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Ulcerative colitis
Description
Ulcerative colitis is an autoimmune disorder that, along with Crohn’s disease, is referred to as inflammatory bowel disease (IBD). See Inflammatory Bowel Disease, p. 352, for a discussion of the disorder.
Urethritis
Urethritis is an inflammation of the urethra. Causes of urethritis include a bacterial or viral infection, trichomonal and monilial infection (especially in women), chlamydial infection, and gonorrhea (especially in men).
In men, purulent discharge usually indicates a gonococcal urethritis. A clear discharge typically signifies a nongonococcal urethritis. Urethritis also produces bothersome lower urinary tract symptoms, including dysuria, urgency, and frequent urination, similar to those seen with cystitis.
In women, urethritis is difficult to diagnose. It frequently produces bothersome lower urinary tract symptoms, but urethral discharge may not be present.
Nursing and collaborative management
Treatment is based on identifying and treating the cause and providing symptomatic relief.
■ Sulfamethoxazole with trimethoprim (Bactrim, Septra) and nitrofurantoin (Furadantin) are examples of medications used for bacterial infections. Metronidazole (Flagyl) and clotrimazole (Mycelex) may be used for trichomonal infection. Medications such as nystatin (Mycostatin) or fluconazole (Diflucan) may be prescribed for monilial infections. In chlamydial infections, doxycycline (Vibramycin) may be used.
■ Women with negative urine cultures and no pyuria usually do not respond to antibiotics. Warm sitz baths may temporarily relieve bothersome symptoms.
Teach patients to avoid using vaginal deodorant sprays, properly cleanse the perineal area after bowel movements and urination, and avoid sexual intercourse until symptoms subside. Teach patients with sexually transmitted urethritis to refer their sex partners for evaluation and testing if they had sexual contact in the 60 days preceding onset of the symptoms or diagnosis.
Urinary incontinence
Description
Urinary incontinence (UI), an involuntary leakage of urine, affects an estimated 17 million people in the United States. Although its prevalence is higher among older women and men, it is not a natural consequence of aging. An estimated 80% of incontinence can be cured or significantly improved.
Pathophysiology
UI can result from anything that interferes with bladder or urethral sphincter control.
■ Using the acronym DRIP, the causes include D: delirium, dehydration, depression; R: restricted mobility, rectal impaction; I: infection, inflammation, impaction; and P: polyuria, polypharmacy.
■ UI disorders include stress, urge, overflow, and reflex incontinence. (For a complete description of UI, see Table 46-17, Lewis et al.: Medical-Surgical Nursing, ed. 9, p. 1088.)
Diagnostic studies
■ A focused history, physical assessment, and a voiding record provide information about the onset of UI, factors that provoke urinary leakage, and associated conditions.
■ Pelvic examination assesses for organ prolapse and evaluates pelvic floor muscle strength.
■ Urinalysis identifies possible factors contributing to transient incontinence or urinary retention (e.g., urinary infection, diabetes mellitus).
■ Measure postvoid residual (PVR) urine in the patient undergoing evaluation for UI. The PVR volume is obtained by asking the patient to urinate, followed by catheterization or use of a bladder ultrasound within a relatively brief period (preferably 10 to 20 minutes).
■ Urodynamic testing is indicated in selected cases of UI.
■ Imaging studies of the upper urinary tract (e.g., ultrasound) are obtained when incontinence is associated with urinary tract infections or there is evidence of upper urinary tract involvement.
Collaborative care
Transient, reversible factors are corrected initially, followed by management of the type of UI. In general, less invasive treatments are attempted before more invasive methods (e.g., surgery) are used.
Several behavioral therapies may be used including (1) pelvic floor muscle training (Kegel exercises) to help some patients manage stress, urge, or mixed UI, and (2) biofeedback to assist the patient to identify, isolate, contract, and relax the pelvic muscles.
Drug therapy
Drug therapy varies according to UI type.
■ In stress UI, drugs have a limited role in management. α-Adrenergic agonists can be used to increase bladder sphincter tone and urethral resistance but have limited benefit.
■ In urge and reflex UI, drugs play a key management role. Anticholinergic drugs and muscarinic receptor antagonists relax the bladder muscle and inhibit overactive detrusor contractions. These preparations include immediate- and extended-release tolterodine (Detrol, Detrol LA); immediate, extended, and transdermal oxybutynin (Ditropan, Ditropan XL, Oxytrol TDS); twice-daily trospium chloride (Sanctura); extended-release solifenacin (VESIcare); and darifenacin (Enablex). Botox (onabotulinumtoxinA) can be used in the treatment of UI as a result of detrusor overactivity. Botox is injected into the bladder, resulting in relaxation of the bladder, an increase in its storage capacity, and a decrease in UI.
Surgical therapy
Surgical techniques also vary according to the type of UI.
■ Surgical correction of stress UI may reposition the urethra and/or create a backboard of support or otherwise stabilize the urethra and bladder neck and make them more receptive to changes in intraabdominal pressure.
■ Another technique for stress UI augments the urethral resistance of the intrinsic sphincter unit with a sling or periurethral injectables.
■ Retropubic colposuspension and pubovaginal sling placement appear to be most effective. Typically, both procedures are performed through low transverse incisions.
■ Placement of a suburethral sling, using autologous fascia, cadaveric fascia, or a synthetic material, is also used to correct stress UI in women.
■ An artificial urethral sphincter can be used in men with intrinsic sphincter deficiency and severe stress UI.
■ Alternatively, one of several bulking agents can be injected underneath the mucosa of the urethra to correct stress UI in women or men.
Nursing management
You need to recognize both the physical and the emotional problems associated with incontinence. Maintain and enhance the patient’s dignity, privacy, and feelings of self-worth.
■ This is a two-step approach involving containment devices to manage existing urinary leakage and a definitive plan to reduce or resolve the factors leading to incontinence.
■ Emphasize consumption of an adequate volume of fluids and reduction or elimination of bladder irritants (particularly caffeine and alcohol) from the diet.
■ Advise the patient to maintain a regular, flexible schedule of urination (usually every 2 to 3 hours while awake).
■ Also advise patients to quit smoking, because it increases the risk of stress UI.
■ Aggressive management of constipation is recommended, beginning with ensuring adequate fluid intake, increasing dietary fiber, lightly exercising, and judiciously using stool softeners.
■ Behavioral treatments include bladder retraining and pelvic floor muscle training. (A patient teaching guide for pelvic floor muscle exercise is found in Table 46-19, Lewis et al.: Medical-Surgical Nursing, ed. 9, p. 1090.)
■ Assess strategies the patient uses to contain UI and share information on products specifically designed to contain urine.
■ In inpatient or long-term care facilities, nursing management of UI includes maximizing toilet access. This assistance may take the form of offering the urinal or bedpan or assisting the patient to the bathroom every 2 to 3 hours or at scheduled times. Ensure that toilets are accessible to patients and there is adequate privacy to allow effective urine elimination.
Urinary retention
Description
Urinary retention is the inability to empty the bladder despite micturition or the accumulation of urine in the bladder because of an inability to urinate. In certain cases, it is associated with urinary leakage or postvoid dribbling, called overflow urinary incontinence (UI).
Pathophysiology
Urinary retention is caused by two different dysfunctions of the urinary system: bladder outlet obstruction and deficient detrusor (bladder muscle) contraction strength.
■ Bladder outlet obstruction leads to urinary retention when the blockage is so severe that the bladder can no longer evacuate its contents despite a detrusor contraction. A common cause of obstruction in men is an enlarged prostate.
■ Common causes of deficient detrusor (bladder wall muscle) contraction strength are neurologic diseases affecting the sacral segments 2, 3, and 4; long-standing diabetes mellitus; overdistention; long-term alcoholism; and drugs (e.g., anticholinergic drugs).
Diagnostic studies
The diagnostic studies for urinary retention are the same as the ones for UI (see Urinary Incontinence, p. 640).
Collaborative care
Behavioral therapies that were described for UI also may be used in the management of urinary retention. Scheduled toileting and double voiding may be effective in chronic urinary retention with moderate postvoid residual volumes.
■ Double voiding is an attempt to maximize bladder evacuation by having the patient urinate, sit on the toilet for 3 to 4 minutes, and urinate again before exiting the bathroom.
■ If catheterization is required for acute or chronic urinary retention, intermittent catheterization is preferred. It allows the patient to remain free of an indwelling catheter with its associated risk of urinary tract infection (UTI) and urethral irritation.
Drug therapy
Several drugs may be administered to promote bladder evacuation. For patients with obstruction at the level of the bladder neck, an α-adrenergic antagonist may be prescribed. These drugs relax the smooth muscle of the bladder neck, prostatic urethra, and possibly dual-innervated rhabdosphincter, diminishing urethral resistance.
Surgical therapy
Surgical interventions are used to manage urinary retention caused by obstruction. Transurethral or open surgical techniques are used to treat benign or malignant prostatic enlargement, bladder neck contracture, urethral strictures, or dyssynergia of the bladder neck.
■ Pelvic reconstruction using an abdominal or transvaginal approach can correct bladder outlet obstruction in women with severe pelvic organ prolapse.
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