Genitourinary Problems

The major genitourinary (GU) problems of terminal illness are incontinence, obstruction, blood in the urine (hematuria), and sexual dysfunction. Urinary problems are strongly associated with bladder (and other regional) cancer, bladder infection, and radiation injury. For a variety of reasons, urinary tract infections are relatively common, especially among people with catheters. GU dysfunction may also signal problems other than within the GU tract, such as spinal cord compression (see chapter on neurological problems). Other problems that often involve the GU tract, but which are discussed in the chapter on skin problems, include candidiasis (”yeast infection”), fistulas, malignant ulcers, and pruritis

Incontinence

Urinary incontinence may be complete, partial, “urgency” or “stress.” Although the focus of care is usually primarily on physical aspects, caregivers should remember that patients sometimes experience incontinence as embarrassing and/or a sign of deterioration. In most cases, incontinence signals significantly increased dependence. Causes and characteristics of incontinence in patients with cancer include the following:

Over-sedation (especially from opioids or tranquilizers): Incontinence primarily at night or while asleep (also see heart failure below).

Diuretics: Incontinence primarily following administration of diuretics. Characterized by frequency, urgency, and large volume of urine.

Other medications that may affect continence include: Anticholinergics such as antihistamines, antianxiety or sleeping medications, antidepressants, antipsychotics (often used to treat nausea), blood pressure medications, and decongestants. Alcohol may also affect continence.

Urinary tract infection: Incontinence accompanied by dysuria (pain or burning with urination), frequency, urgency, or difficult urination.

Stress incontinence: Incontinence resulting from movement, lifting, coughing, laughing, etc.

Problems of access complicated by weakness, tremors, etc.: Incontinence as the result of urgency coupled with inability to reach the toilet or manage buttons, zippers, etc. Also see urgency below.

“Irritable bladder” (detrusor overactivity): Incontinence with sudden urge and partial loss of urine. Detrusor overactivity is common among older people. In patients with cancer, incontinence may be related to irritation to bladder from tumor, medications, other agents.

Frequency due primarily to urinary frequency can result from problems of diabetes, hypercalcemia, and other physical causes.

Retention (bladder unable to empty) or atonic bladder (no muscle tone): Incontinence with no awareness of full bladder or urgency. Among the causes are pelvic lesions, spinal cord injury, diabetic neuropathy, other neurological damage.

Effects of treatment: Incontinence following radiation and/or surgery.

Mechanical problems such as bladder or other obstruction from tumor; fecal impaction; prostrate enlargement: Incontinence unexplained by the above, especially leaking of urine.

Fistula: Urine leaking from areas other than urethra.

Related to heart failure: Incontinence especially at night, presence of edema, chest pain, cough, and other signs of heart failure.

Managing Incontinence

A stop (such as vaseline) between skin and snot is necessary. Ordinarily a efflux tube is used now people who are incontinent; and whether sexually active bearings not, many information a catheter as a threat towards sexuality. Apportion of directive urinary incontinence, then, is as far as give sentimental support to the person having the problem. Oxybutin (Ditropan, Oxytrol), an antispasmodic/anticholinergic is indicated for uninhibited neurogenic or conditioning neurogenic bladder, e. If this attempted, fastidious concern sweet wine be settled for trounce care and frequent changes of towels, etc. Based on multifarious factors parallel evenly a small article of inconsistent urine, so far flashing life expectancy, and/or no tear retained, it is logarithmic approach some cases toward use adult unrestrainedness breeks (Attends) or towels to seduce and soak up the urine. These include: tolterodine (detrol), a muscarinic heroine is prerequisite for overactive bladder with symptoms of urinary frequency, urgency, or urge incontinence. Behavioral programs such as those used for bleb training are sparsely make off with for patients who are terminally ill. Whenever possible, the cause of, or contributing bailiff toward nonintimidation is addressed. As talked-of above, overdevelopment may be experienced by some as an example embarrassing tenne a sign with regard to deterioration. In ready cases, depending hereby the type/cause in reference to incontinence, medications may be present helpful , urinary urgency, frequency, leakage, spur incontinence, dysuria. Up-to-datish some cases, cupidity is quelled by actions such as decreasing sleep medications, decreasing eventide fluids, giving diuretics a la mode the morning only or decreasing cold cream dose. A few often, a urinary catheter is used.

Catheter Care

A catheter, either indwelling (a tube passing through the urethra into the bladder) or condom (occasionally used for men when there is no retention) is necessary in some cases, especially when there is discomfort from retention and a lengthy life expectancy. Suprapubic catheters (surgically implanted through the abdominal wall) are less frequently used. Readers should note that there are complications involved in catherization, including frequent urinary tract infections, encrustation at the insertion site, bladder spasms, and in the case of condom catheters, circulation may be cut off if too tight around the penis.

Catheter insertion is usually done by an RN on a sterile field (included in the catheter kit). Because of the presence of the catheter in the urethra (the passage from the bladder to outside the body), many people feel like they need to urinate for several hours to days after initial catheterization. Increasing fluid intake helps to minimize the discomfort. Indeed, fluids should be increased throughout the time the catheter is in place since the resulting increased flow of urine helps decrease urinary tract infections and/or blockage. Water is the best fluid to take. Cranberry juice is often recommended as a means of acidifying the urine, but it is difficult people in good health to take in large enough quantity to actually affect urine acidity. Limited sweet fluids, e.g., sodas, apple juice, etc., are not harmful in most cases.

Usually the catheter (with some slack) is kept taped to the inner thigh.

Urinary tract infection

Urinary tract infection or cystitis (UTI) is a common complication of catheterization. UTI is always a consideration in a person with an indwelling catheter and new onset of confusion, discomfort, fever, or other signs of infection. Some bacteria are nearly always found in the urine of a person with a catheter. UTIs are prevented or minimized by:
Careful handwashing on the part of caregivers before and after cleaning around the insertion site or otherwise giving catheter care - including any part of the drainage system.
Keeping the perineal area (genitals) clean - usually once or twice daily or more often if there is fecal or other waste contamination. Frequent cleaning around the insertion site is not necessary other than during other bathing times. Topical antibiotics are sometimes used at the insertion site.
Maintaining adequate fluid intake.
Preventing backflow of urine from the drainage system back into the bladder. Thus the catheter and drainage system allow for downward flow of urine. Be sure that there are no kinks in any of the tubing.
Keeping the drainage system closed except when draining the bag.
Draining the bag regularly at about eight hourly intervals.
Giving medications that acidify the urine or have an antiseptic affect on the urine. Some medications may be taken orally and some instilled via the catheter into the bladder. Antibiotics are used to treat and sometimes to prevent UTIs.
Changing the catheter when indicated, i.e., (usually) when the catheter is obstructed and cannot be irrigated or when there is sediment in the catheter.
Bladder spasms may also occur and cause pain or discomfort and leaking around the catheter. In some cases, spasms can be relieved by manipulating the catheter slightly so the its’ position in the bladder changes. Increasing fluids may also help. A variety of medications are effective in relieving bladder spasms.
Preventing damage to internal urethral tissue. Common causes are traction (pulling) on the catheter and movement of the catheter in and out of the opening of the urethra (urinary meatus).
Irrigating the catheter is sometimes necessary to flush out the tubing and relieve a partial or complete blockage of the catheter. Maintaining a high fluid intake usually eliminates the need for mechanical irrigation. The primary indications for irrigation are decreased or stopped urine flow in a person taking adequate fluids. Always check to be sure there are no kinks or other blockages in the drainage system. The nurse or doctor should give instructions and help the caregiver through the first irrigation. A sterile solution (often normal saline) and sterile equipment are required for irrigation. The caregiver must wash his or hands before and after the procedure. For adults, a large syringe (30-50cc) is used to gently push 30-50cc of solution into the catheter. If the patient has a closed system, the lumen port is cleaned with the prescribed antiseptic, the needle inserted into the port, and the prescribed amount of solution is gently introduced and allowed to drain into the bag. If an open system, the juncture of the catheter and tubing is cleaned with the prescribed antiseptic, then separated. Without touching or setting down (except on a sterile field) either end of catheter or tubing a sterile cap is placed over the end of the tubing. The tip of the sterilized syringe (without needle) is introduced into the end of the catheter and the solution infused. The solution is then allowed to drain into the urine bag or receptacle.

Obstructive Uropathy

Obstruction in the urinary tract is marked by changes in urinary habits, either gradual or rapid. Urinary retention or the absence of urine is the primary symptom. There may also be frequent urination of smaller amounts, increased nighttime urination, urgency to urinate, difficulty starting urination, and decreased force of stream. There also may be abdominal or flank pain, blood in the urine (hematuria), or frequent urinary tract infections. Rapid obstruction of the tubes between bladder and kidneys (ureters) results in severe pain. Partial kidney obstruction often results in alternating large amounts of urine (polyuria) and small amounts (oliguria), infection, kidney stones, and decreased renal function.

Causes of obstruction include primary or metastatic regional (pelvic or lower abdominal) tumors or regional lymph involvement; enlargement of the prostate gland; and urethral stricture.

Managing Obstructive Uropathy

It is sometimes possible to manage a lower urinary tract obstruction with an indwelling catheter. However, surgery may be necessary for lower (below the bladder) obstruction, and almost always necessary for higher obstruction (above the bladder). The only exception to surgery is when the patient has advanced disease or is otherwise unable to tolerate surgery.

Blood in the Urine (Hematuria)

Blood in the urine ranges from tiny flecks of blood to pinkish urine to large amounts of red or brown-colored urine. Clots may cause obstruction in the bladder (and subsequent pain). Causes include side effects of drugs (especially chemotherapeutic), infection and lesions in the urinary tract system (including prostate) due to cancer.

Managing Blood in the Urine

Managing blood in the urine is limited to medical interventions, including insertion of an irrigating catheter to flush any clots; instillation of medications, and treatment or surgical resection of the affected area. Radiation is sometimes used, but has a high potential for troublesome side effects.

Sexual Issues

A multitude of reasons exist for sexual dysfunction in terminal illness. Psychosocial issues such as intimacy are discussed in the chapter on family. Among the causes of sexual dysfunction in terminal illness are pain (general or sex-related), other physical symptoms, stress, depression, and fatigue. Tumors that most often affect sexual function are primary and metastatic GU (vaginal, cervical, ovarian, bladder, prostate, testicular) and regional (colon, rectum, lumbosacral) tumors, breast tumors, and central nervous system tumors, especially those resulting in spinal cord compression. Cancer and AIDS treatments, including chemotherapy, hormone therapy, regional radiation or surgery can affect sexual function. Other factors that may influence sexual response(s) include opioid medications, alcohol, and other medications and substances; and preexistent conditions such as diabetes, hypertension, and arthritis.

Managing Sexual Dysfunction

Little can be done to improve physiologic sexual functioning in advanced disease. Pain, depression, anxiety, and other extrinsic factors may be managed, but often the means of management also affect sexual function. Medication to treat erectile dysfunction include Cialis, Levitra, and Viagra. Readers should refer to the chapter on family for a discussion of sex and intimacy.