Genitourinary System

Preferred Practice Patterns

The most relevant practice patterns for the diagnoses discussed in this chapter, based on the American Physical Therapy Association’s Guide to Physical Therapist Practice, second edition, are as follows:

• Primary Prevention/Risk Reduction for Skeletal Demineralization: 4A

• Impaired Aerobic Capacity/Endurance Associated with Deconditioning: 6B

• Primary Prevention/Risk Reduction for Integumentary Disorders: 7A

Please refer to Appendix A for a complete list of the preferred practice patterns, as individual patient conditions are highly variable and other practice patterns may be applicable.

The regulation of fluid and electrolyte levels by the genitourinary system is an essential component of cellular and cardiovascular function. Imbalance of fluids, electrolytes, or both can lead to blood pressure changes or impaired metabolism that can ultimately influence the patient’s activity tolerance (see Chapter 15). Genitourinary structures can also cause pain that is referred to the abdomen and back. To help differentiate neuromuscular and skeletal dysfunction from systemic dysfunction, physical therapists need to be aware of pain referral patterns from these structures (Table 9-1).

TABLE 9-1

Segmental Innervation and Pain Referral Areas of the Urinary System

From Boissonault WG, Bass C: Pathological origins of trunk and neck pain: part 1. Pelvic and abdominal visceral disorders, J Orthop Phys Ther 12:194, 1990.

Body Structure and Function

The genitourinary system consists of two kidneys, two ureters, one urinary bladder, and one urethra. The genitourinary system also includes the reproductive organs: the prostate gland, testicles, and epididymis in men, and the uterus, fallopian tubes, ovaries, vagina, external genitalia, and perineum in women. Of these reproductive organs, only the prostate gland and uterus are discussed in this chapter.

The anatomy of the genitourinary system is shown in Figure 9-1. An expanded, frontal view of the kidney is shown in Figure 9-2. The functional unit of the kidney is the nephron, with approximately 1 million nephrons in each kidney. Urine is formed in the nephron through a process consisting of glomerular filtration, tubular reabsorption, and tubular secretion.¹

FIGURE 9-1 Schematic illustration of the genitourinary system, including trunk musculature.

FIGURE 9-2 Renal cross-section.

The following are the primary functions of the genitourinary system ²:

• Excretion of cellular waste products (e.g., urea and creatinine [Cr],) through urine formation and micturition (voiding).

• Regulation of blood volume by conserving or excreting fluids.

• Electrolyte regulation by conserving or excreting minerals.

• Acid-base balance regulation (H⁺ [acid] and HCO₃⁻ [base] ions are reabsorbed or excreted to maintain homeostasis).

• Arterial blood pressure regulation. Sodium excretion and renin secretion maintain homeostasis. Renin is secreted from the kidneys during states of hypotension, which results in formation of angiotensin I and II. Angiotensin causes vasoconstriction to help increase blood pressure. Angiotensin also triggers the release of aldosterone, resulting in conservation of water by the kidney.

• Erythropoietin secretion (necessary for stimulating red blood cell production).

The brain stem controls micturition through the autonomic nervous system. Parasympathetic fibers stimulate voiding, whereas sympathetic fibers inhibit it. The internal urethral sphincter of the bladder and the external urethral sphincter of the urethra control flow of urine.³

Clinical Evaluation

Evaluation of the genitourinary system involves the integration of patient history, physical findings, and laboratory data.

Physical Examination

History

Patients with suspected genitourinary pathology often present with characteristic complaints or subjective reports. Therefore a detailed history, thorough patient interview, review of the patient’s medical record, or a combination of these provides a good beginning to the diagnostic process for possible genitourinary system pathology. The description of pain can offer clues as to its source: renal pain can be described as aching and dull in nature, whereas urinary pain is generally described as colicky (occurring in wavelike spasms) and/or intermittent.⁴

Changes in voiding habits or a description of micturition patterns are also noted during patient history and are listed here 4–6:

• Dysuria (painful burning or discomfort during urination)

• Nocturia (urinary frequency, more than once, at night)

• Incomplete bladder emptying

• Difficulty initiating urinary stream

• Hematuria (blood in urine)

• Frequency (greater than every 2 hours)

• Hesitancy (weak or interrupted stream)

• Proteinuria (urine appears foamy)

• Oliguria (very low urine output, such as less than 400 ml in a 24-hour period)

Clinical Tip

As a side effect of the medication phenazopyridine (Pyridium), a patient’s urine may turn rust-colored and be misinterpreted as hematuria.⁷ Pyridium is prescribed in the treatment of urinary pain and urgency. However, any new onset of possible hematuria should always be alerted to the medical team for proper delineation of the cause.

Observation

The presence of abdominal or pelvic distention, peripheral edema, incisions, scars, tubes, drains, and catheters should be noted when performing patient inspection, because these may reflect current pathology and recent interventions. Refer to Chapter 18 for more information on medical equipment. The physical therapist must handle external tubes and drains carefully during positioning or functional mobility treatments.

Clinical Tip

Patients with genitourinary disorders may also present with skin changes, such as pallor or rough, dry skin.⁶ Take caution in handling patients with skin changes from dehydration to prevent any skin tears that can lead to infection formation.

Diagnostic Tests *

Urinalysis

Urinalysis is a very common diagnostic tool used not only to examine the genitourinary system, but also to help evaluate for the presence of other systemic diseases. Urine specimens can be collected by bladder catheterization or suprapubic aspiration of bladder urine, or by having the patient void into a sterile specimen container. Urinalysis is performed to examine 6,9,10:

• Urine color, appearance, and odor

• Specific gravity, osmolarity, or both (concentration of urine ranges from 1.005 to 1.030)

• pH (4.6 to 8.0)

• Presence of glucose, ketones, proteins, bilirubin, urobilinogen, occult blood, red blood cells, white blood cells, crystals, casts, bacteria or other microorganisms

Urine abnormalities are summarized in Table 9-2.

TABLE 9-2

Urine Abnormalities

^*Ketones are formed from protein and fat metabolism, and trace amounts in the urine are normal.

Data from Bates P: Nursing assessment: urinary system. In Lewis SM, Heitkemper MM, Dirksen SR, editors: Medical-surgical nursing: assessment and management of clinical problems, ed 5, St Louis, 2000, Mosby, pp 1241-1255; Abdomen. In Seidel HM, Ball JW, Dains JE, et al, editors: Mosby’s guide to physical examination, ed 5, St Louis, 2003, Mosby, p 551; Weigel KA, Potter CK: Assessment of the renal system. In Monahan FD, Neighbors M, Sands JK, editors: Phipps’ medical-surgical nursing: health and illness perspectives, ed 8, St Louis, 2008, Mosby, pp 943-960; Pagana KD, Pagana TJ: Mosby’s diagnostic and laboratory test reference, ed 9, St Louis, 2009, Mosby.

Clinical Tip

If the patient is having his or her urine collected (to measure hormone and metabolite levels), the physical therapist should have the patient use the predesignated receptacle in situations when the patient needs to urinate during a physical therapy session: this will ensure that the collection is not interrupted. The predesignated receptacle can be a urinal for men or a collection “hat” placed on the toilet or commode for women. If micturition occurs during a PT session, do not discard the urine, as it may be necessary to record or process the sample. Urine output (UO) may also be collected throughout the day to measure the patient’s urine output relative to the patient’s fluid intake (input). This provides a general estimate of the patient’s renal function. Measurements of the patient’s input and output are often abbreviated I/Os.

Creatinine Tests

Two measurements of Cr (end product of muscle metabolism) are performed: measurements of plasma Cr and Cr clearance. Plasma Cr is measured by drawing a sample of venous blood. Increased levels are indicative of decreased renal function. The reference range of plasma Cr is 0.5 to 1.2 mg/dl.¹⁰

Cr clearance, also called a 24-hour urine test, specifically measures glomerular filtration rate. Decreased clearance (indicated by elevated levels of plasma creatinine relative to creatinine levels in the urine) indicates decreased renal function. The reference range of Cr clearance is 87 to 139 ml per minute.¹⁰

Estimated Glomerular Filtration Rate

The 24-hour urine collection necessary to measure creatinine clearance has become time consuming and expensive to perform, resulting in a prediction equation for glomerular filtration rate (eGFR). This estimate includes the patient’s age, gender, ethnicity, and serum (blood) creatinine with a reference value of greater than 60 ml/min/1.73 m².¹⁰

Blood Urea Nitrogen

As an end product of protein and amino acid metabolism, increased blood urea nitrogen (BUN) levels can be indicative of any of the following: decreased renal function or fluid intake, increased muscle (protein) catabolism, increased protein intake, congestive heart failure, or acute infection. Levels of BUN need to be correlated with plasma Cr levels to implicate renal dysfunction, because BUN level can be affected by decreased fluid intake, increased muscle catabolism, increased protein intake, and acute infection. Alterations in BUN and Cr level can also lead to an alteration in the patient’s mental status. The reference range of BUN is 10 to 20 mg/dl in adults.6,9,10

Clinical Tip

Noting BUN and Cr levels on a daily basis for any changes may help explain changes in the patient’s mental status, participation in physical therapy sessions, or both.

Radiographic Examination

Kidneys, Ureters, and Bladder X-Ray.

An x-ray of the kidneys, ureters, and bladder (a procedure often abbreviated as “KUB”) is generally performed as an initial screening tool for genitourinary disorders. The size, shape, and position of the renal, ureteral, and bladder structures are delineated to help identify renal calculi (kidney stones), tumor growth or shrinkage (chronic pyelonephritis), and calcifications in the bladder wall. A KUB can also be performed when internal hemorrhage is suspected after major traumatic incidents. Identification of any of these disorders requires further evaluation.6,9,11

Pyelography.

Radiopaque dyes are used to radiographically examine the urinary system. Two types of tests are performed: intravenous pyelography (IVP) and retrograde urography.

Intravenous pyelography consists of (1) taking a baseline radiograph of the genitourinary system, (2) intravenous injection of contrast dye, and (3) sequential radiographs to evaluate the size, shape, and location of urinary tract structures and to evaluate renal excretory function. The location of urinary obstruction or cause of nontraumatic hematuria may be also be identified with this procedure.6,9,11

Retrograde urography consists of passing a catheter or cystoscope into the bladder and then proximally into the ureters before injecting the contrast dye. This procedure is usually performed in conjunction with a cystoscopic examination and is indicated when urinary obstruction or trauma to the genitourinary system is suspected. Evaluation of urethral stent or catheter placement can also be performed with this procedure.5,6,9,11

Renal Arteriography.

Renal arteriography consists of injecting radiopaque dye into the renal artery (arteriography) through a catheter that is inserted into the femoral or brachial artery. Arterial blood supply to the kidneys can then be examined radiographically. Indications for arteriography include suspected aneurysm, renal artery stenosis, renovascular hypertension and trauma, palpable renal masses, chronic pyelonephritis, renal abscesses, and determination of the suitability of a (donor) kidney for renal transplantation.9–12

Clinical Tip

Patients who are scheduled for procedures involving contrast dye are generally restricted from eating or drinking 8 hours before the procedure. A patient who is scheduled for an afternoon procedure may therefore be fatigued earlier in the day and may want to defer a scheduled therapy session. Modifying the intended therapy session and respecting the person’s wishes at this time are both suitable alternatives.

Bladder Examination: Cystoscopy

Cystoscopy consists of passing a flexible, fiberoptic scope through the urethra into the bladder to examine the bladder neck, urothelial lining, and ureteral orifices. The patient is generally placed under general or local anesthesia during this procedure. Cystoscopy is performed to directly examine the prostate in men, bladder, urethra, and ureters, as well as to examine the causes of urinary dysfunction and for removal of small tumors.9,10

Clinical Tip

Patients may experience urinary frequency or dysuria after cystoscopic procedures; therefore the therapist should be prepared for sudden interruptions during a therapy session that is conducted the same day after this diagnostic procedure.

Cystometry (Cystometrogram)

Cystometry is used to evaluate motor and sensory function of the bladder in patients with incontinence or evidence of neurologic bladder dysfunction. The procedure consists of inserting a catheter into the bladder, followed by saline instillation and pressure measurements of the bladder wall.6,10,11

Renal Scanning

The structure, function, and perfusion of the kidneys can be examined with a nuclear scan using different radioisotopes for different testing procedures and structures.¹⁰

Ultrasonography Studies

Ultrasound is used to (1) evaluate kidney size, shape, and position; (2) determine the presence of kidney stones, cysts, and prerenal collections of blood, pus, lymph, urine, and solid masses; (3) identify the presence of a dilated collecting system; and (4) help guide needle placement for biopsy or drainage of a renal abscess or for placement of a nephrostomy tube.⁹ It is the test of choice to help rule out urinary tract obstruction.¹¹

Computed Tomography Scan

Indications for computed tomography (CT) of the genitourinary system include defining renal parenchyma abnormalities and differentiating solid mass densities as cystic or hemorrhagic. Kidney size and shape, as well as the presence of cysts, abscesses, tumors, calculi, congenital abnormalities, infections, hematomas, and collecting system dilation, can also be assessed with CT.5,9–11

Magnetic Resonance Imaging and Angiography

Multiple uses for magnetic resonance imaging (MRI) and angiography (MRA) include imaging the renal vascular system, staging of renal cell carcinoma, identifying bladder tumors and their local metastases, and distinguishing between benign and malignant prostate tumors.9,10

Biopsies

Renal Biopsy.

A renal biopsy consists of examining a small portion of renal tissue that is obtained percutaneously with a needle to determine the pathologic state and diagnosis of a renal disorder, monitor kidney disease progression, evaluate response to medical treatment, and assess for rejection of a renal transplant. A local anesthetic is provided during the procedure, and accuracy of biopsy location is improved when guided by ultrasound, fluoroscope, or CT scanning.6,9–11

Bladder, Prostate, and Urethral Biopsies.

Bladder, prostate, and urethral biopsies involve taking tissue specimens from the bladder, prostate, and urethra with a cystoscope, or needle aspiration via the transrectal or transperineal approach. Biopsy of the prostate can also be performed through an open biopsy procedure, which involves incising the perineal area and removing a wedge of prostate tissue. Examination for pain, hematuria, and suspected neoplasm are indications for these biopsies.⁹

Health Conditions

Renal System Dysfunction

Acute Kidney Injury

Acute kidney injury (AKI) (formerly known as acute renal failure [ARF]) can result from a variety of causes and is defined as an abrupt or rapid deterioration in renal function that results in a rise in serum creatinine levels or blood urea nitrogen with or without decreased urine output occurring over hours or days.¹³ There are three types of AKI, categorized by their etiology: prerenal, intrinsic, and postrenal.^13–15

Prerenal AKI is caused by a decrease in renal blood flow from reduced cardiac output, dehydration, hemorrhage, shock, burns, or trauma.13,14

Intrinsic AKI involves primary damage to kidneys and is caused by acute tubular necrosis (ATN), glomerulonephritis, acute pyelonephritis, atheroembolic renal disease, malignant hypertension, nephrotoxic substances (e.g., aminoglycoside antibiotics or contrast dye), or blood transfusion reactions.¹³

Postrenal AKI involves obstruction distal to the kidney and can be caused by urinary tract obstruction by renal stones, obstructive tumors, or benign prostatic hypertrophy.13,14,16–19

Clinical Tip

Patients who have AKI may have the phrase “due to void” used when the medical team is awaiting urine output after Foley catheterization. Voluntary voiding in sufficient amounts may contribute to discharge planning.

Two primary classification criteria have been developed to monitor the progression and severity of AKI: Risk, Injury, Failure, Loss, End-Stage Kidney Disease (RIFLE) (Table 9-3) and Acute Kidney Injury Network (AKIN) classification (Table 9-4).

TABLE 9-3

Risk, Injury, Failure, Loss, End-Stage Kidney Disease (RIFLE) Classification

Class	Glomerular Filtration Rate (GFR) Criteria	Urine Output Criteria
Risk	GFR decrease > 25% or serum creatinine × 1.5	<0.5 ml/kg/hr × 6 hr
Injury	GFR decrease > 50% or serum creatinine × 2	<0.5 ml/kg/hr × 12 hr
Failure	GRF decrease 75% or serum creatinine × 3 or serum creatinine ≥4 mg/dl with an acute rise > 0.5 mg/dl	<0.3 ml/kg × 24 hr or anuria × 12 hr
Loss	Complete loss of kidney function >4 weeks (persistent acute renal failure)
End-stage kidney disease	End-stage kidney disease >3 months

Data from Bellomo R, Ronco C, Kellum JA et al: Acute renal failure—definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group, Crit Care 8:R204-R212, 2004.

TABLE 9-4

Acute Kidney Injury Network (AKIN) Classification

Classes	Serum Creatinine (sCr) Criteria	Urinary Output Criteria
1	sCr increase × 1.5 or sCr increase > 0.3 mg/dl from baseline	<0.5 ml/kg/hr >6 hr
2	sCr increase × 2 from baseline	<0.5 ml/kg/hr > 12 hr
3	sCr increase × 3 or sCr increase > 4 mg/dl with an acute increase > 0.5 mg/dl	<0.5 ml/kg > 24 hr or anuria × 12 hr

Data from Mehta RL, Kellum JA, Shah SV et al: Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury, Crit Care 11:R31, 2007.

Clinical manifestations of AKI are based upon the specific type and can include the following 13–19:

• Hypovolemic symptoms of thirst, hypotension, and decreased urine output

• Acid-base imbalance

• Electrolyte imbalance

• Infection

• Anemia

• Peripheral edema

• Pulmonary vascular congestion, pleural effusion

• Cardiomegaly, gallop rhythms, elevated jugular venous pressure

• Hepatic congestion

Management of AKI includes any of the following:

• Treatment of the primary etiology, including antimicrobial agents if applicable

• Treatment of life-threatening conditions associated with AKI

• Optimize hemodynamics and fluid status

• Balance acid-base and electrolytes, particularly potassium levels

• Peritoneal dialysis, hemodialysis, continuous renal replacement therapy as necessary (refer to the Renal Replacement Therapy section)

• Transfusions and blood products

• Nutritional support

Chronic Kidney Disease

Chronic kidney disease (CKD) is an irreversible reduction in renal function that occurs as a slow, insidious process from a large number of systemic diseases that injure the kidney or from intrinsic disorders of the kidney. The renal system has considerable functional reserve, and as many as 50% of the nephrons can be destroyed before symptoms occur. Progression of CKD to complete renal failure is termed end-stage kidney disease (ESKD). At this point, renal replacement therapy (RRT) is required for patient survival.14,20

CKD can result from primary renal disease or other systemic diseases. Primary renal diseases that cause CKD are polycystic kidney disease, chronic glomerulonephritis, chronic pyelonephritis, arthroembolic renal disease, and chronic urinary obstruction. The two primary systemic diseases that are associated with CKD are type 2 diabetes and hypertension.²¹ Other systemic diseases that can result in CKD include gout, systemic lupus erythematosus, amyloidosis, nephrocalcinosis, sickle cell anemia, scleroderma, and human immunodeficiency virus.¹⁴ Complications of CKD are similar to those of AKI, including anemia and hypertension, but can also include bone pain and extraosseous calcification.²⁰ Patients with CKD are staged based on the severity of their disease (as measured by GFR), from the United States Kidney Disease Outcomes Quality Initiative (KDOQI). Stage 1 is normal kidney function, whereas renal replacement therapy (RRT) is recommended in stage 5.²¹

Management of CRF includes conservative management or RRT.21,22

Conservative management includes the following 16,17,22,23:

• Nutritional support, dietary modifications (salt and protein restrictions)

• Smoking cessation

• Calcium carbonate and vitamin supplements

• Erythropoietin for anemia

• Allopurinol therapy

• Hyperkalemia correction

• Avoiding use of nonsteroidal antiinflammatory drugs, acetaminophen, bisphosphonates, oral estrogens or herbal therapies

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