Chapter 37
Nursing Care of Patients With Disorders of the Urinary System
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FIGURE 37.3 Hydronephrosis. Progressive thickening of bladder wall and dilation of ureters and kidneys result from obstruction of urine flow.
clots obstructing the urethra, and fistula formation (an open- ing between the bladder and an adjoining structure such as the vagina or bowel). Other symptoms include pelvic pain, pain in the lower back, painful urination, changes in bladder habits, and inability to void. Diagnostic Tests Cystoscopy with biopsy is the preferred diagnostic test for bladder cancer and to determine if it is in the muscle of the bladder wall. A urinalysis can show the presence of blood. A urine culture determines if an infection is causing the symp- toms which are similar to those of bladder cancer. Urine for cytology looks for precancer or cancer cells with a micro- scope. Urine tumor marker testing looks for substances asso- ciated with bladder cancer such as bladder tumor-associated antigen (BTA), carcinoembryonic antigen (CEA), nuclear matrix protein 22 (NMP22) or chromosome changes. Imaging tests may also be done to look at the urinary tract. Therapeutic Measures Treatment depends on the type and staging (severity) of the bladder cancer. For early-stage cancers that affect the inside lining of the bladder, intravesical therapy with chemotherapy or immunotherapy may be used. Chemotherapeutic agents are instilled into the bladder through a urinary catheter, allowed to dwell, and then removed along with the catheter. Bacillus Calmette-Guérin (BCG) therapy is used in the bladder to trigger the immune system to attack the BCG germ as well as cancer cells. BCG may reduce the reoccurrence of blad- der cancer. Photodynamic therapy, in which medications are given that make tumors sensitive to light, may be used. Light applied to the tumor area then kills the cancer cells. Surgery is often used and can be combined with other treatments. There are several surgical treatment options. Transurethral resection of bladder tumor using a
Pathophysiology Cancer of the bladder often starts as a benign growth on the bladder wall that undergoes cancerous changes. Most blad- der cancers begin in the inner lining of the bladder called the urothelium . They are called transition cell cancers . They come in a variety of forms and can behave in different ways. Some occur as small, wartlike growths on the inside of the bladder. Others form large tumors that grow into the muscle wall of the bladder and require surgical removal. If the can- cer affects only the inner lining of the bladder, it is known as a superficial cancer. If it has spread to the muscle wall, it is called an invasive cancer. Common sites for bladder cancer metastasis include the liver, bones, and lungs. Etiology There is a strong correlation between cigarette smoking and bladder cancer. Those who smoke develop bladder cancer twice as often as people who do not smoke. Specific chem- icals that cause bladder cancer have been found in cigarette smoke. The lung absorbs chemicals from smoking tobacco. These chemicals are passed to the kidneys through the blood- stream and collect in the urine. From there, they accumu- late in the urine and damage the cells that line the bladder. Exposure to industrial pollution, such as aniline dyes, benzi- dine and naphthylamine, leather finishers, metal machinery, and petroleum-processing products, also increases the inci- dence of bladder cancer. It can take about 25 years after the exposure to these chemicals for bladder cancer to develop. Signs and Symptoms Cancer of the bladder usually causes painless hematuria. The urine may appear dark or reddish in color. Initially the bleed- ing is intermittent, which often causes the patient to delay seeking treatment. As cancer progresses, the patient devel- ops frank hematuria, bladder irritability, urine retention from
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