Diseases that cause irreversible damage to kidney tissue result in end-stage renal disease (ESRD). Eventually the patient has symptoms resulting from uremic syndrome. An increase in nitrogenous wastes in the blood, marked fluid and electrolyte abnormalities, nausea, vomiting, headache, coma, and convulsions characterize this syndrome. As the uremic symptoms worsen, aggressive treatment is indicated for survival (Box 45-1). These treatments are renal replacement therapies.

The kidneys primarily maintain the balance between retention and excretion of fluids (see Chapter 41). If fluids and the concentration of electrolytes and solutes are in equilibrium, an increase in fluid intake causes an increase in urine production. This amount varies with food and fluid intake. The volume of urine formed at night is about half of the volume formed during the day because both intake and metabolism decline. Nocturia (awakening to void one or more times at night) is often a sign of renal alteration. In a healthy person the intake of water in food and fluids balances the output of water in urine, feces, and insensible losses in perspiration and respiration. An excessive output of urine is polyuria. A urine output that is decreased despite normal intake is called oliguria. Oliguria often occurs when fluid loss through other means (e.g., perspiration, diarrhea, or vomiting) increases. It also occurs in early kidney disease. Often in severe kidney disease no urine is produced (anuria).

Ingestion of certain fluids directly affects urine production and excretion. Coffee, tea, cocoa, and cola drinks that contain caffeine promote increased urine formation (diuresis). Alcohol inhibits the release of antidiuretic hormone (ADH), also resulting in increased water loss in urine.

Febrile conditions affect urine production. A patient with excessive perspiration loses a large amount of fluids through insensible water loss, which decreases urine production. Fever causes an increase in body metabolism and accumulation of body wastes. Although urine volume is reduced, it is highly concentrated.

The stress of surgery initially triggers the general adaptation syndrome (see Chapter 37). Preoperative orders of nothing-by-mouth or an underlying disease condition affect fluid balance before surgery, which reduces urine output. In addition, the stress response releases an increased amount of ADH, which increases water resorption. Stress also elevates the level of aldosterone, causing retention of sodium and water. Both of these substances reduce urine output in an effort to maintain circulatory fluid volume.

Anesthetics and narcotic analgesics slow the glomerular filtration rate, reducing urine output. These pharmacological agents also impair sensory and motor impulses traveling among the bladder, spinal cord, and brain. Patients are often unable to sense bladder fullness and initiate or inhibit micturition. Spinal anesthetics, in particular, create the risk of urinary retention because of an inability to sense the need to void and a possible inability of the bladder muscles and urethral sphincters to respond (Lewis et al., 2011).

Surgery of lower abdominal and pelvic structures sometimes impairs urination because of local trauma to surrounding tissues. After returning from surgery involving the ureters, bladder, and urethra, patients routinely have urinary catheters.

UTI is the most common health care–acquired infection; 80% of these infections result from the use of an indwelling urethral catheter (Lo et al., 2009). Catheterization results in over 1 million UTIs each year in the United States (Matteucci and Walsh, 2011). Infection frequently occurs after placement of urinary catheters, and each day a catheter is in place there is a 5% increase in bacteria in the urine (Saint et al., 2009). Catheter-associated UTIs (CAUTIs) are associated with increased hospitalizations, increased morbidity and mortality, longer hospital stay, and increased hospital costs (Newman, 2007). Each episode of CAUTI and ensuing complications are estimated to cost between $600 and $2800 (Saint et al., 2009). Because a CAUTI is common, costly, and believed to be reasonably preventable, as of October 1, 2008, the Centers for Medicare and Medicaid Services (CMS) chose it as one of the complications for which hospitals no longer receive additional payment to compensate for the extra cost of treatment (Saint et al., 2009). Consequently there has been a shift in reimbursement practices from its traditional focus on early recognition and prompt treatment to one of prevention (Wilson et al., 2009).

Although several different microorganisms cause CAUTIs, the patient’s own colonic flora, including Escherichia coli, remains the most common causative pathogen (Ksycki and Namias, 2009). Bacteriuria (bacteria in the urine) leads to the spread of organisms into the kidneys and possibly to bacteremia or urosepsis (bacteria in the bloodstream) (Lewis et al., 2011). Microorganisms commonly enter the urinary tract through the ascending urethral route. Bacteria inhabit the distal urethra and external genitalia in men and women and the vagina in women. Organisms enter the urethral meatus easily and travel up the inner mucosal lining to the bladder. Women are more susceptible to infection because of a short urethra and the proximity of the anus to the urethral meatus. In men prostatic secretions containing an antibacterial substance and the length of the urethra reduce the susceptibility to UTIs. However, men are at increased risk for infection-related renal disease. Older adults and patients with progressive underlying disease or decreased immunity are also at increased risk.

In a healthy person with good bladder function, organisms are flushed out during voiding. Residual (retained) urine in the bladder becomes more alkaline and is an ideal site for microorganism growth. Any condition resulting in urinary retention such as a kinked, obstructed, or clamped catheter increases the risk of a UTI.

Poor perineal hygiene is another cause of UTIs in women. Inadequate handwashing, failure to wipe from front to back after voiding or defecating, and frequent sexual intercourse predispose women to infection.

Patients with lower UTIs have pain or burning during urination (dysuria) as urine flows over inflamed tissues. Fever, chills, nausea, vomiting, and malaise develop as an infection worsens. An irritated bladder (cystitis) causes a frequent and urgent sensation of the need to void. Irritation to bladder and urethral mucosa results in blood-tinged urine (hematuria). The urine appears concentrated and cloudy because of the presence of white blood cells (WBCs) or bacteria. If infection spreads to the upper urinary tract (kidneys—pyelonephritis), flank pain, tenderness, fever, and chills are common.

Another common cause of infection is the introduction of instruments into the urinary tract. For example, the introduction of a catheter through the urethra provides a direct route for microorganisms (Nazarko, 2008). With an indwelling catheter bacteria ascend along the outside of the catheter on the urethral wall or travel up its lumen. Local irritation to the urethra or bladder predisposes tissues to bacterial invasion.

Urinary incontinence is the involuntary leakage of urine that is sufficient to be a problem. It can be either temporary or permanent, continuous or intermittent. Urinary incontinence related to urinary causes is called either stress or urge urinary incontinence (Palmer and Newman, 2007). Urge incontinence is more common in younger women and may be caused by local irritating factors such as UTIs (Ebersole et al., 2008). Individuals sense the urge to urinate but cannot keep from urinating long enough to reach a toilet. Stress incontinence occurs more often in older women when intraabdominal pressure exceeds urethral resistance. Muscles around the urethra become weak; thus even a small amount of urine may leak spontaneously (Ebersole et al., 2008). Some patients may have a mixed form of incontinence that has features of both stress and urge urinary incontinence. Table 45-5 on p. 1060 describes the types of urinary incontinence, their symptoms, and treatment interventions. Hyperactive or overactive bladder (OAB) is associated with individuals of all ages, but older adults are more likely to have incontinence associated with it following physical and cognitive decline associated with aging and effects of medications (Stewart, 2010). OAB results from sudden, involuntary contraction of the muscles of the urinary bladder, resulting in an urge to urinate (urge incontinence). Common abnormalities of the nervous system that cause OAB include cerebrovascular accident (CVA) and other head injuries, spinal cord injury, and diabetic neuropathy. Other causes include UTI and anxiety.

Approximately 15% to 30% of adult women experience urinary incontinence. It is present in as many as 30% to 70% of nursing home residents and in 30% of adults living at home (Touhy and Jett, 2010). Incontinence can impair body image and often leads to a loss of independence. Clothing becomes wet with urine, and the accompanying odor adds to the embarrassment. As a result, patients with this problem often avoid social activities. They often fail to discuss this condition with health care providers or nurses, and as a result urinary incontinence is underreported and undertreated. Resources for information about continence care, patient education, and treatment are available at the following websites: the Society for Urological Nurses and Associates (http://www.suna.org), the National Association for Continence (http://www.nafc.org), and the Simon Foundation (http://www.simonfoundation.org).

Physical limitations and environmental barriers are risks for incontinence. People with restricted mobility have greater chances of being incontinent because of their inability to reach toilet facilities in time. Low-set chairs and beds raised well above the floor are obstacles for people who must get up to reach a toilet. Some patients often lack the energy to walk very far at one time. The toilet is sometimes too far away for patients with urge incontinence. Patients who have difficulty undoing buttons or manipulating zippers face another obstacle.

Continued episodes of incontinence is a risk for impaired skin integrity. The character of urine changes when it remains in contact with skin, causing skin breakdown. The immobilized patient with frequent incontinence is especially at risk for pressure ulcers (see Chapter 48). Additional health care and patient education resources are available at the websites for the American Geriatrics Society (http://www.americangeriatrics.org) or the American Urogynecologic Society (http://www.augs.org).

Conditions such as bladder cancer, radiation injury to the bladder, or chronic urinary infections may necessitate a urinary diversion to drain urine from a diseased or dysfunctional bladder. There are two types of continent urinary diversions (Fig. 45-4, A). One is a continent urinary reservoir that is created from a distal portion of the ileum and proximal portion of the colon. The ureters are embedded in the reservoir. This reservoir is situated under the abdominal wall and has a narrow ileal segment brought out through the abdominal wall to form a small stoma. The ileocecal valve creates a one-way valve in the pouch through which a catheter is inserted to empty the urine from the pouch. Patients must be willing and able to catheterize the pouch 4 to 6 times a day for the rest of their lives.

Incontinent urinary diversions are less commonly performed. The surgery involves connecting the ureters to a section of the intestinal ileum with formation of a stoma on the abdominal wall (Fig. 45-4, B). Urine drains continuously because a patient has no sensation or control over urinary output, requiring the application of a collection pouch at all times.

Some patients need urinary drainage directly from one or both kidneys. In this case a tube is placed directly into the renal pelvis. This procedure is called a nephrostomy.

Any urinary diversion poses threats to a patient’s body image. The patient must learn how to manage the diversion, and those who do not have a continent urinary diversion must wear an artificial device at all times. However, most patients are able to wear normal clothing, engage in physical activity, travel, and have sexual relations. Care must be taken not to pull on tubing, especially in a nephrostomy, since it can be pulled out, causing tissue and organ damage and infection. Most nephrostomies are sutured into the kidney.

Refer patients with a urinary diversion to an ostomy nurse (a nurse with specialized education in this area). This specialist is a valuable resource for assisting a patient and family with matters pertaining to all aspects of care. The ostomy nurse often meets with the patient and family before surgery. In addition, refer the patient to the United Ostomy Associations of America (http://www.uoaa.org). This organization provides information about support groups to enhance coping and adaptation to lifestyle and body-image changes.