Genitourinary Symptoms

Treat Genitourinary Symptoms

INTRODUCTION

The urinary system and genito or reproductive systems are taught together because they involve many of the same anatomical structures. The urinary system eliminates waste products which is the end result of the function of many of the other body systems. It is essential to ensure the body does not "poison" itself. The presence or absence of symptoms often is used to assist in the diagnosis of a pathologic condition.

Review the Genitourinary System

Anatomy and Physiology

(1) The Urinary System - works with other body systems to maintain homeostasis by removing waste products from the blood and by helping to maintain a constant body fluid volume and composition

(a) Kidneys

(i) Each shaped very much like a kidney bean, lie on the posterior abdominal wall behind the peritoneum

(ii) Located on either side of the vertebral column near the lateral border of the psoas muscles

(iii) The right kidney is slightly lower than the left because of the superior position of the liver

(iv) A fibrous renal capsule surrounds each kidney, as does a dense deposit of adipose tissue that protects the kidney from injury

(v) The basic functional unit of the kidney is the nephron, which consist of a large terminal end called a renal corpuscle, a proximal convoluted tubule, the loop of Henle, and distal convoluted tubule

(vi) The terminal end of the nephron is enlarged to form Bowman's capsule. The wall of this capsule is indented to form a double-walled chamber occupied by a network of blood capillaries called the glomerulus.

(2) Ureters, urinary bladder, and urethra

(a) Ureters

(i) Two in number and extend from the renal pelvis to the urinary bladder

(ii) Allows urine flow from the kidneys to the urinary bladder

(b) Urinary bladder

(i) Hollow, muscular organ that lies in the pelvic cavity just posterior to the pubic symphysis

(ii) Size of the bladder depends on the amount of urine stored

(i) At the junction of the urethra with the urinary bladder, smooth muscle of the bladder forms the internal urinary sphincter

(ii) The external urinary sphincter surrounds the urethra as the urethra extends through the pelvic floor

(iii) These sphincters control the flow of urine through the urethra

(iv) In the male, the urethra extends to the end of the penis

(v) In the female, the urethra is shorter than the male and opens into the vestibule anterior to the vaginal opening

(3) Urine production - more than two million nephrons form urine in a three-step process that includes filtration, reabsorption, and secretion

(a) The first step in urine formation is the passage of fluid from the glomerular capillaries into the Bowman's capsule. Blood flowing through the glomeruli exerts pressure, and this glomerular blood pressure pushes water and small molecular dissolved substances out of the glomeruli into the Bowman's capsule. This filtration normally occurs at a rate of 125 ml/min or 180 l/day, of which 90% is reabsorbed.

(b) The filtrate leaves the renal capsule and flows through the proximal convoluted tubule, the loop of Henle, the distal convoluted tubule, and then into the collecting duct. During this process, many substances in the filtrate are reabsorbed by the blood capillaries around the tubules and reenter the general circulation. These substances include water, glucose, and other nutrients (i.e., sodium and other ions).

(c) Secretion is the process by which substances move into urine in the distal convoluted tubules and collecting duct from blood in the capillaries around these structures. Unlike reabsorption, which moves substances out of the urine and into the blood, secretion moves substances out of the blood and into the urine. These substances include hydrogen ions, potassium ions, ammonia, and certain drugs.

(4) Urine regulation

(a) The body can usually control both the amount and composition of urine it secretes

(b) This involves hormonal mechanisms, autoregulation, and sympathetic nervous system stimulation

The male reproductive system

(1) Testes

(a) Ovoid organs within the scrotum that develop as retroperitoneal organs in the abdominopelvic cavity

(b) They move from the abdominopelvic cavity to the scrotum by way of the inguinal canal. If the inguinal canal weakens or ruptures, an inguinal hernia may result

(c) Before puberty (12 to 14 years of age), the testes remain relatively simple and unchanged. At the time of puberty, however, the interstitial cells increase in number and size, and spermatozoa production begins

(d) The testes contribute approximately 5% of the seminal fluid (semen)

(2) Epididymis (one per testis)

(a) Site of final spermatozoa maturation

(b) A convoluted comma-shaped structure on the posterior side of the testis

(3) Ductus deferens (vas deferens)

(a) These structures and their coverings constitute the spermatic cord

(4) Urethra - passageway for both urine and male reproductive fluids

(5) Seminal vesicle

(a) Sac shaped gland that lies adjacent to each ductus deferens

(6) Prostate gland

(a) Consist of both glandular and muscular tissue and is approximately the size and shape of a walnut

(b) Located dorsal to the symphysis pubis at the base of the bladder, surrounding the prostatic urethra and the two ejaculatory ducts

(7) Bulbourethral glands

(a) A pair of small glands located near the membranous portion of the urethra

(8) Scrotum

(a) Divided into two internal compartments by a connective tissue septum

(b) Beneath the scrotal skin lies a layer of superficial fascia and a layer of cutaneous muscle called the dartos muscle

(c) The dartos muscle and certain abdominal muscles are important for regulating temperature in the testes. They pull the testes toward the body in cold temperatures and allow them to descend away from the body in warm temperatures.

(9) Penis

(a) Consists of three columns of erectile tissue

(b) Engorgement of this tissue with blood causes the penis to enlarge and become firm, producing an erection

The Female Reproductive System

(1) Ovaries (two in number)

(a) Consists of a dense outer portion called the cortex and a looser inner portion called the medulla

(b) Numerous small vesicles called ovarian follicles, distributed throughout the cortex, each contains oocytes (eggs) in various stages of development

(2) Uterine tubes (fallopian tubes)

(a) Ducts for the ovaries to transport oocytes to the uterus

(b) Each tube is located along the superior margin of the broad ligament and opens directly into the peritoneal cavity to receive the oocyte

(c) The broad ligament of the uterus, which is itself part of the parietal peritoneum, attaches to the ovaries by a double-layered fold of the peritoneum called the mesovarium. The ovarian ligament anchors the ovaries to the uterus and the suspensory ligament attaches them to the pelvic wall.

(d) Once inside the uterine tube, the oocyte is transported by cilia and peristaltic contractions of the smooth muscle to the uterus

(3) Uterus

(a) Size and shape of a medium pear

(b) Oriented in the pelvic cavity with the larger rounded portion (the fundus) directed superiorly and the narrower portion (the cervix) directed inferiorly. The main portion of the uterus (the body) is positioned between the fundus and cervix.

(4) Vagina

(a) Female organ of copulation and functions to receive the penis during intercourse

(b) Extends from the uterus to the outside of the body and provides a passage for menstrual flow and childbirth

(c) The smooth muscle layer allows the organ to increase in size to accommodate the penis during intercourse and to greatly stretch during childbirth.

(5) The external genitalia

(a) Referred to as the vulva, consist of the vestibule and its surrounding structures

(b) The vestibule is the space into which the vagina and the urethra open

Recognize specific illnesses

Cystitis

(1) Definition - inflammation of the urinary bladder

NOTE: Urine is normally sterile. Bacteria reach the bladder by way of infected kidneys, lymphatics, and the urethra. Because the urethra is short in women, ascending infections are more common in women.

(2) Causes

(a) Fecal contamination

(b) Catheters

(3) Symptoms

(a) Urgency (a feeling of the need to void although the bladder is not full)

(b) Frequency

(d) Perineal and suprapubic pain

(e) Hematuria

(f) Chills and fever are rare, but may indicate a more serious illness

(4) Diagnosis

(a) Patient's history and physical examination

(a) Urinalysis, urine culture and sensitivity (C&S)—may show an increase in the number of red and white cells, as well as the causative microorganism

(5) Treatment

(a) Increase fluid intake

(b) Identify and correct contributing factors

(d) Urinary (Pyridium) for dysuria

Urethritis

(1) Definition - inflammation of the urethra, more common in men than in women

(2) Causes

(a) If caused by organisms other than gonorrhea--it is known as nonspecific urethritis (NSU)

(b) Gonorrhea causes a specific form of infection that can attack the mucous membrane of the urethra

(d) Nonspecific urethritis in men caused by:

(i) Irritation during vigorous intercourse

(ii) Intercourse with an infected partner

(iii) Most common cause of urethritis is caused by chlamydia trachomatis

(3) Symptoms

(a) Dysuria - ranging from slight tickling to burning or severe discomfort

(b) Urinary frequency

(d) Urethral discharge

(4) Diagnosis

(a) Patient's history and symptoms

(b) In men, urethral smear (gram stain)/ C & S to identify causative organism

(5) Treatment

(a) Antibiotic therapy as prescribed by the MD/PA. Depending on organism must involve MD/PA as treatment needs to be tailored and treatment of syphilis is also required in many cases.

(b) Increase fluid intake

Pyelonephritis

(1) Definition - infection of the renal parenchyma (the functional tissue of an organ as distinguished from supporting or connective tissue) and the lining of the collecting system

(2) Causes

(a) Acute pyelonephritis

(i) Associated with diabetes, pregnancy and extremes of age

(ii) Bacterial infection such as E-coli, streptococcus, pseudomonas, and staph aureus

(iii) More common causes are bladder instrumentation, neurogenic bladder, and inability to completely empty the bladder

(b) Risk factors

(i) Diabetes

(ii) Pregnancy

(iii) Recent instrumentation

(iv) Extremes of age

(3) Symptoms

(a) Acute pyelonephritis

(i) Flank pain

(ii) Chills, fever, and malaise

(iii) Frequency and burning on urination may be present if bladder is also infected.

(iv) Nausea and vomiting, dehydration with secondary

(v) Headache

(4) Diagnosis

(a) Urinalysis positive for leukocyte (WBC’s) casts

(b) Positive urine culture

(5) Treatment

(a) Symptomatic treatment for fever and pain

(b) Antibiotic therapy prescribed by MD/PA. May consider ampicillin. gentamycin or fluoroquinolone (Cipro/Levaquin)

(d) Relief of any urinary obstruction

(e) All patients need to be evaluated by a physician

NOTE: Damage to the kidney can be life threatening if not treated promptly.

(6) Discharge Teaching

(a) Follow diet and fluid regime as prescribed

(b) Take medications exactly as directed

(i) Do not omit or discontinue medication unless told by the physician

(ii) Do not take nonprescription drugs unless cleared by the physician

Infections of the female reproductive system

(1) Vaginitis

(a) Definition - inflammation of the vagina (The normal acidity of the vaginal secretion is a natural defense against infection but, if infected by certain pathogenic organisms, an infection results)

(b) Causes

(i) Bacteria- most common

(ii) Trichomonas vaginalis - a protozoan

(iii) Candida albicans – yeast (fungal)

(i) Commonly occurs during pregnancy and after antibiotic therapy

(ii) Frequently seen in women with diabetes

(iii) Vaginitis may persist for years

(iv) Factors that influence the development of a vaginal infection include

* A change in the vaginal ph.

* Hormonal changes during the menstrual cycle, pregnancy or for any other reason (such as taking steroids).

* Long-term use of birth control pills

* Use of systemic antibiotics

* Compromised immunity

(d) Types of Vaginitis:

(i) Bacterial Vaginosis (BV)

* Known as nonspecific vaginitis.

* Caused by a combination of organisms.

* Increased discharge (white, yellow or gray) with a "fishy" odor.

* Redness or edema not significant.

* May be sexually transmitted

(ii) Trichomonas Vaginalis (Trichomoniasis) - a sexually transmitted disease

(iii) Candidiasis albicans— "typical yeast infection“ may be a sexually transmitted disease

(e) Signs and symptoms

(i) Leukorrhea - whitish or yellow white vaginal discharge

(ii) Discharge may be frothy or thick

(iii) Odorous and profuse discharge (more so in trichomoniasis)

(iv) Perineal, vaginal and urethral burning and itching

(v) Possible discomfort in lower abdominal region

(vi) Redness or rash around vagina

(vii) Painful intercourse

(viii) Occasionally asymptomatic

NOTE: Diagnosis is made upon microscopic examination of the vaginal discharge (usually a wet prep/KOH) and normal saline.

(f) Treatment

(i) Metronidazole (Flagyl) if BV or trichomoniasis infection - dose 250mg po tid x7 days or 2gm po in single dose. Instruct patient not to drink alcohol while taking Flagyl and for three days after completion of therapy. Using together will cause nausea, vomiting, headache, cramps and flushing)

(ii) Nystatin cream (Mycostatin, Nilstat); Miconazole (Monistat, Micatin) Clotrimazole (Mycelex) if candida infection

(iii) If has glycosuria (glucose in urine), patient will need work-up to rule out the diagnosis of diabetes mellitus

(iv) Women with any of the following clinical situations should notify the physician at the first sign of a vaginal infection

* First vaginal infection

* Unsure if it is a yeast infection

* High risk for HIV or AIDS

* Diabetic

* Temperature over 100 degrees

* Under 12 years of age

* Pregnant

* New onset pain especially lower abdomen, back, or shoulder

* Malodorous vaginal discharge

(2) Pelvic Inflammatory Disease (PID)

(a) Definition - an infection or inflammation of the ovaries, fallopian tubes, uterus, or pelvic cavity

(b) Causes and transmission

(i) Infection usually enters the pelvic organs (uterus fallopian tubes, ovaries) through the cervix and vagina

(ii) Organisms commonly associated with causing PID are N. gonorrhea and Chlamydia

(i) Foul-smelling vaginal discharge

(ii) Back ache

(iii) Pelvic pain

(iv) Abdominal pain

(v) Fever, chills, malaise

(vi) Nausea, vomiting

(vii) Menorrhagia

(viii) Dysmenorrhea

(ix) Dyspareunia

(d) Risk factors

(i) Multiple sexual partners

(ii) History of STDs in the past

(iii) Frequent vaginal douching

(iv) IUD (intrauterine device for contraception)-highest risk first four months after insertion

(v) Younger age

(e) Diagnosis

(i) Based on symptoms and physical exam findings-lower abdominal pain is the most frequent presenting complaint

(ii) Wet prep (saline/KOH (potassium hydroxide) of vaginal secretions)

(iii) Culture and sensitivity of vaginal discharge to determine causative organism

(iv) Ultrasound if available

(v) This is a cause of serious illness and death if not treated quickly and properly – Patient may develop toxic shock syndrome that can be rapidly fatal.

(f) Treatment

(i) Serious illness that requires hospitalization for administration of IV antibiotics and supportive care Patient must be treated quickly and properly.

(ii) IV antibiotics as prescribed by the MD/PA

(iii) During the active disease process, douches and sexual intercourse should be avoided

(iv) Remove IUD if in place

(g) Discharge Teaching:

(i) Both sex partners must be instructed to take their prescribed medications even though one partner may be asymptomatic

Kidney Stones

(1) Stones form throughout the urinary system. Patients usually present when the stone has migrated into a ureter

(2) Cause

(a) Dehydration

(b) Increase in minerals in water supply

(3) Symptoms

(a) Acute onset of severe flank pain

(b) Flank pain radiates to the groin, scrotum or labia

(d) Cool clammy skin, diaphoresis, tachycardia and increased blood pressure due to severe pain

(e) Hematuria with dysuria, urinary frequency

(4) Diagnosis

(a) Urine analysis – hematuria

(b) Physical assessment - acute CVA /flank tenderness on affected side

(5) Differential Diagnosis

(a) Aortic dissection

(b) Abdominal aortic aneurysm

(d) Acute myocardial infarction

(e) Acute abdomen

(6) Treatment

(a) Pain control-IV narcotics almost always required

(b) IV hydration

(d) Refer immediately to nearest MTF for management

Acute scrotal pain

(1) Differential Diagnosis

(a) Testicular torsion

(i) Cause

* History of athletic event or trauma

(ii) Symptoms

* Pain is sudden and severe with radiation into abdomen

(iii) Diagnosis

* Malpositioned testes-lateral orientation and elevated

* Ultrasound

(vi) Treatment

* Immediate referral to the nearest treatment facility

* Manual detorsion of the affected testis may be attempted. This is accomplished standing at the foot of or on the right side of the patient’s bed. The torsed testis is detorsed in a fashion similar to "opening a book“. That is, the patient’s right testis is rotated in a counterclockwise fashion and the patient’s left testis in a clockwise fashion.

* Surgical Emergency – patient will lose testicle if torsion is not corrected

(b) Epididymitis

(i) Cause

* Bacterial infection, often STD

* Urinary tract infection

* Prostatitis

* Prolonged use of indwelling catheters

(ii) Signs and symptoms

* Pain more gradual than onset of torsion

* Causes lower abdominal, inguinal and scrotal or testicular pain alone or in combination

(iii) Diagnosis

* Painful urination

* Transient relief of scrotal/testicular pain in the recumbent position with scrotal elevation

* Pyuria (WBC’s and bacteria) on urinalysis

* Epididymis tender on palpation. May feel like a 'bag of worms“

(iv) Management

* Antibiotic therapy as prescribed by MD/PA

* Increase fluid intake – oral or IV

* Rest with scrotal elevation

* Oral analgesics

Sexual Assault Assessment

(1) 5% of violent crimes in U.S.

(a) Much higher incidence in 3rd world countries

(b) Grossly under reported

(2) Assessment

(a) Assess for and treat any life-threatening injuries (compromised airway, hypovolemic shock)

(b) Provide "safe“ environment –shield from other patients, visitors

(d) Tell patient not to shower, bathe, change clothes or throw clothes away until examined by the physician. Evidence preservation is paramount.

(e) Notify MD/PA immediately

Recognize Sexually Transmitted Diseases

Factors that contribute to Sexually Transmitted Diseases (STD)

(1) Unknown carrier of disease

(2) Casual sex

(3) Absence of laws that require reporting of ALL STDs

(4) Length of time between exposure and appearance of symptoms (or positive antibody tests)

(5) Failure to:

(a) Recognize signs and symptoms

(b) Seek early treatment

(6) Lack of knowledge regarding STDs and their prevention

(7) Failure of sexually active person to heed STD warnings

Factors related to prevention and control of STDs

(1) Public education:

(a) School Systems

(b) Television and newspapers

(2) Refrain from sexual activity until disease eradicated

(3) Locate and treat contacts

(4) Continued research

(5) STD clinics

Chlamydia (Appears 7-10 Days after exposure)

(1) Caused by the organism, Chlamydia trachomatis (parasite)

(2) Signs and Symptoms

(a) Urethritis & epididymitis in men

(b) Cervicitis & macopurulent discharge in women

(d) Can be transmitted from mother to infant at birth

(e) Additional problems

(i) Pelvic inflammatory disease

(ii) Ectopic pregnancy

(iii) Sterility

(iv) Systemic infections

(3) Diagnosis

(a) Direct microscopic examination-will observe flagellated parasite

(b) Culture of secretions or tissue scrapings

(4) Management

(a) Antimicrobials, such as tetracycline, erythromycin, sulfonamide as prescribed by MD/PA

(b) Explain the prescribed treatment

(i) Length of treatment is 7-21 days

(ii) Patient should refrain from sexual activity during treatment

NOTE: Treatment failure can be due to either reinfection or patient noncompliance with antimicrobial therapy.

Gonorrhea

(1) Caused by the organism Neisseria gonorrhea. Often co-exists with chlamydial infections.

(2) Signs and Symptoms

(a) Appear 2 to 6 days after exposure

(b) Men

(i) Urethritis with a purulent discharge.

(ii) Pain on urination

(iii) May spread to prostate, seminal vesicles, epididymis

(iv) Sometimes there are no symptoms in men

(v) Gonococcal infection occur in the pharynx and rectum

(i) Vaginal discharge

(ii) Abnormal menstrual bleeding

(iii) Painful urination

(iv) 80% experience no symptoms

(3) Diagnosis

(a) Gram stain and culture

(b) In men, specimen of urethral discharge is obtained; anal and pharyngeal smears if person has practiced anal or oral sex.

NOTE: Lubricants are not used on speculum because these products may destroy the gonococci.

(4) Management

(a) Antibiotics as prescribed by MD/PA. Rocephin 250 mg IM is usually effective treatment

(b) Explain the treatment regimen

(d) Refrain from sexual activity until follow-up smears are negative

(e) Referral to Preventative Medicine for reporting

Syphilis

(1) Caused by spirochete, Treponema pallidum. If untreated, progresses through secondary & tertiary stages.

(2) Signs and Symptoms

(a) Primary (early) stage (Appears 2-6 weeks after exposure)

(i) Chancre appears on genitals, anus, cervix, and other parts of body.

(ii) Chancre first resembles papule, later appears ulcerated, painless

(iii) Heals by itself in several weeks

(b) Secondary Stage: (Appears 2-6 weeks after primary stage)

(i) Fever

(ii) Malaise

(iii) Rash – most common manifestation

(iv) Headache

(v) Sore throat

(vi) Enlarged lymph nodes

(i) May occur years after initial infection. Sometimes as much as twenty years later.

(3) Diagnosis

(a) Lab tests (serum)

(i) VDRL - Venereal Disease Research Laboratory

(ii) RPR - Rapid Plasma Reagent

(iii) Fluorescent treponemal antibody absorption test

(4) Management

(a) Explain the treatment regimen

(b) Instruct the patient to avoid intercourse until permitted

(i) Penicillin G - drug of choice

(ii) Tetracycline or erythromycin - if allergic to penicillin

(iii) Follow-up examination at 3,6, & 12 months

(d) Tertiary stage:

(i) Larger doses of penicillin G

(ii) Response is poor in patients with cardio-vascular syphilis

Herpes Genitalis

(1) Caused by Herpes Simplex Virus

(2) Signs and Symptoms

(a) Painful vesicular lesions on buttocks, penis, perineum, vulva, cervix, vagina (if transmitted by anal intercourse, lesions may appear in rectum and perianal area).

(b) Lesions may persist for several weeks

(d) Fever

(e) Chills

(f) Headache

(g) Reoccurrence in 60 – 90 % of patients

(3) Diagnosis

(a) Examination of lesions-linear vesicles. Microscopic exam will show giant cells.

(b) Viral culture

(4) Management

(a) Acyclovir (Zovirax) - oral, topical, intravenous

NOTE: Acyclovir may decrease the frequency and magnitude of reoccurrences.

(b) Analgesics for pain and discomfort

(d) Instruct the patient to use a condom at all times if there is a periodic reoccurrence of the lesions

(e) Refrain from sexual intercourse or use a condom

(f) Pregnant women must inform the physician if they have a history of herpes. Delivery during an active outbreak can be fatal to the infant.

Genital Warts

(1) Caused by human papilloma virus (HPV)

(2) Signs and Symptoms

(a) Incubation period is normally 1-2 months, but may be longer

(b) Painless, soft, fleshy wart-like growths on the genitalia or cervix or in vagina

(3) Diagnosis: visual examination

(4) Management

(a) No cure

(b) RPR for syphilis

(d) Teach the patient to use a condom

NOTE: There appears to be an increased risk of cancer of the vulva, cervix, and vagina in women with genital warts.

Review Male and Female Catheterization

Urinary Catheterization

(1) Definition - Insertion of a catheter (tube for injecting or removing fluids) through the urethra into the bladder for the purpose of removing urine.

(2) Purposes of Urinary Catheterization

(a) Relieve urinary retention

(b) Obtain sterile urine specimen from female

(d) Empty bladder before, during, and after surgery

(e) To obtain a urine specimen when a specimen cannot be obtained by any other means

(3) Urinary Catheter Sizes

(a) The smaller the number, the smaller the catheter

(b) No. 8 Fr and 10 Fr - used for children

(d) No. 18 Fr, 20 Fr - usually used for male adult

NOTE: Larger size catheter used for male because it is stiffer, thus easier to push the distance of the male urethra.

Types of Urinary Catheters

(1) Intermittent catheter

(a) Used to drain bladder for short periods (5-10 min)

(b) Commonly used for self-catheterization by patients in the home environment (after proper amount of training)

(2) Indwelling/retention catheter

(a) Continuous bladder drainage

(b) Gradual decompression of over-distended bladder

NOTE: Do not remove more than 750cc to 1000cc of urine from the bladder at any one time. Gradual decompression will prevent bladder damage and shock.

(d) Drainage tube and collection device connected to this type of catheter

(e) Most commonly used indwelling catheter is a Foley catheter

(i) Designed with balloon at distal tip which can be inflated with sterile water or saline

(ii) Inflated balloon keeps catheter from slipping out of bladder

(3) Supra pubic catheter

(a) Inserted into bladder through small incision above pubic area

(b) Occasionally used for continuous drainage

Procedure for the insertion of Foley Catheter in the male and female patient

NOTE: When considering catheterization, it is important to remember that the bladder normally is a sterile cavity and the external opening to the urethra can never be sterilized. Pathogens introduced into the bladder can ascend the ureters and lead to bladder and kidney infections.

(1) Gather all equipment - wash hands

(a) Sterile catheterization kit

(b) Flashlight or lamp

(d) Velcro leg strap or anchoring tape

(e) Disposal bag

(f) Waterproof pad or chux

(2) Explain procedure to patient. He/she may experience a burning/pressure sensation as the catheter is inserted, and a feeling of needing to void, once catheter is in place

(3) Provide for adequate lighting

(4) Provide for privacy

(5) Position patient

(a) Males - assist patient into supine position with thighs slightly apart. First place waterproof pad under patient’s buttocks. Drape patient so only penis is exposed.

(b) Females - assist patient to dorsal recumbent position with knees flexed and about 2 feet apart. Females may also be positioned in the Sim's or lateral position with upper leg flexed. Place waterproof pad under patient.

(6) Cleanse genital and perineal areas with soap and water. Rinse and dry. Wash hands.

(7) Open sterile catheterization tray and supplies, using sterile technique.

(8) Put on sterile gloves. Open sterile drape and place on patient's thighs. Place drape with opening over penis (males) or labia (females).

(9) Place catheter set on or next to patient's legs on sterile drape.

(10) For indwelling catheters, test catheter balloon:

(a) Attach pre-filled irrigation syringe to injection port

(b) Inject appropriate amount of fluid

(11) Pour antiseptic solution over cotton balls

(12) Lubricate catheter for about 6 to 7 inches (males) or 1-2 inches (females)

(13) Insertion of Catheter

(a) Males

(i) Lift penis with non-dominant hand, which is then considered contaminated.

(ii) Retract foreskin in uncircumcised male

(iii) Cleanse area at meatus with a cotton ball that is held with forceps

(iv) Use circular motion, moving from meatus toward base of penis. Repeat this three times

(v) Hold penis with slight upward tension and perpendicular to patient's body

(vi) Instruct patient to bear down as if voiding

(vii) With dominant hand, place drainage end of catheter into receptacle (if pre-attached to drainage bag, place bag close to sterile field)

(viii) Insert catheter tip into meatus

(ix) Advance tip 6 to 8 inches until urine flows

(x) Do not use force to introduce catheter

(xi) For slight resistance, ask patient to take a deep breath and rotate catheter slightly

(xii) Once urine drains, advance catheter another 1/2 to 1 inch

(xiii) Inflate the balloon with the pre-filled syringe

(b) Females

(i) With thumb and one finger of non-dominant hand, spread labia and identify meatus. Maintain separation of labia with one hand

(ii) Using antiseptic soaked cotton balls held with forceps, cleanse area from clitoris toward anus, using a different sterile cotton ball each time-first to the right of the urinary meatus, then to the left of the urinary meatus then down the center over the urinary meatus. Discard each cotton ball after one downward stroke.

(iii) With sterile gloved hand, place drainage end of catheter into receptacle. (If pre-attached to drainage bag, place bag close to sterile field)

(iv) Insert catheter tip into meatus 2 to 3 inches or until urine flows.

(v) Do not use force to push catheter through urethra into bladder

(vi) For slight resistance, ask patient to take a deep breath and rotate catheter gently as it reaches external sphincter.

(vii) Once urine drains, advance catheter 1/2 to 1 inch

(viii) Inflate the balloon with the prefilled syringe

(14) Check to insure balloon is properly filled:

(a) Tug gently on catheter to feel for resistance

(b) Attach catheter to drainage system if required

(15) Secure catheter to upper thigh (males and females) or lower abdomen with penis directed toward patient's chest (males). Leave some slack in catheter to prevent tension.

(16) Secure drainage bag below level of bladder. Check that tubing is not kinked and movement of side rails does not impede drainage.

(17) Cleanse and dry perineal area

(18) Remove equipment and make patient comfortable

(19) Wash your hands

(20) Document procedure in record

(a) Type and size of catheter

(b) Time of catheterization

(d) Description of urine

(e) Client's reaction to procedure

(f) Client's teaching and level of understanding

Removing a Retention Bladder Catheter

(1) Assemble all equipment

(a) 10 cc syringe

(b) Waterproof drape

(d) Exam gloves

(e) Privacy drape

(2) Explain procedure to patient, and advise that he/she may feel a slight burning sensation during removal of the catheter and the first time or two that they void.

(3) Provide for privacy and assist female patient to a dorsal recumbent position, or the male patient to a supine position.

(4) Place waterproof drape under patient's buttocks and provide a drape for patient privacy.

(5) Wash hands and don disposable gloves

(6) Remove securing tape on catheter

(7) Attach syringe to balloon valve and aspirate entire amount of water from balloon. Check size of balloon so you know how much to remove.

(8) Encourage patient to take deep breath and relax while gently removing catheter per ward SOP. Wrap catheter in towel or disposable waterproof drape.

(9) Clean the perineal area after the catheter is removed.

(10) Remove gloves and wash hands

(11) Reposition patient comfortably

(12) Instruct patient to drink plenty of fluids, if appropriate. Record intake and output, and instruct patient regarding need to void into bedpan or urinal.

(13) Inform patient that it may take a while for bladder to reestablish voluntary control, and that an accident is not unusual.

(14) Discard equipment and return it to appropriate area

(15) Record procedure, including the following

(a) Time of procedure

(b) Description and amount of urine in drainage bag

(16) Record and report any unusual signs to the charge nurse. These include, but are not limited to:

(a) Discomfort

(b) Bleeding

(d) Increase in temperature

(e) Strong odor

Care of the patient with an indwelling urinary catheter

(1) Catheter care

(a) Wash hands before and after catheter care

(b) Clean perineal area and proximal third of catheter twice a day and after bowel movements. Use soap and water, or designated solution per hospital SOP. Do not use powders or lotions, rinse well.

(i) Empty catheter bag every 8 hours or as directed by SOP/physician’s order

(ii) Ensure drainage spout does not contact contaminated surface.

(iii) Measure and record I&O as ordered

(iv) Observe patient for fever, chills or a sudden onset of pain

(v) Apply topical antibiotic ointment to meatus, as ordered

(vi) Check catheter frequently for patency and drainage of urine

(vii) Secure catheter to patient to avoid pulling or pressure

(viii) Clamp catheter temporarily if urine bag must be elevated higher then bladder

NOTE: This prevents urine from draining back into bladder

(ix) Drainage system tubing should extend straight down from bed to drainage bag

NOTE: Any loops hanging down from bed level may promote stasis of urine, leading to infection.

SUMMARY

With practice and an understanding of some basic principles, the insertion of a foley catheter can be done with a minimum of discomfort and embarrassment. Infectious and noninfectious urinary diseases may range in severity from mild but annoying infection to a severe, debilitating condition. The patient will need much emotional support as well as assistance with routine daily activities when the condition is severe.