URETHRITIS P 1129 Inflammation of the urethra Causes bacteria or viral infection trichomonas and monilial infection especially in women chlamydia and gonorrhea especially in men o In men the cause is usually STIs purulent discharge gonococcal urethritis or clear discharge nongonococcal o More difficult to diagnosis in women discharge may not be present Clinical manifestations LUTS dysuria urgency frequency Discharge or split urine culture urine collection at beginning of urine flow and midstream for diagnosis Treatment based on identifying cause and symptomatic relief o Bacteria trimethoprim sulfaethoxazole and nitrofurantoin o Trichomonas metronidazole flagyl and clotrimazole Mycelex o Monilial infection nystatin mycostatin and fluconazole diflucan o Chlamydia doxycycline vibramycin o Women with negative cultures and no pyuria warm sitz bath Do not use vaginal sprays properly cleanse and wipe perineal area and avoid sex until symptoms subside Refer sexual partners within the past 60 days for medical evaluation URETHRAL DIVERTICULA P 1129 1130 Result of obstruction and subsequent rupture of the periurethral glands into the urethral lumen with epithelialization regrowth of issue over the opening of the resulting periurethral cavity More common in women men occurrences usually due to congenital anomalies Skene s glands are the largest most distal and common site of diverticula formation Causes urethral trauma childbearing instruments dilation and gonococcal infection Symptoms 1 4 women have no symptoms o Dysuria post void dribbling frequency every 2 hours or less urgency suprapubic pressure discomfort dysparenunia incomplete bladder emptying o Cloudy urine with sediment and gross hematuria o Anterior vaginal wall mass tender and express purulent discharge Diagnosis cystourethrography to confirm dx ultrasound and MRI to determine size Treatment o transurethral incision of diverticular neck o marsupialization permanent opening of the diverticular sac into the vagina o Surgical excision very cautious procedure result in defect neourethra new Spence procedure urethra o Other precautions diverticular neck closure complete sac mucosal lining removal to prevent reoccurrence and multiple layered closure to prevent fistula formation Complications stress urinary incontinence INTERSTITAL CYSTITIS PAINFUL BLADDER SYNDROME P 1130 1131 Interstitial cystitis IC chronic painful inflammatory disorder of the bladder Symptoms of urgency frequency and pain in the bladder and pelvis Painful bladder syndrome PBS suprapubic pain r t bladder filling Other symptoms of frequency with no UTI or obvious pathology CAUSE Most common in women over 40 Unknown suspected factors o Chronic inflammation with bladder mast cell invasion o Glycosaminoglycan layer defect protective bladder mucosa against urine exposure o Abnormal urine contents o dysfunction of the lower urinary tract and reflex sympathetic dystrophy CLINICAL MANIFESTATIONS Pain in the suprapubic area but also the vagina labia or entire perineal area o Exacerbated by bladder filling postponing urination physical exertion suprapubic pressure eating and emotional distress o Pain is relieved by urination o Women pain before menstruation and aggravated by sex and emotional distress Bothersome LUTS frequency and urgency o Often misdiagnosed as recurrent UTIs or chronic prostatitis men Get worse over time can suddenly disappear after weeks months or persist for years DIAGNOSIS Diagnosed by exclusion o Suspected if UTI symptoms but no bacteriuria pyuria or positive urine culture o Similar to UTI and endometriosis symptoms Must have at least one negative urine culture during active symptoms o IC cystoscopic exam reveals small bladder capacity and superficial ulcerations Also bladder filling called glomerulations these findings are not found in PBS Inclusion criteria Exclusion criteria o Pain during bladder filling relieved by voiding o Urgency and frequency o Small bladder capacity on urodynamic testing o Cystoscopic evidence of ulcerations of glomerulations o Bladder capacity 350 ml of urodynamic testing o Overactive bladder contractions on urodynamic testing o Daytime voiding frequency 8 times day o Active genital herpes o Hx of chemotherapy especially cyclophosphamide Cytoxan or pelvic radiation o Tubercular cystitis o Balder tumor COLLABORATIVE CARE Dietary alterations to relieve pain and voiding complications o Low acidic foods no coffee tea alcohol carbonation o Over the counter calcium phosphorus prelief assists with diet associated pain Alkalinizes the urine and provides pain relief Basic relaxation techniques o Sitz baths heat or cold application to perineum bladder and stress reduction tapes Altered positions and lubricants during sex DRUG THERAPY Tricyclic antidepressants amitriptyline Elavil and nortriptyline Aventyl o Reduce burning pain and frequency Pentosan Elmiron only oral agent to treat IC o Enhances glycosaminoglycan layer of the bladder o Take weeks to become effective immediate relief with opioid analgesics short term Agents instilled directly into the bladder via small catheter o Dimethyl sulfoxide DMSO desensitizes bladder wall pain receptors o Heparin and hyaluronic acid to relieve symptoms Thought to enhance the glycosaminoglycan protective properties o Instilled with lidocaine due to rapid instillation pain Bacille Calmette Guerin BCG intravesically o Mechanism of action unclear possible alleviation of autoimmune disorder Surgery ileal conduit o Last resort when pain is severe and unrelieved o May still experience pain in the diversion indication the urine itself is the issue NURSING MANAGEMENT Focus on pain characterization and specific dietary lifestyle factors Bladder log and voiding diary over at least 3 days frequency and nocturia o Include a pain record Reassure patient that IC PBS is real and experienced by others relieves anxiety guilt frustration UTI can occur due to diagnostic instruments and testing acute LUTS and pain exacerbation Education o Diet most effective pain treatment Caffeine alcohol citrus aged cheese nuts vinegar curry hot peppers o Avoid high potency vitamin supplements o Avoid tight belts restrictive waistlines or any clothing producing suprapubic pressure o Coping support for frequency and emotional burden Support groups ad patient advocacy groups RENAL TUBERCULOSIS P 1131 Usually secondary to TB of the lung rarely a primary lesion o Tubercle bacilli reaches the kidney through the blood stream o 5 8 years