1. Anatomy & Physiology
The genitourinary system comprises the kidneys, ureters, bladder, and urethra.
Kidneys
- Bean-shaped, covered by renal capsule; lie in retroperitoneal space on either side of vertebral column
- Adrenal glands located on top of each kidney
- Renal parenchyma: outer cortex (glomeruli, Bowman's capsule, proximal & distal tubules) + inner medulla (renal pyramids with collecting tubules/ducts)
- Nephron — functional unit: vascular system (Bowman's capsule + Glomerulus) and renal tubule (PCT, Loop of Henle, DCT, collecting duct)
Kidney Functions
- Glomerular filtration: normal GFR ~125 mL/min; average urine ~1 L/day
- Tubular function: reabsorption, secretion & excretion of water/electrolytes (controlled by ADH & Aldosterone)
- Blood pressure control: Renin-Angiotensin-Aldosterone System
- Maintain acid-base & fluid/electrolyte balance
- Vitamin D synthesis & activation
- Release erythropoietin (from juxtaglomerular apparatus) → stimulates erythropoiesis
Ureters
- ~25–35 cm long; contain uretero-vesical valve preventing backflow of urine
Bladder
- Reservoir capacity 1000–1800 mL; moderately full ~500 mL
- Wall = detrusor muscle; neck = trigone muscle
- Contraction of detrusor + relaxation of trigone releases urine
Urethra
- ~3–5 cm in women, ~20 cm in men
Male Reproductive System
- Testis: exocrine & endocrine function
- Epididymis: stores spermatozoa
- Vas deferens: carries sperm into GU tract via spermatic cord
- Prostate: below bladder, in front of rectum; produces milky fluid nourishing sperm
- Cowper's glands: secrete lubricating fluid
- Seminal vesicles: nourish & activate sperm
2. Diagnostic Tests & Lab Values
Urinalysis (UA)
| Test | Normal | Notes |
|---|
| Color | Pale yellow to amber | |
| pH | 4.6–8.0 | |
| Specific gravity | 1.010–1.030 | ↑ in insufficient intake, ↓ renal perfusion, SIADH; ↓ in ↑ fluid intake, DI |
| Osmolality | ~800 mOsm/kg | Large = concentrated; small = diluted |
Key Blood Tests
| Lab | Normal Range | Notes |
|---|
| BUN | 10–20 mg/dL | ↑ in renal impairment, dehydration, high-protein diet |
| Serum Creatinine | 0.7–1.4 mg/dL | Best indicator of renal function |
| Creatinine Clearance | M: 16–24 mg/kg/24hr; F: 10–20 mg/kg/24hr | Measured via 24-hr urine + blood |
| PSA | < 4 ng/dL | Avoid prostatic stimulation before blood draw |
| Uric Acid | 2.5–8 mg/dL | |
Other Tests
- X-ray KUB: identifies stones, malformations, tumors
- IVP: fluoroscopic exam after iodine dye; check for allergy to iodine/seafood; NPO night before; force fluids post-test
- Retrograde pyelogram: for patients allergic to dye; catheter passed via cystoscope into ureter
- Cystoscopy: rigid (lithotomy) or flexible (prone/supine); post: warm sitz bath, mild hematuria normal, force fluids, monitor I&O
- Renal biopsy: percutaneous needle; pre: hold anticoagulants; NPO; contraindicated with uncontrolled HTN. Post: supine bed rest 6–8 hr, monitor for hematuria, avoid heavy lifting 2 weeks
3. Urinary Tract Infection (UTI)
Bacterial invasion of the urinary tract; usually caused by E. coli.
Predisposing Factors
- Stagnation of urine, obstruction, incontinence, poor hygiene, sexual intercourse
- Higher risk in children (short urethra, easy contamination); low estrogen levels
Findings
- Frequency, urgency, dysuria, enuresis, hematuria, low-grade fever, abdominal pain
Management
- Antibiotics based on C&S: Bactrim, Sulfisoxazole, Ciprofloxacin, Norfloxacin, Nitrofurantoin (Macrobid)
- Urinary analgesic: Phenazopyridine (Pyridium)
- Nursing: force fluids, warm sitz bath, frequent voiding, wipe front-to-back, avoid bubble baths, avoid synthetic undergarments, acidify urine (cranberry, prunes, vitamin C, no carbonated beverages)
4. Pyelonephritis
Inflammation of the renal pelvis; may be unilateral or bilateral; acute or chronic.
Findings
- Acute: fever, chills, N/V, severe flank pain or dull ache
- Chronic: chronic fatigue, dull ache over kidneys, eventual hypertension, kidney atrophy
Management
- Antibiotics, antispasmodics; surgical removal of obstruction for chronic
5. Glomerulonephritis
Immune complex disease from antigen-antibody reaction → destruction, inflammation, and sclerosis of glomeruli. May occur 2–3 weeks after group A Beta-hemolytic streptococcal infection (APSGN). Usually self-limiting (~14 days).
Findings
- Fever, HTN, edema, anorexia, lethargy, oliguria/anuria
- Hematuria (dark/red-brown urine)
Diagnosis
- ↑ BUN & creatinine, ↑ ESR, ↑ ASO titer, ↓ Hgb/Hct, ↑ urine specific gravity
- UA: RBCs, WBCs, protein, cellular casts
Management
- Antibiotics for strep (Penicillins), antihypertensives, digoxin & diuretics if circulatory overload, fluid restriction, high-calorie low-protein diet, Na restriction
- Peritoneal dialysis if severe
6. Acute Kidney Injury (AKI)
Sudden loss of kidney function; may be reversible.
Causes
- Pre-renal: ↓ renal perfusion (MI, CHF, hypovolemia from burns/hemorrhage)
- Intra-renal: nephron damage (DM, malignant HTN, nephrotoxic drugs, transfusion reaction)
- Post-renal: mechanical obstruction (renal calculi, BPH, tumors, trauma)
Phases & Findings
Oliguric Phase (1–2 weeks)
Urine < 400 mL/24hr; A/N/V; fluid overload (HTN, edema); pruritus; tingling extremities; altered LOC; ↑BUN/Cr; hyponatremia; hyperkalemia; hyperphosphatemia; hypocalcemia; hypermagnesemia; metabolic acidosis
Diuretic Phase (2–3 weeks)
Diuresis 4–5 L/day; hyponatremia; hypokalemia; hypovolemia; hypotension & tachycardia; gradual ↓ in BUN/Cr
Recovery Phase (1–2 years)
Renal function stabilizes; may develop CRF
Management
- Diuretics, antihypertensives, cardiac glycosides; dialysis as needed
- Cardiac monitoring; daily weight; hourly I&O; fluid restriction in oliguric phase
- ↑calorie, ↓Na, ↓K, ↓phosphorus, protein-restricted diet; meticulous skin care
7. Chronic Kidney Disease (CKD) & ESRD
Progressive irreversible loss of kidney function; nephrons replaced by scar tissue.
Causes
- DM, HTN, autoimmune disorders, progression of ARF, chronic UTI/obstruction
Stages
- Diminished renal reserve: ↓ function, no waste accumulation
- Renal insufficiency: oliguria, edema, metabolic waste accumulation
- ESRD: fluid overload, severe metabolic waste; dialysis or transplant required
Complications & Management
| Complication | Cause / Intervention |
|---|
| HTN & cardiopulmonary (edema, SOB) | Diuretics, digoxin; fluid restriction; strict I&O, daily weight; monitor for CHF, pulmonary edema |
| Hyperkalemia (tall peaked T waves) | ↓ K diet; Kayexalate; glucose-insulin bolus; calcium gluconate; dialysis |
| Hyperphosphatemia | Phosphate binders (Amphogel, Basalgel, Phoslo, Renagel) with meals; stool softeners |
| Hypocalcemia | Calcium supplements + activated vitamin D (Calcitriol) |
| Anemia | Epoetin alfa (Epogen, Procrit, Aranesp); folic acid; blood transfusions |
| Metabolic acidosis | Sodium bicarbonate as ordered |
| Neurologic signs (fatigue, confusion) | Safety measures; calm environment |
| Pruritus (uremic frost) | Bathe in plain water; avoid soap; antipruritics |
| GI symptoms (N/V/D, stomatitis, GI bleed) | Antihistamines; monitor GI bleed (H/H, stool OB); avoid IM injections |
| Ocular irritation | Lubricating eye drops |
| Insomnia & fatigue | Adequate rest periods |
| Infection risk | Avoid people with infections; strict asepsis |
8. Nephrolithiasis (Renal Calculi)
Presence of stones anywhere in kidneys. Higher risk in men; more common in summer. Stones composed of calcium, oxalate, uric acid, struvite (Mg/NH₄/phosphate), or cysteine.
Risk Factors
- Diet high in calcium, oxalate, purine; family history of gout/calculi/hyperparathyroidism
- Conditions causing bone demineralization; sedentary lifestyle, immobility
Findings
- Severe pain (abdominal, flank, shoulder, costovertebral) depending on stone location
- Signs of UTI with long-standing obstruction; GI symptoms N/V/D
Diagnosis
- X-ray KUB, IVP, UA, urine C&S, stone analysis, 24-hour urine
Management
- Medical: opioid analgesics, antibiotics if infection, diuretics
- ESWL: ultrasound waves pulverize stone; ear plugs needed; plenty of fluids post-procedure
- PCNL: surgical removal via small puncture; ureteroscopy with stent placement
- Nursing: strain all urine, crush clots, ambulation to facilitate passage
Dietary Modifications by Stone Type
| Stone Type | Reduce | Urine pH |
|---|
| Calcium phosphate | Milk products, high-calcium drugs | Acidic |
| Calcium oxalate | Spinach, chocolate, cashew, green tea, rhubarb | Alkaline |
| Struvite | Dairy, red meat, organ meats, whole grains | Acidic |
| Uric acid | Liver, brain, kidneys, shellfish, gravy, legumes | Alkaline |
| Cysteine | Meat, milk, cheese, eggs (methionine) | Alkaline |
9. Dialysis
Removal of metabolic waste products, excess fluid, and electrolytes by artificial method. Indicated for renal failure, poisoning, snake bites.
Principles
- Diffusion: movement of solute from high → low concentration across semipermeable membrane
- Osmosis: movement of water from lesser → greater concentration
- Ultrafiltration: fluid movement across membrane via pressure gradient
Hemodialysis (HD)
| Access | Features |
|---|
| External AV shunt | Used immediately; higher risk of clotting & infection; monitor warmth for patency; change dressing daily |
| Internal AV fistula | Takes 4–6 weeks to mature; low risk of clotting; auscultate bruit & palpate thrill; avoid sleeping on that side; no BP/injections on that arm |
| Internal AV graft | Ready in 2 weeks; artificial (Gore-tex or bovine carotid) |
| Femoral/Subclavian catheter | Short-term (up to 6 weeks); monitor peripheral pulses |
HD — Nursing Care
- Before: check weight & VS; withhold antihypertensives, sedatives, vasodilators unless ordered
- During: VS q30min; bed rest with position changes; monitor for bleeding
- After: monitor weight & VS; watch for hypovolemic shock, dialysis disequilibrium syndrome (DDS) — N/V, ↑BP, disorientation, leg cramps, paresthesias, coma — prevent by slowing initial dialysis
Peritoneal Dialysis (PD)
- Peritoneum acts as semipermeable membrane; indicated for children, CV instability
- Contraindications: recent abdominal surgery, peritonitis, impending renal transplant
- Process: inflow (1–2 L over 5–10 min) → dwell (30–45 min) → outflow (10–30 min)
- CAPD: 4 cycles/24 hr, performed at home
PD — Nursing Care
- Check weight; VS q15min during first exchange; warm dialysate
- Observe outflow: clear pale yellow (normal), cloudy (infection/peritonitis), brownish (bowel perforation), bloody (normal initially)
- Monitor for: abdominal pain, insufficient outflow, peritonitis, atelectasis/pneumonia, hypoalbuminemia, hyperglycemia
10. Benign Prostatic Hyperplasia (BPH)
Occurs in 50% of men over 50 and 75% over 75. Glandular enlargement causing urethral compression.
Findings
- Hesitancy, decreased force of stream, nocturia, frequency, hematuria, dribbling, urgency
Diagnosis
- Enlarged prostate on DRE; ↑ PSA; ↑ urine alkalinity; ↑ BUN/Cr if long-standing; cystoscopy
Management
- Alpha blockers: Tamsulosin (Flomax), Terazosin (Hytrin), Doxazosin (Cardura) — relax bladder sphincter
- Testosterone inhibitors: Finasteride (Proscar), Dutasteride (Avodart) — shrink prostate
- Saw Palmetto; catheterization; balloon dilation; laser surgery; TURP
11. Prostate Cancer
Malignant neoplasm (usually adenocarcinoma). Highest incidence in African-American men over 60. Androgen-dependent tumor.
Findings
- Similar to BPH: hesitancy, frequency, nocturia
- Rectal discomfort, anemia, weight loss, edema
- ↑ Acid phosphatase (metastasis), ↑ Alkaline phosphatase (bone metastasis)
Management
- Radiotherapy (Strontium-89, radium seeds, gamma knife)
- Antiandrogens (Bicalutamide/Casodex), estrogens, chemotherapy
- Surgery: TURP, suprapubic, retropubic, perineal prostatectomy
Post-Op Nursing (Prostatic Surgery)
- Continuous bladder irrigation (CBI) with NS to remove clots & maintain patency of 3-way Foley
- Expect hematuria 2–3 days; report bright red thick blood or persistent clots
- Control bladder spasms with anticholinergics (Oxybutynin, Propantheline, B&O suppository)
- Stool softeners to prevent straining; avoid rectal temps & enemas
- Bladder retraining after Foley removal: Kegel exercises, restrict caffeine, limit evening liquids
12. Testicular Disorders
Epididymitis
- Inflammation of epididymis; most common intrascrotal infection; often from STD (Chlamydia, Gonorrhea)
- Findings: gradual scrotal pain & edema, fever, dysuria, urethral discharge, positive Prehn's sign
- Management: ABT, analgesics, ice packs, bed rest with scrotal elevation
Testicular Torsion
- Twisting of spermatic cord → cuts off blood supply; more common in winter
- Findings: sudden severe testicular pain, unilateral swelling, N/V, negative Prehn's sign, absent cremasteric reflex
- Surgical emergency: must be treated within 6 hours to save testis
13. Urinary Diversions & Catheters
Urinary Diversion Types
- Ileal conduit (Bricker's): ureters implanted into segment of ileum → abdominal stoma
- Cutaneous ureterostomy: ureters brought through abdominal wall → stoma
- Nephrostomy: catheter into renal pelvis via flank or percutaneous
- Ureterosigmoidostomy: ureters implanted into sigmoid colon; urine excreted via rectum
- Kock pouch: continent urinary diversion
Nursing Care — Urinary Diversion
- Report signs of impaired stomal healing (pale/dark blue-black color, increased height, edema, bleeding)
- Monitor for stomal obstruction (↓ urine output, ↑ abdominal tenderness/distension)
- Inspect peristomal skin; patch test adhesives; change appliance when urine production slowest
- Place rolled gauze on stomal opening when appliance off; cleanse with mild soap & water
- Remove alkaline encrustations with vinegar & water; maintain acidic urine (acid-ash diet, vitamin C, omit milk products)
Indwelling Catheter Care
- Maintain patency; observe for obstruction (↓ output, voiding around catheter, bladder distension, discomfort)
- Irrigate as necessary; relieve bladder spasm with belladonna suppositories if ordered
- Keep bag below level of waist to prevent backflow
- Leg bag during day for ambulatory patients; acid-ash diet or ascorbic acid to ↓ UTI risk
- Change catheter/bag per protocol for long-term patients
14. NCLEX Priorities
🟡 Top NCLEX Priorities — Genitourinary & Renal
- Hyperkalemia in CKD/ESRD is life-threatening — monitor for tall peaked T waves, report immediately; Kayexalate, glucose-insulin, calcium gluconate
- Dialysis disequilibrium syndrome: neurological emergency from rapid urea removal; prevent by slowing initial dialysis
- AV fistula care: auscultate bruit & palpate thrill daily; no BP or venipuncture on that arm; no restrictive clothing
- Peritonitis in PD: cloudy outflow is earliest sign — report immediately
- Post-TURP: monitor CBI for patency & color; bright red blood or clots = report; avoid straining, rectal temps, enemas
- AKI oliguric phase: monitor I&O hourly, daily weight, fluid restriction, cardiac monitor for hyperkalemia
- Renal calculi: strain all urine; know dietary restrictions by stone type; force fluids
- UTI prevention: wipe front-to-back, void frequently, acidify urine with cranberry/vitamin C, avoid synthetic underwear
- Testicular torsion: surgical emergency — detorsion within 6 hours to save testicle
- Prostate surgery discharge: no heavy lifting 8–12 weeks; Kegel exercises; annual DRE/PSA
- Continuous bladder irrigation (CBI): maintain adequate flow to prevent clot obstruction; monitor for occlusion
- CKD nutrition: ↓ Na, ↓ K, ↓ phosphorus, ↓ protein; phosphate binders with meals; restrict fluids as ordered