Lesson 1, Topic 1
In Progress

Urinary System Diseases and Disorders

April 11, 2024

Learning Objective: Differentiate among the types of urinary system diseases and disorders, including the etiology, signs, symptoms, diagnostic procedures, and treatments.
Common urinary signs and symptoms include the following:
                • Dysuria: Painful or difficult urination
                • Nocturia: Urination at night
                • Polyuria: Excessive excretion of urine may be accompanied by polydipsia (excessive thirst)
                • Frequency: Urination at short periods without an increase in the daily volume of urine output
                • Urgency: The sudden, almost uncontrollable need to urinate
                • Urinary incontinence: Inability to hold urine
                • Urinary retention: Inability to release urine
Typically, common signs of urinary system disorders found on medical imaging and laboratory tests include these:
                • Calculi: Stones formed in the kidneys, gallbladder, and other parts of the body
                • Hydronephrosis: A backup of urine that causes dilation of the ureters and calyces; can increase pressure on the nephron units
                • Azotemia: An abnormal increase in nitrogenous waste products in the blood; also called uremia
                • Abnormal substances in the urine: Albuminuria or proteinuria (albumin), azoturia (excessive nitrogen compounds), bacteriuria (bacteria), glycosuria (glycose [sugar]), hematuria (blood), and pyuria (pus)
The following sections describe cancers, genetic and congenital disorders, infectious and inflammatory disorders, and structural and functional disorders of the urinary system.


Urinary System Cancers
Learning Objective: Describe types of urinary system cancers, including the etiology, signs, symptoms, diagnostic procedures, and treatments.
Bladder and kidney cancer are the most common types of urinary system cancers. The following sections discuss each of these types of cancers.


Bladder Cancer
Bladder cancer is the sixth most common cancer in the United States. Bladder cancer tends to recur, so follow-up testing is critical. Transitional cell carcinoma (also called urothelial carcinoma) is the most common type of bladder cancer in the United States.
      Smoking, chemical exposure, family history of the disease, some chemotherapy medications, and chronic bladder infections can increase the risk of bladder cancer. People over 40 years of age, men, and Caucasians are also more at risk. Common signs and symptoms include hematuria, frequency, urgency, dysuria, pelvic pain, and low back pain.
      The provider will do a physical exam. Urine testing, cystoscopy, and a biopsy may be done to diagnose bladder cancer. Additional imaging tests are done to check if the cancer has spread to other parts of the body. Treatments used for bladder cancer include surgery, radiation therapy, and chemotherapy. Biological therapy or immunotherapy can be useful, as it increases the body’s ability to help fight the cancer.


Kidney Cancer
Kidney cancer or primary kidney cancer occurs when cancer starts in the kidney. There are three main types of primary kidney cancer:

                • Renal cell carcinoma (RCC) (or renal adenocarcinoma): Most common type in adults; forms in the lining of the kidney tubules
                • Wilms tumor (or nephroblastoma): Most common type in children younger than 5 years; occurs in the kidney tissue; improved treatments have increased the survival rate
                • Transitional cell cancer: Occurs in adults; forms in the ureter and renal pelvis
      It is unclear what causes the mutation of the kidney cell that leads to a tumor development. With kidney cancer, pain and hematuria can be key symptoms. See TABLE 27.3 for the symptoms of the three types of kidney cancer.
      Diagnostic procedures for the three types of kidney cancer are similar (see TABLE 27.3). During the exam, the provider may identify a kidney mass. Urinalysis and blood work may be done to check for hematuria and the person’s overall health. Once kidney cancer is diagnosed, imaging tests are done to check for cancer in other parts of the body. Treatment for kidney cancer can involve surgery. If no kidney function exists, then dialysis and a kidney transplant are done. If surgery is not an option, arterial embolization can be done. A catheter is inserted through an incision and passed into the main blood vessel of the kidney. A special gelatin sponge is inserted through the catheter into the blood vessel, creating a blockage and preventing blood flow, thus killing the tumor.
Genetic and Congenital Urinary

System Disorders
Learning Objective: Describe types of genetic and congenital urinary system disorders, including the etiology, signs, symptoms, diagnostic procedures, and treatments.
      Genetic and congenital urinary system disorders cause kidney loss or malfunction later in life. Polycystic kidney disease is one of the more common genetic and congenital urinary system disorders.

Polycystic Kidney Disease
Polycystic kidney disease (PKD) is an inherited condition. Cysts form in the kidneys, causing the kidneys to become enlarged (FIGURE 27.6). A cyst-filled kidney can weigh up to 30 pounds. There are two types of PKD:
                • Autosomal dominant: If the gene is inherited from one parent, the child will get the disease. Often the parent also has the disease. This is the most common form of PKD and inherited kidney disorder. It is typically identified between the ages of 30 and 50, although it can occur in childhood.    

FIGURE 27.6  Comparison of a polycystic kidney (right) with a normal kidney (left). From Lewis SM: Medical-surgical nursing: assessment and management of clinical problems, ed 8, St. Louis, 2011, Mosby.

                • Autosomal recessive: To get the disease, a person must get a copy of the defective gene from both parents.
      People with PKD may also have cysts in their liver and pancreas. Aneurysms and diverticula of the colon may also be associated with PKD. Males can have cysts in their testes and tend to have more kidney failure. Women with PKD, hypertension (high blood pressure), and who have had three or more pregnancies are also more at risk for kidney failure. PKD can cause the following conditions:
                • Pain in the flank, abdomen, and joints
                • Nocturia and hematuria
                • Drowsiness and nail abnormalities
                • Pain or tenderness over the liver and an enlarged liver
                • Heart murmur and hypertension
      During the physical examination, the provider may order a computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound (US) to check the cysts on the kidneys. PKD is a chronic condition that slowly gets worse. The treatment goals are to control symptoms and prevent complications. Treatment often includes antihypertensive medications, diuretics, and a low-salt diet. PKD can increase the risk of urinary tract infections due to blockages. UTIs should be treated quickly with antibiotics. Surgery to remove one or both kidneys may be required. The patient may also need dialysis or kidney transplantation. With the chronic nature of this condition, it is important for patients to get support. Sometimes, support groups can help the patient and family cope with the disease process.

Additional Genetic and Congenital Disorders
Besides PKD, there are several genetic and congenital disorders that affect the urinary system:
                • Hydronephrosis: Distention of the renal pelvis and calyces due to urinary tract obstruction; caused by a congenital defect or renal calculi.
                • Prune belly syndrome (PBS): Group of genetic birth defects usually occurring in boys; involves enlarged ureters and bladder, hydronephrosis (kidney swelling), poor development of the abdominal muscles, undescended testicles, and wrinkled skin over the abdomen.
                • Ureterocele: End of ureter is malformed and bulges, creating a ureterocele, and may obstruct the ureter or bladder.
                • Ureteropelvic junction (UPJ) obstruction: Blockage where the ureter joins the kidney, causing kidney swelling.
                • Vesicoureteral reflux (VUR): Urine backs up into the ureter from the bladder due to a malformed or missing valve over the end of the ureter.

Infectious and Inflammatory Urinary System Diseases and Disorders
Learning Objective: Describe types of infectious and inflammatory urinary system diseases and disorders, including the etiology, signs, symptoms, diagnostic procedures, and treatments.
      A urinary tract infection (UTI) is an infection in one or more of the urinary tract structures. There are several infections and inflammatory disorders that affect the urinary system. Examples of these disorders include the following:
                • Interstitial cystitis (IC): Causes recurring bladder and pelvic region pain and discomfort, frequency, and urgency; also called painful bladder syndrome (PBS).
                • Interstitial nephritis: Inflammation of the kidneys with an increase of interstitial tissue and thickening of blood vessel walls.
                • Membranous glomerulonephritis: Inflammation occurs in the kidney due to glomerular changes, and large amounts of protein are excreted in the urine. The exact etiology is unknown.
                • Nephritis: Inflammation of the kidney; can be chronic, acute, or nephrosis (also called nephrotic syndrome).
                • Urethritis: Inflammation of the urethra due to bacteria, viruses, injury, or chemical sensitivity.
      Acute cystitis, glomerulonephritis, and pyelonephritis are also conditions in this category and described in the following sections.

Acute Cystitis
Acute cystitis is an inflammation of the bladder. Due to the shorter urethra, women are more at risk than men of getting infections.
      Typically, acute cystitis is caused by a bacterial infection, most commonly Escherichia coli (E. coli). Other causes of inflammation can include medications, radiation therapy, spermicidal jellies, and long-term catheterization. Being pregnant, going through menopause, a catheter, urinary tract procedure, urinary retention, an obstruction, bowel incontinence, or diabetes can increase the risk of cystitis. Signs and symptoms include the following:
                • Nocturia, dysuria, urgency, frequency, and urinary retention
                • Cloudy, bloody, or strong/foul-smelling urine
                • Low abdominal pressure or cramping, low-grade fever
                • With older adults: confusion and mental changes
Usually, the provider will order a urinalysis, a urine culture, and a sensitivity (C&S) test (discussed in Chapter 32). The urinalysis provides information to help diagnose cystitis, and the C&S may take up to 3 days to identify the organism. If the urinalysis and culture come back negative for an infection, the provider may do additional tests (e.g., cystoscopy) to try to identify the cause of the symptoms. Treatment for bacterial cystitis consists of antibiotics.
      Home care treatments may include drinking plenty of liquids; avoiding coffee, alcohol, and soft drinks; taking an analgesic, having a sitz bath, or using a heating pad to decrease the discomfort.

Glomerulonephritis
Several diseases affect kidney functioning because of their effects on the glomeruli. Glomerulonephritis is inflammation of the glomeruli. Damage to the glomeruli can cause protein and red blood cells to leak into the urine. Glomerulonephritis usually has an abrupt onset.
      The cause is often unknown, and it can follow a streptococcal infection. Signs and symptoms include puffy eyes, fatigue, low-grade fever, headache, and pain in the kidney region. Hematuria, cola-colored urine, proteinuria, and oliguria can also be seen.
      After the physical exam, the provider may order a urinalysis, blood urea nitrogen (BUN), creatinine, erythrocyte sedimentation rate (ESR), imaging tests (e.g., CT scan, x-ray, and ultrasound), and a renal biopsy. Treatment is based on the cause of the illness. Bed rest, antihypertensive medications, antibiotics, diuretics, and dietary restrictions (e.g., protein, salt, and potassium) may be ordered.

Pyelonephritis
Pyelonephritis is a urinary tract infection of one or both kidneys. Prompt treatment is required to prevent kidney damage and septicemia. The bacteria can spread to the bloodstream, causing an overwhelming infection that can be life-threatening.
      Pyelonephritis is caused by a bacterium or virus. The pathogen can move from the bladder to the kidneys, or carried by the bloodstream to the kidneys. An increased risk of pyelonephritis may be seen with structural defects, urinary reflux, obstruction, and bladder infection. The signs and symptoms consist of fever, chills, nausea, vomiting, dysuria, frequency, hematuria, foul-smelling urine, and low back, side (flank), or groin pain. Young children may only experience a fever, and some adults may have confusion and speech difficulties.
       After the patient’s history has been taken and the physical examination has concluded, the provider will usually order a urinalysis, urine culture, blood culture, and blood work. For the most accurate results, all cultures need to be obtained before the patient starts on antibiotics. Additional tests may include a US, a CT scan, a voiding cystourethrogram (VCUG), a digital rectal exam (DRE), and a dimercaptosuccinic acid (DMSA) scan. Initially, the provider will treat the infection with a broad-spectrum antibiotic. When the blood and urine culture results are known, the provider may have the patient take an antibiotic that is known to kill the pathogen. For severely ill patients, hospitalization, intravenous (IV) fluids, antibiotics, and close observation may be required. Repeat cultures may be taken after the antibiotics have been completed to ensure the infection is gone.

27.4 Critical Thinking Application
Hannah is working with Dr. Riney. He ordered an antibiotic for Mrs. Williams, who has a UTI. When the urine culture and sensitivity (C&S) report comes back to the department, he asks Hannah to call Mrs. Williams about a change in the antibiotic. Why might the provider change the antibiotic once the urine C&S report becomes available?

Structural and Functional Urinary System Diseases and Disorders
Learning Objective: Describe types of structural and functional urinary system diseases and disorders, including the etiology, signs, symptoms, diagnostic procedures, and treatments.
      Several diseases cause structural or functional changes in the urinary system. Chronic kidney disease, end-stage renal disease, nephrotic syndrome, neurogenic bladder, renal calculi, and urinary incontinence are common disorders that cause structural or functional changes. Additional diseases include the following:
                • Acute tubular necrosis: Rapid destruction of the tubular sections of the nephrons due to blood flow impairment or toxins.
                • Anterior prolapse: Also called cystocele, prolapse, or dropped bladder. Anterior prolapse is a bulging or dropping of the bladder into the vagina caused by the weakening and stretching of supportive tissues and muscles (FIGURE 27.7).
                • Bladder outlet obstruction (BOO): Blockage at the opening of the bladder or in the urethra.
                • Minimal change disease: Damage occurs to the glomeruli, though the cause is unknown.
                • Reflux nephropathy: Urine backflows from the bladder, causing kidney damage. Can be due to a ureter defect, obstruction, or swelling.
      The following sections describe the common diseases that cause structural or functional changes in the urinary system.

Chronic Kidney Disease
Chronic kidney disease is also called chronic kidney failure. With this condition, kidney function is gradually lost. During the early stage of chronic kidney disease, there may be few symptoms. As the kidney function diminishes, more symptoms occur.
      Many diseases can lead to chronic kidney disease, including hypertension, diabetes mellitus, glomerulonephritis, interstitial nephritis, PKD, and vesicoureteral reflux. Signs and symptoms may be minimal at first. As the kidney function diminishes, the person may experience nausea, vomiting, loss of appetite, weakness, fatigue, muscle cramps, twitching, itching (pruritus), hypertension, decreased amounts of urine, sleep issues, and a reduction in mental sharpness.
       After a history and examination, the provider may order urine and blood tests to assess the kidney function. Imaging tests may be done to assess the kidney size, shape, and structure. A kidney biopsy can also be done. For chronic kidney disease, there is no cure. Treatment is focused on slowing the progression of the disease and reducing complications. Underlying conditions, such as hypertension and diabetes, are also treated.

FIGURE 27.7  Anterior prolapse. The urinary bladder is displaced downward (arrow), which causes bulging of the anterior vaginal wall. From Ignatavicius DD, Workman ML: Medical-surgical nursing: critical thinking for collaborative care, ed 6, Philadelphia, 2011, Saunders.

End-Stage Renal Disease
End-stage renal disease (ESRD), also called end-stage kidney disease and kidney failure, is advanced-stage chronic kidney disease. ESRD occurs when the kidneys are no longer filtering waste from the blood. Dangerous levels of electrolytes, waste products, and fluids build up in the bloodstream. More than 660,000 Americans have kidney failure. Over 44% of those patients are between the ages of 45 and 64.
      The top two causes of ESRD are diabetes mellitus and hypertension. Additional causes include glomerulonephritis, polycystic kidney disease, prolonged obstructions, recurrent kidney infections, and vesicoureteral reflux. Using tobacco increases the risk of ESRD. Men, African Americans, and being 45 years or older can also increase the risk. The kidneys can slowly stop functioning over the course of 10 to 20 years before ESRD occurs. The signs and symptoms are the same as for chronic kidney disease.
      Besides performing a physical exam, providers will order blood work and a bone density test. The blood work usually includes tests that evaluate the patient’s complete blood count (CBC), electrolytes (e.g., potassium, sodium, calcium, and magnesium), albumin, and parathyroid hormone. The patient’s blood pressure will be monitored closely.
      ESRD is often treated with dialysis or kidney transplantation. Dialysis works like a kidney by filtering out the waste products, extra fluids, and electrolytes. There are two different types of dialysis:
                • Peritoneal dialysis: A catheter is surgically placed in the abdomen. The patient can then infuse a special sterile solution through the catheter into the abdomen. The peritoneal membrane is used as a natural filter, and waste from the blood moves into the infused solution. After a few hours, the patient drains the fluid out of the abdomen via the catheter (FIGURE 27.8). New fluid is then infused into the abdomen. There may be four to six exchanges of fluid a day. This type of dialysis allows the person to work, travel, or sleep during the process.

FIGURE 27.8  Peritoneal dialysis.

                • Hemodialysis: A vascular access (i.e., catheter, arteriovenous [ahr teer ee oh VEE nuhs] graft, arteriovenous fistula) is placed. The patient is hooked up to a dialysis machine using the vascular access. The person’s blood flows through the special filter inside of the machine (FIGURE 27.9). The filter cleans the blood of waste products and extra fluids. Typically, patients need to have hemodialysis three times a week at the dialysis center.
Besides dialysis and kidney transplantation, other treatments are available:
                • Dietary modifications, such as low protein, limiting fluids, and electrolyte supplements
              • Antihypertensive medication and supplements (i.e., iron and vitamin D)\

27.5 Critical Thinking Application
With Hannah’s experience in the dialysis unit, she has learned that many people need to do hemodialysis three times a week for several hours each day. How might this affect a patient’s lifestyle?

Nephrotic Syndrome
Nephrotic syndrome consists of a collection of symptoms that indicate kidney damage. The syndrome is caused by other disorders that eventually lead to kidney tissue destruction.
      Nephrotic syndrome occurs more often in males than in females. It can affect children, usually 2 to 6 years of age, and adults. Minimal change disease is the most common cause of nephrotic syndrome in children. Membranous glomerulonephritis is the most common cause in adults. Nephrotic syndrome can also occur as the result of cancer, chronic disease (e.g., diabetes, systemic lupus erythematosus), infections, immune and genetic disorders, and with certain drugs. The most common sign is swelling of the face, extremities, and abdomen. Additional symptoms can include poor appetite, weight gain, seizures, skin sores, and foamy-appearing urine. Blood and urine tests show proteinuria, hyperlipidemia, and hypoalbuminemia.

FIGURE 27.9  Hemodialysis machine. From Ignatavicius DD, Workman ML: Medical-surgical nursing: critical thinking for collaborative care, ed 6, Philadelphia, 2011, Saunders.

      Providers will do a physical exam, laboratory testing (blood testing [albumin, blood chemistry tests, BUN, and creatinine] and urine testing [creatinine clearance and urinalysis]), and a kidney biopsy. Additional testing may be ordered to identify the specific cause of nephrotic syndrome. Infection with the human immunodeficiency virus (HIV), hepatitis, and syphilis are just a few of the diseases that could lead to nephrotic syndrome. The treatment goals are to reduce symptoms, delay kidney damage, and prevent additional complications. The following are common treatments:
                • Antihypertensive medications to keep the blood pressure in the normal range
                • Vitamin D supplements
                • Corticosteroids, anticoagulants, antihyperlipidemics, and diuretics
                • Dietary modifications, such as low-fat, low-cholesterol, low-salt, and low-protein diets

Neurogenic Bladder
The central nervous system, nerves that supply the bladder, and muscles work together for bladder control. Damage or disorders that impact the bladder nerves or the central nervous system can cause a neurogenic bladder. A person with a neurogenic bladder lacks bladder control, causing it to be overactive (the bladder muscles contract controllably) or underactive (the person does not have the urge to go even though the bladder is full).
       The central nervous system disorders that can cause neurogenic bladder include birth defects, cerebral palsy, Alzheimer disease, brain or spinal cord tumors, multiple sclerosis (MS), Parkinson disease, stroke, and spinal cord injury. Damage and disorders of the bladder nerves can be caused by diabetes, syphilis, heavy alcohol use, neuropathy, nerve damage from pelvic surgery, herniated disk, or spinal canal stenosis. With an overactive bladder, urgency and frequency to urinate are common. With an underactive bladder, the bladder fills but the person does not have the urge to go, and incontinence (urine leakage) can occur. Problems with starting to urinate or completely emptying the bladder can also be experienced.
      After a physical exam, additional procedures may be ordered, including a postvoid residual volume, blood tests to check kidney functioning (e.g., serum creatinine), renal ultrasonography, and cystoscopy. Treatment is aimed at managing the symptoms of neurogenic bladder. Possible treatments include the following:
                • Medications: Antimuscarinic, anticholinergic, botulinum toxin, gamma-aminobutyric acid (GABA) supplements, and antiepileptics
                • Surgical procedures: Artificial urinary sphincter, an implanted electronic device to stimulate bladder nerves, and urinary stoma (or urostomy)
                • Additional procedures: Kegel exercises and a urinary catheter

Kegel Exercises
Kegel exercises are used to strengthen the pelvic floor muscles. Both males and females can do them. To use the right muscles, pretend you have to urinate but hold it. The muscles you tighten to stop urination help tighten the pelvic floor muscles. Muscles in the vagina (for females), rectum, and bladder should tighten. The muscles in the thighs, buttock, and abdomen should not be tightened. Kegel exercises should be done three times a day.
Take the following steps to perform Kegel exercises:
                1. Empty your bladder.
                2. Either sit or lie down while doing the exercises.
                3. Tighten the pelvic floor muscles (“hold the urine”). Tighten as you count to 8.
                4. Relax the muscles as you count to 10.
                5. Repeat this sequence 10 times.

27.6 Critical Thinking Application
Dr. Riney asks Hannah to coach Mrs. Smith on doing Kegel exercises. How might Hannah explain the process of doing Kegels to Mrs. Smith?

Renal Calculi
Renal calculi, or kidney stones, are mineral pebbles that form in the kidney. Symptoms can occur if the calculi grow larger or move into the ureters or renal pelvis (FIGURE 27.10). If a stone blocks the flow of urine, infection can develop from the backflow of urine. This blockage also can result in hydronephrosis (FIGURE 27.11).
      Renal calculi can occur when high levels of certain minerals, such as calcium, oxalate, and uric acid, collect in the kidney. Calculi can also form if fluid intake is low and the filtrate becomes highly concentrated. The tendency to develop kidney stones runs in families. With small stones, the person may not experience symptoms. With larger stones or stones that cause blockages, symptoms will be experienced. Signs and symptoms of kidney stones include dysuria, nausea, vomiting, fever, chills, and severe constant pain on either side of the lower back. The person may have cloudy, foul-smelling, or bloody urine.
      After the physical exam is concluded, a urinalysis, blood tests, and imaging tests (e.g., CT scan and abdominal x-ray) are used to diagnose renal calculi. Treatment depends on the size, type, and location of the stones. Small stones may pass on their own. Analgesics may be encouraged for the pain and discomfort. Extra fluids are encouraged to flush the stone out. Typically, patients are asked to strain their urine. Kidney stone strainers should be supplied. If the patient finds a stone, it should be placed in a specimen container and brought to the lab to be analyzed (FIGURE 27.12). Additional procedures include the following:
                • Extracorporeal shock wave lithotripsy (ESWL): Shock waves are used to break up the stones, so they pass without a problem (FIGURE 27.13).

FIGURE 27.10  Locations of ureteral calculi. From Shiland B: Mastering healthcare terminology, ed 5. St. Louis, 2016, Elsevier.

FIGURE 27.11  Hydronephrosis.

FIGURE 27.12  Urine strainer with a urine/stool collection container (also called a hat or a pan).

                • Ureteroscopy: The ureteroscope is threaded up through the bladder and ureter. If the provider sees a stone, it can be removed during the procedure. Sometimes ESWL and ureteroscopy are both done. The stone is broken up before it is removed.
                • Nephrolithotomy: A surgical incision is made, and the stones are removed by the tube. With percutaneous nephrolithotripsy (PNL), the stones are crushed and removed using suction.

27.7 Critical Thinking Application
Hannah receives a call from Zach Backstrom. He states that he has a kidney stone and wonders if he really needs to strain his urine and have it analyzed in the lab. What might be the benefit to Zach if he continues to strain his urine for the stones?

Urinary Incontinence
Urinary incontinence (UI) is the loss of bladder control, causing an accidental loss of urine. There are several types of urinary incontinence:
                • Stress incontinence: Leakage of urine from stress on the bladder; caused by obesity, pregnancy, laughing, running, sneezing, coughing, or lifting heavy objects.
                • Urge incontinence: Also called overactive bladder; strong sudden urge (urgency) before the accidental loss of urine.
                • Overflow incontinence: Most often affects males; the person has difficulty emptying the bladder.
                • Functional incontinence: Caused by a mental or physical disease; leakage occurs before the person can reach the toilet.
                • Mixed incontinence: Typically affects females; leakage of urine due to overactive bladder and stress incontinence.
                • Total incontinence: Severest type; constant urine leakage.
                • Enuresis: Also known as “bed wetting.” This condition is usually seen in children; the bladder fills during the night, and the child does not get up to urinate.

FIGURE 27.13  Extracorporeal shock wave lithotripsy. From Linton AD: Introduction to medical-surgical nursing, ed 6, Philadelphia, 2016, Saunders.

     UI can occur for many reasons, including damage to the nerves that control the bladder, weak or overactive bladder muscles, diseases that limit mobility, urethral blockages (e.g., enlarged prostate), increase in urine volume, UTI, and constipation. Persistent incontinence can come from pregnancy, childbirth, menopause, pelvic surgery, aging, prostate diseases, obstructions, and neurologic disorders. Accidental leakage of urine, urgency, constant dribbling, and inability to empty the bladder are possible signs and symptoms.
      Procedures used to diagnose incontinence include urinalysis, postvoid residual measurement, cystoscopy, cystogram, and pelvic ultrasound. The patient may keep a bladder diary, recording the amount of fluid consumed and urinated, the number of incontinence episodes, and frequency and urgency feelings. Urodynamic testing may also be done, which involves the bladder being filled via a catheter while the bladder pressure is measured. Treatments can vary based on the type of incontinence:
                • Behavior techniques: Bladder training, double voiding, scheduled toilet trips, and management of fluid and diet.
                • Kegel exercises and electrical stimulation: Used to strengthen pelvic floor muscles.
                • Medications: Anticholinergics, mirabegron, alpha-blockers, Botox, and topical estrogen.
                • Surgical procedures: Can also be performed to treat certain types of incontinence.
                • Medical devices: A urethral insert is a disposable device inserted into the urethra before activities that trigger incontinence. A pessary is a stiff ring that is inserted into the vagina and holds up the bladder, related to a prolapsed bladder. A nerve stimulator is an implanted device that delivers electrical pulses to the nerves that control the bladder.