Chapter 49: Managing Urinary Disorders

Urinary tract infections (UTIs) are categorized as upper (pyelonephritis) or lower (cystitis, urethritis), with the most significant hospital concern being the catheter-associated urinary tract infection (CAUTI), which is identified as a "never event" by Centers for Medicare and Medicaid Services (CMS) due to its preventable nature and high risk of progression to urosepsis. The chapter discusses contributing factors to infection, notably urethrovesical and ureterovesical reflux, impaired host defenses such as the glycosaminoglycan (GAG) layer, and instrumentation of the urinary tract. Diagnostic confirmation often relies on urine cultures showing bacteria counts of 100,000 CFU/mL or more, and treatment involves tailored antimicrobial regimens, emphasizing hydration and patient education on proper hygiene. Adult voiding dysfunctions are thoroughly covered, including various forms of urinary incontinence such as stress incontinence (loss of urine with exertion), urge incontinence (involuntary loss linked to a strong urge), functional incontinence, iatrogenic incontinence, and overflow incontinence. Management prioritizes behavioral therapies like pelvic floor muscle exercises (PME/Kegel exercises), bladder retraining, and biofeedback, often supplemented by medications (anticholinergic agents, beta-3 adrenergic agonists) or surgical corrections like periurethral bulking or artificial sphincter placement. Urinary retention is assessed via post-void residual urine volume and treated by promoting natural elimination or through intermittent or suprapubic catheterization. Urolithiasis and nephrolithiasis (urinary stones) are addressed, describing stone formation through supersaturation of substances like calcium oxalate or uric acid, presenting with excruciating pain known as renal or ureteral colic. Interventions involve managing acute pain, increasing fluid intake, dietary restrictions (e.g., low purine for uric acid stones), and physical removal or fragmentation methods such as Extracorporeal Shock Wave Lithotripsy (ESWL) or ureteroscopy. Finally, the chapter details urinary tract cancers, specifically bladder cancer, which commonly manifests as painless hematuria and may necessitate a radical cystectomy followed by a urinary diversion procedure, such as the standard ileal conduit (external stoma with continuous drainage) or continent procedures like the orthotopic neobladder reconstruction, which requires rigorous postoperative bladder retraining and is associated with risks like metabolic acidosis.