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 Table of contents

1. The urinary system....................................................................................................................................... 1

11 April 2017 ii ProQuest

Document 1 of 1

The urinary system

Author: McLafferty, Ella; Johnstone, Carolyn; Hendry, Charles; Farley, Alistair

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Abstract:  
The urinary system plays an important role in regulating fluid and electrolyte balance and maintaining
homeostatic balance within the body. Assessment and management of fluid and electrolyte balance is a vital
part of the nurses' role, therefore it is important that nurses understand the functions of the urinary system. This
article explores the anatomy and physiology of the urinary system, with reference to the production and
excretion of urine. It also provides an overview of urinary tract infection.

Full text:  
THE URINARY SYSTEM is the main excretory system, consisting of two kidneys, two ureters, the urinary
bladder and the urethra. The kidneys produce urine that contains metabolic waste products. Urine is transported
via the ureters to the bladder for storage and is excreted by the micturition process via the urethra.
Role of the kidneys
The kidneys are the major functional units of the urinary system. They are responsible for the production of
urine as well as several other functions, including balance of electrolytes such as sodium, potassium, chloride
and phosphate levels. The kidneys also have a role in maintaining blood pH because of their ability to excrete
hydrogen and conserve bicarbonate. They also regulate blood volume by conserving or eliminating water in the
urine, which has a direct effect on blood pressure. In addition, they produce the enzyme renin, which allows
control of blood pressure ( Tortora and Derrickson 2011 ).
The kidneys produce erythropoietin, which helps to stimulate the development of mature red blood cells in the
bone marrow ( Porth 2011 ). Calcitriol (activated vitamin D) is produced in the liver and kidneys and is vital for
calcium absorption and thus calcium levels in the bones ( Porth 2011 ). The kidneys are also involved in the
regulation of blood glucose levels through the process of gluconeogenesis. Gluconeogenesis involves the
synthesis of glucose from the amino acid glutamine, which supports normal blood glucose levels ( Tortora and
Derrickson 2011 ). In addition, the kidneys eliminate waste products such as urea ( Tortora and Derrickson
2011 ) and some drugs such as penicillin and morphine ( Porth 2011 ).
The article focuses on the role of the kidneys in the production of urine, maintenance of fluid and electrolyte
balance, regulation of blood pressure and elimination of waste products.
Anatomy of the kidneys
The kidneys have been described as two bean-shaped organs lying retroperitoneally on the posterior abdominal
wall, with one on each side of the vertebral column ( Deshmukh and Wong 2009 ). They extend from the 12th
thoracic vertebra to the third lumbar vertebra ( Brooker and Nicol 2011 ), with the 11th and 12th pairs of ribs
giving them a degree of protection. Damage to these ribs can lead to injury of the kidneys ( Tortora and
Derrickson 2011 ) as can a blow to the right side of the back below the rib cage. If caring for a patient with injury
to the chest involving the 11th and 12th pairs of ribs, damage to the kidneys should be considered. The kidneys
are outside the peritoneal cavity towards the back of the upper part of the abdomen, and because of the
position of and space occupied by the liver, the right kidney is normally lower than the left ( Porth 2011 ). This
position outside the peritoneal cavity is of clinical significance because renal inflammation or infection does not,
therefore, carry the same risk of peritoneal involvement as that associated with organs inside the peritoneum (
Porth 2011 ).
The kidneys are anchored in place by their outer lining, which is composed of three layers. The renal fascia is a
superficial thin layer of dense connective tissue that protects the kidneys from trauma and helps to maintain

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their shape ( Tortora and Derrickson 2011 ). The middle layer consists of adipose tissue, which protects the
kidneys from damage and helps to keep them in place. The innermost or deepest layer is the renal capsule,
which comprises dense irregular connective tissue that provides shape to the kidneys and further protection.
This layer is continuous with the outer coat of the ureter ( Tortora and Derrickson 2011 ). Because of their
position close to the diaphragm, the kidneys are pushed downwards during inspiration ( O'Callaghan 2009 ).
The hilum is the concave medial border of the kidney through which the ureter emerges along with blood
vessels, lymphatic vessels and nerves ( Brooker and Nicol 2011 ). The area known as the renal pelvis is
continuous with the ureters and consists of calyces that are cup-like structures that drain urine from the upper
and lower parts of the kidneys.
The kidneys are relatively small organs, around 10-12cm long, 5-7cm wide and 3cm thick, and weigh 135-150g
( Tortora and Derrickson 2011 ). Each kidney receives about 625mL of blood per minute and together they
receive in excess of 20% of the cardiac output ( Munger et al 2012 ). The kidneys receive blood from the renal
arteries, which branch from the abdominal aorta. Immediately before the renal artery enters the kidney at the
hilum, it divides into five branches known as segmental arteries ( Porth 2011 ). These segmented arteries
further divide into lobular and eventually interlobular arteries as the blood supply penetrates into the kidney. The
interlobular arteries enter the renal cortex, subdividing to form the afferent arterioles, with each afferent arteriole
supplying one nephron ( Tortora and Derrickson 2011 ). The afferent arteriole enters the glomerular capsule
where it divides to become a small tangled network of capillaries known as the glomerulus. The capillaries of
the glomerulus reunite to form the efferent arteriole ( Brooker and Nicol 2011 ). Branches of the efferent
arteriole known as the peritubular capillaries supply the renal tubules while a specialised network called the
vasa recta supply the loop of Henle. The peritubular capillaries and the vasa recta are designed to allow
reabsorption ( Porth 2011 ). The peritubular capillaries join up to form the peritubular venules, interlobular veins
and eventually the renal vein, which leaves the kidney at the hilum, carrying venous blood to the inferior vena
cava ( Tortora and Derrickson 2011 ).
The majority of renal nerves originate from the sympathetic division of the autonomic nervous system, with most
being vasomotor in nature and resulting in dilation or constriction of arterioles ( Tortora and Derrickson 2011 ),
thus controlling renal blood flow ( Field et al 2010 ). Sympathetic stimulation of the kidneys results in a reduction
in renal blood flow because of vasoconstriction of the renal arterioles ( Field et al 2010 ) and subsequent
reduction in urine production.
Each kidney has two distinct regions: the renal cortex and the renal medulla ( Figure 1 ). The renal medulla is
made up of a number of cone-shaped areas known as the renal pyramids, and the apex of each pyramid (the
renal papilla) points towards the hilum ( Tortora and Derrickson 2011 ). The renal cortex is the site of the
glomeruli, convoluted tubules and blood vessels ( Tortora and Derrickson 2011 ). Together, these form the
functional unit of the kidney, the nephron, with each kidney consisting of in excess of one million nephrons (
Porth 2011 ).
The nephron consists of the glomerulus, proximal convoluted tubule, loop of Henle, distal convoluted tubule,
collecting ducts, and associated blood supply and capillary networks ( Figure 2 ). Although all nephrons have
their glomeruli in the renal cortex, about 15% of nephrons arise in the deepest part of the cortex closer to the
medulla, while the remaining 85% of nephrons arise in the outer area of the cortex ( Field et al 2010 ).
The glomerulus sits inside the glomerular capsule, which together are known as the renal corpuscle ( Tortora
and Derrickson 2013 ). The afferent arteriole enters the glomerulus and divides to form the capillary network
and the efferent arteriole leaves the glomerulus; this capillary network is unique because it sits between two
arterioles ( Tortora and Derrickson 2011 ). The diameter of the afferent arteriole is larger than that of the
efferent arteriole, creating a difference in pressure that forces fluid out of the capillary network and into the
glomerular capsule ( Deshmukh and Wong 2009 ).
The movement of fluid from the capillary network to the glomerular capsule occurs through the three-layer

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glomerular filtration barrier. The first layer of this barrier is the thin endothelial or lining layer of the capillary
network, which has fenestrations or perforations that allow larger molecules to pass through it ( O'Callaghan
2009 , Porth 2011 ). Next is the glomerular basement membrane, a collagen-based layer with pores that help to
determine the permeability of the filtration barrier in terms of the size of the molecules that can move through it (
Porth 2011 ). The final layer is the epithelial layer of the glomerular capsule, which is a specialised layer that
has pores that allow the selective filtering of substances, for example larger molecules such as the protein
albumin cannot usually cross this barrier ( O'Callaghan 2009 ). Specialised epithelial cells known as podocytes
have projections that wrap around the endothelial lining of the capillaries, providing an extensive filtration
membrane ( Tortora and Derrickson 2011 ).
The capillary basement membrane is susceptible to damage in people with diabetes mellitus. This damage is a
result of insulin deficiency and glucose intolerance, which when combined with changes to the micro-circulation
leads to thickening of the basement membrane and leakage of protein into the filtrate ( Deshmukh and Wong
2009 ). This is known as diabetic nephropathy and is a well-recognised potential complication of diabetes
mellitus.
Production of urine
Filtration
Once fluid, and a range of dissolved substances, has moved through the filtration barrier, it enters the
glomerular capsule and is known as filtrate. Filtrate is similar to blood plasma, but it contains almost no proteins
because proteins do not cross the filtration barrier in normal circumstances. The filtration barrier only allows
certain substances to move through, and filtration is dependent on three main principles. Inside the glomerulus,
a hydrostatic pressure of 55mmHg in the plasma promotes the movement of water and dissolved substances
through the filtration barrier. This pressure is opposed by the filtrate hydrostatic pressure inside the glomerular
capsule, which is 15mmHg. The pressure is also opposed by the osmotic pressure of the blood. Proteins exert
an osmotic pressure of around 30mmHg, drawing fluid into the circulation. Overall, there is a greater pressure to
push fluid out of the circulation and into the filtrate ( Tortora and Derrickson 2011 ).
The rate of filtration is known as the glomerular filtration rate, which is a measure of all the filtrate formed in one
minute in both kidneys. Although the glomerular filtration rate can vary from 200mL per minute to as little as a
few mL per minute, the average is 125mL per minute ( Porth 2011 ). Under normal circumstances, the
glomerular filtration rate is maintained at a relatively constant level via a process known as renal autoregulation.
Autoregulation is a means of maintaining blood flow via negative feedback, which can cause constriction or
relaxation of the afferent arteriole, thus altering the pressure in the glomerulus and in turn influencing the
filtration rate ( Tortora and Derrickson 2011 ). The kidneys maintain efficient blood flow through autoregulation (
Munger et al 2012 ), meaning that they are protected against fluctuations in blood pressure. The glomerular
filtration rate will remain relatively constant when mean arterial blood pressure is between 80mmHg and
180mmHg, but will be affected by levels outside this; for example when arterial blood pressure falls to below
80mmHg, pressure in the renal arterioles will fall, lowering the glomerular filtration rate and slowing urine
production. A healthy balance of body fluids depends upon the constant glomerular filtration rate because a rate
that is too fast will not allow adequate time for reabsorption, while a rate that is too slow may lead to too much
reabsorption and inadequate excretion of waste products ( Tortora and Derrickson 2011 ).
Hormonal control plays an important part in the maintenance of the glomerular filtration rate. Atrial natriuretic
peptide (ANP) is produced by the atria of the heart in response to stretching of the arterial wall, which occurs
when there is an increase in circulating blood volume. One of the effects of an increase in the level of ANP is an
increase in the glomerular filtration rate and an increase in the amount of filtrate produced ( Tortora and
Derrickson 2011 ).
The filtrate consists of fluid and dissolved substances that have passed through the filtration membrane, with
only substances of 3-7nm in size crossing the filtration barrier ( Brooker and Nicol 2011 ). In normal

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circumstances, large molecules such as proteins and blood cells do not cross the filtration barrier ( Brooker and
Nicol 2011 ) and will, therefore, not be found in urine when tested. The presence of these substances in urine is
an indication of dysfunction of some kind. Filtrate normally contains water, sodium, chloride, bicarbonate,
potassium, calcium, magnesium, glucose, amino acids, water soluble vitamins, uric acid and creatinine ( Porth
2011 , Tortora and Derrickson 2011 ). On average, 105-125mL of filtrate is produced per hour, with 99% of the
filtrate being reabsorbed ( McDonough and Thomson 2012 ). The process of reabsorption ensures that
substances required by the body are reclaimed, while waste products are eliminated.
Reabsorption
With an average of 7,500mL of filtrate produced per hour, reabsorption is vital to ensure the maintenance of
fluid balance. Reabsorption is a delicate balance of returning essential nutrients to the circulation, return of
controlled amounts of electrolytes to the circulation and reabsorption of the majority of the fluid. Reabsorption
involves the normal processes of solute transport across cell membranes, for example water and urea are
passively reabsorbed while other substances such as glucose, amino acids, sodium and potassium are
reabsorbed via active transport mechanisms ( Porth 2011 ). According to Porth ( 2011 ), only 1mL of the filtrate
forms urine, meaning that 124mL per minute are reabsorbed. Overall, this leads to a normal production level for
urine of around 60mL per hour. In practice, it is common to use the average of 30mL per hour when measuring
hourly urine volumes in patients with acute conditions. Nurses should be aware that volumes of 30mL per hour
are half the average normal urine production and that levels below this may indicate diminishing renal function.
Reabsorption begins in the proximal convoluted tubule, where the majority of solute reabsorption takes place (
O'Callaghan 2009 ). Around 65% of all reabsorption processes take place in the proximal tubule and, crucially,
nearly all the nutrients, for example glucose, amino acids and water-soluble vitamins, are reabsorbed from this
tubule ( Porth 2011 ). In normal circumstances, glucose is reabsorbed completely and, therefore, should not be
detected in urine. Only when the level of glucose in the blood rises above normal levels does glucose appear in
urine, and this is because glucose transport to the peritubular capillaries is not able to match the volume of
glucose being filtered, thus some glucose remains in the filtrate and is eliminated in urine ( Tortora and
Derrickson 2013 ). The proximal convoluted tubule is highly permeable to water so there is rapid osmotic
movement of water and reabsorption of 65-80% of electrolytes such as sodium, potassium, chloride and
bicarbonate ( Porth 2011 ).
A more balanced approach to reabsorption is found in the loop of Henle. The loop of Henle helps control the
concentration of urine ( Porth 2011 ), with reabsorption varying along its length because of differences in the
properties of its lining. In the thin descending loop, the walls are relatively impermeable to solutes but
permeable to water, and the water moves by osmosis. The fluid in the tubule now contains a higher level of
solutes and is hypertonic. The thick ascending loop is impermeable to water and is permeable to sodium and
chloride, and these diffuse down the concentration gradient. The filtrate becomes hypotonic. Because water and
solute movement are not always linked in the loop of Henle, the volume of body fluids can be controlled
separately from the osmolality. The overall function of the loop of Henle is the reabsorption of sodium and
chloride and other electrolytes, and the concentration of urine ( Tortora and Derrickson 2011 ).
The distal convoluted tubule is generally impermeable to water, therefore only solutes, especially sodium and
chloride, are reabsorbed. Calcium can also be reabsorbed although this depends on stimulation by parathyroid
hormone ( Field et al 2010 ). The overall level of reabsorption in the distal convoluted tubule is influenced
directly by antidiuretic hormone (ADH). If ADH is present, the tubule becomes permeable to water, causing it to
be reabsorbed making the urine more concentrated. When ADH is not present, the walls remain impermeable to
water and more dilute urine is formed. The role of ADH is to conserve body fluids by decreasing urine output.
The production of ADH is stimulated by dehydration, loss of blood, pain or stress, and is inhibited by alcohol,
which is one of the reasons for dehydration following excessive alcohol consumption ( Tortora and Derrickson
2011 ).

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Sodium plays an important role in the maintenance of fluid balance. It is the most abundant electrolyte in
extracellular fluid with levels controlled by the action of aldosterone, ADH and ANP. Levels of sodium are
monitored constantly in the hypothalamus, with homeostatic levels of sodium maintained by an interplay of
hormonal control influencing levels of reabsorption, thus the level of sodium in the blood has a direct influence
on urine output ( Tortora and Derrickson 2011 ).
Several distal tubules join together to form collecting ducts, which are generally impermeable to water. These
ducts are also affected by ADH in much the same way as the distal tubules, therefore sodium is reabsorbed as
is some chloride, but by the time filtrate reaches the collecting ducts up to 95% of the solutes and water have
been returned to the blood ( Tortora and Derrickson 2011 ). Potassium levels in the blood are regulated by cells
in the wall of the tubules because they secrete potassium back into the tubule. In addition, hydrogen and
bicarbonate levels are regulated, and secretion of hydrogen is vital to the overall maintenance of pH levels in
the blood. The role of the kidney in pH balance is to reabsorb the filtered bicarbonate and secrete hydrogen
buffered by phosphate and ammonia. Ammonia is manufactured by cells of the renal tubule from the amino acid
glutamine ( Porth 2011 ).
Secretion
Secretion is the movement of substances from the blood into the tubule of the nephron and is an important renal
process that regulates the level of several substances. It occurs mainly in the distal convoluted tubule and the
collecting ducts ( Chalmers 2008 ). Although creatinine is freely filtered, it is also secreted increasing the total
amount in filtrate by about 20%. Other substances such as hydrogen, potassium and ammonia, and some drugs
are also secreted, for example morphine, aspirin and penicillin ( Porth 2011 ). The collecting ducts unite to form
larger ducts, ultimately leading the filtrate to the pelvis of the kidney ( Porth 2011 ) where the filtrate exits the
kidneys via the ureters, and is known as urine.
Normal urine consists of 95% water (with an average adult producing around 1-2L of urine per day), urea,
creatinine, potassium, ammonia, uric acid, sodium, chloride, magnesium, sulphate, phosphate and calcium (
Tortora and Derrickson 2013 ). It is important that nurses are aware of the normal levels of these elements, as
well substances that do not normally appear in urine because these are important indicators of renal function
and wider abnormalities in the body. For example, albumin is a plasma protein that should not appear in urine
because it is too large to cross the filtration barrier and, therefore, its presence can indicate renal damage.
Glucose is normally completely reabsorbed and its presence indicates that the renal threshold for reabsorption
has been exceeded as occurs in diabetes mellitus. White blood cells are part of the immune response and their
presence in urine indicates infection. The presence of ketones in urine has several potential causes such as
starvation, a low carbohydrate diet or diabetes mellitus ( Tortora and Derrickson 2013 ).
Normal urine should be clear, although it may vary in colour from pale yellow to dark amber according to the
concentration. Colour can also be influenced by food or drugs. There should be no unpleasant odour initially,
but urine left standing can develop a smell of ammonia. The normal pH of urine is 4-8 with an average of 6, but
this can vary considerably with diet, for example a high protein diet will increase the acidity of urine ( Chalmers
2008 , Tortora and Derrickson 2013 ).
Role and anatomy of the ureters
The end result of the renal process is urine, which exits the pelvis of the kidneys via the ureters. The ureters are
long tubes about 25-30cm in length that pass behind the peritoneum and connect the kidneys to the bladder (
Brooker and Nicol 2011 ). The ureters pass under the bladder and enter obliquely, eventually opening into the
bladder at the posterior inner surface ( Brooker and Nicol 2011 , Tortora and Derrickson 2013 ). This means of
entering the bladder is important because it prevents back flow of urine to the ureters by creating a valve-like
effect in which the ureters are compressed and the openings occluded when urine accumulates and pressure in
the bladder increases. Preventing back flow of urine is important to prevent the upwards movement of
microorganisms from the bladder to the kidneys, reducing the risk of transfer of infection.

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Role and anatomy of the bladder and urethra
The position of the bladder differs slightly in men and women. In females, the bladder is situated in front of and
below the uterus and rests against the vagina, while in men it is situated directly in front of the rectum ( Tortora
and Derrickson 2013 ). The bladder is a hollow muscular sac made up of four layers: an outer fibrous coating, a
longitudinal and circular layer of smooth muscle known as the detrusor muscle, a layer of connective tissue and
an inner layer of transitional epithelium ( Brooker and Nicol 2011 ). Emptying of the bladder involves both
voluntary and involuntary nervous control. Activation via the parasympathetic nervous system brings about
contraction of the detrusor muscle and relaxation of the internal sphincter in the bladder neck during micturition.
Voluntary control is via the sympathetic nervous system, which aids bladder filling by promoting relaxation of the
smooth muscle and contraction of the internal sphincter ( Porth 2011 ).
The urethra varies in length between men and women. In men, it measures about 20-25cm and passes through
the prostate gland. In men, the urethra also has a sexual function in carrying semen. Semen enters the urethra
via a duct known as the vas deferens. The vas deferens links with the epididymis that exits the testes ( Brooker
and Nicol 2011 ). The external sphincter is a ring of voluntary muscle and in men, it is situated where the
urethra exits the prostate gland. In women, the urethra is shorter, about 3-5cm in length with its orifice between
the clitoris and the vagina. The external sphincter is near the urethral orifice and is under voluntary control. The
urethra is made largely of an outer layer of smooth muscle continuous with the bladder, a middle layer that has
nerve, lymph and blood supply, and an inner mucous lining, which is continuous with the bladder ( Brooker and
Nicol 2011 ).
Micturition
The bladder acts essentially as a store for urine until it is time to expel it from the body in the process of
micturition. In normal circumstances, urine will remain in the bladder until the detrusor muscle contracts,
bringing about opening of the bladder neck alongside relaxation of pelvic floor muscles and external urinary
sphincter muscles ( Brooker and Nicol 2011 ). Tortora and Derrickson ( 2011 ) stated that the pressure inside
the bladder increases during filling and that when a volume of 200-400mL is reached, stretch receptors send
impulses to the spinal cord triggering the micturition reflex and stimulating contraction of the detrusor muscle
and relaxation of the internal sphincter. Urination or voiding is stimulated at a conscious level before initiation of
the micturition reflex, and it is this conscious control that children learn via control of the external sphincter and
some pelvic floor muscles ( Tortora and Derrickson 2011 ). Conscious control is normally achieved by the age
of three, but cannot be achieved until the necessary nerve pathways have matured ( Brooker and Nicol 2011 ).
Urinary tract infection
Several conditions may be associated with the urinary system such as chronic kidney disease, acute kidney
injury and urinary tract infection (UTI). In England, chronic kidney disease occurs in 14% of males and 13% of
females, although many individuals will be at an early stage of the condition and may be unaware that they have
it ( Roderick et al 2011 ). This long-term condition is associated with deterioration, reduced quality of life, and
may necessitate dialysis. Acute kidney injury occurs in 13-18% of individuals admitted to hospital in developed
countries and develops often in individuals with other conditions being cared for in non-renal specialist areas (
National Institute for Health and Care Excellence 2013 ). Because acute kidney injury tends to develop in
patients in general wards, it is essential that nurses have an understanding of basic renal function and
deviations from normal plasma and urine levels that may indicate renal dysfunction.
UTI is discussed here because of its prevalence and tendency to reoccur. Almost half of all women will report at
least one UTI at some point in their lives and 20-30% will experience a recurrence ( Patient.co.uk 2013 ).
Although rare in men under aged 50, UTI occurs in about 3% of men in their 60s and 10% of men in their 80s (
Patient.co.uk 2013 ). According to the Scottish Intercollegiate Guidelines Network (SIGN) ( 2012 ), UTI is the
second most common reason for the use of antimicrobial treatment in both primary and secondary care
settings. A UTI is defined as 'the presence of bacteria or other microorganisms in the urine or genito-urinary

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tissues', although the term infection is usually used when the concentration of organisms meets set quantitative
criteria ( Nicolle 2012 ). The presence of bacteria in urine does not indicate an infection that requires
intervention necessarily, with an average of 16% of women and 6% of men between the ages of 65 and 74 in
Scotland having asymptomatic bacteriuria ( SIGN 2012 ). There are several risks that increase the likelihood of
developing bacteriuria, including female gender, age, comorbid diabetes mellitus, institutionalisation, sexual
activity and presence of an indwelling urinary catheter ( SIGN 2012 ). Age is an important factor because post-
menopausal women experience more non-specific symptoms such as low abdominal and back pain, and a
delay in diagnosis ( Arinzon et al 2012 ). Pre-menopausal women are more likely to report local signs such as
pain on passing urine ( Brooker and Nicol 2011 , Arinzon et al 2012 ). Typical signs of UTI are dysuria,
increased frequency of urination, suprapubic tenderness, urgency, polyuria and haematuria ( SIGN 2012 ).
A lower UTI affects the urethra and bladder, for example cystitis, and an upper UTI affects the ureters and
kidneys, for example pyelonephritis ( Porth 2011 ). Uncomplicated lower UTIs are more common than upper
UTIs and generally respond well to treatment involving a short course of antibiotics. Pyelonephritis is more likely
to occur in children and those with obstructions or other conditions such as those with neurogenic bladder
dysfunction secondary to diabetes ( Porth 2011 , SIGN 2012 ). Pyelonephritis is potentially more serious than
lower UTI, creating more widespread symptoms such as pain, nausea and pyrexia, and warranting antibiotic
treatment ( Brooker and Nicol 2011 ). However, Chalmers ( 2008 ) stated that although antibiotics are useful in
treating the initial acute infection, there is little evidence to support prophylactic use to slow the development of
renal disease.
Diagnosis
UTIs in men should be confirmed with a urine sample for culture. Because there is a strong correlation between
UTI in men and an enlarged prostate, this must be considered during investigation and diagnosis ( SIGN 2012 ).
Most bacteria enter the urinary tract via the urethra and travel to the bladder, with Escherichia coli accounting
for the majority of infections in the community and half of all hospital-acquired infections ( Brooker and Nicol
2011 ). A UTI diagnosis is based on the presenting symptoms and urine sample testing. In otherwise healthy
women, it is recommended that diagnosis is made and treatment with antibiotics is considered when three or
more of the previously mentioned typical symptoms are present ( SIGN 2012 ). The likelihood of the presence of
a UTI is further confirmed when urine is cloudy with suspended particles - the presence of white blood cells
(pus) creates this cloudiness and is known as pyuria. A dipstick test may be useful when fewer symptoms are
present.
Treatment
Treatment of UTI varies with gender, and type and severity of infection. Antibiotic therapy with a three-day
course of trimethoprim or nitrofurantoin should be considered in non-pregnant women under 65 when there are
three or more typical symptoms ( SIGN 2012 ). Pregnant women should have a urine sample taken for culture
before antibiotic treatment, be treated with an antibiotic chosen from the local formulary and usually for seven
days, and have a further urine sample taken for culture one week after completion of antibiotic therapy to
ensure the infection has resolved ( SIGN 2012 ). Recurrent UTIs in older women often lead to the repeated use
of antibiotic therapy. McMurdo et al ( 2009 ) found that in older women with recurrent UTI, there is little
difference between the effectiveness of cranberry extract and trimethoprim in terms of prevention of infection,
suggesting that these women may wish to consider this option, in discussion with their clinician, as a means of
reducing the risk of antimicrobial resistance. Infection in men should be treated with quinolone when there is a
suggestion of prostatitis, and referral to a urology specialist should be considered when there is failure to
respond to antibiotic therapy, recurrent UTI or upper UTI ( SIGN 2012 ).
The link between UTI and catheterisation is well-recognised, with increasing duration of catheterisation
increasing the risk of infection ( SIGN 2012 ). While catheterisation is an essential part of nursing management
in many situations, it is vital that the catheter is removed as soon as it is no longer clinically indicated to reduce

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the risk of UTI and that catheterisation is not viewed as a solution to urinary incontinence ( Hooton et al 2010 ).
Catheter-associated urinary tract infections may present with worsening fever, rigors, altered mental state, flank
pain, acute haematuria or pelvic discomfort. Dipstick testing will be unreliable as pyuria is common in patients
who have been catheterised and is not predictive of infection ( SIGN 2012 ).
Hooton et al ( 2010 ) stated that prevention measures such as a closed drainage system are important in
reducing the risk of infection. SIGN ( 2012 ) states that hospital admission is required when systemic symptoms
such as fever, rigors, chills or vomiting are present. In terms of antibiotic therapy, treatment should be guided by
symptoms and follow local antibiotic policy. Long-term catheters should be changed before commencement of
antibiotic therapy, and therapy should then be guided by local policy. It should be noted that because of the
prevalence of bacteriuria in people who are catheterised, screening would be unhelpful and there is no need to
treat those with asymptomatic bacteriuria ( SIGN 2012 ).
Conclusion
Although the primary function of the urinary system is the production of urine, it has a range of other roles that
link it closely to other systems in the body. For example, the kidneys have a vital role in the maintenance of
blood pressure while blood pH is maintained by the interplay of actions of the urinary and respiratory systems.
Producing urine is a major means of eliminating waste products and toxic substances from the body, thus
maintaining fluid balance in the body.
The kidneys are the primary active units in the urinary system filtering more than 600mL of blood per minute;
however, this can create vulnerability because of the close contact the nephrons have with blood and any
potential toxins ( Porth 2011 ).
Assessment and monitoring of renal function is a major part of the nurses' role and is inherently linked to fluid
balance. Nurses need to have an understanding of renal physiology and fluid management. In addition, they
need to be aware of how to identify and treat UTI because of the prevalence of this condition and the potential
for associated complications.
POINTS FOR PRACTICE
List some of the signs and symptoms of a lower urinary tract infection (UTI) and explain why these might occur.
Refer to local protocols and outline a nursing care plan for a patient presenting with a lower UTI.
Review local guidelines in relation to catheterisation and catheter management with a view to reducing or
preventing the incidence of UTI.
References
Arinzon Z, Shabat S, Peisakh A, Berner Y ( 2012 ) Clinical presentation or urinary tract infection (UTI) differs
with aging in women. Archives of Gerontology and Geriatrics . 55, 1, 145- 147. 21963175
10.1016/j.archger.2011.07.012
Brooker C, Nicol M ( 2011 ) Alexander's Nursing Practice . Fourth edition. Churchill Livingstone Elsevier,
Edinburgh.
Chalmers CA ( 2008 ) Applied anatomy and physiology and the renal disease process. In Thomas N (Ed)
Renal Nursing . Third edition. Bailliere Tindall Elsevier, Edinburgh, 27- 72.
Deshmukh SR, Wong NWK ( 2009 ) The Renal System Explained. An Illustrated Core Text . Nottingham
University Press, Nottingham.
Field M, Pollock C, Harris D ( 2010 ) The Renal System: Basic Science And Clinical Conditions . Second
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Subject: Kidneys; Rodents; Abdomen; Anatomy & physiology; Antibiotics; Infections; Veins & arteries; Urine;
Urogenital system; Vertebra;

Identifier / keyword: Kidneys nephrons micturition ureters urethra urinary system and disorders urinary tract
infection urine production

Publication title: Nursing Standard (2014+); London

Volume: 28

Issue: 27

First page: 43

Publication year: 2014

Publication date: Mar 5, 2014

Year: 2014

Publisher: BMJ Publishing Group LTD

Place of publication: London

Country of publication: United Kingdom

Publication subject: Medical Sciences--Nurses And Nursing

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ISSN: 00296570

CODEN: NSTAEU

Source type: Scholarly Journals

Language of publication: English

Document type: Journal Article

DOI: http://dx.doi.org/10.7748/ns2014.03.28.27.43.e7283

ProQuest document ID: 1784957582

Document URL: https://search.proquest.com/docview/1784957582?accountid=170128

Copyright: Copyright: 2012 (c)2012 RCN Publishing Company Ltd. All rights reserved. Not to be copied,
transmitted or recorded in any way, in whole or part, without prior permission of the publishers.

Last updated: 2016-04-30

Database: Public Health Database

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