Chapter 6 - Genitourinary System
Chapter 6 - Genitourinary System
First Nations and Inuit Health Branch (FNIHB) Clinical Practice Guidelines for Nurses in Primary Care.
The content of this chapter was revised in October 2011.
Table of Contents
GENERAL Percussion
–– Apparent state of health –– Suprapubic or costovertebral angle tenderness
–– Appearance of comfort or distress –– Bladder distention
–– Colour (for example, flushed, pale) Remember to also examine the following areas as part
–– Hydration status of your assessment:
–– Nutritional status (emaciated or obese)
–– Head, eyes, ears, nose, throat: assess for
–– Match between appearance and stated age
pharyngitis and conjunctivitis (chlamydial
VITAL SIGNS infection, gonorrhea)
–– Skin: assess for skin lesions, rashes, polyarthralgias
–– Temperature of systemic gonorrhea and hydration status
–– Heart rate
–– Respiratory rate MALE GENITAL TRACT
–– Blood pressure
Inspection
URINARY SYSTEM –– Penis (including urethra, prepuce, glans, shaft,
(ABDOMINAL EXAMINATION) skin): inflammation, discharge (at urethral meatus
before and after instructing the client to “milk”
Inspection the penis from its base), lesions (ulcers, warts),
–– Inguinal and femoral areas nodules, scars, swelling, asymmetry, stenosis,
–– Abdominal contour looking for asymmetry or ability to retract foreskin (if present), phimosis,
distention (a sign of ascites), pulsations, or masses paraphimosis, hypospadias, epispadias
–– Peripheral vascular irregularities –– Scrotum: inflammation, lesions, swelling, masses,
–– Previous abdominal or flank surgical scars asymmetry, rashes, warts, veins
–– Edema (facial, peripheral) –– Pubic area: inflammation, lesions (warts, ulcers),
nodules, scars, changes in hair distribution, nits
–– Ulcers, warts, nodules, scars, and inflammation
–– Inguinal and femoral areas (for hernial bulges)
–– Ask the client to bear down or cough while
inspecting urethra for stress incontinence; repeat
Palpation
in females with pressure to lateral vaginal fornix
–– Rectum looking for lesions, discharge, swelling, –– Penis: tenderness, induration, nodules, lesions
hemorrhoids, excoriations, masses, inflammation –– Testes and scrotal contents (including epididymis,
spermatic cord): size, position, shape, consistency,
Palpation atrophy of testes, tenderness, swelling, warmth,
masses, hydrocele
–– Suprapubic tenderness
–– Prostate (digital rectal exam): size, shape, contour,
–– Bladder distention
consistency, mobility, tenderness, or nodules
–– Abdominal tenderness, induration, or masses
–– Superficial inguinal ring (for hernia)
–– Costovertebral angle tenderness
–– Inguinal canal (while standing) and femoral areas
–– Enlargement of kidney (normal kidneys are usually
(for hernia)
not palpable unless the client is thin)
–– Cremasteric reflex
–– Inguinal nodes or swellings
–– Femoral area (anterior thigh) for hernias FEMALE GENITAL TRACT
–– Supraclavicular lymphadenopathy
See Chapter 13, “Women’s Health and Gynecology”,
–– Rectum (digital rectal exam): hemorrhoids, masses, for details of this examination.
anal sphincter tone
In clients with an indwelling catheter, evaluate for –– Diagnostic uncertainty exists (for example,
cystitis if they develop a fever or other systemic atypical symptoms OR typical cystitis
symptoms (for example, malaise, confusion, symptoms and negative leukocyte esterase
hypotension). dipstick)
–– Client is pregnant
PHYSICAL FINDINGS –– Only one of the following or none of the
–– There may be no physical findings in cystitis following signs and symptoms are present:
–– Temperature may be elevated (usually only in dysuria, more than trace amount of urine
upper urinary tract infections) leukocytes, or positive nitrites on urine dipstick
–– Mild to moderate suprapubic tenderness –– Client symptoms persist after empiric therapy
–– Prostate may be enlarged –– A relapse occurs less than a month after therapy
–– No costovertebral angle tenderness or flank pain when no culture was done for the initial infection
–– Pelvic examination if urethral or vaginal discharge –– Obtain urine sample for culture and sensitivity in
is present, or vaginal irritation reported, sexually those with an indwelling catheter by removing the
active male, or uncertain diagnosis. In pure cystitis old one and inserting a new one
one would not expect to see signs of vaginitis, –– Obtain a vaginal swab for analysis (routine and
urethral discharge, herpetic ulcerations, nor any microscopy, culture and sensitivity) as required
signs of cervicitis –– Obtain appropriate swabs or urine sample for
Neisseria gonorrhoeae and Chlamydia trachomatis
DIFFERENTIAL DIAGNOSIS if an STI is suspected (for example, if dysuria
–– Pyelonephritis and positive for leukocyte esterase, but negative
urine culture and sensitivity) (see Chapter 11,
–– Urethritis
“Communicable Diseases”)
–– Vulvovaginitis
–– Consider additional diagnostic tests (for
–– Urinary calculi
example, for HIV, hepatitis A, B and C, syphilis)
–– Sexually transmitted infection (STI) for individuals with risk factors for sexually
–– Pelvic inflammatory disease transmitted infections (STIs) (see Chapter 11,
–– Benign prostatic hyperplasia “Communicable Diseases”)
–– Diabetes mellitus –– Check the blood glucose level if symptoms suggest
–– Chronic prostatitis (if recurrent cystitis) diabetes mellitus
–– Renal tuberculosis (TB)
MANAGEMENT
COMPLICATIONS
Goals of Treatment
–– Ascending infection (pyelonephritis)
–– Relieve symptoms
–– Sepsis
–– Eradicate bacteria from the bladder
–– Kidney failure
–– Prevent recurrent infection
–– Chronic cystitis
Appropriate Consultation
DIAGNOSTIC TESTS
Consult a physician if the client is suspected to have a
–– Obtain midstream urine for urine dipstick testing
relapse, as further testing may be required.
(leukocyte esterase and nitrites positive)
–– Urine culture and sensitivity might be useful if:
–– Client is not responding to treatment
–– Client is known to have an abnormality of the
GU tract
–– Client is suspected to have a complicated
infection (for example, male), (see the section
“Cystitis”)
Risk Factors
Table 2 – Selected Drugs Related to Incontinence81
–– Childbearing (including vaginal delivery) Drug class Example
–– Obesity Drugs with anticholinergic effects
–– Increasing age
Antipsychotic agents prochlorperazine (Stemetil)a
–– Functional impairment (for example, lower and
Tricyclic antidepressants amitriptyline
upper extremity weakness, sensory or cognitive
impairment) Antihistamines b
diphenhydramine (Benadryl)
–– Other urinary symptoms (for example, dysuria) Hormones estrogen, oral
contraceptives
–– Childhood enuresis
Antihypertensives
–– Diabetes
Calcium channel blockers amlodipine, nifedipine
–– Menopause
–– Stroke ACE inhibitors enalapril
–– Neurologic examination if sudden onset, known PSA levels should not be drawn if a digital prostate
neurologic disease, or new onset of neurologic exam has been done in the previous 3 days because
symptoms (for example, perineal sensation, levels may be falsely elevated.
anal sphincter tone, anal wink, vibration and
sensation testing) MANAGEMENT85
–– Older adults: assess cognitive and functional status Management is based on identifying and treating the
(for example, mobility, ability to transfer, manual underlying cause. Treatment is focused on the most
dexterity, ability to toilet) troublesome aspects for the client, so the client’s goals
–– Screen for depression are consistent with the care provider’s and should start
with the least invasive (nonpharmacologic) measures
DIFFERENTIAL DIAGNOSIS83 first, as they carry the least risk.
–– Cauda equina syndrome
Goals of Treatment
–– Spinal cord compression or trauma
–– Uterine prolapse –– Achieve relief of urinary symptoms (reduction in
–– Renal calculi incontinent episodes, urinary frequency, urinary
–– Multiple sclerosis urgency)
–– Brain or spinal cord tumour –– Increase functional capacity of the bladder
–– Cystitis or pyelonephritis –– Improve quality of life
–– Pelvic inflammatory disease Appropriate Consultation
–– Prostatitis
Consult a physician if the incontinence is associated
–– Vaginitis
with abdominal or pelvic pain, hematuria (and not
COMPLICATIONS cystitis), elevated prostate specific antigen, abnormal
prostate examination, a fistula is suspected, there are
–– Irritation neurologic abnormalities, medication is a suspected
–– Breakdown and ulceration of skin in the genital cause, or there is a pelvic mass or prolapse.
area
–– Social embarrassment Nonpharmacologic Interventions
–– Social and psychological problems The following simple measures should be tried.
–– Urgency suppression using relaxation techniques; Chronic Day and Nocturnal Incontinence
stand still or sit down when urgency occurs then
–– Advise client to toilet regularly at a bedside
take a deep breath and let it out slowly while
commode or urinal to train the bladder
contracting pelvic muscles; after feel in control
walk slowly to a bathroom (for urge and mixed –– Instruct client and family members about good skin
incontinence); reassure clients that this takes weeks care to prevent skin breakdown and infection
to achieve In the elderly client, assess life situation and any
–– Kegel exercises to strengthen pelvic floor and recent life changes, cognitive status (to detect recent
perineal muscles; advise client to do 10–15 changes, depression or confusion), general medical
repetitions of slow velocity contractions, held status (to identify concurrent illness, medications and
for 6–8 seconds, three times a day for at least whether client has physical difficulty getting to the
15–20 weeks (for urge, stress, mixed incontinence, toilet). Correcting these factors should be the focus,
prevention); confirm that the client is doing them to start. Discuss medications, cognitive changes and
properly by digital vaginal examination (for uncontrolled comorbid conditions with a physician.
example, vaginal muscles squeeze, but not buttock Prompted voiding (like bladder training, but timed by
or abdominal ones). Educate that it takes 6–8 a caregiver) can help cognitively impaired clients.
weeks to start to see results. A client education
If client has a distended bladder, see “Acute Urinary
sheet on Kegel exercises is available from The
Retention”.
Canadian Continence Foundation at: http://www.
canadiancontinence.ca/pdf/pelvicmuscleexercises.pdf Pharmacologic Interventions
–– Suggest sanitary napkins or adult diapers
specifically designed for urinary incontinence Medications are sometimes used as an adjuvant
or a condom catheter to help maintain dryness therapeutic intervention to these nonpharmacologic
measures. They would be used only after clear
–– Explain disease process and expected course
diagnosis of the type of incontinence (see “Causes”)
–– Counsel client about appropriate use of medication and would be prescribed only by a physician.
(dose, frequency, side effects, completion of entire Examples of medications used to treat urinary
course prescribed) incontinence include anticholinergic agents such
–– Client education sheets on incontinence are as oxybutynin, flavoxate, tolterodine, trospium,
available to download from The Canadian solifenacin, and darifenacin; alpha-adrenergic
Continence Foundation at: http://www.continence- antagonists such as terazosin, doxazosin, tamsulosin,
fdn.ca/english/documents.html alfuzosin; and the antidepressant duloxetine. Injection
Stress Incontinence of botulinum toxin type A by a specialist into the
detrusor muscle may also be used in selected clients.
–– Encourage weight loss and increased physical
activity, if appropriate, to reduce symptoms Relieve fecal impaction with gentle disimpaction or
–– Encourage frequent toileting, complete emptying water enemas (see “Constipation,” in Chapter 5,
of the bladder, voiding before strenuous activities “Gastrointestinal System”).
and use of sanitary napkins to maintain dryness
Monitoring and Follow-Up
Urinary stress incontinence of some small degree may
Follow up in 1 month and in 4 months to ensure
be physiological and may not be abnormal.
client is continuing their Kegel exercises and other
Nighttime Incontinence nonpharmacologic interventions, and to provide
positive reinforcement. If no difference is noted
–– Advise client to reduce fluid intake in the evening
in 4 months and the client wants to pursue further
(especially caffeine products)
treatment, refer to a physician.
–– Advise client to take diuretic drugs earlier in the
evening or day Referral
–– Suggest a bedside commode or urinal, if available,
or a condom catheter Men with pelvic pain, severe incontinence or lower
urinary tract symptoms, and frequent urologic
infections should be referred to a physician
upon presentation.
2011 (Revised April 2013) Clinical Practice Guidelines for Nurses in Primary Care
Genitourinary System 6–21
–– Benign prostatic hyperplasia with urinary tract Encourage intake of fluids (in particular if mucous
infection membranes are dry).
–– Epididymitis Severe Symptoms
–– Urethritis
Bed rest.
–– Cystitis
–– Pyelonephritis Pharmacologic Interventions
–– Malignancy
Mild to Moderate Symptoms
COMPLICATIONS Consider treating clients < 35 years for sexually
–– Epididymitis transmitted infections as well.
–– Pyelonephritis Antibiotics vary in their ability to penetrate prostate
–– Acute urinary retention tissue. Prolonged antibiotic therapy is often required
–– Sepsis to eradicate the causative organism. Because of the
–– Chronic prostatitis prolonged duration of therapy ensure that the dose
is adjusted in clients with the potential for renal
–– Prostatic abscess
dysfunction (for example, elderly clients, clients with Mild to Moderate Symptoms
renal disease and/or diabetes mellitus). Discuss dosing
–– Follow up at days 2 and 7 of therapy, sooner
with a physician.
if the client’s symptoms are not improving
sulfamethoxazole/trimethoprim (Septra DS), 1 tab or are worsening. Asses compliance with the
PO bid for 4 weeks medication regimen
For clients with an allergy to Septra or sulfa drugs, a –– Repeat urine culture on day 7 of treatment; a
fluoroquinolone can be prescribed: negative culture at this time predicts that the client
will be cured after 4–6 weeks of therapy; a positive
ciprofloxacin 500 mg PO bid for 4 weeks16
culture suggests that an alternative antibiotic should
Severe Symptoms be considered in consultation with a physician
For symptoms such as sepsis, hypotension, urinary –– Educate about the importance of finishing the
retention, inability to tolerate oral medication, and course of antibiotics
immunodeficiency, start IV therapy with normal saline Severe Symptoms
for fluids and IV antibiotics, after consultation with a
physician. –– Watch for distended bladder and/or signs of sepsis
–– If the client is unable to void and has a distended
Manage fever and pain: bladder, have him sit in a tub filled with warm
acetaminophen (Tylenol), 325 mg, 1–2 tabs PO q4h water and attempt to void into the water
prn (maximum 12 regular-strength tabs/day [4 g]) –– Do not catheterize, as it is contraindicated in acute
or prostatitis
–– See “Acute Urinary Retention” if treatment as
ibuprofen (Advil, Motrin, generics), 200 mg, 1–2 tabs
described here is not successful
PO tid-qid prn
or Referral
naproxen (Naprosyn, generics), 250 mg, 1–2 tabs Severe Symptoms
PO bid-tid prn
Medevac as soon as possible for continued inpatient
Avoid NSAIDs in clients with renal dysfunction IV therapy.
and do not use if there are contraindications such as
a history of allergy to aspirin or NSAIDs or peptic
ulcer disease. BALANITIS17
Discuss the need for IV antibiotics with physician. Inflammation of glans penis.
Antibiotic selection will vary according to
circumstances. The dose of some agents (for example, CAUSES AND/OR RISK FACTORS
gentamicin) will need to be tailored to the client’s –– Allergic or irritant reaction (for example, after use
renal function. of latex condoms, contraceptive jelly, soaps)
–– Infection: Fungal (for example, Candida albicans),
Monitoring and Follow-Up viral (for example, herpes simplex), or bacterial
Be sure to review the results of the urine culture and (for example, Streptococcus spp or Staphylococcus spp)
sensitivities and adjust the antibiotic accordingly if –– Skin disorders (for example, circinate balanitis,
the organism is not sensitive to the empiric antibiotic psoriasis)
prescribed. –– Poor personal hygiene in uncircumcised males
–– Trauma (for example, zippers)
–– Reactive arthritis
–– Medication reaction (for example, tetracycline,
salicylates); causing fixed drug eruption
–– Presence of foreskin
–– Diabetes
–– Morbid obesity
Table 3 – Selected Drugs Associated with Urinary Retention that have the Potential to Exacerbate
the Symptoms of BPH23,24,25
Drug class Example
Drugs with anticholinergic effects
Antipsychotic agents Prochlorperazine (Stemetil)a
Tricyclic antidepressants Amitriptyline
Antispasmodic agents Hyoscine butylbromide (Buscopan)
Antiparkinsonian agents Benztropine (Cogentin)
Antihistaminesb Diphenhydramine (Benadryl)
Inhaled anticholinergic agents (for COPD) Ipratropium, tiotropium26
Sympathomimetics
Alpha-adrenergic agonists (in cold remedies) Phenylephrine, pseudoephedrine
Hormones Testosterone
Antihypertensive agents Hydralazine, nifedipine
Skeletal muscle relaxants Cyclobenzaprine (Flexeril), diazepam, baclofen
a. Often used as an antinauseant
b. It is the older histamine H1 receptor antagonists that are a problem in this regard
An accumulation of urine in the bladder due to an –– Strong urge to void but inability to do so for hours
abrupt inability to empty the bladder. It occurs most –– Suprapubic and/or lower abdominal fullness and
often in men over age 60, and is often the result of pain
benign prostatic hyperplasia. It is the most common –– Voiding habits before retention (hematuria, dysuria,
urologic emergency. hesitancy, dribbling, daytime frequency, nocturia)
–– Bowel habits, last bowel movement and its
CAUSES consistency
Usually related to obstruction, but may also be due to –– History of fever, low back pain, neurologic
trauma, neurologic disease, infection, or psychologic symptoms, rash, intravenous drug use, low back
concerns. pain (may be due to spinal cord compression)
–– Previous history of retention, surgery, radiation,
–– Any process that causes increased bladder-outlet
pelvic trauma, cancer
resistance or decreases bladder contractility
–– Causes (see “Causes”) and risk factors
–– Benign prostatic hyperplasia
(see “Risk factors”), as listed above
–– Side effects of drugs, both prescription and
–– Review medications, noting any drugs that might
nonprescription (for example, decongestants,
predispose to acute urinary retention (excessive
amitriptyline, oxybutynin, estrogen, haloperidol,
alcohol intake, sedatives, decongestants in over-
diphenhydramine), see “Table 3”
the-counter cold remedies, anticholinergics,
–– Constipation antipsychotics, and antidepressants)
–– Prostate cancer
With a neurogenic bladder, symptoms of pain, fullness
–– Genitourinary infection (for example, acute
and urgency may be absent. However, dribbling of
prostatitis, urethritis, cystitis, vulvovaginitis,
small amounts of urine (overflow dribbling) may
genital herpes simplex virus)
be present.
–– Neurogenic bladder
–– Urethral stricture or stone PHYSICAL FINDINGS
–– Postoperative
–– Pulse may be elevated
–– Neurologic condition (for example, spinal cord
–– Client may appear in moderate to acute distress
injury, diabetic neuropathy, stroke, epidural mass
(but there may be no evidence of distress with
compressing the spinal cord)
a neurogenic bladder)
–– Impingement on sacral nerves by protruding
–– Client may be restless and sweaty
intervertebral disk or epidural mass
–– Bladder distention may be noted on abdominal
–– Malignancy – bladder neoplasm, tumour causing
inspection
spinal cord compression
–– Weak flow of urine
–– Phimosis or paraphimosis
–– Tender, distended bladder may be felt above
–– Pelvic mass
symphysis, often reaching umbilicus (neurogenic
–– Poorly positioned indwelling catheter bladder is distended but nontender)
–– Pelvic organ prolapse in women (for example, –– Rectal examination (in men and women): masses,
cystocele, rectocele) fecal impaction, enlargement of prostate, nodular
or rocky hard prostate, decreased anal tone, rectal
Risk Factors
sphincter tone or absent perineal sensation may be
Established for men with benign prostatic hyperplasia: present, bladder may be palpable
–– Age over 70 –– Pelvic examination for women with acute retention
to examine for anatomic distortions (for example,
–– International Prostate Symptom Score >7
fibroids, tumours of the pelvis, urethra or vagina,
(available at: http://www.usli.net/uro/Forms/ipss.pdf)
vulvar edema, labial fusion, imperforate hymen)
–– Prostate volume > 30 mL
–– Neurologic examination
–– Urinary flow rate < 12 mL/sec
2011 (Revised April 2013) Clinical Practice Guidelines for Nurses in Primary Care
Genitourinary System 6–35
Monitoring and Follow-Up For those with suspected intermittent testicular torsion
refer to a physician as a urology referral is often
If intermittent testicular torsion is suspected and the warranted.
examination was normal, follow up in 7 days (sooner
if the pain recurs) and do another complete physical
examination.
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