specific disease process to plan individualized teaching.

• Explain pathophysiology of the disease and how it relates to anatomy and physiology.

• Describe rationale behind management/therapy/treatment recommendations to promote compliance with treatment.

• Describe possible chronic complications to emphasize the need for completion of treatment.

Teaching: Prescribed Medication

• Instruct patient on the purpose and action of each medication.

• Instruct patient on possible adverse effects of each medication so patient can identify problems.

• Instruct patient on appropriate actions to take if side effects occur to prevent serious problems.

Collaborative Problems

Potential Complication

Urosepsis (bacteriuria and bacteremia) related to systemic extension of UTI

Nursing Goals	Interventions (NIC) and Rationales
• Anticipate potential for urosepsis in patients at risk. • Report deviations from acceptable parameters. • Carry out appropriate medical and nursing interventions.	• Monitor vital signs and watch for changes in mental status in patients at risk (immunocompromised, elderly, those with frequent urinary system instrumentation or anatomic abnormalities) to detect inadequate tissue perfusion. • Report abnormalities such as hyperthermia or hypothermia; decreasing blood pressure; rapid pulse and respirations; and warm, flushed skin as indicators of septic shock resulting from urosepsis. • Monitor platelet levels and coagulation function tests because alterations indicate bleeding tendencies.

Nursing Goals

Interventions (NIC) and Rationales

• Anticipate potential for urosepsis in patients at risk.

• Report deviations from acceptable parameters.

• Carry out appropriate medical and nursing interventions.

• Monitor vital signs and watch for changes in mental status in patients at risk (immunocompromised, elderly, those with frequent urinary system instrumentation or anatomic abnormalities) to detect inadequate tissue perfusion.

• Report abnormalities such as hyperthermia or hypothermia; decreasing blood pressure; rapid pulse and respirations; and warm, flushed skin as indicators of septic shock resulting from urosepsis.

• Monitor platelet levels and coagulation function tests because alterations indicate bleeding tendencies.

^*Nursing diagnoses arranged in order of priority.

eNursing Care Plan 46-2 Patient With Urinary Tract Calculi

Nursing Diagnosis*

Impaired urinary elimination related to trauma or obstruction of ureters or urethra as evidenced by decreased urinary output, hematuria

Patient Goal

Maintains free flow of urine with minimal hematuria

Outcomes (NOC)	Interventions (NIC) and Rationales
Urinary Elimination • Elimination pattern _____ • Urine amount _____ • Urine color _____ • Fluid intake _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromise 5 = Not compromised	Urinary Elimination Management • Monitor urinary elimination including frequency, consistency, odor, volume, and color to evaluate patency of urinary system and degree of hematuria. • Teach patient to drink 8 oz of liquid with meals, between meals, and in early evening to provide fluids for hydration but not to an excess that may increase renal colic. • Teach patient signs and symptoms of urinary tract infection as infection may result from renal stones.

Outcomes (NOC)

Interventions (NIC) and Rationales

Urinary Elimination

• Elimination pattern _____

1 = Severely compromised

2 = Substantially compromised

3 = Moderately compromised

4 = Mildly compromise

5 = Not compromised

Urinary Elimination Management

• Monitor urinary elimination including frequency, consistency, odor, volume, and color to evaluate patency of urinary system and degree of hematuria.

• Teach patient to drink 8 oz of liquid with meals, between meals, and in early evening to provide fluids for hydration but not to an excess that may increase renal colic.

• Teach patient signs and symptoms of urinary tract infection as infection may result from renal stones.

Nursing Diagnosis

Acute pain related to effects of renal stone and inadequate pain control or comfort measures as evidenced by complaints of severe pain, diaphoresis, protective gestures, and guarding behavior

Patient Goal

Reports satisfactory pain relief

Outcomes (NOC)	Interventions (NIC) and Rationales
Pain Control • Uses analgesics as recommended _____ • Uses nonanalgesic relief measures _____ • Reports uncontrolled symptoms to health professional _____ • Reports pain controlled _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	Pain Management • Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors to plan appropriate interventions. • Provide the person optimal pain relief with prescribed analgesics as renal colic is a severe type of pain. • Implement the use of PCA to permit patient control of analgesic dosing. • Use pain control measures before pain becomes severe to prevent breakthrough pain that is difficult to control. • Teach the use of nonpharmacologic techniques before pain occurs or increases, along with other pain relief measures to optimize pain relief with a variety of measures. • Institute and modify pain control measures on the basis of patient response to individualize interventions.

Outcomes (NOC)

Interventions (NIC) and Rationales

Pain Control

• Uses analgesics as recommended _____

• Uses nonanalgesic relief measures _____

• Reports uncontrolled symptoms to health professional _____

• Reports pain controlled _____

Measurement Scale

1 = Never demonstrated

2 = Rarely demonstrated

3 = Sometimes demonstrated

4 = Often demonstrated

5 = Consistently demonstrated

Pain Management

• Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors to plan appropriate interventions.

• Provide the person optimal pain relief with prescribed analgesics as renal colic is a severe type of pain.

• Implement the use of PCA to permit patient control of analgesic dosing.

• Use pain control measures before pain becomes severe to prevent breakthrough pain that is difficult to control.

• Teach the use of nonpharmacologic techniques before pain occurs or increases, along with other pain relief measures to optimize pain relief with a variety of measures.

• Institute and modify pain control measures on the basis of patient response to individualize interventions.

Nursing Diagnosis

Deficient knowledge related to unfamiliarity with information resources and lack of experience with renal stones as evidenced by questions about how to prevent future renal stones

Patient Goal

Verbalizes understanding of disease process and measures to prevent recurrence

Outcomes (NOC)	Interventions (NIC) and Rationales
Knowledge: Illness Care • Recommended diet _____ • Specific disease process _____ • Treatment regimen _____ • Reputable health care resources _____ Measurement Scale 1 = No knowledge 2 = Limited knowledge 3 = Moderate knowledge 4 = Substantial knowledge 5 = Extensive knowledge	Teaching: Disease Process • Appraise the patient’s current level of knowledge related to specific disease process to plan appropriate teaching. • Describe the disease process. • Identify possible etiologies to decrease or avoid recurrence. • Describe rationale behind management/therapy/treatment recommendations to increase compliance. • Explore possible resources/support for further information on renal stones. Teaching: Prescribed Diet • Explain the purpose of the diet to increase compliance with the diet. • Assist patient to accommodate food preferences into the prescribed diet.

Outcomes (NOC)

Interventions (NIC) and Rationales

Knowledge: Illness Care

• Recommended diet _____

• Specific disease process _____

• Treatment regimen _____

• Reputable health care resources _____

Measurement Scale

1 = No knowledge

2 = Limited knowledge

3 = Moderate knowledge

4 = Substantial knowledge

5 = Extensive knowledge

Teaching: Disease Process

• Appraise the patient’s current level of knowledge related to specific disease process to plan appropriate teaching.

• Describe the disease process.

• Identify possible etiologies to decrease or avoid recurrence.

• Describe rationale behind management/therapy/treatment recommendations to increase compliance.

• Explore possible resources/support for further information on renal stones.

Teaching: Prescribed Diet

• Explain the purpose of the diet to increase compliance with the diet.

• Assist patient to accommodate food preferences into the prescribed diet.

PCA, Patient-controlled analgesia.

^*Nursing diagnoses listed in order of priority.

eNursing Care Plan 46-3 Patient With an Ileal Conduit *

Nursing Diagnosis**

Patient Goals

1. Reports decreased anxiety regarding the effects of surgery on lifestyle

2. Verbalizes understanding of surgical procedure and postoperative expectations

Outcomes (NOC)	Interventions (NIC) and Rationales
Preprocedure Readiness • Knowledge of procedure _____ • Knowledge of preprocedure routines _____ • Knowledge of postprocedure routines _____ • Identification of changes in health status _____ • Discussion of concerns about procedure _____ Measurement Scale 1 = Not adequate 2 = Slightly adequate 3 = Moderately adequate 4 = Substantially adequate 5 = Totally adequate Anxiety Self-Control • Seeks information to reduce anxiety _____ • Uses effective coping strategies _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	Teaching: Preoperative • Appraise the patient’s/caregiver’s anxiety relating to surgery to plan appropriate interventions. • Determine the patient’s expectations of the surgery to clarify misconceptions as needed. • Provide time for the patient to ask questions and discuss concerns to increase patient understanding of the procedure and decrease anxiety. • Describe the preoperative and postoperative routines to reduce fear of the unknown. • Instruct the patient to use coping techniques directed at controlling specific aspects of the experience (e.g., relaxation, imagery) as appropriate to increase patient’s sense of control. Anxiety Reduction • Provide factual information concerning diagnosis, treatment, and prognosis to reduce fear of the unknown and convey a caring attitude. • Assist patient to articulate a realistic description of an upcoming event to reduce anxiety and promote decision making. • Instruct patient in use of relaxation techniques to promote coping.

Outcomes (NOC)

Interventions (NIC) and Rationales

Preprocedure Readiness

• Knowledge of procedure _____

• Knowledge of preprocedure routines _____

• Knowledge of postprocedure routines _____

• Identification of changes in health status _____

• Discussion of concerns about procedure _____

Measurement Scale

1 = Not adequate

2 = Slightly adequate

3 = Moderately adequate

4 = Substantially adequate

5 = Totally adequate

Anxiety Self-Control

• Seeks information to reduce anxiety _____

• Uses effective coping strategies _____

Measurement Scale

1 = Never demonstrated

2 = Rarely demonstrated

3 = Sometimes demonstrated

4 = Often demonstrated

5 = Consistently demonstrated

Teaching: Preoperative

• Appraise the patient’s/caregiver’s anxiety relating to surgery to plan appropriate interventions.

• Determine the patient’s expectations of the surgery to clarify misconceptions as needed.

• Provide time for the patient to ask questions and discuss concerns to increase patient understanding of the procedure and decrease anxiety.

• Describe the preoperative and postoperative routines to reduce fear of the unknown.

• Instruct the patient to use coping techniques directed at controlling specific aspects of the experience (e.g., relaxation, imagery) as appropriate to increase patient’s sense of control.

Anxiety Reduction

• Provide factual information concerning diagnosis, treatment, and prognosis to reduce fear of the unknown and convey a caring attitude.

• Assist patient to articulate a realistic description of an upcoming event to reduce anxiety and promote decision making.

• Instruct patient in use of relaxation techniques to promote coping.

Nursing Diagnosis

Disturbed body image related to effects of change in body function on lifestyle or relationships as evidenced by negative feelings about self, refusal to look at or touch stoma or participate in self-care, expression of concern about effect on family and lifestyle

Patient Goals

1. Verbalizes acceptance of changes in body appearance and function

2. Participates in care of ileal conduit

Outcomes (NOC)	Interventions (NIC) and Rationales
Body Image • Description of affected body part _____ • Willingness to touch affected body part _____ • Satisfaction with body function _____ • Adjustment to changes in physical appearance _____ • Adjustment to changes in body function _____ Measurement Scale 1 = Never positive 2 = Rarely positive 3 = Sometimes positive 4 = Often positive 5 = Consistently positive	Body Image Enhancement • Help patient determine extent of actual changes in the body or its level of functioning to assist with issues and misconceptions and plan appropriate interventions. • Monitor whether patient can look at changed body part to assess readiness to participate in self-care. • Assist patient to separate physical appearance from feelings of personal worth to provide support and convey a sense of worth. • Facilitate contact with individuals with similar changes in body image to provide patient with realistic experiences related to ostomy care. • Identify support groups available to patient as these resources may provide new information and suggestion of ways to modify lifestyle.

Outcomes (NOC)

Interventions (NIC) and Rationales

Body Image

• Description of affected body part _____

• Willingness to touch affected body part _____

• Satisfaction with body function _____

• Adjustment to changes in physical appearance _____

• Adjustment to changes in body function _____

Measurement Scale

1 = Never positive

2 = Rarely positive

3 = Sometimes positive

4 = Often positive

5 = Consistently positive

Body Image Enhancement

• Help patient determine extent of actual changes in the body or its level of functioning to assist with issues and misconceptions and plan appropriate interventions.

• Monitor whether patient can look at changed body part to assess readiness to participate in self-care.

• Assist patient to separate physical appearance from feelings of personal worth to provide support and convey a sense of worth.

• Facilitate contact with individuals with similar changes in body image to provide patient with realistic experiences related to ostomy care.

• Identify support groups available to patient as these resources may provide new information and suggestion of ways to modify lifestyle.

Nursing Diagnosis

Risk for impaired skin integrity related to need for chronic use of external appliance on skin and/or ill-fitting appliance

Patient Goal

Maintains intact, healthy skin around stoma

Outcomes (NOC)	Interventions (NIC) and Rationales
Tissue Integrity: Skin and Mucous Membranes • Skin lesions _____ • Skin scaling _____ • Erythema _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None	Ostomy Care • Apply appropriately fitting ostomy appliance to protect the skin from urine exposure. • Monitor stoma/surrounding tissue healing and adaptation to ostomy equipment to ensure prompt identification of problems. • Change/empty ostomy bag as appropriate, to prevent urine leakage onto the skin. Skin Care: Topical Treatments • Refrain from using alkaline soap on the skin around the stoma to prevent alkaline accumulation on the skin.

Outcomes (NOC)

Interventions (NIC) and Rationales

Tissue Integrity: Skin and Mucous Membranes

• Apply appropriately fitting ostomy appliance to protect the skin from urine exposure.

• Monitor stoma/surrounding tissue healing and adaptation to ostomy equipment to ensure prompt identification of problems.

• Change/empty ostomy bag as appropriate, to prevent urine leakage onto the skin.

Skin Care: Topical Treatments

• Refrain from using alkaline soap on the skin around the stoma to prevent alkaline accumulation on the skin.

Nursing Diagnosis

Readiness for enhanced self-health management as evidenced by expression of desire to learn how to manage the illness and the ileal conduit.

Patient Goals

1. Describes all factors involved in the care and maintenance of the ileal conduit

2. Demonstrates correct removal and application of ostomy appliance and maintenance of ostomy pouch

Outcomes (NOC)	Interventions (NIC) and Rationales
Ostomy Self-Care • Describes functioning of ostomy _____ • Appears comfortable viewing stoma _____ • Measures stoma for proper appliance fit _____ • Maintains skin care around ostomy _____ • Empties ostomy bag _____ • Changes ostomy bag _____ • Monitors for complications related to stoma _____ • Expresses acceptance of ostomy _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	Ostomy Care • Instruct patient/significant other in the use of ostomy equipment and care to promote self-care. • Have patient/significant other demonstrate use of equipment to evaluate performance and correct any deficiencies. • Provide support and assistance while patient develops skill in caring for stoma/surrounding tissue to give support and convey acceptance of the altered body function. • Instruct patient on measures to reduce odor. • Instruct patient how to monitor for complications (e.g., mechanical breakdown, chemical breakdown, rash, leaks, dehydration, infection) to obtain early treatment of complications. Teaching: Psychomotor Skill • Provide written information/diagrams to enhance learning and to provide references for future use. • Provide frequent feedback to patient on what he or she is doing correctly and incorrectly so that bad habits are not formed.

Outcomes (NOC)

Interventions (NIC) and Rationales

Ostomy Self-Care

• Describes functioning of ostomy _____

• Appears comfortable viewing stoma _____

• Measures stoma for proper appliance fit _____

• Maintains skin care around ostomy _____

• Empties ostomy bag _____

• Changes ostomy bag _____

• Monitors for complications related to stoma _____

• Expresses acceptance of ostomy _____

Measurement Scale

1 = Never demonstrated

2 = Rarely demonstrated

3 = Sometimes demonstrated

4 = Often demonstrated

5 = Consistently demonstrated

Ostomy Care

• Instruct patient/significant other in the use of ostomy equipment and care to promote self-care.

• Have patient/significant other demonstrate use of equipment to evaluate performance and correct any deficiencies.

• Provide support and assistance while patient develops skill in caring for stoma/surrounding tissue to give support and convey acceptance of the altered body function.

• Instruct patient on measures to reduce odor.

• Instruct patient how to monitor for complications (e.g., mechanical breakdown, chemical breakdown, rash, leaks, dehydration, infection) to obtain early treatment of complications.

Teaching: Psychomotor Skill

• Provide written information/diagrams to enhance learning and to provide references for future use.

• Provide frequent feedback to patient on what he or she is doing correctly and incorrectly so that bad habits are not formed.

^*Postoperative care of the patient with an ileal conduit includes nursing diagnoses for the postoperative patient found in eNCP 20-1: Postoperative Patient, available at the website for that chapter.

^**Nursing diagnoses listed in order of priority.

eTABLE 46-1

STAGING OF KIDNEY CARCINOMA

Stage	Tumor Size	Lymph Node Involvement	Metastasis
I	≤7 cm found only in the kidney	No	No
II	>7 cm found only in the kidney	No	No
III	Tumor is any size and found only in the kidney	One or more nearby lymph node	No
III	Tumor is found in the main blood vessels of the kidney or in the layer of fatty tissue around the kidney	Yes, regional lymph nodes	No
IV	Tumor invades beyond layer of fatty tissue around the kidney and may be found in the adrenal gland	Yes, regional lymph nodes	No
IV	Any size	Any type of nodal involvement	Yes

Source: American Cancer Society.

eTABLE 46-2

STAGING OF BLADDER CANCER

Stage	Tumor Size	Lymph Node Involvement	Metastasis
0	Flat, noninvasive carcinoma (Tis), also known as flat carcinoma in situ (CIS). Cancer only growing in inner lining layer of the bladder	No	No
I	Tumor has grown into the layer of connective tissue under the lining layer of the bladder	No	No
II	Tumor has grown into the thick muscle layer of the bladder wall, but it has not passed completely through	No	No
III	Tumor has grown into the layer of fatty tissue that surrounds the bladder. May have spread into prostate, uterus, or vagina, but not growing into pelvic or abdominal wall.	No	No
IV	Tumor has grown through the bladder wall and into the pelvic or abdominal wall.	Yes	Yes

Source: American Cancer Society.

Infectious and Inflammatory Disorders of Urinary System

Urinary Tract Infection

Urinary tract infections (UTIs) are the most common bacterial infection in women. During their lifetime, at least 20% of women develop at least one UTI.¹ More than 100,000 people are hospitalized annually for UTIs. More than 15% of patients who develop gram-negative bacteremia die, and one third of these cases are caused by bacterial infections originating in the urinary tract.²

Inflammation of the urinary tract may be caused by a variety of disorders, but bacterial infection is by far the most common. The bladder and its contents are free from bacteria in the majority of healthy persons. Nevertheless, a minority of otherwise healthy individuals have some bacteria colonizing the bladder. This condition is called asymptomatic bacteriuria and does not justify screening or treatment except in pregnant women.

Escherichia coli is the most common pathogen causing a UTI (Table 46-1) and is primarily seen in women. Bacterial counts of 10⁵ colony-forming units per milliliter (CFU/mL) or higher typically indicate a clinically significant UTI. However, counts as low as 10² to 10³ CFU/mL in a person with signs and symptoms are indicative of UTI.

Although fungal and parasitic infections may also cause UTIs, this is uncommon. UTIs from these causes are sometimes found in patients who are immunosuppressed, have diabetes mellitus, or have undergone multiple courses of antibiotic therapy. These types of UTIs may also be found in persons who live in or have traveled to certain developing countries.

Cultural & Ethnic Health Disparities

Urologic Disorders

• Urinary tract calculi are more common among whites than African Americans.

• Uric acid stones are more common in Jewish men.

• Bladder cancer has a higher incidence among white men than African American men.

• In all ethnic groups, bladder cancer affects men about three times more often than women.

• Urinary incontinence is underreported because culturally it is seen as a social hygiene problem causing patient embarrassment.

Classification of Urinary Tract Infection

A UTI can be broadly classified as an upper or lower UTI according to its location within the urinary system (Fig. 46-1). Infection of the upper urinary tract (involving the renal parenchyma, pelvis, and ureters) typically causes fever, chills, and flank pain, whereas a UTI confined to the lower urinary tract does not usually have systemic manifestations. Specific terms are used to further delineate the location of a UTI. For example, pyelonephritis implies inflammation (usually caused by infection) of the renal parenchyma and collecting system, cystitis indicates inflammation of the bladder, and urethritis means inflammation of the urethra. Urosepsis is a UTI that has spread systemically and is a life-threatening condition requiring emergency treatment.

FIG. 46-1 Sites of infectious processes in the upper and lower urinary tracts.

Classifying a UTI as complicated or uncomplicated is also useful. Uncomplicated UTIs occur in an otherwise normal urinary tract and usually involve only the bladder. Complicated UTIs include those infections with coexisting obstruction, stones, or catheters; diabetes or neurologic diseases; or pregnancy-induced changes. The term also applies to a recurrent infection. The individual with a complicated infection is at risk for pyelonephritis, urosepsis, and renal damage.

Etiology and Pathophysiology

The urinary tract above the urethra is normally sterile. Several mechanical and physiologic defense mechanisms assist in maintaining sterility and preventing UTIs. These defenses include normal voiding with complete emptying of the bladder, ureterovesical junction competence, and ureteral peristaltic activity that propels urine toward the bladder. Antibacterial characteristics of urine are maintained by an acidic pH (less than 6.0), high urea concentration, and abundant glycoproteins that interfere with the growth of bacteria. An alteration in any of these defense mechanisms increases the risk for a UTI (Table 46-2).

TABLE 46-2

RISK FACTORS FOR URINARY TRACT INFECTIONS

Factors Increasing Urinary Stasis

• Intrinsic obstruction (stone, tumor of urinary tract, urethral stricture, BPH)

• Extrinsic obstruction (tumor, fibrosis compressing urinary tract)

• Urinary retention (including neurogenic bladder and low bladder wall compliance)

• Renal impairment

Foreign Bodies

• Urinary tract calculi

• Catheters (indwelling, external condom catheter, ureteral stent, nephrostomy tube, intermittent catheterization)

• Urinary tract instrumentation (cystoscopy, urodynamics)

Anatomic Factors

• Congenital defects leading to obstruction or urinary stasis

• Fistula (abnormal opening) exposing urinary stream to skin, vagina, or fecal stream

• Shorter female urethra and colonization from normal vaginal flora

• Obesity

Factors Compromising Immune Response

• Aging

• Human immunodeficiency virus infection

• Diabetes mellitus

Functional Disorders

• Constipation

• Voiding dysfunction with detrusor sphincter dyssynergia

Other Factors

• Pregnancy

• Hypoestrogenic state (menopause)

• Multiple sex partners (women)

• Use of spermicidal agents or contraceptive diaphragm (women)

• Poor personal hygiene

• Habitual delay of urination (“nurse’s bladder,” “teacher’s bladder”)

The organisms that usually cause UTIs are introduced via the ascending route from the urethra and originate in the perineum. Most infections are caused by gram-negative bacilli normally found in the gastrointestinal (GI) tract, although gram-positive organisms such as streptococci, enterococci, and Staphylococcus saprophyticus can also cause UTIs.

A common factor contributing to ascending infection is urologic instrumentation (e.g., catheterization, cystoscopic examinations).³ Instrumentation allows bacteria that are normally present at the opening of the urethra to enter into the urethra or bladder. Sexual intercourse promotes “milking” of bacteria from the vagina and perineum and may cause minor urethral trauma that predisposes women to UTIs.

Rarely do UTIs result from a hematogenous route, where blood-borne bacteria secondarily invade the kidneys, ureters, or bladder from elsewhere in the body. There must be prior injury to the urinary tract, such as obstruction of the ureter, damage caused by stones, or renal scars, for a kidney infection to occur from hematogenous transmission.

An important source of UTIs is health care–associated infections (HAIs), previously called nosocomial infections, which account for 31% of all HAIs.2,4 The cause of HAIs is often E. coli and, less frequently, Pseudomonas organisms. Catheter-acquired urinary tract infections (CAUTIs) are the most common HAIs and are caused by development of bacterial biofilms that are found on the catheter’s inner surface. Most often these infections are underrecognized and undertreated, leading to complications such as renal abscesses, epididymitis, periurethral gland infections, and bacteremia.