GENITO-URINARY SYSTEM

NCM 112: MEDICAL - SURGICAL NURSING

Rivera, Artemio Jerome S., PhD

BSN 3 A&B – 1st SEMESTER | AY 2024 – 2025

ANATOMY AND PHYSIOLOGY ● Glomerulus - capillaries enclosed in an epithelial

structure—the Bowman’s capsule.
ANATOMY OF THE KIDNEY AND URINARY SYSTEMS ● The tubular component consists of: the Bowman’s
The kidney and urinary systems include the kidneys, ureters. capsule, the proximal tubule, the limbs of the loop
bladder and the urethra. Urine is formed by the kidney and of Henle and the connecting ducts. This portion is
flows through the other structures to be eliminated from the responsible for making adjustments to the filtrate
body. according to the body’s needs.
Ureters
Kidneys ● Long, fibromuscular tubes that connect each
● Bean shaped, brownish red structures kidney to the bladder.
● Their main function is to filter the blood, to remove ● each 24-30 cm long, originates at the lower portion
the waste and balance the body’s fluids and of the renal pelvis and ends at the trigone (tissue
electrolytes. b/w the opening of the ureters and the urethra) of
● positioned retroperitoneally (behind and outside the the bladder wall.
peritoneal cavity) on the back wall of the abdomen. ● lined with transitional epithelium called urothelium.
From the 12th thoracic vertebrae to the 3rd lumbar This prevents reabsorption of urine.
vertebrae. ● The smooth muscle of the ureters promotes
● The outer surface of the kidneys is called the hilum. movement of the urine through peristaltic
They are both penetrated with blood vessels, contractions.
nerves and the ureter. ● The narrow sites of the ureter are prone to
● approx. 4.5 oz, 10-12 cm long, 6cm wide. the right obstruction due to renal calculi, these sites are the
kidney is lower than the left due to the location of ureteropelvic junction, the ureteral segment near
the liver the sacroiliac junction and the ureterovesical
● The kidney parenchyma (functional tissue) is junction. Obstruction of the ureteropelvic junction is
divided into two parts, the cortex and the medulla. the most serious due to its closeness to the kidney
The medulla (inner portion) contains the loops of and associated kidney dysfunction.
Henle, the vasa recta, the collecting ducts of the Urinary Bladder
juxtamedullary and the cortical nephrons. ● Distensible muscular sac, just behind the pubic
● Both types of nephrons connect to the renal bone
pyramids, of which both kidneys have approx. 8-18 ● usual adult capacity is 400-500mL
of. These drain into minor calyces (sing. calyx), ● central, hollow area (the vesicle) with two inlets
which drain into major calyces that open directly (ureters) and an outlet (urethra)
into the renal pelvis. This is the beginning of the ● the angling of the area surrounding the bladder
collecting system which is designed to collect and neck, the ureterovesical junction, promotes the
transport urine. downward movement of urine (efflux of urine)
● The kidneys receive 20-25% of the total cardiac ● the walls of the bladder contain 4 layers:
output (all of the body’s blood circulates through ○ adventitia - made of connective tissue
the kidneys approx. 12 times per hour) ○ detrusor - smooth muscle layer
● The renal artery (from the abdominal aorta) divides ○ submucosal layer of loose connective
into increasingly smaller vessels. Each arteriole tissue - acts as a middle layer b/w the
branches to form a glomerulus, where filtration detrusor and the innermost mucosal layer
occurs. ○ mucosal lining - contains transitional cell
Nephrons epithelium. impermeable to water and
● each kidney has one million nephrons responsible prevents reabsorption of urine in the
for the formation of filtrate that will become urine bladder
● The large amount of nephrons allows proper renal ● the bladder neck has an involuntary internal
function even when one of the kidneys is sphincter and a voluntary external sphincter
dysfunctional (<20% function = kidney replacement ● during micturition (urination/voiding) increased
therapy must be considered) pressure keeps the ureterovesical junction closed
● There are two types, cortical nephrons (80-85%) and keeps urine within the ureters. As soon as
located in the outer cortex and juxtamedullary micturition is complete, intravesical pressure
nephrons (15-20%), located deeper in the cortex. returns to its low normal baseline value, allowing
Juxtamedullary nephrons have long loops of Henle the efflux of urine to continue.
and are surrounded by long capillary loops called ● the only time the bladder is completely empty is
vasa recta. during the last seconds of micturition before the
● composed of a filtering element (glomerulus) and efflux of urine resumes.
the attached tubule.

1 |GROUP 4
 GENITO-URINARY SYSTEM
NCM 112: MEDICAL - SURGICAL NURSING

Rivera, Artemio Jerome S., PhD

BSN 3 A&B – 1st SEMESTER | AY 2024 – 2025

Urethra
● where urine exits the body ANTIDIURETIC HORMONE (ADH)
● arises from the base of the bladder ● a.k.a., vasopressin - a hormone that promotes fluid
● passes through the penis in males; opens anterior retention
to the vagina in females ● responds to the changes in blood osmolality;
● in the male, the prostate gland surrounds the decreased water intake->stimulates ADH release,
urethra posteriorly and laterally increasing water reabsorption
● increased water intake -> inhibits ADH release, less
PHYSIOLOGY OF THE KIDNEY AND URINARY SYSTEMS is reabsorbed, leading to diuresis (increased
amount of urine)
URINE FORMATION ● a dilute urine w/ a fixed specific gravity or
● urine is formed in the nephrons through a complex osmolality indicates an inability to concentrate or
three step process: glomerular filtration, tubular dilute urine = common early sign of kidney disease
reabsorption and tubular secretion.
● the various substances filtered by the glomerulus, OSMOLARITY AND OSMOLALITY
reabsorbed by the tubules, and excreted through ● osmolarity - amount of solute in water
the urine are Na, Cl, HCO3, K, glucose, urea, ● osmolarity and ionic composition are maintained by
creatinine and uric acid the body w/n narrow limits (1-2% osmolarity
● amino acids and glucose are usually filtered and change -> body wants to conserve water)
reabsorbed so that they won't be excreted. ● osmolality - no. of osmoles dissolved per kilogram
● glycosuria, the abnormal excretion of glucose in the of solution
urine, occurs if the amount of glucose in the blood ● the filtrate in glomerular capillary = same
exceeds the amount that the tubules are able to concentration in blood (200-300 mOsm/kg)
absorb
● Low-molecular-weight proteins like globulins and REGULATION OF WATER EXCRETION
albumin are periodically excreted in small amounts. ● increased fluid intake - dilute urine; decreased fluid
An abnormal increase in protein in urine is intake - concentrated urine
proteinuria ● Normally, 1300mL of normally ingested oral fluids,
1000mL in food per day.
GLOMERULAR FILTRATION ● approx. 800mL is lost thru skin and lungs, 200mL
● as blood flows through the glomerulus, filtration through feces
occurs. ● monitoring weight is a reliable way of determining
● normal blood flow into the kidneys is b/w 1000 and overall fluid status. even 1lb or 500 mL is enough to
1300 mL/min suggest fluid gain or loss
● filtrate/ultrafiltrate - the filtered fluid. this enters the REGULATION OF ELECTROLYTE EXCRETION
tubules. Usually 20% of the blood passing is ● with full kidney function, the amount of electrolytes
filtered into the nephron. normally consists of water, excreted per day is equal to the amount ingested.
electrolytes and other small molecules. ● regulation of Na+ volume excreted depends on
aldosterone, synthesized and secreted by the
TUBULAR ABSORPTION AND SECRETION adrenal cortex. Aldosterone promotes sodium
● second and third step of urine formation occur in retention by decreasing the amount excreted in
the renal tubules urine. excretion is regulated by the RAAS
● in reabsorption, the substance moves from the
vasa recta into the tubular filtrate REGULATION OF ACID-BASE IMBALANCE
● of the 180L (45 gallons) of filtrate produced, 99% is ● normal pH - 7.35-7.45
reabsorbed into the bloodstream -> 1-2L of urine ● kidneys reabsorb bicarbonate (HCO3) into the
per day. this can either be done through passive or blood to regulate serum pH
active transport ● kidneys also excrete or reabsorb acid, synthesize
● tubular secretion - substances move from blood ammonia and excrete ammonium chloride
into the filtrate. this helps eliminate K+, H+, ● to replace any lost HCO3, the tubular cells generate
ammonia, uric acid, some drugs and other waste new bicarbonate through a variety of chemical
products reactions
● filtrate becomes concentrated in the distal tubule ● acid production -> by product of catabolism
and collecting ducts under hormonal influence, (breakdown of proteins). also produces phosphoric
becomes urine. this enters the renal pelvis for and sulfuric acids, which must be excreted through
volume depletion urine. If H+ are low, they will be reabsorbed.

2 |GROUP 4
 GENITO-URINARY SYSTEM
NCM 112: MEDICAL - SURGICAL NURSING

Rivera, Artemio Jerome S., PhD

BSN 3 A&B – 1st SEMESTER | AY 2024 – 2025

● normal kidney function = 70 mEq of acid directly EXCRETION OF WASTE PRODUCTS

excreted through the urine. pH can only be lowered ● kidneys eliminate the body’s metabolic waste
to 4.5 pH—1000x more acidic that blood products
● excess acids that couldn’t be excreted are bound ● urea is a major waste product of protein
to chemical buffers like phosphate ions and metabolism and must be excreted as to not
ammonia (NH3). with a buffer, ammonia becomes accumulate in the tissues. Other waste products
ammonium (NH4). through this process the kidney that must be excreted in the urine include
is able to excrete large amounts of acid without creatinine, phosphates, sulfates, uric acid and drug
lowering the pH of the urine any further metabolites.

AUTOREGULATION OF BLOOD PRESSURE URINE STORAGE

● RAAS - vasa recta monitor blood pressure; when it ● the bladder is the reservoir of urine
lowers, juxtaglomerular cells secrete renin. renin ● filling and emptying are facilitated by sympathetic
converts angiotensin I into angiotensin II—the most and parasympathetic NS control.
powerful vasoconstrictor. This increases blood ● under normal circumstances, ave. fluid intake is
pressure. This also signals the release of 1-2L per day and the bladder stores urine for 2-4
aldosterone, which further increases blood hours at a time. sleep allows the storage and build
pressure due to fluid retention. when the vasa recta up of urine for 6-8 hours to the body to sleep
recognizes the heightened blood pressure, renin ● in older adults, decreased bladder compliance and
secretion stops. the failure of this feedback decreased vasopressin levels can lead to nocturia
mechanism is one of the primary causes of (awakening at night to urinate)
hypertension
RENAL CLEARANCE BLADDER EMPTYING
● the ability of the kidneys to clear solutes from the ● micturition occurs 8x w/n a 24 hr period, activated
plasma. via the micturition reflex arc w/n the SNS and
● depends on several factors: how quickly the PSNS
substance is filtered across the glomerulus, how ● pelvic nerves stimulate bladder to contract ->
much is being reabsorbed by the tubules and how relaxation of urethral sphincter decreases urethral
much is being secreted into the tubules. pressure -> contraction of detrusor muscle,
● Creatinine - endogenous waste product of skeletal opening proximal urethra -> flow of urine
muscle that is excreted through the urine w/o any ● pressure generated during micturition - 20 - 40 cm
change. Creatinine clearance is a good measure of H2O in females; higher and more variable in males
glomerular filtration rate (GFR). due to prostate enlargement
● adult GFR varies from 125 mL/min to 200 mL/min
● creatinine clearance - best approximation of renal
function. renal function declines = creatinine/renal DIAGNOSTIC TESTS AND LAB EXAMS
clearance decreases
> Routine Urinalysis (UA)
REGULATION OF RED BLOOD CELL PRODUCTION ● Collect urine in the morning upon waking.
● kidneys can detect the decrease in oxygen tension ● Cleanse genitals with soap and water to prevent
in renal blood flow, whether it be due to anemia, contamination.
arterial hypoxia, or inadequate blood flow. ● Collect midstream urine, discarding the first and
● Erythropoietin is a glycoprotein that stimulates the last flow.
bone marrow to produce RBCs ● Label and promptly send the sample to the lab.
● Urine becomes more alkaline after eating.
VITAMIN D SYNTHESIS
● kidneys convert inactive Vit. D to uts active form,
1,25-dihydroxycholecalciferol. This is necessary for
maintenance of normal calcium homeostasis in the
body
●
SECRETION OF PROSTAGLANDINS AND OTHER
SUBSTANCES
● kidneys produce prostaglandin E and prostacyclin,
thromboxanes and leukotrienes, which have
vasoactive effects. these all help maintain renal
blood flow through vasodilation or constriction.

3 |GROUP 4
 GENITO-URINARY SYSTEM
NCM 112: MEDICAL - SURGICAL NURSING

Rivera, Artemio Jerome S., PhD

BSN 3 A&B – 1st SEMESTER | AY 2024 – 2025

Results of (UA)
Serum Uric Acid 2.5 – 8 mg/dl

Results Values Albumin 3.2 – 5.5 mg/dl

Color Amber/Straw RBC 4.5 – 5.5 mg/dl

4.5-8.0 (Average:6) HCT 38 – 54 vol. %

pH
slightly acidic
Serum Electrolytes

Specific Gravity 1.010 – 1.025

Potassium (K+) 3.5 – 5.5 mEq/L

Protein Absent
Sodium (Na+) 135 – 145 mEq/L

RBC Ca+ 4.5 – 5.5 mEq/L (8.6 – 10

0-5/hpf (If present,
indicate UTI) mg/dL)
WBC
Mg+ 1.5 – 2.5 mEq/L
Pus Absent
Phosphorous 2.8 – 4.5 mEq/dL
Glucose Absent (If present,
indicate diabetic Chloride 98 – 108 mEq/L
Ketones ketoacidosis (DKA)

Casts 0-4 > Cystoscopy

● Direct visualization of the urethra, bladder, and
openings.
> Creatinine Clearance (24-hour urine test)
Nursing Interventions
● Before:
● Best indicator of glomerular function; decreases
● Obtain consent.
with renal impairment.
● Encourage fluids (local anesthesia) or keep
● Normal: 100–120 mL/min (males), 90–110 mL/min
NPO (general anesthesia).
(females).
● Inform patient about voiding sensation
● Discard the first urine, collect all subsequent
during insertion.
specimens, including the final void.
● Position in lithotomy.
● Restart collection if any specimen is missed.
● After:
○ Example: Monday 10 AM to Tuesday 10
● Bed rest until stable.
AM. Discard the urine specimen voided on
● Monitor urine output (pink-tinged urine
Monday 10 AM, collect the specimen
normal for 24–48 hours).
voided on Tuesday 10AM. If a specimen
● Watch for retention, infection, or heavy
was inadvertently discarded, restart the
bleeding; notify the physician if needed.
collection the following day.
● Use Sitz baths or warm soaks for
discomfort or cramps.
> Blood Studies
● Encourage fluids to prevent UTI.
● Includes Complete Blood Count (CBC)
● Blood pH (metabolic acidosis) in renal failure.
> KUB X - ray
● Visualizes kidneys, ureters, and bladder.
Results Values ● Reassure the patient it is painless.
● Bowel prep (laxative and enema as ordered) to
avoid interference.
Blood Urea Nitrogen 10 – 20 mg/dl
(BUN) >Excretory Urogram/Intravenous Pyelography
● X-ray of kidneys, ureters, and bladder using IV
Serum Creatinine 0.4 – 1.2 mg/dl contrast (iodinated).

4 |GROUP 4
 GENITO-URINARY SYSTEM
NCM 112: MEDICAL - SURGICAL NURSING

Rivera, Artemio Jerome S., PhD

BSN 3 A&B – 1st SEMESTER | AY 2024 – 2025

Nursing Interventions ● Before:

● Before: ● Cleanse bowel (laxative as ordered).
● Obtain consent. ● Shave catheter insertion site
● NPO 6–8 hours, bowel prep as ordered.
(lumbar/femoral).
● Check for iodine/seafood allergies.
● Locate distal pulses.
● Keep epinephrine ready for anaphylaxis.
● After: ● After:
● Monitor vital signs. ● Monitor vital signs until stable.
● Encourage fluids to flush dye. ● Apply cold to the puncture site to prevent
● Expect possible burning during urination. bleeding.
● Watch for delayed allergic reactions (rash, ● Check for swelling or hematoma.
itching, dyspnea).
● Use a sandbag over the insertion site to
> Retrograde Pyelogram (RPG) prevent bleeding.
● Visualizes pelvis and ureters using contrast via ● Palpate pulses to assess circulation.
cystoscope. ● Bedrest for 24 hours, no sitting.
Nursing Interventions ● Measure urine output to assess renal
● Before: function.
● Obtain consent.
> Ultrasound (UTZ)
● Check dye allergies.
● Uses soundwaves to detect tumors, cysts,
● Explain possible discomfort.
obstructions, and abscesses.
● Have epinephrine ready.
● Cleanse the bowel (laxative as ordered).
● After:
● Drink 2 glasses of water 3 minutes before to
● Monitor vital signs.
distend the bladder for better imaging.
● Watch for retention, infection, or
● Withhold voiding.
prolonged hematuria; notify the physician
if needed.
> Renal Biopsy
● Removes renal tissue for microscopic examination,
> Voiding Cystourethrogram
● X-ray of the bladder and urethra with a full bladder most accurate for detecting malignancy.
and during urination. Nursing Interventions
● Contrast is introduced via a urinary catheter. ● Before:
● Identifies: ● NPO for 6–8 hours.
● Repeated UTIs ● Check PTT and Pro Time (bleeding risk).
● Incontinence
● Mild sedation and local anesthesia.
● Urine reflux/backflow
● Position prone, ensure UTZ/X-ray
● Bladder/urethral injuries, BPH, or
structural defects. availability.
● Instruct the client to hold breath and stay
still during needle insertion.
> Cystometrogram ● After:
● Measures bladder pressure during filling to assess ● Bed rest for 24 hours.
neuro-sensory function and tone. ● Monitor vital signs for bleeding.
● Evaluates stream initiation, hesitancy, intermittent ● Provide fluids (up to 3000 mL).
voiding, and terminal dribbling. ● Check Hct/Hgb 8 hours later for bleeding.
● Uses a retention catheter attached to a manometer; ● Avoid strenuous activities for 2 weeks.
sterile NSS is introduced at a set rate. ● Notify the physician for bleeding,
● Records bladder volume and pressure at key hematoma, or infection.
points, including first urge to void and maximum
fullness.

> Renal Arteriogram

● X-ray of renal circulation with contrast injected into
the renal artery via catheter.
Nursing Interventions

5 |GROUP 4
 GENITO-URINARY SYSTEM
NCM 112: MEDICAL - SURGICAL NURSING

Rivera, Artemio Jerome S., PhD

BSN 3 A&B – 1st SEMESTER | AY 2024 – 2025

> Physical Assessment of the Urinary System PATHOPHYSIOLOGY

● Normal:
● No costovertebral tenderness.
● Nonpalpable kidneys and bladder.
● No masses.
● Common Abnormalities:
● Anuria: No urination (output <100 ml/24
hours).
● Burning: Painful urination.
● Chemical Cystitis: Pain or difficulty
urinating.
● Enuresis: Bedwetting.
● Frequency: Increased urination.
● Hematuria: Blood in urine.
● Hesitancy: Difficulty starting urination.
● Incontinence: Involuntary urine leakage.
● Nocturia: Nighttime urination.
● Oliguria: Low urine output (100-400 ml/24
hours).
● Pneumaturia: Urine with gas. SIGNS AND SYMPTOMS
● Polyuria: Excessive urine output.
● Colicky lumbar pain radiating to the lower
● Retention: Inability to urinate despite full
abdomen.
bladder. ● Nausea, vomiting, diarrhea, or constipation due to
● Stress Incontinence: Involuntary urination shared GI and GU nerve supply.
with pressure (e.g., sneezing). ● Hematuria, dysuria, frequency.
● Fever and chills.
RENAL CALCULI (UROLITHIASIS)
PHARMACOLOGIC MANAGEMENT
● Common cause: UTI leading to urinary stasis.
● 70% of stones form in the kidneys. ● Calcium stones
■ Aluminum Chloride / Calcibind -
● Other risk factors:
● Phosphate stones
● Metabolic issues raising calcium, oxalate, ■ Amphogel
uric acid, or citric acid in urine. ● Uric stones
● Warm climates (increased fluid loss, low ■ Allopurinol
urine volume).
● High protein intake, excessive tea/juice NURSING CONSIDERATION
(elevate oxalate/uric acid).
● Increase fluid intake to at least 3000 ml per day to
● Low fluid intake, family history, cystinuria,
help pass the stone
gout, renal acidosis.
● Strain all urine. If a stone is passed, submit it for
● Sedentary lifestyle or immobility.
laboratory analysis.
● Higher risk in males aged 30-50 years.
● Adjust urine pH:
● Types of urinary calculi:
○ Calcium stones (alkaline):
● Alkaline stones
■ Limit dairy products
■ Calcium oxalate stones
■ Acid - ash diet (cranberry juice,
■ calcium phosphate stones
prune juice, meat, eggs, fish,
■ Struvite or staghorn stones
poultry, tomatoes, grapes, whole
(MgNH3PO4)
grains, corn, legumes).
● Acidic stones
■ Uric acid stones
■ Cystine stones

6 |GROUP 4
 GENITO-URINARY SYSTEM
NCM 112: MEDICAL - SURGICAL NURSING

Rivera, Artemio Jerome S., PhD

BSN 3 A&B – 1st SEMESTER | AY 2024 – 2025

○ Oxalate stones (alkaline) PATHOPHYSIOLOGY

■ Avoid excess tea, chocolate,
spinach and other green leafy
vegetables, broccoli, almonds,
cashew, beans.
○ Acidic stones
■ Alkaline - ash diet (milk,
vegetables, fruits except
cranberries, plums and prunes;
rhubarb; small amounts of beef;
halibut; veal; trout; and salmon).
○ Uric acid stones
■ Avoid purine rich foods.
● Encourage ambulation. To help pass the stone.
● Relieve pain.
● Surgery (nephrolithotomy, pyelolithotomy,
uretero-lithotomy)
● Extracorporeal Shock Wave Lithotripsy (ESWL) -
the crushing of stone with the use of high
frequency or ultrasonic waves while the body is half
- immersed in water. No incision, no drains.
CLINICAL MANIFESTATIONS
○ Patient teaching: take 3 - 4 liters of fluid
per day to flush the stone.
● Painless hematuria (most common)
● Percutaneous lithotripsy. A guide is inserted
● Dysuria, gross hematuria, obstruction to urine flow,
under fluoroscopy near the area of the stone.
development of fistula between bladder and uterus
Ultrasonic waves break the stones into fragments.
or bladder and colon (urine is expelled from the
A nephrostomy tube will be in place.
vagina or fecal material is excreted in the urine)

PHARMACOLOGIC MANAGEMENT
BLADDER CANCER
Intravesical Chemotherapy
● Drugs: Thiotepa, Mitomycin, BCG.
● It is more common among males.
● Side Effects: Bladder irritation, dysuria, hematuria,
● Risk factors:
fever.
○ Cigarette smoking
● Considerations: Rotate position during treatment,
○ Chronic cystitis
dispose of urine as biohazard, encourage
○ Large phenacetin intake (analgesic
hydration.
chemical component
Systemic Chemotherapy
○ Bladder calculi
● Drugs: Cisplatin, Doxorubicin, Methotrexate.
○ Pelvic radiation
● Side Effects: Nausea, alopecia, bone marrow
○ Use of cyclophosphamide
suppression.
○ Schistosomiasis
● Considerations: Monitor labs (CBC, liver, renal),
manage nausea, prevent infection.
Immunotherapy
● Drug: BCG.
● Side Effects: Flu-like symptoms, hematuria, urinary
frequency.
● Considerations: Monitor for fever and teach
symptom management.

7 |GROUP 4
 GENITO-URINARY SYSTEM
NCM 112: MEDICAL - SURGICAL NURSING

Rivera, Artemio Jerome S., PhD

BSN 3 A&B – 1st SEMESTER | AY 2024 – 2025

Targeted Therapy ■ Disinfect toilet with bleach for 6

● Drug: Erdafitinib (for FGFR mutation). hours.
● Side Effects: Electrolyte imbalance, dry eyes, ■ Common agents: Thiotepa,
Mitomycin, Doxorubicin,
fatigue.
Cyclophosphamide, BCG.
● Considerations: Monitor labs, ensure hydration,
refer for eye care. ○ Systemic Chemotherapy:
Pain Management ■ Agents include Cisplatin,
● Drugs: NSAIDs, opioids. Doxorubicin, Cyclophosphamide,
● Considerations: Assess pain regularly, monitor for Methotrexate, and Pyridoxine.
sedation or constipation. ○ Radiation Therapy
● Can be internal or external.

MEDICAL MANAGEMENT
NURSING CONSIDERATION
● Surgery/Urinary Diversions
Before Surgery:
○ Ileal Conduit: Ureters are connected to a
segment of the ileum, creating an ● Educate about the procedure, outcomes, and
abdominal stoma with continuous urine complications.
outflow. Requires a urinary appliance to ● Address concerns about body image and urinary
collect urine. diversions.
○ Koch Pouch: A segment of ileum forms a ● Ensure NPO status, bowel prep (if needed), and
pouch with ureters implanted. Nipple
signed consent.
valves control urine storage. The client
● Assess vitals, renal function (BUN, creatinine), and
uses a straight catheter every 4–6 hours to
empty the pouch. Also called a Continent check for infections.
Ileal Urinary Reservoir. During Surgery:
○ Indiana Pouch: A larger continent ● Maintain sterile technique to prevent infections.
reservoir made from the colon and ileum. ● Monitor vitals for stability and bleeding.
The client uses a straight catheter every ● Prepare stoma supplies if urinary diversion is
4–6 hours to empty it.
planned.
○ Ureterostomy: Ureters are attached to the
After Surgery:
abdomen, draining urine into an external
appliance. ● Monitor urine output for obstruction or leakage.
○ Vesicostomy: The bladder is sutured to ● Check stoma (if present) for color, skin integrity,
the abdomen, creating a stoma for and appliance fit.
drainage. ● Watch for infection, bleeding, or DVT.
○ Percutaneous Nephrostomy: A ● Manage pain and encourage early mobilization.
nephrostomy tube is inserted into the
● Educate on urinary diversion care, infection signs,
kidney for drainage, used for obstructive
or inoperable cases. and when to seek help.
○ TURB (Transurethral Resection and ● Provide emotional support and resources for
Fulguration of the Bladder): A procedure coping.
to remove or destroy bladder tissue.
● Chemotherapy
○ Intravesicular Instillation:
■ Medication is introduced via
catheter and retained for 2 hours.
The client changes position every
15–30 minutes. Afterward:
■ Void in a sitting position.
■ Increase fluid intake to flush the
bladder.
■ Treat urine as biohazard; send for
lab monitoring.

8 |GROUP 4
 GENITO-URINARY SYSTEM
NCM 112: MEDICAL - SURGICAL NURSING

Rivera, Artemio Jerome S., PhD

BSN 3 A&B – 1st SEMESTER | AY 2024 – 2025

BENIGN PROSTATIC HYPERPLASIA (BPH) ● Recurrent urinary tract infections (UTIs).

● Bladder stones.
● BPH is a common, nonmalignant and gradual ● Hydronephrosis and renal failure (in severe cases)
enlargement of the prostate gland with hypertrophy
and hyperplasia that occurs with aging, usually DIAGNOSIS
occurring among men over 50 years of age.
● It can lead to bothersome lower urinary tract A. Clinical Evaluation
symptoms (LUTS) by compressing the urethra and
obstructing urinary flow. Although not cancerous, 1. Patient History:
BPH significantly impacts quality of life. ○ Onset, frequency, and severity of
● The cause is unknown. symptoms.
● Transition zone - Primary site for BPH. ○ Use of validated tools like the International
Prostate Symptom Score (IPSS).
PATHOPHYSIOLOGY 2. Physical Examination:
○ Digital Rectal Exam (DRE): Assess
prostate size, shape, and consistency.

B. Diagnostic Tests

1. Urinalysis: Rules out infection or hematuria.

2. Serum Prostate-Specific Antigen (PSA): Assesses
for elevated levels, which may indicate BPH or
prostate cancer.
3. Postvoid Residual (PVR) Volume: Measures urine
left in the bladder after voiding.
4. Uroflowmetry: Evaluates urine flow rate.
5. Imaging: Ultrasound (abdominal or transrectal) for
prostate size and structural abnormalities.

TREATMENT AND MEDICAL MANAGEMENT

A. Lifestyle Modifications

● Avoid bladder irritants (caffeine, alcohol).

● Limit fluid intake in the evening.
CLINICAL MANIFESTATIONS ● Scheduled voiding or bladder training.

A. Lower Urinary Tract Symptoms (LUTS)

B. Pharmacologic Therapy
1. Obstructive Symptoms:
○ Hesitancy in initiating urination.
1. Alpha-Adrenergic Blockers: Relax smooth muscle
○ Weak or intermittent urinary stream.
in the bladder neck and prostate.
○ Sensation of incomplete bladder
○ Examples: Tamsulosin, Terazosin.
emptying.
○ Side Effects: Dizziness, hypotension.
○ Post-void dribbling.
2. 5-Alpha-Reductase Inhibitors: Reduce prostate size
2. Irritative Symptoms
by inhibiting DHT production.
○ Urinary frequency.
○ Examples: Finasteride, Dutasteride.
○ Nocturia (waking to urinate at night).
○ Side Effects: Decreased libido, erectile
○ Urgency.
dysfunction.
○ Dysuria (painful urination).
3. Combination Therapy: For moderate to severe
B. Complications
symptoms.
● Acute urinary retention.

9 |GROUP 4
 GENITO-URINARY SYSTEM
NCM 112: MEDICAL - SURGICAL NURSING

Rivera, Artemio Jerome S., PhD

BSN 3 A&B – 1st SEMESTER | AY 2024 – 2025

4. Anticholinergics: Manage irritative symptoms like ○ Involves removal of the prostate gland
urgency and frequency. through abdominal and bladder incision.
○ The client will have cystostomy tube and 2
C. Minimally Invasive Procedures - way Foley catheter. To drain urine
adequately and prevent leakage through
1. Transurethral Microwave Thermotherapy (TUMT): the incision. (Whenever bladder incision is
Heat destroys excess prostate tissue. done, cystostomy tube will be in place).
2. Transurethral Needle Ablation (TUNA): ○ continuous bladder irrigation is prescribed
Radiofrequency energy ablates tissue. and administered to keep urine pink.
3. Prostatic Urethral Lift (PUL): Implants open the ○ The surgery does not cause incontinence
urethra by compressing prostate lobes. or impotence postop.

D. Surgical Options

> The only successful management of BPH is surgery.

1. Transurethral Resection of the Prostate (TURP):

○ Gold standard procedure for BPH.
○ Involves resecting prostate tissue via the
urethra. Prostatic tissues are excised
through a resectoscope. There is no
incision.
○ Continuous bladder irrigation (CBI) or
cystoclysis is done postop to irrigate the
bladder and remove blood clots. This is
done through 3-way Foley catheter.
○ The surgery does not cause incontinence
or impotence postop.

3. Retropubic Prostatectomy:
○ Involves removal of the prostate gland
through abdominal and bladder incision.
There is no incision into the bladder.
Continuous bladder irrigation may be
done.
○ The surgery does not cause incontinence
or impotence postop.

2. Suprapubic Prostatectomy
10 |GROUP 4
 GENITO-URINARY SYSTEM
NCM 112: MEDICAL - SURGICAL NURSING

Rivera, Artemio Jerome S., PhD

BSN 3 A&B – 1st SEMESTER | AY 2024 – 2025

B. Postoperative Care

1. Monitor for complications:

○ Bleeding.
○ Infection.
○ Urinary retention.
2. Manage indwelling catheter:
○ Continuous bladder irrigation (CBI) may be
needed to prevent clot formation; maintain
patency of catheter. If drainage is reddish,
increase the flow rate as the drainage
becomes clear.
○ Use sterile NS (normal saline). To prevent
infection and water intoxication. Repeated
administration of hypotonic solution e.g.,
sterile water, may cause water
intoxication.
○ Monitor output for color, consistency, and
volume; expect red to light pink urine for
the first 24 hours then it becomes amber
in 3 days postop.
○ Monitor for hemorrhage.
3. Promote early ambulation to prevent venous
thromboembolism.
4. Educate on post-discharge care:
○ Avoid heavy lifting or straining.
4. Perineal Prostatectomy ○ Drink plenty of fluids.
○ Involves removal of the prostate gland
C. Long-Term Care
through an incision made between the
scrotum and the anus.
● Teach pelvic floor exercises to improve urinary
○ The procedure causes incontinence and
control; kegel’s exercise.
sterility.
● Reinforce follow-up visits for PSA monitoring and
○ Avoid inserting rectal tubes, taking rectal
symptom evaluation.
temperature, or administering enemas.

COMPLICATIONS OF UNTREATED BPH:

● Acute urinary retention requiring catheterization.

NURSING MANAGEMENT
● Chronic bladder dysfunction.
A. Preoperative Care ● Upper urinary tract complications (e.g.,
hydronephrosis, renal insufficiency).
1. Assess baseline urinary symptoms.
2. Educate the patient about the procedure, potential
complications, and recovery process.
3. Address anxiety or concerns.

11 |GROUP 4
 GENITO-URINARY SYSTEM
NCM 112: MEDICAL - SURGICAL NURSING

Rivera, Artemio Jerome S., PhD

BSN 3 A&B – 1st SEMESTER | AY 2024 – 2025

PROSTATE CANCER CLINICAL MANIFESTATIONS

● Prostate cancer is the most common cancer in ● Early Stages: Often asymptomatic; cancer is often
men (excluding skin cancer) and the second detected via screening.
leading cause of cancer-related deaths in males. It ● Later Stages:
typically grows slowly, often remaining confined to ○ Urinary symptoms: Hesitancy, weak
the prostate gland for years, though some forms stream, frequency, nocturia.
are aggressive and metastasize rapidly. ○ Hematuria (rare).
○ Erectile dysfunction.
Prostate ○ Signs of Metastasis:
■ Bone pain (common in advanced
> Below the bladder, surrounding the urethra. disease).
■ Unexplained weight loss and
> Produces fluid that nourishes and transports sperm. fatigue.

> Zones: DIAGNOSTIC TESTS AND EXAMINATIONS

○ Peripheral zone: Common site for cancer. A. Screening

○ Central zone. 1. Prostate-Specific Antigen (PSA):
○ Transitional zone: Common site for ○ Blood test measuring PSA, a protein
benign prostatic hyperplasia (BPH). produced by prostate cells.
○ Elevated levels (>4 ng/mL) may indicate
cancer, but also rise with BPH or
RISK FACTORS
prostatitis.
2. Digital Rectal Exam (DRE):
● Non-modifiable Factors:
○ Physical exam to detect prostate
○ Age: Rare before age 50; incidence rises abnormalities.
with age. B. Diagnostic Tests
○ Race/Ethnicity: Higher in African American 1. Prostate Biopsy:
men. ○ Transrectal or transperineal biopsy guided
○ Family History: Genetic predisposition by ultrasound or MRI.
○ Confirms diagnosis and provides a
(e.g., BRCA1/2 mutations).
Gleason score (grades aggressiveness).
● Modifiable Factors: 2. Imaging:
○ Diet high in red meat and high-fat dairy. ○ Multiparametric MRI for localized cancer
○ Obesity and sedentary lifestyle. evaluation.
○ Exposure to environmental toxins. ○ Bone scan, CT, or PET for metastatic
disease.
PATHOPHYSIOLOGY Staging and Grading
A. Staging: TNM Classification
● Most prostate cancers are adenocarcinomas, ● T: Tumor size and extent.
● N: Lymph node involvement.
arising from glandular cells.
● M: Metastasis.
● Growth is influenced by androgens (testosterone ● Stages range from I (localized) to IV (metastatic).
and dihydrotestosterone). B. Grading: Gleason Scoring System
● Spread: Local (seminal vesicles, bladder) or distant ● Grades cancer cells from 1 (normal-like) to 5
(bones, lymph nodes). (abnormal).
● Combined score (2-10) determines aggressiveness:
○ 6 = low-grade.
○ 7 = intermediate-grade.
○ 8-10 = high-grade.

12 |GROUP 4
 GENITO-URINARY SYSTEM
NCM 112: MEDICAL - SURGICAL NURSING

Rivera, Artemio Jerome S., PhD

BSN 3 A&B – 1st SEMESTER | AY 2024 – 2025

TREATMENT AND MEDICAL MANAGEMENT Complications:

A. Localized Prostate Cancer ● Treatment-Related:
1. Active Surveillance: ○ Urinary incontinence.
○ For low-risk cancers. ○ Erectile dysfunction.
○ Involves regular PSA tests, DRE, and ○ Bowel dysfunction (following radiation).
biopsies. ● Disease Progression:
2. Radical Prostatectomy: ○ Bone metastases leading to fractures.
○ Surgical removal of the prostate. ○ Spinal cord compression.
○ Risks: Urinary incontinence, erectile ○
dysfunction.
3. Radiation Therapy: TOXIC SHOCK SYNDROME (TSS)
○ External beam radiation or brachytherapy
(internal radioactive seeds). ● TSS is a rare, acute, and potentially life-threatening
B. Advanced/Metastatic Prostate Cancer
condition caused by bacterial exotoxins,
1. Androgen Deprivation Therapy (ADT):
particularly from Staphylococcus aureus and
○ Reduces testosterone levels.
○ Includes GnRH agonists/antagonists (e.g., Streptococcus pyogenes. It results in systemic
leuprolide) or orchiectomy. inflammatory response, leading to shock and
2. Chemotherapy: multi-organ dysfunction.
○ Docetaxel for hormone-refractory cancer.
3. Targeted Therapy: PATHOPHYSIOLOGY
○ PARP inhibitors for cancers with BRCA
mutations.
4. Radiopharmaceuticals:
○ Radium-223 for bone metastases.
C. Palliative Care
● Focused on managing symptoms in advanced
disease.
● Bone-targeted therapies (e.g., bisphosphonates,
denosumab) for metastases.

NURSING MANAGEMENT

A. Assessment
1. Pre-treatment:
○ Assess urinary and sexual function.
○ Evaluate patient’s understanding of the
disease and treatment options.
2. Post-treatment:
○ Monitor for complications (e.g.,
incontinence, infection).
○ Assess psychosocial impacts (e.g.,
anxiety, depression).
B. Interventions
1. Symptom Management:
○ Manage urinary symptoms with bladder
training or pelvic floor exercises.
○ Address pain with appropriate analgesics.
2. Education:
○ Explain treatment options and potential
side effects.
○ Encourage adherence to follow-up care.
C. Supportive Care
● Facilitate support groups or counseling.
● Provide resources for sexual health and coping with
changes in body image.

13 |GROUP 4
 GENITO-URINARY SYSTEM
NCM 112: MEDICAL - SURGICAL NURSING

Rivera, Artemio Jerome S., PhD

BSN 3 A&B – 1st SEMESTER | AY 2024 – 2025

CLINICAL MANIFESTATIONS MANAGEMENT AND TREATMENT

A. Initial Stabilization
A. Staphylococcal TSS 1. Fluid Resuscitation:
● Early Symptoms: ○ Administer isotonic fluids (e.g., normal
○ High fever (>38.9°C or >102°F). saline or lactated Ringer's).
○ Hypotension (systolic BP <90 mmHg). ○ Monitor urine output and blood pressure.
○ Diffuse macular rash resembling sunburn. 2. Hemodynamic Support:
● Systemic Involvement (criteria require three or ○ Vasopressors (e.g., norepinephrine) for
more): persistent hypotension.
○ Gastrointestinal: Vomiting, diarrhea. B. Antibiotic Therapy
○ Renal: Elevated creatinine or urea levels. ● Empiric Coverage:
○ Hepatic: Increased liver enzymes. ○ Clindamycin: Inhibits toxin production.
○ Muscular: Severe myalgia or creatine ○ Vancomycin: Covers methicillin-resistant
kinase elevation. Staphylococcus aureus (MRSA).
○ CNS: Altered mental status or confusion. ○ Broad-Spectrum Beta-Lactam (e.g.,
○ Late Sign: Desquamation of palms and piperacillin-tazobactam).
soles, typically 1-2 weeks later. ● Targeted Therapy (once organism identified):
B. Streptococcal TSS ○ S. aureus: Nafcillin or oxacillin (if
● Localized Pain: Severe, disproportionate pain at the methicillin-sensitive).
infection site. ○ S. pyogenes: Clindamycin + Penicillin G.
● Systemic Features: C. Source Control
○ Rapid-onset hypotension and shock. ● Remove foreign bodies (tampons, nasal packing).
○ Multisystem organ failure. ● Surgical debridement for necrotic or infected
● May present with necrotizing fasciitis or soft tissue tissue.
infections. D. Adjunctive Therapy
● Intravenous Immunoglobulin (IVIG): Neutralizes
DIAGNOSTIC CRITERIA circulating toxins (especially for streptococcal TSS).
A. Staphylococcal TSS ● Glucocorticoids: May be used in severe cases to
1. Clinical Features: Fever, rash, hypotension, mitigate inflammation.
desquamation, and multi-organ involvement.
2. Blood cultures typically negative for other NURSING MANAGEMENT
pathogens.
B. Streptococcal TSS A. Assessment and Monitoring
1. Isolation of Streptococcus pyogenes from a sterile 1. Vital Signs:
site (blood, wound). ○ Frequent monitoring for hypotension,
2. Hypotension with signs of multi-organ involvement. tachycardia, and fever.
2. Neurological Status:
LABORATORY AND IMAGING STUDIES ○ Watch for confusion or changes in mental
● Blood Tests: state.
○ Complete blood count: Leukocytosis or 3. Skin and Wound Assessment:
leukopenia, thrombocytopenia. ○ Observe for rash, signs of desquamation,
○ Liver and kidney function tests: Elevated or wound infection.
creatinine, urea, and transaminases. B. Interventions
○ Coagulation panel: May indicate 1. Fluid and Electrolyte Balance:
disseminated intravascular coagulation ○ Administer fluids and monitor
(DIC). intake/output.
● Cultures: 2. Medications:
○ Blood, wound, or fluid cultures for ○ Administer antibiotics and IVIG as
bacterial identification. prescribed.
○ Swabs of tampon or wound sites. 3. Psychosocial Support:
● Imaging: ○ Provide education and emotional support
○ CT or MRI: To identify necrotizing fasciitis to patients and families.
or abscesses in streptococcal TSS. Complications:
● Acute kidney injury.
● Respiratory distress syndrome.
● Disseminated intravascular coagulation (DIC).
● Multisystem organ failure.

14 |GROUP 4
 GENITO-URINARY SYSTEM
NCM 112: MEDICAL - SURGICAL NURSING

Rivera, Artemio Jerome S., PhD

BSN 3 A&B – 1st SEMESTER | AY 2024 – 2025

LABORATORY AND DIAGNOSTIC EXAMS

URINARY TRACT INFECTION (UTI) ● Urinalysis: Detects pyuria, bacteriuria, and

hematuria.
An infection of the urinary tract caused by pathogenic ● Urine Culture and Sensitivity: Identifies the
causative organism and guides antibiotic therapy.
microorganisms, commonly bacteria, such as Escherichia ● Complete Blood Count (CBC): Elevated white blood
coli. It can be classified into: cell count in systemic infection.
● Lower UTI: Cystitis (involves the bladder) or ● Blood Cultures: To rule out bacteremia in suspected
Urethritis (involves the urethra) upper UTI or sepsis.
● Upper UTI: Acute/Chronic Pyelonephritis (involves ● Imaging Studies (for complicated UTI):
the kidneys) - Ultrasound: Detects urinary obstruction or
abscess.
Women also have a higher risk of developing UTI due to
- CT Scan: Evaluates severe or recurrent
having shorter urethra than men. infections.

PATHOPHYSIOLOGY
PHARMACOTHERAPY

Antibiotics:
- Trimethoprim-sulfamethoxazole, Nitrofurantoin
(first-line for uncomplicated UTI)
- Fluoroquinolones (e.g., Ciprofloxacin) for
complicated or upper UTIs
Analgesics:
- Phenazopyridine for symptomatic relief of dysuria
Hydration Therapy: Increased fluid intake to flush out
bacteria

NURSING CONSIDERATIONS

Independent Dependent Collaborative

Management Management Management

Encourage Administer Collaborate with

increased fluid prescribed the healthcare
intake (2-3 L/day) antibiotics and provider to adjust
unless monitor for side antibiotic therapy
contraindicated. effects. based on urine
culture results.
Educate patients Provide prescribed
on proper perineal urinary analgesics Refer patients with
hygiene (e.g., (e.g., recurrent UTIs to a
wiping front to Phenazopyridine). specialist for further
back). evaluation.
CLINICAL MANIFESTATIONS
Monitor vital signs
Advise frequent for signs of Work with dietitians
urination to prevent systemic infection. to ensure an
LOWER UTI UPPER UTI
bladder stasis. adequate fluid and
nutritional intake.
-Dysuria (painful urination) -Flank pain/ costovertebral
-Urinary frequency and angle tenderness
urgency -Fever & chills
-Suprapubic pain or pressure -Nausea and vomiting
-Hematuria (blood in urine) -Fatigue or malaise
-Cloudy or foul-smelling -Increased WBC count or
urine Bacteriuria

15 |GROUP 4
 GENITO-URINARY SYSTEM
NCM 112: MEDICAL - SURGICAL NURSING

Rivera, Artemio Jerome S., PhD

BSN 3 A&B – 1st SEMESTER | AY 2024 – 2025

ADULT VOIDING DYSFUNCTION ● Imaging Studies: Ultrasound or MRI may be used

to identify structural causes such as bladder stones
Adult voiding dysfunction refers to the inability to properly or tumors.
store or eliminate urine due to abnormalities in the lower
urinary tract, nervous system, or surrounding structures. It
can be classified as: NURSING CONSIDERATIONS
Storage dysfunction: Overactive bladder, urinary retention,
or incontinence. Assessment:
Emptying dysfunction: Difficulty initiating or completing - Monitor voiding patterns, urine output, and
urination, often due to obstructions or neurogenic causes. characteristics.
- Assess for associated symptoms like pain or
changes in bowel habits.
PATHOPHYSIOLOGY Patient Education:
- Teach pelvic floor exercises (e.g., Kegel exercises)
Neurological Causes: for incontinence.
- Disruption of communication between the brain and - Advise on lifestyle changes such as fluid
bladder (e.g., spinal cord injury, stroke, multiple management, avoiding bladder irritants (e.g.,
sclerosis) leads to abnormal detrusor muscle caffeine, alcohol), and timed voiding.
activity. - Encourage smoking cessation to reduce the risk of
Obstructive Causes: bladder irritability.
- Conditions like benign prostatic hyperplasia (BPH) Interventions:
or urethral strictures can obstruct urine flow, - Catheterization (intermittent or indwelling) if
causing retention or overflow incontinence. retention is severe.
Muscle Dysfunction: - Encourage regular voiding schedules to prevent
- Overactive detrusor muscle results in urgency and retention.
urge incontinence, while underactive muscle leads - Administer prescribed medications and monitor for
to incomplete emptying. side effects like dry mouth or hypotension.
Anatomical Factors: Complications:
- Pelvic floor dysfunction or bladder prolapse can Monitor for complications like urinary tract infections,
affect normal voiding mechanisms. hydronephrosis, or kidney damage.

CLINICAL MANIFESTATIONS POLYCYSTIC KIDNEY DISEASE

● Urgency, frequency, or nocturia (frequent urination

at night). ● a usually genetic condition in which cysts (fluid filled
● Difficulty starting urination (hesitancy). sacs) grow in clusters within the kidneys, causing a
● Weak or intermittent urine stream. decline in function. These cysts often destroy
● Incomplete bladder emptying. neighboring nephrons by compressing the blood
● Urinary incontinence (stress, urge, overflow, or vessels that feed into them. this
functional).
● Pain or discomfort during urination (dysuria).
There are two types of polycystic kidney disease, autosomal
dominant and autosomal recessive.
LABORATORY EXAMS AND DIAGNOSTIC FINDINGS

● Urinalysis: To rule out infection or hematuria as

causes of symptoms.
● Post-Void Residual (PVR) Measurement:
Assesses the amount of urine left in the bladder
after voiding using ultrasound or catheterization.
● Urodynamic Studies: Evaluate bladder function,
detrusor muscle activity, and sphincter coordination.
● Cystoscopy: Direct visualization of the bladder and
urethra for anatomical abnormalities.

16 |GROUP 4