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GENITOURINARY SYSTEM 579
• Pyuria
• Mild hematuria
• Mild proteinuria
Management of interstitial nephritis includes any of the following"·32:
• Fluid and nutritional support
• Anti-infective agents (as indicated)
• Dialysis (as indicated)
• Surgery to relieve obstructions (if present)
• Renal transplantation
Nephrolithiasis
Nephrolithiasis is a condition that occurs more commonly in men
and is characrerized by renal calculi (kidney stones) thar form in rhe
renal pelvis. There are three primary types of kidney stOnes, which
are categorized according to the stone-forming substances: calcium
oxalate, struvite (composed of magnesium, ammonium, and phosphate), and uric acid. Many factors contribute to stone formation and include the foliowing8.9•J3•J4:
• High urinary concentration of stone-forming substances
• Presence of crystal growth facilitatOrs
• Metabolic abnormalities
• Dietary factors (low Auid and high protein intake)
• Infection may contribute to the formation of kidney stOnes
• Urinary tract obstruction
• Medications (carbonic anhydrase inhibitors, triamterene, indinavir, and vitamin C)8.9,JJ
Signs and symptoms of kidney stones include rhe following8•9:
• Pain in the Aank or groin, depending on the stone location (Pain
increases greatly as the stone passes through the ureters.)
580 ActrrE CARE HANDBOOK FOR PHYSICAL THERAPISTS
• Hematuria
• Fever
• Variable urine pH
• Variable levels of serum calcium, chloride, phosphate, carbon
dioxide, uric acid, and Cr
Management of kidney stones includes any of the followings.,.33-3s:
• Analgesics
• Hydration and diuretics
• Discontinuation of the aforementioned medications
• Anti-infective agents
• Reduction in dietary consumption of predisposing factors, such
as salt and protein
• Specific therapies aimed at reducing stone formation, including
thiazide diuretics, pyridoxine, magnesium, orthophosphate, and
potassium citrate
• Surgery (as a last resort)
Diabetic Nephropathy
Approximately 20-30% of people with type 'lor type 2 diabetes will
develop diabetic nephropathy," which is characterized by systemic
vascular changes in the kidneys that result in scarring (nephrosclerosis) of the glomeruli and, ultimately, in reduced kidney function.
Pyelonephritis and necrosis of the renal papillae arc also associated
with diabetic nephropathy. Patients who demonstrate poor glycemic
control with resultant vascular disease and hypertension are more
likely to develop diabetic nephropathy. Hypertension can lead to or
result from diabetic nephropathy.8.36,37
Signs and symptoms of diabetic nephropathy include the
following,,36.37:
• Microalbuminuria, oliguria, anuria. Microalbuminuria is a critical screening tool for early detection of nephropathy.
• Peripheral edema.
GENITOURINARY SYSTEM 581
Management of diabetic nephropathy includes any of the
followingR•16.P:
• Strict glycemic control (Refer to Diabetes Mellitus in Chapter 11.)
• Antihypertensive agents (ACE inhibitors, calcium channel
blockers)
• Rc�rriction of protein intake
• Hydration
• Diuretics
• Nutritional support
• Dialysis
• Simultaneous pancreas-kidney transplantation (See Chapter
12.)
Rellal Vascl/lar Abllom,alities
Renal Artery Stenosis or Occlusion
Renal artery stenosis is a narrowing of the renal artery lumen; renal
artery oCc/l/sioll is blockage of the renal artery lumen. Renal artery
stenosis or occlusion can result from any or all of the following:
atherosclerotic disease, diabetes mellirus, subacute bacterial endocarditis, emboli from mitral valve stenosis, and mural thrombi that develop afrer myocardial infarction. Decreased renal perfusion
results in renovascular hypertension as a result of increased renin
production. IUS
Signs and symptoms of renal artery stenosis or occlusion include
the followingS.,,:
• II yperrension
• Microscopic hematuria
• Flank or upper abdominal pain
• Abdominal aortic, renal artery bruits, or both
• Peripheral edema
582 AClITE CARE HANDBOOK FOR PHYSICAL THERAPISTS
Management of renal artery stenosis or occlusion includes any of
the foliowingS,3s:
• Antihypertensive agents (ACE inhibitors)
• Anticoagulation agents
• Analgesics
• Dialysis
• Surgery (bypass grafting, angioplasty with possible stent placement, or nephrectomy in unilateral renovascular disease) Renal Veill Thrombosis
Renal vein thrombosis is an uncommon disorder, resulting in the
accumulation of plaque in the renal vein. Renal vein throll"lbosis can
be caused by dehydration, sepsis, a hypercoagulable state, injury to
the abdomen or back, renal tumors extending into the renal vein, and
nephrotic syndrome, Sudden occlusion of the renal vein results in
renal infarcts.8.39
Signs and symptoms of renal vein thrombosis include the
following7,s.39:
• Flank pain
• Gross hematuria
• Proteinuria
• Oliguria
Renal vein thrombosis can be managed with anticoagulants or
thrombolytic agents.7,8.39
Urillary Tract Dysfrmctioll
Cystitis
Bacteria, viruses, fungi, chemical agents, radiation exposure, and
autoimmune dysfunction are all potential causative factors thar
can lead to cystitis, which is an inAammation of the bladder wall.
Cystitis and urinary tract infections are nor synonymous, as inflammarion of the bladder can occur from noninfectious causes. How-
GENITOURINARY SYSTEM 583
ever, cystitis can occur with prostatitis or pyelonephritis.18 Cystitis
that occurs from noninfectious causes is called interstitial cystitis
and is relatively uncommon.40.41 People who are sexually active or
who have an indwelling catheter, urinary tract obstructions, diabetes mellitus, neurogenic bladder, or poor hygiene are at greater risk of developing cystitisI8
Signs and symptoms of cystitis include the following'8,.o ... :
• Urinary frequency and urgency
• Dysuria
• Hematuria (in more serious cases)
• Nocruria
• Suprapubic pain, low back pain, or both
Management of cystitis includes any of the following'8,.o,4':
• Anti-inflammatory agents, tricyclic antidepressants, antihistamines, immunosuppressives, antispasmodics, calcium channel blocking agents, and interstitial cystitis agents.
• Increased fluid intake.
• Therapeutic hydrodistention with or without intra vesicular
instillation. Therapeutic hydrodistention is performed under general anesthesia, and the bladder is hydrodistended to help identify areas of inflamed epithelium and promote healing of these areas, as
well as to help distend the bladder, which may help with pain
relief. Intravesicular instillation is commonly performed with therapeutic hydrodistention and involves infusion of agents such as anti-inflammatory analgesic agents into the bladder.
• Surgical management with total or subtotal cystectomy, denervation of the bladder, or procedures that increase bladder capaciry (all of these are last-resort measures).
Urinary Calculi
Urinary calculi are stones (llrolithiasis) that can form anywhere in the
urinary tract outside of the kidneys. Formation of stones, symptoms,
and management are similar to that of kidney stones (see Nephrolithiasis for further details on the formation and clinical presentation of