sign in sign up
<<
Home , Acute prostatitis, Anuria, Balanitis, Genitourinary system, Labial fusion

CHAPTER 6 – GENITOURINARY SYSTEM

First Nations and Inuit Health Branch (FNIHB) Clinical Practice Guidelines for Nurses in Primary Care. The content of this chapter was revised in October 2011.

Table of Contents

ASSESSMENT OF THE GENITOURINARY SYSTEM...... 6–1 PHYSICAL EXAMINATION OF THE GENITOURINARY SYSTEM...... 6–3 Cancer Screening...... 6–4 COMMON PROBLEMS OF THE GENITOURINARY SYSTEM...... 6–4 Asymptomatic Bacteriuria...... 6–4 Cystitis...... 6–6 Pyelonephritis, Acute...... 6–9 Urethritis...... 6–11 ...... 6–13 Urolithiasis...... 6–18 COMMON PROBLEMS OF THE MALE GENITOURINARY SYSTEM...... 6–20 Acute ...... 6–20 ...... 6–22 Benign Prostatic Hyperplasia...... 6–24 ...... 6–26 ...... 6–28 EMERGENCIES OF THE MALE GENITOURINARY SYSTEM...... 6–31 Acute ...... 6–31 ...... 6–33 Partial or Intermittent Testicular Torsion...... 6–33 SOURCES...... 6–35

Clinical Practice Guidelines for Nurses in Primary Care 2011

Genitourinary System 6–1

ASSESSMENT OF THE GENITOURINARY SYSTEM1,2,3

The following characteristics of each symptom should –– be elicited and explored: –– Incontinence (including urge, overflow, , –– Onset (sudden or gradual) mixed, and stress) –– Acuity or chronicity –– Leakage of involuntarily –– Chronology –– Leakage of urine when coughing, laughing or exercising –– Current situation (improving or deteriorating) –– Leakage of urine when walking to the –– Location and character washroom –– Radiation –– Use of pads or other devices to catch urine –– Timing (frequency, duration, intermittent or –– Inability to completely empty bladder constant) –– Amount of urine lost each time –– Severity and extent –– Nature of urine stream (speed, strength, volume) –– Precipitating and aggravating factors –– Colour and odour of urine –– Relieving factors –– Presence of sediment, sand or stones in urine –– Associated symptoms –– Hematuria –– Effects on daily activities –– Presence of urethral or genital discharge or lesions –– Previous diagnosis of similar episodes –– Pain in costovertebral angle, flank or abdomen –– Previous treatments –– Suprapubic pain –– Efficacy of previous treatments –– Perineal, genital, groin or low back pain –– Associated symptoms (for example, , chills, trauma, repetitive activity) –– Painful intercourse –– Libido Assess and monitor pain or discomfort using a pain –– Fertility intensity instrument such as the Wong-Baker Faces Pain Scale, the Numeric Rating Scale, or the Comfort Male Genital System Scale (available at: http://painconsortium.nih.gov/ pain_scales/). Also assess presence of night pain, –– Difficulty in starting or stopping urinary stream radiation or referred pain and course. –– Voluntary bearing down (straining) to urinate –– Hesitancy, intermittency CARDINAL SYMPTOMS –– Post-void dribbling or post-void fullness In addition, the general characteristics outlined above –– should be explored for each symptom described –– Discharge from penis, itching below, if applicable. –– Blood in sperm –– Lesions on the external genitalia (Male and Female) –– Genital, groin, suprapubic or low back pain –– Frequency of –– Testicular or scrotal pain or swelling –– Amount of urine (large or small) –– Erectile dysfunction –– Urgency (client’s sense that he or she must void –– Testicular self-examination (frequency, regularity) now, cannot wait) –– History of hydrocele, epididymitis, prostatism, –– and its timing during voiding (at beginning , hernia, undescended testis, or end, throughout) , recent vasectomy –– (new onset or increase in usual pattern) –– Urinary retention or

Clinical Practice Guidelines for Nurses in Primary Care 2011 6–2 Genitourinary System

Other Associated Symptoms FAMILY HISTORY (SPECIFIC TO GENITOURINARY SYSTEM) –– Fever, chills, rigors, malaise –– Nausea, vomiting –– Urinary tract –– Diarrhea, constipation –– Renal (for example, renal cancer, –– Decrease in appetite polycystic kidneys) –– Weight loss –– –– Change in sleep pattern –– mellitus –– Lymphadenopathy –– stones –– Sexual or physical abuse MEDICAL HISTORY (SPECIFIC TO GENITOURINARY SYSTEM) PERSONAL AND SOCIAL HISTORY (SPECIFIC TO GENITOURINARY SYSTEM)4 –– Cystitis, pyelonephritis –– Renal disease –– Personal hygiene, toileting habits –– Congenital structural abnormalities in the –– Fluid intake genitourinary tract –– Recent or trauma –– Renal stones –– Current sexual activity; last sexual contact –– Recent onset of or increase in sexual activity –– Sexual orientation (male and/or female partners) –– Recent genitourinary tract instrumentation (for –– Contraception and condom use example, catheter, urethral dilatation, cystoscopy) –– Sexual practices, including risk behaviours –– Menopause (with no hormone replacement (for example, oral, anal or vaginal intercourse) therapy) –– Number of sexual partners in past 2 months; –– Diabetes mellitus in past year –– Immunocompromised state –– Satisfaction with frequency and quality of sexual –– Sexually transmitted infections (including HIV experiences and hepatitis) –– Symptomatic sexual partner –– Sexual abuse –– History of sexually transmitted –– Mental status (can contribute to urinary –– Use of contraceptive creams, foam, condoms, etc. incontinence) –– Use of bubble bath, (by women) –– Allergies –– Tight-fitting underwear or other clothing –– Exposure to chemical irritants –– Disruption in sex life (from GU symptoms) –– (for example, immunosuppressants, –– (associated with risk of ) oral contraceptives, antihypertensives, –– Substance use (alcohol and drugs) antipsychotics) –– Sex while under the influence of drugs or alcohol –– Surgical procedures –– Missing work, school or social functions because –– Risk behaviours (for example, unprotected sex, of genitourinary symptoms (for example, substance abuse, use of illicit drugs) incontinence) –– Victim of abuse (for example, sexual) –– Occupational exposure (for example, volatile hydrocarbons, benzene, aniline, heavy metals, ionizing radiation) – increased risk of kidney concerns

2011 Clinical Practice Guidelines for Nurses in Primary Care Genitourinary System 6–3

PHYSICAL EXAMINATION OF THE GENITOURINARY SYSTEM5,6

GENERAL Percussion –– Apparent state of health –– Suprapubic or costovertebral angle tenderness –– Appearance of comfort or distress –– Bladder distention –– Colour (for example, flushed, pale) Remember to also examine the following areas as part –– Hydration status of your assessment: –– Nutritional status (emaciated or obese) –– Head, eyes, , nose, throat: assess for –– Match between appearance and stated age pharyngitis and conjunctivitis (chlamydial VITAL SIGNS infection, gonorrhea) –– : assess for skin lesions, rashes, polyarthralgias –– Temperature of systemic gonorrhea and hydration status –– rate –– Respiratory rate MALE GENITAL TRACT –– Blood pressure Inspection URINARY SYSTEM –– Penis (including , prepuce, glans, shaft, (ABDOMINAL EXAMINATION) skin): , discharge (at urethral meatus before and after instructing the client to “milk” Inspection the penis from its base), lesions (ulcers, warts), –– Inguinal and femoral areas nodules, scars, swelling, asymmetry, stenosis, –– Abdominal contour looking for asymmetry or ability to retract (if present), , distention (a sign of ascites), pulsations, or masses , , –– Peripheral vascular irregularities –– : inflammation, lesions, swelling, masses, –– Previous abdominal or flank surgical scars asymmetry, rashes, warts, –– Edema (facial, peripheral) –– Pubic area: inflammation, lesions (warts, ulcers), nodules, scars, changes in hair distribution, nits –– Ulcers, warts, nodules, scars, and inflammation –– Inguinal and femoral areas (for hernial bulges) –– Ask the client to bear down or cough while inspecting urethra for ; repeat Palpation in females with pressure to lateral vaginal fornix –– looking for lesions, discharge, swelling, –– Penis: tenderness, induration, nodules, lesions hemorrhoids, excoriations, masses, inflammation –– Testes and scrotal contents (including , spermatic cord): size, position, shape, consistency, Palpation atrophy of testes, tenderness, swelling, warmth, masses, hydrocele –– Suprapubic tenderness –– Prostate (digital rectal exam): size, shape, contour, –– Bladder distention consistency, mobility, tenderness, or nodules –– Abdominal tenderness, induration, or masses –– Superficial inguinal ring (for hernia) –– Costovertebral angle tenderness –– Inguinal canal (while standing) and femoral areas –– Enlargement of kidney (normal kidneys are usually (for hernia) not palpable unless the client is thin) –– Cremasteric reflex –– Inguinal nodes or swellings –– Femoral area (anterior thigh) for hernias FEMALE GENITAL TRACT –– Supraclavicular lymphadenopathy See Chapter 13, “Women’s Health and Gynecology”, –– Rectum (digital rectal exam): hemorrhoids, masses, for details of this examination. anal sphincter tone

Clinical Practice Guidelines for Nurses in Primary Care 2011 6–4 Genitourinary System

LABORATORY EVALUATION Prostate cancer screening is controversial. Screening –– Urine: colour, cloudy or clear using a digital rectal exam (DRE) does not ensure early detection of the cancer. Serum prostate specific –– Dipstick testing: blood, protein, white blood cells antigen (PSA) testing results may cause unnecessary (WBC), nitrites, pH stress if the client requires further testing. –– Microscopic urine (spun urine): white and red blood cells, or casts, epithelial cells Refer all asymptomatic men who are expected to live –– Urine culture and sensitivity at least 10 years and who are over age 50 (40 in those –– Culture and sensitivity of urethral discharge or with a family history of prostate cancer) to a physician prostatic secretions or nurse practitioner to discuss the risks and benefits of prostate cancer screening with DRE and/or serum –– Prostate specific antigen (has limited specificity) PSA testing. The decision to screen or not screen must –– Creatinine and blood urea nitrogen (for kidney be individualized to the client. function) If an asymptomatic man has positive screening results Consider additional diagnostic tests (for example, from the DRE and/or serum PSA testing, refer the HIV, N. gonorrhoeae, hepatitis) for individuals with client to a physician or nurse practitioner to discuss risk factors for sexually transmitted infections (STIs) the results. (see Chapter 11, “Communicable ”). If a client has symptoms that may signify prostate PROSTATE CANCER SCREENING7,8 cancer (for example, genitourinary symptoms such as urgency or nocturia) a DRE should be done. Prostate cancer is the leading non-skin cancer in men9 Advanced prostate cancer may present with erectile and causes more mortality for First Nations males dysfunction, hematuria and in older than the rest of the Canadian population.10 Risk factors men, and metastases (for example, pain). Any for prostate cancer are increasing age (most significant man with symptoms that may signify prostate cancer after age 40), genetics, and possibly diet.11 (with or without an abnormal DRE) should be referred urgently to a physician for further assessment and/or investigations (for example, serum PSA testing and/ or a prostate ). A diagnosis of prostate cancer requires a biopsy.

COMMON PROBLEMS OF THE GENITOURINARY SYSTEM

ASYMPTOMATIC Risk Factors BACTERIURIA43,44,45,46,47,48 –– Diabetes (in particular women, those using insulin, those who have had diabetes for a longer time, and Presence of bacteria in appropriately collected urine First Nations individuals) without the client experiencing symptoms or signs of –– Older age a , as demonstrated by more than 105 cfu/mL of a single bacterial species cultured on 2 –– Sexual activity successive midstream urine specimens for women and –– Female (more common in women because one specimen for men or those who are catheterized. the urethra is short and located close to the ) –– Males practising insertive anal intercourse In the young and healthy this condition is transient, –– Uncircumcised male often only lasting a couple of weeks. –– Bladder outlet obstruction (for example, prostatic CAUSES hyperplasia) –– Urinary tract instrumentation –– Bacteria (for example, E. coli) –– Indwelling catheters –– Contamination of specimen

2011 Clinical Practice Guidelines for Nurses in Primary Care Genitourinary System 6–5

HISTORY –– Eradicate bacteria from genitourinary (GU) tract –– No urinary complaints in clients undergoing invasive urologic procedures where mucosal bleeding is expected –– Usually discovered on routine examination of urine –– Avoid treating all other clients to decrease the –– The prevalence of asymptomatic bacteriuria among potential for resistance healthy women increases with advancing age –– Common in women 20–50 years of age, and in Nonpharmacologic Interventions up to 30% of pregnant women –– Asymptomatic bacteriuria is rare among healthy Client Education young men –– Recommend adequate fluid intake to flush bacteria –– Chronic low-grade prostatitis is often present from the bladder and prevent stasis of urine in men > 50 years of age (6–8 glasses of fluid per day) –– Common in elderly clients and those with –– Instruct female client about proper hygiene (wiping an indwelling urinary catheter from front to back) –– Teach client the of acute PHYSICAL FINDINGS infection and advise client to return to the clinic if these occur Normal. Pharmacologic Interventions COMPLICATIONS Females require 2 consecutive positive cultures and –– Cystitis males require one positive culture before treatment is –– Pyelonephritis warranted. –– Preterm birth –– Low birth weight Pregnant Women –– Perinatal mortality Treat all pregnant women with this condition to ensure resolution of the bacteriuria: DIAGNOSTIC TESTS amoxicillin 500 mg PO tid for 3–7 days Pregnant clients (12–16 weeks’ gestation) and those pre-operative to invasive urologic procedures (for For clients with allergy to penicillin: example, transurethral resection of the prostate) are nitrofurantoin (MacroBID), 100 mg PO bid for 3–7 days the only ones who should be screened. All other Nitrofurantoin is contraindicated at term (after 35 clients should not have their urine screened for weeks) and during labour in pregnant women. Contact asymptomatic bacteriuria. a physician for help in choosing an antibiotic if the –– Urine: clear pregnant client is allergic to penicillin and is near –– Dipstick test: normal term. –– Microscopic examination: bacteria evident Pre-Operative to Invasive Urologic Procedures where –– Culture: positive in 24–48 hours Mucosal Bleeding is Expected Ensure that the specimen is a properly collected, As per specific pre-operative recommendations. midstream urine sample. Other Groups: Healthy Nonpregnant Women, MANAGEMENT Diabetics, Elderly, Clients with a Urethral Catheter Antibiotic treatment is not needed. Goals of Treatment If there have been no GU problems in the –– Recognize the significance of asymptomatic past and there are currently no symptoms, the bacteriuria in the various subgroups (prenatal, problem is probably only contamination. Educate immunocompromised, elderly) about Nonpharmacologic Interventions (see –– Eradicate bacteria from genitourinary (GU) tract “Nonpharmacologic Interventions”). in pregnant women; it may progress to urinary tract infection, pyelonephritis, miscarriage, pre- eclampsia or

Clinical Practice Guidelines for Nurses in Primary Care 2011 6–6 Genitourinary System

Follow-Up –– Congenital abnormality of GU tract Pregnant Women: –– Renal calculi –– Tumour Follow up with midstream urine for culture and –– Urethral stricture sensitivity 1 week post-treatment. Repeat culture and sensitivity monthly. Retreat if necessary based on –– Pregnancy the susceptibility report with either a longer duration –– Related to sexual activity (in women) of the same antibiotic or a different one. Discuss –– Use of spermicides (including condoms coated persistent positive cultures with a physician. with them), diaphragm –– Bladder outlet obstruction (for example, prostatic CYSTITIS45,46,49,50,51,52,53,54 hypertrophy) –– Immunocompromised state (for example HIV Infection of the bladder. It can occur alone or in infection) conjunction with pyelonephritis. They are common –– History of > 6 urinary tract infections throughout a female’s lifespan. –– Recent antimicrobial use Uncomplicated if: nonpregnant female with no –– Male performing insertive anal intercourse structural or functional genitourinary abnormalities –– Uncircumcised male (for example, chronic catheter, obstruction, spinal –– Sexual intercourse with a female partner with cord injury). a urinary tract infection Complicated: all other individuals other than Risk Factors for Recurrent Cystitis those listed as uncomplicated (for example, males, genitourinary tract abnormalities, pregnant); often is –– Genetic or biologic factors due to a mixed bacterial infection and is more likely –– Frequent sexual intercourse to involve resistant organisms. –– Spermicide use within the last year –– New sexual partner within last year Recurrent UTI is defined as 2 uncomplicated UTIs in 6 months or, more traditionally, as 3 or more positive –– First cystitis at < 15 years of age cultures within the preceding 12 months. It can be –– Mother with a history of cystitis attributed to: –– Shorter length from urethra to anus –– Urinary incontinence –– Reinfection: cystitis caused by a different organism than the original infection OR the same organism if –– History of cystitis before menopause it occurs more than 2 weeks after end of treatment HISTORY OR if there is documentation of a sterile urine culture after treatment ending before the onset –– Dysuria of another infection –– , small amounts –– Relapse: cystitis caused by the same organism as –– Hematuria the original infection and occurring within 2 weeks –– Urgency of treatment ending –– Suprapubic discomfort CAUSES –– No nausea or vomiting –– No vaginal discharge or irritation –– E. coli (most common organism, in 80–90% of cases) –– No urethral discharge –– Also Klebsiella, Staphylococcus saprophyticus, –– Risk factors as described above (see “Risk Pseudomonas, group B Streptococcus, Proteus factors”) mirabilis, fungi In women, note last menstrual period. In men, note Risk Factors symptoms suggestive of benign prostatic hyperplasia –– Female (see the section “Benign Prostatic Hyperplasia”). Often symptoms are more subtle in older adults. –– Diabetes mellitus treated with insulin –– Urinary instrumentation (for example, catheter) –– Urinary retention (for example, due to multiple sclerosis)

2011 Clinical Practice Guidelines for Nurses in Primary Care Genitourinary System 6–7

In clients with an indwelling catheter, evaluate for –– Diagnostic uncertainty exists (for example, cystitis if they develop a fever or other systemic atypical symptoms OR typical cystitis symptoms (for example, malaise, confusion, symptoms and negative leukocyte esterase hypotension). dipstick) –– Client is pregnant PHYSICAL FINDINGS –– Only one of the following or none of the –– There may be no physical findings in cystitis following signs and symptoms are present: –– Temperature may be elevated (usually only in dysuria, more than trace amount of urine upper urinary tract infections) leukocytes, or positive nitrites on urine dipstick –– Mild to moderate suprapubic tenderness –– Client symptoms persist after empiric therapy –– Prostate may be enlarged –– A relapse occurs less than a month after therapy –– No costovertebral angle tenderness or flank pain when no culture was done for the initial infection –– Pelvic examination if urethral or vaginal discharge –– Obtain urine sample for culture and sensitivity in is present, or vaginal irritation reported, sexually those with an indwelling catheter by removing the active male, or uncertain diagnosis. In pure cystitis old one and inserting a new one one would not expect to see signs of vaginitis, –– Obtain a vaginal swab for analysis (routine and urethral discharge, herpetic ulcerations, nor any microscopy, culture and sensitivity) as required signs of cervicitis –– Obtain appropriate swabs or urine sample for Neisseria gonorrhoeae and Chlamydia trachomatis DIFFERENTIAL DIAGNOSIS if an STI is suspected (for example, if dysuria –– Pyelonephritis and positive for leukocyte esterase, but negative urine culture and sensitivity) (see Chapter 11, –– Urethritis “Communicable Diseases”) –– Vulvovaginitis –– Consider additional diagnostic tests (for –– Urinary calculi example, for HIV, , B and C, syphilis) –– Sexually transmitted infection (STI) for individuals with risk factors for sexually –– Pelvic inflammatory disease transmitted infections (STIs) (see Chapter 11, –– Benign prostatic hyperplasia “Communicable Diseases”) –– Diabetes mellitus –– Check the blood glucose level if symptoms suggest –– Chronic prostatitis (if recurrent cystitis) diabetes mellitus –– Renal (TB) MANAGEMENT COMPLICATIONS Goals of Treatment –– Ascending infection (pyelonephritis) –– Relieve symptoms –– Sepsis –– Eradicate bacteria from the bladder –– Kidney failure –– Prevent recurrent infection –– Chronic cystitis Appropriate Consultation DIAGNOSTIC TESTS Consult a physician if the client is suspected to have a –– Obtain midstream urine for urine dipstick testing relapse, as further testing may be required. (leukocyte esterase and nitrites positive) –– Urine culture and sensitivity might be useful if: –– Client is not responding to treatment –– Client is known to have an abnormality of the GU tract –– Client is suspected to have a complicated infection (for example, male), (see the section “Cystitis”)

Clinical Practice Guidelines for Nurses in Primary Care 2011 6–8 Genitourinary System

Nonpharmacologic Interventions Complicated Cystitis58 (see the section “Cystitis”)

Client Education For those with no systemic symptoms (for example, Counsel client about appropriate use of medications high fever, vomiting) (dose, frequency, side effects, need to complete entire sulfamethoxazole/trimethoprim (Septra DS, course of treatment) generics), 1 tab PO bid for 7–10 days –– Instruct client in proper perineal hygiene (wiping or from front to back) to prevent recurrence 250 mg PO bid for 7–10 days –– Remove catheter if not required; if one is required use intermittent catheterization if possible, Monitoring and Follow-Up otherwise replace the catheter when beginning –– Once culture and sensitivity results are received antibiotic treatment (if applicable), tailor treatment according to the Pharmacologic Interventions56 susceptibility profile –– If symptoms do not begin to resolve within 48 If ≥ 2 of the following are present treat with hours or if symptoms progress despite treatment, , without waiting for the urine culture and client should return to the clinic for reassessment sensitivity result (if testing required): –– Arrange follow-up after the completion of therapy; –– Dysuria (burning or pain on urination) assess for continuing symptoms; if the client is –– More than trace amount of urine leukocytes asymptomatic (except for pregnant clients) there –– Positive for nitrites is no need to repeat the urinalysis and culture to ensure resolution of cystitis 57 Uncomplicated Cystitis (see the section “Cystitis”) –– For pregnant clients, follow up with midstream nitrofurantoin (MacroBID), 100 mg PO bid for 5 days urine for culture and sensitivity 1–2 weeks post- or treatment. Repeat culture and sensitivity monthly. Re-treat if necessary based on the susceptibility sulfamethoxazole/trimethoprim (Septra report with either a longer duration of the same DS, generics) 1 tab PO bid for 3 days (use antibiotic or a different one sulfamethoxazole/trimethoprim as a first-line agent only if the level of resistance is ≤ 20% Referral or the organism is susceptible to this agent) Clients with chronic or recurrent cystitis should be Recurrent Cystitis58 (see the section “Cystitis”) referred to a physician. Men ≥ 50 years of age who sulfamethoxazole/trimethoprim (Septra DS, present with a true (culture-positive) urinary tract generics), 1 tab PO bid for 7–14 days infection for the first time should also be referred or to a physician for further evaluation.

ciprofloxacin 250 mg bid for 7–14 days PREVENTION 58 Cystitis in Pregnancy To prevent recurrent cystitis: nitrofurantoin (MacroBID), 100 mg PO bid for 7 days –– Do not use spermicide-containing products Nitrofurantoin is contraindicated at term (after –– Void early after sexual intercourse 35 weeks) and during labour in pregnant women. –– Advise women with recurrent cystitis to drink or cranberry juice or take cranberry tablets59 –– Antibiotic prophylaxis for women with amoxicillin 500 mg PO tid for 7 days; do not start unless the culture and sensitivity indicates the > 2 episodes of symptomatic cystitis in 6 months bacteria are susceptible OR >3 over 12 months OR pregnant female who has another condition (for example, diabetes) that Contact a physician for help in choosing an antibiotic increases their risk of cystitis after first infection. if the pregnant client is allergic to penicillin and is Consult a physician to discuss the need for a near term. prescription –– Postmenopausal women may use intravaginal estrogen . Consult a physician to discuss the need for a prescription

2011 Clinical Practice Guidelines for Nurses in Primary Care Genitourinary System 6–9

PYELONEPHRITIS, ACUTE45,54,60,61,62,63,64 Males Infection of the kidney that is characterized by –– Homosexuality infection within the renal , tubules, or –– Lack of circumcision interstitial tissue. –– Anatomic abnormality Uncomplicated if: non-pregnant female with no –– Obstruction of normal flow resulting from prostatic structural or functional genitourinary abnormalities hypertrophy and urethral strictures (for example, chronic catheter, no obstruction), not HISTORY immunocompromised (for example, diabetic), and with no vomiting and no fever or sepsis. –– Flank pain –– Fever (> 38°C), shaking chills Complicated: all other individuals other than those listed as uncomplicated (for example, –– Headache obstruction, males, genitourinary tract abnormalities, –– Malaise immunocompromised, pregnant, injury); –– Nausea and vomiting often is mixed bacterial and more resistant organisms; –– Dysuria, frequency, urgency may be present results from a progression to emphysematous –– Abdominal or flank pain may be present pyelonephritis, renal corticomedullary or perinephric –– Complicated case may have weeks to months , or papillary necrosis. of malaise, fatigue, nausea, , hematuria CAUSES –– E. coli (most common) PHYSICAL FINDINGS –– Also Enterobacter, Klebsiella, S. saprophyticus, –– Temperature elevated Pseudomonas and Proteus (among others) –– Heart rate may be elevated –– Fungi –– Blood pressure may be mildly elevated –– In unresolving pyelonephritis, suspect tuberculosis –– Client appears moderately to acutely ill of the kidney –– Mild, generalized abdominal discomfort Risk Factors –– Marked or severe pain with deep abdominal palpation of kidney –– Genetic factors –– Marked or severe costovertebral angle tenderness Complicated: with percussion over kidney

–– Urinary tract obstruction DIFFERENTIAL DIAGNOSIS –– Urologic dysfunction –– Pneumonia –– Antimicrobial resistant pathogen –– Acute cholecystitis with fever –– Diabetes –– Appendicitis Females (at highest risk due to proximity of urethra –– Acute pancreatitis to anus and vagina) –– Pelvic inflammatory disease –– Increased sexual activity (> 3 times per week –– in past 30 days) –– Bladder obstruction –– New sexual partner in past year –– Musculoskeletal pain –– Recent spermicide use –– Shingles –– Pregnancy, in particular nulliparous women –– Urinary tract infection (upper or lower tract) in the past year –– Stress incontinence in the past 30 days –– Mother with history of urinary tract infection –– Anatomic abnormalities

Clinical Practice Guidelines for Nurses in Primary Care 2011 6–10 Genitourinary System

COMPLICATIONS Adjuvant Therapy –– Acute renal failure Moderate or Severe Infection –– Chronic renal failure –– Start IV therapy with normal saline –– Renal abscess –– Adjust IV rate according to hydration status –– Sepsis (see the section “Dehydration” in Chapter 5, –– Focal renal scarring “Gastrointestinal System”), age and other medical –– Renal papillary necrosis problems (for example, diabetes mellitus, heart –– Emphysematous pyelitis and/or cystitis disease) –– Respiratory dysfunction Nonpharmacologic Interventions DIAGNOSTIC TESTS Mild Infection (Uncomplicated) –– Obtain midstream urine for urine dipstick testing –– Rest until symptoms improve (leukocyte esterase positive [pyuria] in most clients with acute pyelonephritis) Client Education –– Obtain midstream urine for urinalysis (routine and –– Counsel client about appropriate use of microscopy, culture and sensitivity) medications (dose, frequency, completion of entire –– , if pregnant or suspected to be septic course of antibiotics) –– Pregnancy test to rule it out, if child-bearing-age –– Instruct client about proper hygiene to prevent female recurrence of infection –– Ask client to report recurrence of symptoms MANAGEMENT immediately Early or mild infections may be treated on an Pharmacologic Interventions outpatient basis. Mild, Uncomplicated Infection (see “Management” Moderate or severe (complicated and uncomplicated) above and the section “Pyelonephritis, Acute”) infections usually require inpatient treatment. This includes those with: Early or mild infections may be treated on an outpatient basis. –– Moderate to severe infection (high , pain and are debilitated) Analgesic and antipyretic: –– Sepsis acetaminophen (Tylenol), 325 mg, 1–2 tabs PO –– Nausea and/or vomiting with an inability to q4–6h prn (maximum 12 regular-strength tabs, rehydrate or take medications orally 4 g/day) –– Pregnancy Oral antibiotics65: –– Potential compliance concerns sulfamethoxazole/trimethoprim (Septra DS, generics), 1 tab PO bid x 14 days if the pathogen Goals of Treatment is known to be susceptible to this agent –– Relieve symptoms or –– Eradicate bacterial infection ciprofloxacin 500 mg po bid x 7 days –– Prevent complications or reinfection Consult a physician for choice of antibiotic if there Appropriate Consultation is an allergy to the recommended agents. Moderate or Severe Infection Complicated Infections and Severe Uncomplicated –– Consult a physician regarding choice of Infection (see the section “Pyelonephritis, Acute”) intravenous (IV) antibiotics and need for medevac Analgesia and antipyretics for fever and pain: acetaminophen (Tylenol), 325 mg, 1 or 2 tabs PO q4–6h prn (maximum 12 regular-strength tabs, 4 g/day)

2011 Clinical Practice Guidelines for Nurses in Primary Care Genitourinary System 6–11

Antiemetics to control severe nausea and vomiting: CAUSES dimenhydrinate (Gravol), 50 or 75 mg IM or IV if line –– Neisseria gonorrhoeae (often symptomatic in men, in place asymptomatic in women) For antibiotics, consult a physician. –– Chlamydia trachomatis (often symptomatic in women, asymptomatic in men) Extra consideration is required in choosing drugs for –– Trichomonas vaginalis a pregnant woman. Consult a physician. –– Herpes simplex virus Monitoring and Follow-Up66 –– Mycoplasma genitalium, Ureaplasma urealyticum –– Candida albicans Mild Infection (Uncomplicated and Complicated) –– Adenovirus –– Follow up in 2–3 days to determine clinical –– Chemical irritation from products used and/or those response to therapy; if poor response after 72 hours inserted into vagina (for example, spermicides, of therapy (for example, no improvement or condom, tampon, soaps) worsening), consult a physician as radiographic evaluation may be warranted Risk Factors –– Arrange follow-up after the completion of therapy; –– Repeated sexual exposure assess for continuing symptoms; if the client is –– Inadequate treatment for a previous sexually asymptomatic (except for pregnant clients) there is transmitted infection no need to repeat the urinalysis and culture –– New, recent sexual partner Moderate to Severe Infection (Complicated) –– Partner with urethral discharge and/or diagnosed –– Monitor response to therapy, vital signs, and sexually transmitted infection urinary output –– History of sexually transmitted infection –– For pregnant clients, follow up with midstream (for example, gonorrhea) urine for culture and sensitivity 1–2 weeks post- –– Multiple sexual partners treatment. Repeat culture and sensitivity monthly –– Young age for the rest of the pregnancy –– Inconsistent use of barrier contraception –– Low socioeconomic status Referral Moderate to Severe Infection (Complicated) HISTORY –– Medevac to hospital as soon as possible –– Dysuria (pain, tingling or burning in perineal area with voiding or just after) may be present; Refer the following individuals to a physician, as they in women may be on and off for a day or two may require further investigation: (chlamydia); occurs prior to lesions developing –– Poor response after 72 hours of antibiotics (herpes simplex) –– Males with pyelonephritis –– Meatal discharge may be present (for example, –– Infection with Pseudomonas for entire day, at first morning void, scanty); Gonorrhea often has acute onset and copious –– Individuals with diabetes purulent discharge; often none for Chlamydia –– Recurrent pyelonephritis after a course of –– Pruritus at urethral meatus may be present appropriate therapy –– Ulcer may be present –– Immunocompromised –– Frequency, urgency may be present –– History of renal stones or another urologic concern –– Fever, chills, inguinal lymphadenopathy, headache –– Prior urologic surgery may be present (initial herpes simplex virus presentation) 67,68,69,70,71,72,73 URETHRITIS –– No hematuria Infection of the urethra causing inflammation –– Activity causing irritation precedes dysuria (dysuria and/or urethral discharge). (if chemical irritant) –– Ask about risk factors (see “Risk factors”) –– Take a sexual history; see “Personal and Social History (Specific to Genitourinary System)”

Clinical Practice Guidelines for Nurses in Primary Care 2011 6–12 Genitourinary System

PHYSICAL FINDINGS DIAGNOSTIC TESTS –– Client appears well –– Obtain midstream urine for dipstick testing –– Urethral meatus may be crusted or erythematous (positive leukocyte esterase, no hematuria for –– Mucoid, mucopurulent or purulent urethral Chlamydia, N. Gonorrhoeae, and Trichomonas) discharge may be present (gonorrhea, chlamydia); –– Obtain midstream urine for urinalysis (routine and in males must retract foreskin and milk the urethra microscopy, culture and sensitivity); culture has no from the base of the penis to the meatus; discharge growth in Chlamydia may also be present at cervical os in females –– Take endourethral swabs for culture or first 20 mL –– Lymph nodes (for example, inguinal) may be of first morning void or after > 2 hours of not present and/or tender (in syphilis) voiding for nucleic acid amplification testing for –– Perineal area lesions or ulcer(s) may be present N. gonorrhoeae and Chlamydia; swabs are the best (syphilitic chancre or herpes simplex virus) route to diagnose N. gonorrhoeae –– Abdominal (including costovertebral angle –– Offer urethral swabs for trichomoniasis in men tenderness) and digital rectal (males only) exams –– Consider offering additional diagnostic tests (for have no acute findings example, for HIV, hepatitis A, B, and C virus) –– Temperature not elevated for individuals with risk factors for sexually –– No testicular or epididymal swelling, masses transmitted infections (STIs), (see Chapter 11, or tenderness “Communicable Diseases”) –– Offer Venereal Disease Research Laboratory DIFFERENTIAL DIAGNOSIS (VDRL) or Rapid Plasma Reagin (RPR) testing for syphilis (perform it if an ulcer is present) –– Epididymitis –– If a genital ulcer is present, take a culture for –– Prostatitis (acute or chronic) herpes simplex virus –– Cystitis –– Pyelonephritis MANAGEMENT –– Treatment depends on suspected cause, based –– Chemical irritation on signs, symptoms, risk factors and diagnostic –– Endourethral chancre (syphilis) test results. –– Chronic pelvic pain disorder Goals of Treatment COMPLICATIONS –– Relieve symptoms –– Pelvic inflammatory disease –– Prevent complications of infection –– Tubo-ovarian abscess –– Prevent recurrence –– Infertility –– Cervicitis Appropriate Consultation –– Vaginitis Consult a physician if urethritis has recurred or if it –– Urinary tract infection (cystitis or pyelonephritis) has not resolved after the course of treatment. –– Epididymitis Nonpharmacologic Interventions –– Prostatitis –– Urethral stricture or stenosis –– Advise client to return to the clinic for –– Abscess reassessment if symptoms worsen –– If sexually transmitted infection is suspected or is the cause, educate client about the importance of their partner being tested and treated

2011 Clinical Practice Guidelines for Nurses in Primary Care Genitourinary System 6–13

Client Education Monitoring and Follow-Up –– Educate to avoid chemical irritants (for example, –– Follow up in 7 days, when the course of antibiotics spermicide), if it is a potential cause is completed to ensure symptom resolution, good –– Explain disease process and expected course (for compliance with medication, no re-exposure to example, symptoms may be present for up to 7 days partner and no new partners after treatment is completed) –– If N. gonorrhoeae or Chlamydia are confirmed as –– Counsel client about appropriate use of medication the causative organism, ensure contact tracing and (dose, frequency, side effects, completion of entire a report to Public Health is made according to the course prescribed) procedures in your region –– Counsel client about preventing spread of STIs –– Treat current sexual partner(s) and those within the to sexual partners (for example, abstain from sex past 60 days, even if asymptomatic for 1 week after treatment begins for last partner –– Do a test of cure (repeat sexually transmitted treated, consistent condom use, explore barriers infection testing) 3 weeks after treatment only for to safe sexual practices) pregnant women Pharmacologic Interventions –– If N. gonorrhoeae or Chlamydia are confirmed as the causative organism, repeat STI testing in 6 Urethral discharge present OR lab results indicate months N. gonorrhoeae infection: cefixime (Suprax), 400 mg PO single dose Referral and either Refer to a physician if the client presents with recurrent urethritis. , 100 mg PO bid for 7 days (if not pregnant) URINARY INCONTINENCE74,75,76,77,78,79,80 or azithromycin 1 g PO single dose (if poor compliance Involuntary loss of urine. Incontinence is so frequent is expected) in women that many consider it normal, although it is not, nor is it age related. In men, dribbling is Lab results indicate Chlamydia OR if usually associated with other symptoms of bladder- nongonococcal infection: outlet obstruction (see the section “Benign Prostatic doxycycline (Vibramycin), 100 mg PO bid for 7 days Hyperplasia”). (if not pregnant) One should routinely screen for incontinence in those or who are at risk, as more than half of clients do not azithromycin 1 g PO single dose (if poor compliance report it. It has a large adverse impact on quality is expected) of life. Lab results indicate Trichomonas or recurrence CAUSES of urethritis with no new partner or re-exposure and good compliance with medication: See Table 1, “Incontinence Types and Causes”. metronidazole 2 g PO single dose

Clinical Practice Guidelines for Nurses in Primary Care 2011 6–14 Genitourinary System

Table 1 – Incontinence Types and Causes Type Description and Causes Stress Incontinence Leakage of urine due to an increase in intra-abdominal pressure (for example, cough, exercise, climbing stairs, sneeze) leading to impaired urethral sphincter functioning or hypermobility. Most common type in younger women. Poor pelvic support (for example, multiple vaginal deliveries, postmenopausal estrogen deficiency, prostate surgery) is the primary cause. Urge Incontinence Leakage of urine due to inability to delay voiding when an urge is perceived. ( syndrome) Causes include detrusor hyperactivity (contractions) or instability of the bladder wall, disorders of the central (for example, Parkinson’s disease), and bladder irritability from infection, stones, diverticula or tumour. Functional Incontinence Leakage of urine due to inability to get to the toilet. Causes include age‑related (potentially reversible) problems (for example, decreased mobility and manual dexterity, cognitive disability), alcohol intoxication, environmental factors, medications (for example, diuretics, sedatives) and diabetes mellitus (neurogenic bladder). Can affect other types of incontinence and/or be a cause by itself. Mixed Incontinence Combination of urge and stress incontinence. Most common type in women. Constant leakage of urine due to overdistention of the bladder (incomplete bladder emptying resulting in high post-void residual volume) or fullness of the bladder. Commonly caused by obstruction of the bladder outlet (for example, prostatic enlargement, fecal impaction), impaired detrusor contractility and/ or neurologic disease (for example, multiple sclerosis). Often associated with weak stream, hesitancy, frequency, and nocturia.

Risk Factors Table 2 – Selected Drugs Related to Incontinence81 –– Childbearing (including vaginal delivery) Drug class Example –– Obesity Drugs with anticholinergic effects –– Increasing age Antipsychotic agents prochlorperazine (Stemetil)a –– Functional impairment (for example, lower and Tricyclic antidepressants amitriptyline upper extremity weakness, sensory or cognitive b impairment) Antihistamines diphenhydramine (Benadryl) –– Other urinary symptoms (for example, dysuria) Hormones estrogen, oral contraceptives –– Childhood enuresis Antihypertensives –– Diabetes –– Menopause Calcium channel blockers amlodipine, nifedipine –– Stroke ACE inhibitors enalapril –– Loop diuretics furosemide –– Depression a. Often used as an antinauseant b. It is the older histamine H1 receptor antagonists that –– Lower estrogen are a problem in this regard –– Genitourinary surgery (for example, hysterectomy, prostate surgery) Urge Incontinence –– Medications that may cause or worsen urinary incontinence are shown in Table 2 (see “Table 2”). –– Increasing age Anticholinergic agents impair emptying and can –– Prostate disorder and/or radiation cause retention of urine. Some drugs can cause –– History of urinary tract infections (in men) pedal edema, which is associated with nocturia –– Constipation and nighttime incontinence. Examples include Stress Incontinence gabapentin and pregabalin, thiazolidinediones and calcium channel blockers. ACE inhibitors –– Pelvic trauma can cause cough in some clients, which worsens –– High impact physical activities stress incontinence –– Smoking

2011 Clinical Practice Guidelines for Nurses in Primary Care Genitourinary System 6–15

Overflow Incontinence –– Bladder diary is helpful if it is difficult to determine the severity of incontinence, if nocturia –– Previous anti-incontinence surgery is present and/or if there is frequency. It can also –– Pelvic prolapse help establish efficacy of treatment if done before –– Older adult and after treatment. Ask the client or caregiver to –– Peripheral neuropathy keep track of the time, volume (amount or drop, small, medium, soaking), and circumstances of all HISTORY continence and incontinence episodes for 3 days. –– Loss of bladder control Also have them record associated activities (for –– Onset and course (for example, sudden onset may example, time, type and amount of fluid intake, indicate neurologic or neoplastic cause) exercise, hours of sleep). A sample bladder diary is –– How often, how much and when leakage occurs available from the Institute for Clinical Evaluative (severity) Sciences at: http://www.ices.on.ca/informed/ periodical/subissue/21-ip5311.PDF –– Qualify degree of difficulty in maintaining continence Previously “dry” elderly clients who suddenly become –– Urgency (strong and sudden, so lose control before incontinent may have an early urinary tract infection getting to the toilet) or an intercurrent illness or infection elsewhere. –– Precipitating factors (for example, medications, If infection is present, there will be symptoms of caffeinated beverages, alcohol, amount of fluid cystitis. consumed, physical activity, coughing, laughing, sneezing, sound of water, placing hands in water) If diabetes is suspected, ask about polyuria, and what caused loss of bladder control most often polydipsia, polyphagia, weight loss, recurrent cystitis or vaginitis. –– Associated symptoms (for example, frequency, nocturia, hesitancy, interrupted voiding, dribbling, PHYSICAL FINDINGS82 continuous leakage, weak urinary stream, incomplete emptying, straining to empty) The findings will depend upon the specific cause. –– Assess bowel habits, sexual function, history –– Distention of the bladder may be present of prostate disease and/or treatment, number of –– Cardiovascular examination to rule out volume pregnancies and vaginal deliveries, postmenopausal overload (for example, peripheral edema) symptoms, neurologic deficits –– Palpate abdomen for masses and tenderness –– Impact on quality of life of client and caregiver, (for example, bladder distention, costovertebral if applicable (for example, restrictions to work, angle tenderness) exercise, social activities); most bothersome part –– Examine the extremities for mobility, of incontinence function, and venous stasis –– Previous continence therapy, in particular, surgeries –– Assess prostate, anal-sphincter tone, rectal wall –– In females, feeling of prolapse (masses), amount of stool present in rectum –– Comorbid conditions –– Note atrophic urethral and vaginal changes (for –– Risk factors, as listed above and the timing of example, pallor, thinning, loss of rugae), relaxation them compared to the onset of incontinence of pelvic floor (for example, cystocele, uterine (see “Risk factors”) prolapse), pelvic masses (for example, fibroids) and tenderness, inflammation (for example, erythema, friability) –– Assess penis, scrotal contents and pelvic area for infection, masses, hernia, position of urethral meatus –– Assess for stress incontinence by asking client to cough or bear down while observing their urethral meatus –– Assess deep reflexes and perineal sensation

Clinical Practice Guidelines for Nurses in Primary Care 2011 6–16 Genitourinary System

–– Neurologic examination if sudden onset, known PSA levels should not be drawn if a digital prostate neurologic disease, or new onset of neurologic exam has been done in the previous 3 days because symptoms (for example, perineal sensation, levels may be falsely elevated. anal sphincter tone, anal wink, vibration and sensation testing) MANAGEMENT85 –– Older adults: assess cognitive and functional status Management is based on identifying and treating the (for example, mobility, ability to transfer, manual underlying cause. Treatment is focused on the most dexterity, ability to toilet) troublesome aspects for the client, so the client’s goals –– Screen for depression are consistent with the care provider’s and should start with the least invasive (nonpharmacologic) measures DIFFERENTIAL DIAGNOSIS83 first, as they carry the least risk. –– Cauda equina syndrome Goals of Treatment –– Spinal cord compression or trauma –– Uterine prolapse –– Achieve relief of urinary symptoms (reduction in –– Renal calculi incontinent episodes, urinary frequency, urinary –– Multiple sclerosis urgency) –– Brain or spinal cord tumour –– Increase functional capacity of the bladder –– Cystitis or pyelonephritis –– Improve quality of life –– Pelvic inflammatory disease Appropriate Consultation –– Prostatitis Consult a physician if the incontinence is associated –– Vaginitis with abdominal or pelvic pain, hematuria (and not COMPLICATIONS cystitis), elevated prostate specific antigen, abnormal prostate examination, a fistula is suspected, there are –– Irritation neurologic abnormalities, medication is a suspected –– Breakdown and ulceration of skin in the genital cause, or there is a pelvic mass or prolapse. area –– Social embarrassment Nonpharmacologic Interventions –– Social and psychological problems The following simple measures should be tried.

DIAGNOSTIC TESTS All Types of Incontinence –– Obtain urine for urinalysis (routine and –– Manage fluid intake (maximum of 1.5–2 L per day) microscopy) –– Avoid caffeinated, carbonated, and alcoholic –– Obtain midstream urine for culture and sensitivity beverages if infection is suspected (to identify cystitis) –– Avoid constipation (for example, eat more fibre, –– Post-void in and out catheterization to measure avoid straining while having a bowel movement) amount of residual urine only if requested by –– Treat cough a physician (for example, when the diagnosis –– Advise smoking cessation if the client is a smoker is not clear or the client fails to improve after –– Avoid straining while urinating 84 nonpharmacologic treatment) –– Avoid voiding > 2 times a night, if possible –– Perform , and measure –– Bladder training (if cognitively intact) to gradually creatinine, blood urea nitrogen (BUN), and lengthen the time between voids by timed voiding electrolytes to check renal function (start voiding at the shortest time between voids –– Measure blood sugar to rule out diabetes (from a bladder diary) or every 2 hours while the –– Serum calcium if frequency and/or increased client is awake and then increase by 30–60 minute urine volume intervals after 2 days without leaking, until it is –– In men, prostate surface antigen (PSA): optional a period that works for the client, or every 3–4 and controversial but is generally recommended hours without incontinence (for urge and mixed when a diagnosis of prostate cancer would alter incontinence); reassure clients that this takes weeks treatment in a healthy man between 50 and 70 years to achieve of age and who is expected to live at least 10 years

2011 Clinical Practice Guidelines for Nurses in Primary Care Genitourinary System 6–17

–– Urgency suppression using relaxation techniques; Chronic Day and Nocturnal Incontinence stand still or sit down when urgency occurs then –– Advise client to toilet regularly at a bedside take a deep breath and let it out slowly while commode or urinal to train the bladder contracting pelvic muscles; after feel in control walk slowly to a bathroom (for urge and mixed –– Instruct client and family members about good skin incontinence); reassure clients that this takes weeks care to prevent skin breakdown and infection to achieve In the elderly client, assess life situation and any –– Kegel exercises to strengthen pelvic floor and recent life changes, cognitive status (to detect recent perineal muscles; advise client to do 10–15 changes, depression or confusion), general medical repetitions of slow velocity contractions, held status (to identify concurrent illness, medications and for 6–8 seconds, three times a day for at least whether client has physical difficulty getting to the 15–20 weeks (for urge, stress, mixed incontinence, toilet). Correcting these factors should be the focus, prevention); confirm that the client is doing them to start. Discuss medications, cognitive changes and properly by digital vaginal examination (for uncontrolled comorbid conditions with a physician. example, vaginal muscles squeeze, but not buttock Prompted voiding (like bladder training, but timed by or abdominal ones). Educate that it takes 6–8 a caregiver) can help cognitively impaired clients. weeks to start to see results. A client education If client has a distended bladder, see “Acute Urinary sheet on Kegel exercises is available from The Retention”. Canadian Continence Foundation at: http://www. canadiancontinence.ca/pdf/pelvicmuscleexercises.pdf Pharmacologic Interventions –– Suggest sanitary napkins or adult diapers specifically designed for urinary incontinence Medications are sometimes used as an adjuvant or a condom catheter to help maintain dryness therapeutic intervention to these nonpharmacologic measures. They would be used only after clear –– Explain disease process and expected course diagnosis of the type of incontinence (see “Causes”) –– Counsel client about appropriate use of medication and would be prescribed only by a physician. (dose, frequency, side effects, completion of entire Examples of medications used to treat urinary course prescribed) incontinence include anticholinergic agents such –– Client education sheets on incontinence are as oxybutynin, flavoxate, tolterodine, trospium, available to download from The Canadian solifenacin, and darifenacin; alpha-adrenergic Continence Foundation at: http://www.continence- antagonists such as terazosin, doxazosin, tamsulosin, fdn.ca/english/documents.html alfuzosin; and the antidepressant duloxetine. Injection Stress Incontinence of botulinum toxin type A by a specialist into the detrusor muscle may also be used in selected clients. –– Encourage weight loss and increased physical activity, if appropriate, to reduce symptoms Relieve fecal impaction with gentle disimpaction or –– Encourage frequent toileting, complete emptying water (see “Constipation,” in Chapter 5, of the bladder, voiding before strenuous activities “Gastrointestinal System”). and use of sanitary napkins to maintain dryness Monitoring and Follow-Up Urinary stress incontinence of some small degree may Follow up in 1 month and in 4 months to ensure be physiological and may not be abnormal. client is continuing their Kegel exercises and other Nighttime Incontinence nonpharmacologic interventions, and to provide positive reinforcement. If no difference is noted –– Advise client to reduce fluid intake in the evening in 4 months and the client wants to pursue further (especially caffeine products) treatment, refer to a physician. –– Advise client to take diuretic drugs earlier in the evening or day Referral –– Suggest a bedside commode or urinal, if available, or a condom catheter Men with pelvic pain, severe incontinence or lower urinary tract symptoms, and frequent urologic infections should be referred to a physician upon presentation.

Clinical Practice Guidelines for Nurses in Primary Care 2011 6–18 Genitourinary System

Refer to a physician for evaluation if conservative Risk Factors measures fail to improve symptoms, the diagnosis –– Hypertension is uncertain, client has had prior pelvic surgery or –– Age 20–49 irradiation, and/or the client would like further options –– Family history of urolithiasis (for example, , medication, surgery). –– Personal history of urolithiasis Prevention –– Recurrent upper urinary tract infections –– Bone resorption –– Manage fluid intake (maximum of 2 L per day) –– Low fluid intake –– Avoid caffeinated, carbonated, and alcoholic beverages –– Possible risk factors include diabetes, obesity, gout, excessive physical exercise –– Regular bowel movements –– Asian or Caucasian race –– Kegel exercises to strengthen pelvic floor and perineal muscles; advise client to do 10–15 Calcium stones (are most common)91: repetitions of slow velocity contractions, held for –– Hypercalciuria 6–8 seconds, three times a day for at least 15–20 –– Hypocitraturia weeks (for first year after vaginal delivery, after –– Hyperoxaluria pelvic or prostate surgery, older women). A client education sheet on Kegel exercises is available –– Low urine volume from The Canadian Continence Foundation –– Alkaline urine at: http://www.canadiancontinence.ca/pdf/ –– Dietary factors (for example, low calcium, high pelvicmuscleexercises.pdf oxalate (for example, spinach), high animal –– Encourage weight loss (if obese) protein, high sodium, low fluid, high vitamin C or D supplementation) –– Increase physical activity –– Primary hyperparathyroidism –– Smoking cessation –– Improve diet Uric acid stones: –– Manage conditions associated with incontinence –– Acidic urine (for example, due to chronic diarrhea, (for example, diabetes, neurologic conditions) gout, diabetes, obesity, metabolic syndrome) –– High serum uric acid 86,87,88,89,90,91 UROLITHIASIS Struvite stones: Calculi (stone) in the urinary tract (for example, –– Upper urinary tract infection due to Proteus or kidneys, bladder, urethra). Often cau˚ses renal colic, Klebsiella a pain produced by the presence and movement of a –– Recurrent urinary tract infections stone within the or renal pelvis. Some clients are asymptomatic. Clients may have one or more HISTORY types of stones. –– Sudden onset of mild ache to severe, colicky pain in one flank that often increases and decreases in CAUSES severity –– Calcium oxalate or calcium phosphate –– Pain may radiate to lower abdomen, flank, groin, accumulation or –– Magnesium ammonium phosphate (struvite stones) –– Exact location of pain depends on location of stone –– Uric acid accumulation and level of obstruction (may be vague or acute, –– Medications (for example, indinavir, acyclovir, abdominal or flank, may change location as the sulfadiazine) stone moves) –– Enhanced oxalate absorption (for example, gastric –– Gross hematuria present in most clients bypass surgery) –– Dysuria, urgency, frequency may develop –– Other genetic disorders (for example, cystine –– Nausea and vomiting are often present stones, an inborn error of amino acid metabolism) –– May be penile or –– Stone or “gravel” in urine may be present –– May have low fluid intake –– Risk factors, as listed above (see “Risk factors”)

2011 Clinical Practice Guidelines for Nurses in Primary Care Genitourinary System 6–19

PHYSICAL FINDINGS DIAGNOSTIC TESTS –– Temperature may be elevated (unusual unless –– Obtain urine for urinalysis (routine and infection is also present) microscopic and for culture); often hematuria is –– Heart rate may be elevated present –– Blood pressure may be elevated –– Strain all urine for stones and send for –– Client appears in acute distress –– Pregnancy test to rule out pregnancy, if child- –– Client pale, cool and sweaty bearing age –– Client restless, tossing about, unable to find a –– Consider imaging in consultation with a physician comfortable position MANAGEMENT92 –– Abdomen may be distended (uncommon) –– Costovertebral angle and/or abdominal tenderness If symptoms are mild, client is afebrile and able to –– Bowel sounds may be decreased (because of tolerate oral fluids and medication, and diagnosis is reactive ileus) clear, treat on outpatient basis. If symptoms are uncontrollable or severe, client DIFFERENTIAL DIAGNOSIS is unable to tolerate oral fluids, or the diagnosis –– Abdominal aortic aneurysm (the most important is questionable, consultation with a physician and differential diagnosis to rule out, often mimics inpatient treatment will be needed. urinary colic) –– (important to rule out in any Goals of Treatment woman of child-bearing age with abdominal pain) –– Control pain –– Acute abdomen (cholecystitis, appendicitis, –– Maintain hydration , diverticulitis, peritonitis) –– Identify complications –– Acute pyelonephritis –– Peptic ulcer disease Appropriate Consultation –– Biliary colic Severe Condition or Questionable Diagnosis –– Salpingitis, tubo-ovarain abscess Consult a physician as soon as possible. –– Ovarian cysts –– Herpes zoster prodromal pain (shingles) Adjuvant Therapy –– Pancreatitis Severe Condition or Questionable Diagnosis –– Low back pain –– Renal carcinoma –– Start IV therapy with normal saline –– Attention- or drug-seeking client –– Adjust rate according to severity of vomiting and dehydration, client’s age and underlying medical COMPLICATIONS problems –– Renal abscess Nonpharmacologic Interventions –– Ureteral perforation Mild Condition –– Ureteral stenosis and scarring –– Urinary fistula formation –– Encourage increase in fluid intake (to produce –– Recurrent stones 2 L of urine daily) –– Chronic renal failure secondary to obstruction –– Strain urine to collect stones for several days and send stones for pathology –– Recurrent infection of the lower urinary tract –– Hydronephrosis (asymptomatic obstruction of the Severe Condition or Questionable Diagnosis kidney leading to decreased renal function or renal –– Bed rest failure) –– Nothing by mouth if vomiting –– Pyelonephritis –– Strain urine to collect stones for several days and –– Sepsis send stones for pathology

Clinical Practice Guidelines for Nurses in Primary Care 2011 6–20 Genitourinary System

Pharmacologic Interventions Severe Condition or Questionable Diagnosis Mild Condition –– Monitor urine output To control pain: –– Strain all urine for stones –– Send all stones for laboratory analysis ibuprofen 600–800 mg PO tid prn –– Client may be discharged home once pain and nausea or are controlled (and if they are not being medevaced) naproxen 500 mg, then 250–500 mg PO tid prn –– Instruct client to collect and strain all urine for stones (maximum 1500 mg/day) and save any stones that are passed and then bring or them to the clinic so they can be sent for analysis –– Encourage fluid intake to produce 2 L of urine ketorolac 30 mg IM/IV q6h prn (maximum 120 mg/day) daily For pain unresponsive to NSAIDs or in clients unable –– Follow up 12–24 hours after discharge to take NSAIDs because of a contraindication (allergy, history of ulcers, renal disease): Referral morphine 5 mg IM or IV or SC once; Mild Condition upon consultation with a physician Refer to a physician if client fails to pass stone (as the Antiemetics for nausea and vomiting: stone may have to be removed by some other means) dimenhydrinate (Gravol), 50–75 mg IM/IV q4–6h or if pain is uncontrollable. Physician may order as required medication such as tamsulosin (which can be obtained through an NIHB pharmacy provider) to help with Monitoring and Follow-Up stone passage. Mild Condition Severe Condition or Questionable Diagnosis –– Client may be discharged home once pain and Medevac to hospital upon recommendation of a nausea are controlled physician if: –– Instruct client to collect and strain all urine for –– pain, nausea, vomiting or fever persist or are not stones and save any stones that are passed and then controlled; urosepsis; bring them to the clinic so they can be sent for analysis –– acute renal failure; –– Follow up 48 hours after discharge; sooner if pain –– anuria is uncontrollable Imaging studies or urgent consultation may be warranted.

COMMON PROBLEMS OF THE MALE GENITOURINARY SYSTEM

ACUTE PROSTATITIS12,13 –– Young and middle-aged male –– Trauma (for example, bicycle or horseback riding) Acute infection of the prostate gland. The diagnosis is –– Dehydration presumed with clinical symptoms and a swollen and tender prostate on exam. –– Sexual abstinence –– Chronic indwelling urinary catheter CAUSES –– Urethral stricture The same organisms that cause cystitis (E. coli, –– Intraprostatic ductal reflux Proteus spp, Klebsiella spp). –– Phimosis –– Unprotected anal intercourse Risk Factors14 –– Acute epididymitis –– Urinary tract infection –– Transurethral surgery –– Prostatic calculi

2011 (Revised April 2013) Clinical Practice Guidelines for Nurses in Primary Care Genitourinary System 6–21

HISTORY DIAGNOSTIC TESTS –– Abrupt onset of fever and chills –– Obtain urine for urinalysis (routine and –– Genital pain microscopy, culture and sensitivity): –– Lower abdominal pain –– Urine cloudy or clear –– Pain in sacrum and low back may be present –– Dipstick test: blood and protein may be present –– Perineal and/or rectal pain –– Microscopic examination of urine: bacteria, –– Pain with ejaculation WBC and a few red blood cells (RBC) may –– Dysuria, frequency, urgency (all symptoms be present of cystitis), nocturia –– Take urethral swabs for culture (N. gonorrhoeae –– Symptoms of bladder-neck obstruction may and Chlamydia) if an STI is suspected (because be present of history) or urethral discharge is detected –– Cloudy urine –– Offer HIV testing –– Flow and stream may be abnormal (for example, –– Perform Venereal Disease Research Laboratory dribbling, hesitancy, urinary retention) (VDRL) or Rapid Plasma Reagin (RPR) testing for syphilis15 –– Pain with bowel movements –– May be blood in MANAGEMENT –– Malaise, myalgia If the symptoms are mild to moderate, treat on an PHYSICAL FINDINGS outpatient basis. If the symptoms are severe and the client appears acutely ill, inpatient care is required. –– May be a fever –– May be tachycardia Goals of Treatment –– Client may be in moderate to severe distress and –– Relieve symptoms appear acutely ill (for example, septic shock) –– Prevent complications –– Client walks slowly, with legs apart –– Eradicate infection (if present) –– Bladder may be visibly distended on abdominal inspection Appropriate Consultation –– Prostate gland enlarged, acutely tender, warm, Consult a physician, especially if the symptoms are with soft-firm consistency severe or the client appears systemically unwell. –– Small amounts of pus may be expressed from urethra Nonpharmacologic Interventions –– Avoid massage of prostate (may cause bacteremia) Educate the client that fever and dysuria usually DIFFERENTIAL DIAGNOSIS resolve after 2–6 days of treatment. –– Benign prostatic hyperplasia with urinary tract Encourage intake of fluids (in particular if mucous infection membranes are dry). –– Epididymitis Severe Symptoms –– Urethritis Bed rest. –– Cystitis –– Pyelonephritis Pharmacologic Interventions –– Malignancy Mild to Moderate Symptoms COMPLICATIONS Consider treating clients < 35 years for sexually –– Epididymitis transmitted infections as well. –– Pyelonephritis Antibiotics vary in their ability to penetrate prostate –– Acute urinary retention tissue. Prolonged antibiotic therapy is often required –– Sepsis to eradicate the causative organism. Because of the –– Chronic prostatitis prolonged duration of therapy ensure that the dose is adjusted in clients with the potential for renal –– Prostatic abscess

Clinical Practice Guidelines for Nurses in Primary Care 2011 6–22 Genitourinary System dysfunction (for example, elderly clients, clients with Mild to Moderate Symptoms renal disease and/or diabetes mellitus). Discuss dosing –– Follow up at days 2 and 7 of therapy, sooner with a physician. if the client’s symptoms are not improving sulfamethoxazole/trimethoprim (Septra DS), 1 tab or are worsening. Asses compliance with the PO bid for 4 weeks medication regimen For clients with an allergy to Septra or sulfa drugs, a –– Repeat urine culture on day 7 of treatment; a fluoroquinolone can be prescribed: negative culture at this time predicts that the client will be cured after 4–6 weeks of therapy; a positive ciprofloxacin 500 mg PO bid for 4 weeks16 culture suggests that an alternative antibiotic should Severe Symptoms be considered in consultation with a physician For symptoms such as sepsis, hypotension, urinary –– Educate about the importance of finishing the retention, inability to tolerate oral medication, and course of antibiotics , start IV therapy with normal saline Severe Symptoms for fluids and IV antibiotics, after consultation with a physician. –– Watch for distended bladder and/or signs of sepsis –– If the client is unable to void and has a distended Manage fever and pain: bladder, have him sit in a tub filled with warm acetaminophen (Tylenol), 325 mg, 1–2 tabs PO q4h water and attempt to void into the water prn (maximum 12 regular-strength tabs/day [4 g]) –– Do not catheterize, as it is contraindicated in acute or prostatitis –– See “Acute Urinary Retention” if treatment as ibuprofen (Advil, Motrin, generics), 200 mg, 1–2 tabs described here is not successful PO tid-qid prn or Referral naproxen (Naprosyn, generics), 250 mg, 1–2 tabs Severe Symptoms PO bid-tid prn Medevac as soon as possible for continued inpatient Avoid NSAIDs in clients with renal dysfunction IV therapy. and do not use if there are contraindications such as a history of allergy to aspirin or NSAIDs or peptic 17 ulcer disease. BALANITIS Discuss the need for IV antibiotics with physician. Inflammation of . Antibiotic selection will vary according to circumstances. The dose of some agents (for example, CAUSES AND/OR RISK FACTORS gentamicin) will need to be tailored to the client’s –– Allergic or irritant reaction (for example, after use renal function. of latex condoms, contraceptive jelly, soaps) –– Infection: Fungal (for example, Candida albicans), Monitoring and Follow-Up viral (for example, herpes simplex), or bacterial Be sure to review the results of the urine culture and (for example, Streptococcus spp or Staphylococcus spp) sensitivities and adjust the antibiotic accordingly if –– Skin disorders (for example, circinate balanitis, the organism is not sensitive to the empiric antibiotic psoriasis) prescribed. –– Poor personal hygiene in uncircumcised males –– Trauma (for example, zippers) –– Reactive arthritis –– Medication reaction (for example, , salicylates); causing fixed drug eruption –– Presence of foreskin –– Diabetes –– Morbid obesity

2011 Clinical Practice Guidelines for Nurses in Primary Care Genitourinary System 6–23

HISTORY –– Take urethral swabs for culture (N. gonorrhoeae –– Symptoms appear over 3–7 days and Chlamydia) if an STI is suspected (because of history) or urethral discharge is detected –– Penile pain –– Serum glucose, after consultation with a physician –– Tenderness (if candidal infection is suspected – for example, –– Pruritus associated with small erythematous lesions young client) on the glans or prepuce –– Thick, foul smelling, purulent discharge is often MANAGEMENT present –– Dysuria Goals of Treatment –– Drainage at site of infection –– Relieve symptoms –– Erythema of glans –– Prevent recurrence –– Swelling of prepuce –– Ulceration or scaly lesions Appropriate Consultation –– Plaques Consult a physician if the lesion is well circumscribed, –– Symptoms may be worse after sexual intercourse red and velvety, or if there is induration and white –– Systemic symptoms may be present, such as patches. They may be indicative of carcinoma in situ. painful or erections, mouth sores, swollen Additionally, consult a physician if there are systemic or painful glands, painful voiding, and malaise signs and symptoms. or fatigue Nonpharmacologic Interventions PHYSICAL FINDINGS –– Warm compresses or sitz baths –– Redness, swelling of the glans penis –– Local hygiene: retract foreskin and wash with –– Discharge around glans saline BID; ensure adequate drying of tissues –– Examine genitals (in particular for paraphimosis), after cleansing and voiding; continue daily after oral mucosa, joints, skin inflammation resolves –– Ensure foreskin is easily retractable DIFFERENTIAL DIAGNOSIS –– Avoid chemical and soap irritants or allergens –– Leukoplakia Pharmacologic Interventions –– Lichen planus –– Psoriasis Start topical therapy. The choice of agent depends on whether you think it is a fungal infection (40% are) or –– Reactive arthritis . –– Nummular eczema –– Scabies Fungal: –– Human papillomavirus clotrimazole 1% cream (Canesten, generic ), bid to affected area for 1–3 weeks COMPLICATIONS Dermatitis: –– Urinary meatal stenosis hydrocortisone 1% cream (Cortate), bid to affected –– Premalignant changes resulting from chronic area for 1 week irritation –– Urinary tract infection Monitoring and Follow-Up –– Ulcerative lesions of the glans/prepuce Reassess client in 1 week and then weekly if signs and –– Phimosis, paraphimosis symptoms have not resolved.

DIAGNOSTIC TESTS Referral –– Sample any discharge for culture and sensitivity, Refer to a physician if symptoms have not improved KOH testing (for fungi) within 1 week or if signs and symptoms have not resolved within 3 weeks. A referral for allergy testing or biopsy may be warranted.

Clinical Practice Guidelines for Nurses in Primary Care 2011 6–24 Genitourinary System

BENIGN PROSTATIC Risk Factors HYPERPLASIA18,19,20,21,22 –– Age > 50 years Benign enlargement of prostate gland which may –– Higher free prostate specific antigen, testosterone result in obstruction of the bladder outlet. and/or estradiol levels –– Heart disease CAUSES –– Beta-blocker use –– Unknown –– Obesity –– Possible link with hormonal activity –– Diabetes –– Genetic susceptibility (for example, family history) –– Lack of physical exercise Drugs do not cause BPH, although treatment with some classes of drugs can exacerbate symptoms and thus should be avoided if possible; see Table 3 below.

Table 3 – Selected Drugs Associated with Urinary Retention that have the Potential to Exacerbate the Symptoms of BPH23,24,25 Drug class Example Drugs with anticholinergic effects Antipsychotic agents Prochlorperazine (Stemetil)a Tricyclic antidepressants Amitriptyline Antispasmodic agents Hyoscine butylbromide (Buscopan) Antiparkinsonian agents Benztropine (Cogentin) Antihistaminesb Diphenhydramine (Benadryl) Inhaled anticholinergic agents (for COPD) Ipratropium, tiotropium26 Sympathomimetics Alpha-adrenergic agonists (in cold remedies) Phenylephrine, pseudoephedrine Hormones Testosterone Antihypertensive agents Hydralazine, nifedipine relaxants Cyclobenzaprine (Flexeril), diazepam, baclofen a. Often used as an antinauseant b. It is the older histamine H1 receptor antagonists that are a problem in this regard

HISTORY –– Continued sense of bladder fullness even after Urinary symptoms occur when the prostate gland has voiding enlarged to a size that produces partial obstruction of –– the bladder outlet. Usually symptoms start slowly and –– Risk factors as listed above (see “Risk factors”) progress. –– 24-hour voiding chart to assess frequency, volume, nocturia –– Hesitancy –– Overflow incontinence Urinary tract infection or urinary retention may be –– Straining to start flow the presenting complaint. Hematuria may be an early symptom. –– Loss of stream force –– Frequent urination in small amounts –– Sense of urgency –– Post-void dribbling –– Nocturia –– Hematuria

2011 Clinical Practice Guidelines for Nurses in Primary Care Genitourinary System 6–25

To rule out other conditions, assess for: DIAGNOSTIC TESTS22 –– Neurologic disease symptoms (neurogenic bladder) –– Urine for urinalysis (routine and microscopy, –– Gross hematuria or bladder pain (bladder cancer culture and sensitivity) or calculi) –– Rule out infection, hematuria and glycosuria –– History of urethral trauma, urethritis, and/or –– Creatinine level urethral instrumentation (urethral stricture) –– Prostate specific antigen (PSA): optional and –– Family history of prostate cancer controversial but is generally recommended when –– Medications that can impair the bladder (for a diagnosis of prostate cancer would alter treatment example, anticholinergics) or increase outflow in a healthy man between 50 and 70 years of age resistance (for example, sympathomimetics) and who is expected to live at least 10 years PSA levels should not be drawn if a digital prostate PHYSICAL FINDINGS exam has been done in the previous 3 days because –– Abdomen: bladder may be enlarged if acute urinary levels may be falsely elevated. retention present; enlarged bladder may be noted on percussion MANAGEMENT27 –– Rectal exam: prostate gland enlarged, rectal Goals of Treatment sphincter tone strong –– Prostate: normal consistency, top or margins may –– Improve or eliminate symptoms not be palpable, median sulcus may be indistinct, –– Prevent the complications of long-term obstruction no nodules, induration or asymmetry of bladder outlet (for example, urinary tract –– Neurologic examination: within normal limits infections, bladder stones, hydronephrosis)

The clinical size of the prostate gland correlates Appropriate Consultation poorly with the severity of symptoms. A client with mild clinical enlargement may present with very Consult a physician if client’s symptoms are severe troublesome symptoms. or bothersome enough that he wants immediate treatment (low quality of life), if there is hematuria, DIFFERENTIAL DIAGNOSIS nodularity or induration or asymmetry of the prostate, unexpected back pain, or if there is acute bladder –– Cystitis obstruction (see “Nonpharmacologic Interventions”). –– Cancer of the prostate Prostatic carcinoma with metastasis to bone must –– Bladder tumour be ruled out in men > 35 years of age who have –– Bladder calculi symptoms of bladder-neck obstruction and new onset –– Prostatitis (chronic) of back pain. –– Urethral stricture –– Bladder neck contracture Nonpharmacologic Interventions –– Neurogenic bladder Assess the severity of symptoms once a client has been diagnosed with benign prostatic hyperplasia COMPLICATIONS using the International Prostate Symptom Score –– Recurrent urinary tract infections or renal calculi (available at: http://www.usli.net/uro/Forms/ipss.pdf). –– Bladder wall trabeculation –– Educate that many men have symptoms improve or –– Acute urinary retention stabilize, even without treatment –– Hemorrhoids or hernias caused by straining with –– Instruct client to avoid fluids – especially tea, urination coffee and alcohol – before bedtime or leaving –– Renal damage secondary to chronic obstruction the house, as they tend to cause diuresis –– Hydronephrosis –– Double void to help empty the bladder –– Overflow incontinence –– Erectile dysfunction

Clinical Practice Guidelines for Nurses in Primary Care 2011 6–26 Genitourinary System

–– Review all medications that the client is taking; EPIDIDYMITIS28,29,30,31,32,33 discontinue if possible after consultation with a physician Bacterial infection of epididymis leading to inflammation. Epididymitis is one of the most –– Cold remedies with decongestants, common infections of the male reproductive tract. antihistamines, anticholinergics, antipsychotics, antidepressants and anxiolytics can cause poor CAUSES AND RISK FACTORS bladder emptying and increase obstruction of the bladder outlet (see Table 3) Sexually transmitted infections: usually a sexually –– Advise client to report any sudden change in transmitted infection (for example, Neisseria symptoms for re-evaluation gonorrhoeae, Chlamydia). –– Counsel client about appropriate use of –– Risk factors: client < 35 years of age, sexually medications (dose, frequency, side effects, active, multiple sexual partners adherence to regimen between attacks to prevent Other infectious causes (for example, not an STI) future attacks) include urinary tract pathogens (, –– Surgery to reduce the size of the prostate may Klebsiella, Proteus) most often, and more rarely, be warranted: transurethral prostatectomy, tuberculosis or a fungus. transurethral incision prostatectomy or laser prostatectomy –– Risk factors: client > 35 years of age, urinary tract –– If surgery was performed, avoid lifting, performing infection, outflow obstruction, , strenuous exercises or remaining seated for urinary tract surgery, instrumentation of the prolonged periods of time, for up to 1 month post- lower genitourinary (GU) tract (for example, surgery catheterization), men who engage in anal –– No sexual intercourse for several weeks post-surgery intercourse (insertive), and urethral stricture Non-infectious cause: reflux of urine through Pharmacologic Interventions ejaculatory ducts causing inflammation. To improve symptoms, 5-α-reductase inhibitors such –– Risk factors: prolonged sitting, heavy physical as finasteride (Proscar) or dutasteride (Avodart) and exertion or exercise, bicycle or motorcycle riding α1-adrenergic blockers such as terazosin (Hytrin) or tamsulosin (Flomax) may be prescribed. Clients HISTORY prescribed a 5-α-reductase inhibitor should be advised that 6–12 months of continuous treatment is required –– Gradual onset of unilateral testicular pain and before the prostate volume decreases to an extent swelling sufficient to improve symptoms.27 In contrast, the –– Elevation of scrotum provides relief of pain –– Fever, chills, rigors, malaise may be present onset of effect of the α1-adrenergic blockers is more rapid. Symptomatic improvement may be noted –– Symptoms of cystitis or urethritis may be present within 1 month of initiating treatment. These must (frequency, urgency, dysuria, pruritus or meatal be prescribed by a physician and the client usually discharge) remains on them for the rest of his life. –– Take a sexual history; see “Personal and Social History (Specific to Genitourinary System)” above Monitoring and Follow-Up –– Risk factors as listed above (see “Risk factors”) If symptoms are mild, arrange elective follow-up with a physician. Client’s symptoms should be monitored PHYSICAL FINDINGS every 6 months, and a digital rectal exam performed –– Temperature may be elevated (in acute annually. If symptoms are moderate to severe, refer to epididymitis) a physician. If a client is on pharmacologic therapy, –– Moderate distress they should be reassessed every 3–6 months. –– Client walks slowly and carefully, often holding scrotum Referral –– Unilateral testicular swelling, pain and redness, Refer to a physician for assessment. Urological if advanced consultation may be necessary if symptoms are moderate to severe, causing inconvenience to the client, or if there are complications.

2011 Clinical Practice Guidelines for Nurses in Primary Care Genitourinary System 6–27

–– Urethral discharge may be present after retracting MANAGEMENT foreskin and/or after milking the urethra from the Treatment depends on suspected cause and severity of base to the meatus (related to sexually transmitted symptoms. In general, mild infections are treated on infection) an outpatient basis; more severe infections, which are –– Testicle tender and warm to touch associated with fever and chills, require inpatient care. –– Epididymis enlarged (may not be if subacute), cord-like (indurated) and acutely tender Goals of Treatment –– Hydrocele may be present –– Relieve symptoms –– Abdominal (including costovertebral angle –– Eradicate infection (if present) tenderness), digital rectal, , groin, –– Prevent complications of infection pubic area skin, and inguinal exams have no acute –– Prevent recurrence findings –– Prevent transmission (if STI) DIFFERENTIAL DIAGNOSIS Appropriate Consultation –– Testicular torsion (surgical emergency) Mild Infection –– Scrotal abscess –– Infected sebaceous cyst, folliculitis, insect bites Consult a physician if there is concern about –– Trauma underlying non-infectious pathology, especially in a –– client > 35 years of age. –– Testicular tumour Severe Infection (for example, high fever, sepsis) –– Spermatocele Consult a physician regarding choice of intravenous –– Hydrocele (IV) antibiotics and/or need for medevac. –– Varicocele –– Testicular torsion Adjuvant Therapy –– Inguinal hernia Severe Infection COMPLICATIONS Start IV therapy with normal saline to keep open.

–– Spread of infection to testis Nonpharmacologic Interventions –– Abscess –– Bed rest during acute phase (1–2 days) –– Orchitis –– Elevation of scrotum to relieve pain –– Atrophy –– Client should use a scrotal support when –– Infarction ambulatory –– Sepsis –– Ice should be applied to scrotum for 20 minutes –– Trauma q4–6h to relieve pain DIAGNOSTIC TESTS –– Client should avoid heavy lifting, straining with stool and sexual intercourse during acute phase –– Obtain midstream urine for urinalysis (routine and –– Advise client to return to the clinic for microscopy, culture and sensitivity) reassessment if symptoms worsen –– Take urethral swabs for culture or first 20 mL of –– If sexually transmitted infection is suspected or first morning (or at least 2 hours after previous) is the cause, educate client about the importance void for nucleic acid amplification testing for of their partner being tested and treated N. gonorrhoeae and Chlamydia –– Offer HIV, hepatitis A, B, and C virus testing for individual with risk factors for sexually transmitted infections (STIs) (see adult Chapter 11, “Communicable Diseases”) –– Perform Venereal Disease Research Laboratory (VDRL) or Rapid Plasma Reagin (RPR) testing for syphilis

Clinical Practice Guidelines for Nurses in Primary Care 2011 6–28 Genitourinary System

Client Education –– If N. gonorrhoeae or Chlamydia are confirmed as –– Explain disease process and expected course the causative organism, ensure contact tracing (for –– Counsel client about appropriate use of medication the 60 days prior to symptoms or the last partner (dose, frequency, side effects, completion of entire if before that time) and a report to Public Health is course prescribed) made according to the procedures in your region –– Counsel client about preventing spread of STIs to Referral sexual partners (for example, abstain from sex until 7 days after both partners started treatment for a Mild Infection sexually transmitted infection) If no response to pharmacologic treatment within Pharmacologic Interventions 3 days consult a physician. Mild Infection Severe Infection Analgesia and antipyretics:31 Medevac as soon as possible for ongoing inpatient intravenous drug and hydration therapy. ibuprofen (Advil, Motrin, generics), 200 mg, 1–2 tabs PO tid-qid prn ERECTILE DYSFUNCTION35,36,37,38,39,40 or naproxen (Naprosyn, generics), 250 mg, 1–2 tabs The inability to achieve or maintain an erection PO bid-tid prn sufficient for satisfactory sexual performance.41 Impotence affects males of all age groups, but Avoid NSAIDs in clients with renal dysfunction and incidence increases with age. Can signal serious do not use if there are contraindications such as a disease. history of allergy to aspirin or NSAIDs, or peptic ulcer disease. If NSAIDs are not well tolerated or are CAUSES contraindicated use: –– 80% of cases believed to have an organic cause (for acetaminophen (Tylenol), 325 mg, 1–2 tabs PO example, pelvic trauma, medications, hormonal q4–6h prn abnormalities, neurologic or vascular concerns) Antibiotics for treatment of acute epididymitis most –– Others believed to be psychogenic in origin (for likely caused by chlamydial or gonococcal infection example, performance anxiety, no affection for (for example, client < 35 years or client with multiple sexual partner, emotional concern) sexual partners):34 Risk Factors ceftriaxone 250 mg IM single dose Reversible: and doxycycline 100 mg PO bid for 10 days –– Smoking –– Medication use (for example, antidepressants, Consult physician for choice of antibiotics for , thiazide diuretics, cimetidine, clients with severe infection, clients > 35 years with ketoconazole) nonsexually transmitted infection (for example, –– Psychosocial factors (for example, depression, enteric organism; sulfamethoxazole/trimethoprim stress) [Septra DS] or ciprofloxacin [Cipro] are commonly used) or if a non-infectious cause is suspected. –– Serious disruption of marital or other sexual relationships Monitoring and Follow-Up –– Decreased testosterone levels Mild Infection –– Obesity –– Physical inactivity –– Follow up in 48–72 hours and note response to –– Intercourse less than once per week therapy –– Bicycling (in those doing > 3 hours/week) –– Follow up again in 10–14 days, when the course –– Alcohol and drug use (for example, marijuana, of antibiotics is completed, to ensure medications cocaine) were taken properly, symptoms have disappeared, and there was no re-exposure to an infected partner

2011 Clinical Practice Guidelines for Nurses in Primary Care Genitourinary System 6–29

Irreversible: –– Assess for risk factors noted above (see “Risk factors”), including a full assessment for depression –– Pelvic trauma and anxiety (see Chapter 15, “Mental Health”) –– Prostate surgery (for example, radical –– Take a sexual history; see “Personal and Social prostatectomy) History (Specific to Genitourinary System)” above –– Increasing age –– The “Sexual Health Inventory for Men” is a –– Diabetes mellitus questionnaire that can be used to cover some of –– Cardiovascular disease (for example, hypertension, the areas that need to be assessed. It is available vascular insufficiency, dyslipidemia) on page 9 of the Towards Optimized Practice –– Scleroderma Program guideline (available at: http://www. –– Peyronie’s disease topalbertadoctors.org/cpgs.php?sid=13&cpg_ –– Neurologic disease (for example, stroke, multiple cats=43&cpg_info=20) sclerosis, spinal cord injury) PHYSICAL FINDINGS HISTORY –– Occasionally, client will present with: A nonjudgmental attitude and empathy in a –– Anxious appearance confidential environment helps clients feel safer and –– Signs of depression (see Chapter 15, “Mental more comfortable disclosing their sexual concerns. Be Health”) direct with open-ended and specific questions to allow –– Rule out other causes with an assessment: candid responses. Acknowledge that these discussions –– Palpate femoral and peripheral pulses may be difficult and/or embarrassing. –– Abdominal or femoral bruits (occlusion Assess the impact on the partner as well, whenever of pelvic blood flow) possible and if the client agrees, as it impacts both –– Ankle brachial index partners. Often, sexual arousal and desire play a factor –– Hypertension in erectile dysfunction. –– Heart sounds and size –– Inability to achieve erection –– Visual field defects (hypogonadism with –– Inability to sustain erection after penetration (often pituitary tumours) due to anxiety or vascular steal syndrome) –– Gynecomastia (Klinefelter’s syndrome) –– Sudden loss of erectile function – usually –– Penile plaques (Peyronie’s disease) psychogenic in origin, unless genital tract trauma is –– Cremasteric reflex present (for example, after radical prostatectomy) –– Testicular atrophy, fine body hair, hepatomegaly –– Gradual decline in sexual function (for example, (hypotestosteronism) sporadic at first then more consistent) –– Testicular asymmetry or masses –– Erectile reserve (ability or inability to have –– Prostate enlargement (digital rectal exam) spontaneous erections; for example, during night –– Neurologic causes (pelvic sensation and anal or early morning); ask client and partner, if client sphincter tone) agrees –– Flaccidity of penis during foreplay, attempting DIFFERENTIAL DIAGNOSIS intercourse, wakening from sleep, and when self- –– Vascular disease stimulated –– Hypogonadism –– Excitement (in mind) and arousal during sexual activity may be reduced –– Hyperprolactinemia –– Negative thoughts during sexual activity may be –– Hypo / hyperthyroidism present (for example, fear of losing erection) –– Peyronie’s disease –– Sexual thoughts, fantasies, and desire to self- –– Klinefelter’s syndrome stimulate may be reduced –– Desire for sexual intimacy and activity (libido) –– Ability to ejaculate –– Interpersonal conflict, often unexpressed

Clinical Practice Guidelines for Nurses in Primary Care 2011 6–30 Genitourinary System

COMPLICATIONS Client Education –– Marital concerns –– Educate about importance of controlling diseases (for example, compliance with medications for –– Quality of life decline disorders that have a high prevalence of erectile –– May be an indication of comorbid disease dysfunction) (for example, diabetes, atherosclerosis) –– Educate that specific sexual activities (for example, DIAGNOSTIC TESTS oral sex) are engaged in by many couples –– Explain causes (see “Causes”) and risk factors In consultation with a physician, try to rule out (see “Risk factors”) and that many men are affected conditions that may cause erectile dysfunction: as they age –– Morning free and bioavailable testosterone –– Explain importance of foreplay levels – may be decreased (for example, due –– Counsel client about appropriate use of medication to hypogonadism) (dose, frequency, side effects, reinforce –– Prolactin contraindications while taking medication) –– -stimulating hormone –– (erection lasting longer than 4 hours) –– Fasting blood glucose requires one to get immediate help –– Fasting lipid profile –– Towards Optimized Practice Program provides –– Nocturnal penile tumescence test client information (available at: http://www. topalbertadoctors.org/cpgs.php?sid=13&cpg_ MANAGEMENT42 cats=43&cpg_info=20)

Goals of Treatment Pharmacologic Interventions –– Address underlying medical conditions that present Cessation of medications that may cause erectile with erectile dysfunction dysfunction should be guided by a physician. –– Improve or restore erectile function Treatment options to be prescribed by a physician –– Correct reversible erectile dysfunction include: –– Prevent complications –– Phosphodiesterase-5 inhibitors (for example, Treatment depends on cause, severity of the problem, sildenafil, tadalafil, vardenafil) and client preference. –– Alprostadil, administration intraurethrally or by intercavernosal injection Appropriate Consultation –– Vacuum erection devices Consult and refer client to a physician, as further tests –– Surgical interventions (for example, to rule out cardiovascular disease) and/ or a referral may be warranted. Monitoring and Follow-Up Follow up after 1 month of treatment, as there may be Nonpharmacologic Interventions more than one “cause” that can contribute to treatment –– Encourage sexual intimacy (for example, making failure (for example, sexual arousal, low desire). time, using sexual comments) –– Avoidance of alcohol Referral –– Smoking cessation Refer to a physician for assessment, treatment, –– Healthy diet and weight loss (if obese) and possibly referral (for example, for surgery, –– Increased physical activity psychotherapy, certified sexual therapist). –– Decrease stress Psychological counselling has benefits if mainly a –– Remove television from bedroom (to decrease psychogenic cause (for example, depression, anxiety). fatigue) Couples counselling can help if the concern is likely due to interpersonal conflict (helps in 25% of cases).

2011 Clinical Practice Guidelines for Nurses in Primary Care Genitourinary System 6–31

EMERGENCIES OF THE MALE GENITOURINARY SYSTEM

ACUTE URINARY RETENTION93,94 HISTORY An accumulation of urine in the bladder due to an –– Strong urge to void but inability to do so for hours abrupt inability to empty the bladder. It occurs most –– Suprapubic and/or lower abdominal fullness and often in men over age 60, and is often the result of pain benign prostatic hyperplasia. It is the most common –– Voiding habits before retention (hematuria, dysuria, urologic emergency. hesitancy, dribbling, daytime frequency, nocturia) –– Bowel habits, last bowel movement and its CAUSES consistency Usually related to obstruction, but may also be due to –– History of fever, low back pain, neurologic trauma, neurologic disease, infection, or psychologic symptoms, rash, intravenous drug use, low back concerns. pain (may be due to spinal cord compression) –– Previous history of retention, surgery, radiation, –– Any process that causes increased bladder-outlet pelvic trauma, cancer resistance or decreases bladder contractility –– Causes (see “Causes”) and risk factors –– Benign prostatic hyperplasia (see “Risk factors”), as listed above –– Side effects of drugs, both prescription and –– Review medications, noting any drugs that might nonprescription (for example, decongestants, predispose to acute urinary retention (excessive amitriptyline, oxybutynin, estrogen, haloperidol, alcohol intake, sedatives, decongestants in over- diphenhydramine), see “Table 3” the-counter cold remedies, anticholinergics, –– Constipation antipsychotics, and antidepressants) –– Prostate cancer With a neurogenic bladder, symptoms of pain, fullness –– Genitourinary infection (for example, acute and urgency may be absent. However, dribbling of prostatitis, urethritis, cystitis, vulvovaginitis, small amounts of urine (overflow dribbling) may genital herpes simplex virus) be present. –– Neurogenic bladder –– Urethral stricture or stone PHYSICAL FINDINGS –– Postoperative –– Pulse may be elevated –– Neurologic condition (for example, spinal cord –– Client may appear in moderate to acute distress injury, , stroke, epidural mass (but there may be no evidence of distress with compressing the spinal cord) a neurogenic bladder) –– Impingement on sacral by protruding –– Client may be restless and sweaty intervertebral disk or epidural mass –– Bladder distention may be noted on abdominal –– Malignancy – bladder , tumour causing inspection spinal cord compression –– Weak flow of urine –– Phimosis or paraphimosis –– Tender, distended bladder may be felt above –– Pelvic mass symphysis, often reaching umbilicus (neurogenic –– Poorly positioned indwelling catheter bladder is distended but nontender) –– Pelvic organ prolapse in women (for example, –– (in men and women): masses, cystocele, rectocele) fecal impaction, enlargement of prostate, nodular or rocky hard prostate, decreased anal tone, rectal Risk Factors sphincter tone or absent perineal sensation may be Established for men with benign prostatic hyperplasia: present, bladder may be palpable –– Age over 70 –– Pelvic examination for women with acute retention to examine for anatomic distortions (for example, –– International Prostate Symptom Score >7 fibroids, tumours of the pelvis, urethra or vagina, (available at: http://www.usli.net/uro/Forms/ipss.pdf) vulvar edema, , imperforate hymen) –– Prostate volume > 30 mL –– Neurologic examination –– Urinary flow rate < 12 mL/sec

Clinical Practice Guidelines for Nurses in Primary Care 2011 6–32 Genitourinary System

DIFFERENTIAL DIAGNOSIS –– If the client is known to have benign prostatic See “Causes.” hyperplasia, a 14–16 French catheter may be tried if catheterization is unsuccessful with the larger COMPLICATIONS size of catheter; one may go down to a 10 French if the client has had a previous transurethral –– Decreased renal function procedure (for example, transurethral resection of –– Post-obstructive diuresis the prostate) that may have left a scar; if there has –– Renal failure not been previous transurethral instrumentation –– Infection of stagnant urine try a 20 or 22 gauge Coude (firm tip) catheter if an enlarged prostate is suspected93 DIAGNOSTIC TESTS –– Insert catheter and decompress the bladder by –– Obtain midstream or catheterized urine for removing all of the urine at once until the bladder urinalysis (routine and microscopy) and for culture is empty and sensitivity –– Leave catheter in place after decompression –– Perform complete blood count if suspected –– Monitor clients during this procedure, in particular infection elderly ones –– Measure creatinine and electrolytes to check renal –– Hematuria, transient hypotension and diuresis function if the obstruction is prolonged are common, but not usually significant during –– Imaging studies may be indicated: consult with this procedure physician If retention is due to acute prostatitis, do not insert catheter unless absolutely necessary, as this may MANAGEMENT cause bacteremia. Likewise, do not insert catheter if Definitive management depends on the underlying the pelvis is fractured or if there was recent urologic cause and usually involves surgical or medical surgery. Do not attempt catheterization more than treatment. three consecutive times.

Goals of Treatment Client Education Educate clients who will be going home about catheter –– Identify underlying cause care (for example, emptying the bag, cleansing) –– Relieve bladder distention and monitoring urinary output once the bladder is decompressed. Appropriate Consultation Consult a physician for all clients. Most clients do not Pharmacologic Interventions require emergency surgery, however, some do and/or Medications are sometimes used in combination require hospitalization. with catheterization. They would be used if benign prostatic hyperplasia is the most likely cause and Nonpharmacologic Interventions would be prescribed only by a physician. Ideally, Encourage client to sit in a tub full of warm water and they should be started when the catheter is inserted to try voiding into the water. If the client is able to do and continued after its removal: alpha adrenergic so, reassess the bladder for residual distention. antagonists such as terazosin, doxazosin, tamsulosin If the bladder is severely distended, the client is in or alfuzosin may be prescribed by a physician to relax pain or it is still distended after trying to void in the bladder neck and prostatic . tub, prompt catheterization is required (unless there Monitoring and Follow-Up are contraindications). Use the following technique: Monitor hourly urine output carefully for the –– Use a Foley catheter (18 French in a male, development of post-obstruction diuresis, a 16 French in a female) complication that occurs after the release of the obstruction, because of temporary impairment of renal function.

2011 Clinical Practice Guidelines for Nurses in Primary Care Genitourinary System 6–33

Diuresis is generally self-limiting and can be managed PARTIAL OR INTERMITTENT with oral fluid intake based on thirst, but a client may TESTICULAR TORSION99 require IV fluid therapy to prevent dehydration. Torsion is not an all-or-nothing phenomenon. It can If a client was initially sent home with a catheter: be complete (usually twisting ≥ 360°), incomplete, –– Follow-up in 3 days, or sooner if the catheter stops or intermittent. draining or volume declines or if the client has Some boys and men have warning pains in a testis concerns every now and then, before a full-blown torsion. –– At day 3, if output remains acceptable, try These occur suddenly, last a few minutes, then ease removing the catheter and then seeing if the client just as suddenly. These pains occur if a testis twists can void independently. If they cannot void insert a little, and then returns back to its normal place on another catheter and have another trial without its own. the catheter (to see if the client can void by themselves) at 7 days. If they cannot void this time An incomplete or partial testicular torsion is difficult insert a catheter and leave it in place to diagnose because of its subacute presentation with –– Educate men that a recurrence after the catheter is nonspecific symptoms and signs. removed is likely, so they should return if it occurs CAUSES prior to their referral to a physician for definitive treatment –– Usually spontaneous and idiopathic (often occurs during sleep) Referral –– Predisposing structural (genetic) defect (for Medevac to hospital, if after consultation with a example, inadequate fixation of testis to tunica physician, they agree. Hospitalization is necessary vaginalis, bell clapper deformity) for clients who could not have their bladder –– Occasionally caused by minor trauma to the groin decompressed, clients with urosepsis or those –– Strenuous physical activity with obstruction from malignancy or spinal cord –– Sexual activity or arousal compression. Emergency surgery is rarely required –– Undescended testicle any more due to its increased risks. –– Testicular tumour All clients who are not seen by a physician initially will require a referral to a physician, urologist, and/ HISTORY or gynecologist to correct the cause, if possible. All –– Sudden onset of severe, constant, unilateral pain referrals should be done after consultation with a in scrotum or testicle, usually for < 12–24 hours physician. Surgery for those with benign prostatic –– Prior episode(s) of intermittent testicular pain may hyperplasia usually takes place 30 days or more from be reported (torsion and then detorsion) the acute urinary retention episode, to decrease the –– May be described as abdominal or inguinal pain risk of complications. –– Pain may radiate to lower abdomen –– Pain made worse by elevation of scrotum 95,96,97,98 TESTICULAR TORSION –– Pain not relieved by lying down Abnormal twisting of spermatic cord and testis, which –– Decreased appetite, nausea and vomiting may compromises blood supply to these structures and be present results in ischemic injury and pain. Testicular torsion –– Urinary frequency may uncommonly occur is an acute, severely painful condition. –– Assess for causes as listed above (see “Causes”) Testicular torsion is a medical emergency. If the blood For intermittent torsion: supply to the testis is cut off for more than about six –– Intermittent sharp testicular pain (resolves within hours permanent damage to the testis is likely to occur. seconds to minutes) Torsion can occur at any age; however, it is most –– Long periods without symptoms common in adolescence, with a peak at 14 years of age. –– Number of occasions it occurred

Clinical Practice Guidelines for Nurses in Primary Care 2011 6–34 Genitourinary System

PHYSICAL FINDINGS COMPLICATIONS –– Temperature usually normal (rarely elevated) –– Testicular atrophy or loss –– Heart rate elevated –– Abnormal spermatogenesis –– Blood pressure mildly elevated (because of pain) –– Infertility –– Client in acute distress –– Infarction of testicle –– Client bent over or unable to walk –– Infection –– Unilateral scrotal swelling –– Testis acutely tender, may be warm DIAGNOSTIC TESTS –– Testis swollen and found higher up (retracted) in None. the scrotal sac than expected on the affected side –– Affected testis might be lying horizontally MANAGEMENT (epididymis not posterolateral) Goals of Treatment –– Hydrocele and scrotal skin erythema may be present (often a later finding) –– Relieve pain –– Slight elevation of the testis increases or has no –– Prevent complications effect on pain (negative Prehn’s sign – used to differentiate torsion from epididymitis) Appropriate Consultation –– Cremasteric reflex (elevation of testis after stroking If you suspect testicular torsion at all, consult the upper, inner thigh on the same side) almost a physician without delay. This is a surgical always not present emergency; prompt diagnosis and surgical referral is –– Perform a complete assessment of the abdomen, critical to a satisfactory outcome. testes, epididymis, spermatic cord, scrotal skin If intermittent torsion is suspected consult a physician. and inguinal area For intermittent torsion, in addition to the above, Adjuvant Therapy the following may also be present: –– Start intravenous (IV) therapy with normal saline –– Very mobile testes –– Adjust IV rate according to age and state of –– Bulky spermatic cord hydration –– Normal examination Nonpharmacologic Interventions DIFFERENTIAL DIAGNOSIS –– Nothing by mouth before surgery –– Epididymitis –– Bed rest –– Orchitis –– Promote the client’s comfort –– Trauma Pharmacologic Interventions –– Hydrocele Analgesia as needed with either an NSAID such as –– Incarcerated or strangulated inguinal hernia ibuprofen or naproxen or acetaminophen. If simple –– Torsion of testicular appendage analgesics are ineffective then morphine could be used –– Acute varicocele to relieve severe pain. –– Testicular tumour ibuprofen 200 mg, 1–2 tabs PO tid-qid prn –– Scrotal abscess –– Testicular infarction or –– Henoch-Schonlein purpura naproxen 250 mg, 1–2 tabs PO bid-tid prn –– Appendicitis Avoid NSAIDs in clients with renal dysfunction and do not use if there are contraindications such as a history of allergy to aspirin or NSAIDs or peptic ulcer disease. For severe pain: morphine 5 mg IV or IM or SC once; upon consultation with a physician

2011 (Revised April 2013) Clinical Practice Guidelines for Nurses in Primary Care Genitourinary System 6–35

Antiemetic for nausea and vomiting: Referral dimenhydrinate (Gravol), 50–75 mg IM/IV Medevac as soon as possible. This is a surgical q4–6h as required emergency.

Monitoring and Follow-Up For those with suspected intermittent testicular torsion refer to a physician as a urology referral is often If intermittent testicular torsion is suspected and the warranted. examination was normal, follow up in 7 days (sooner if the pain recurs) and do another complete physical examination.

SOURCES

Internet addresses are valid as of March 2012. Robinson DL, Kidd P, Rogers KM. Primary care across the lifespan. St. Louis, MO: Mosby; 2000. BOOKS AND MONOGRAPHS Sanford J, et al. The Sanford guide to antimicrobial Anti-Infective Review panel. Anti-infective guidelines therapy. 32nd ed. Antimicrobial Therapy, Inc; 2002. for community-acquired infections. Toronto, ON: MUMS Guideline Clearinghouse; 2010. Tierney L, Henderson M. The patient history: Evidence-based approach. New York, NY: McGraw Bickley LS. Bates’ guide to physical examination and Hill; 2005 history taking. 10th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2009. Toth PP, Jothivijayarani A (Editors). University of Iowa family practice handbook. 3rd ed. St. Louis, Cash JC, Glass CA. Family practice guidelines. MO: Mosby; 1997 Philadelphia, PA: Lippincott Williams & Wilkins; 1999. Uphold C, Graham V. Clinical guidelines in family Enkin M, et al. A guide to effective care in pregnancy practice. 4th ed. Gainsville, FL: Barmarrae Books and childbirth. 3rd ed. New York: Oxford University Inc.; 2003. Press; 2000. CD-ROMS Fischbach FT. A manual of laboratory and diagnostic tests. 6th ed. Lippincott; 2000. Briggs GG, Freeman RK, Yaffe SJ (Editors). Drugs in pregnancy and lactation: A reference Guide to fetal Fitzpatrick TB, Allen R, Johnson K, et al. Color and neonatal risk. 5th ed. Lippincott, Williams and atlas and synopsis of clinical dermatology. 4th ed. Wilkins; 1999. McGraw-Hill; 2001. Braunwald E, et al. Harrison’s principles of internal Gray J (Editor). Therapeutic choices. 5th ed. Ottawa, medicine. 15th ed. CD-ROM version 1.0. McGraw- ON: Canadian Pharmacists Association; 2007. Hill; 2001. Jamison J. Differential diagnosis for primary practice. Tintinalli JE, Stapczynski JS, Kelen GD (Editors). London, UK: Churchill Livingston; 1999. Emergency medicine plus. CD-ROM version 2.0. Karch AM. Lippincott’s 2002 nursing drug guide. New York: McGraw-Hill Professional; 2001. Philadelphia, PA: Lippincott; 2002. INTERNET GUIDELINES Pagna K, Pagna T. Diagnostic testing and nursing implications. 5th ed. St. Louis, MO: Mosby; 1999. Oxford University, Bandolier: Evidence based thinking about health care; c. 1994-2007. Benign Prateek L, Waddel, A. Toronto notes – MCCQE 2003 prostatic hyperplasia. Available at: http://www. review notes. 19th ed. Toronto, ON: University of medicine.ox.ac.uk/bandolier/booth/booths/bph.html Toronto Faculty of Medicine; 2003. The Canadian Continence Foundation; c. 2010. Ratcliffe S, et al (Editors). Family practice obstetrics. Available at: http://www.canadiancontinence.ca/ 2nd ed. Salt Lake City, UT: Hanley and Belfus; 2001.

Clinical Practice Guidelines for Nurses in Primary Care 2011 6–36 Genitourinary System

END NOTES 14 Rhee JJ. (2009, December 21). Acute bacterial prostatitis and prostatic abscess. eMedicine. 1 Public Health Agency of Canada. Canadian guideline Available at: http://emedicine.medscape.com/ on sexually transmitted infections. Ottawa, Ontario: article/439968-overview Public Health Agency of Canada; 2010, January. Primary Care and Sexually Transmitted Infections 15 Public Health Agency of Canada. Canadian guideline chapter. p. 5-8. Available at: http://www.phac-aspc. on sexually transmitted infections. Ottawa, Ontario: gc.ca/std-mts/sti-its/guide-lignesdir-eng.php Public Health Agency of Canada; 2010, January. Syphilis section. p. 6-13. Available at: http://www. 2 Filate W, Leung R, Ng D, Sinyor M. Essentials of phac-aspc.gc.ca/std-mts/sti-its/guide-lignesdir-eng.php clinical examination handbook. 5th ed. Toronto, ON: Medical Society, Faculty of Medicine, University of 16 Snow DC, Shoskes DA. Pharmacotherapy of Toronto; 2005. p. 295-303. prostatitis. Expert opinion on pharmacotherapy 2010;11(14):2319-30. Available at: http://www.ncbi. 3 Dains JE, Baumann LC, Scheibel, P. Advanced health nlm.nih.gov/pubmed/20569089 assessment and clinical diagnosis in primary care. 3rd ed. Philadelphia, PA: Mosby Elsevier; 2007. 17 Barrisford G. (2010, September). Balanitis and p. 235-78. balanoposthitis in adults. UpToDate Online. Available by subscription: www.uptodate.com 4 Cope DW. (2010, September). The sexual history and approach to the patient with sexual dysfunction. 18 Uphold C, Graham V. Clinical guidelines in family UpToDate Online. Available by subscription: practice. 4th ed. Gainsville, FL: Barmarrae Books www.uptodate.com Inc.; 2003. p 608-611. 5 Bickley L. Bates’ guide to physical examination and 19 Nurses quick check. 2nd ed. 2009. Benign prostatic history taking. 8th ed. Philadelphia, PA: Lippincott hyperplasia. Lippincott and Wilkins. p. 112. Williams & Wilkins; 2003. p. 375-78. 20 Cunningham GR, Kadmon D. (2010, September). 6 Swartz M. Textbook of physical diagnosis history Clinical manifestations and diagnosis of benign and examination. 4th ed. Philadelphia, PA: Saunders; prostatic hyperplasia. UpToDate Online. Available 2002. pp. 473-71. by subscription: www.uptodate.com 7 Hoffman RM. (2011, January). Screening for prostate 21 Cunningham GR, Kadmon D. (2010, September). cancer. UpToDate Online. Available by subscription: Epidemiology and pathogenesis of benign prostatic www.uptodate.com hyperplasia. UpToDate Online. Available by subscription: www.uptodate.com 8 Kantoff PW, Taplin ME. (2011, January). Clinical presentation, diagnosis, and staging of prostate 22 Norman RW. Lower urinary tract symptoms and cancer. UpToDate Online. Available by subscription: benign prostatic hyperplasia. In: Gray J, editor. www.uptodate.com Therapeutic choices. 5th ed. Ottawa, ON: Canadian Pharmacists Association; 2007. p. 779-88. 9 BC Cancer Agency. (2010, Nov. 4) PSA screening. Available at: http://www.bccancer.bc.ca/HPI/ 23 Pharmacologic agents associated with urinary CancerManagementGuidelines/Genitourinary/ retention. C 2011. UpToDate Online. Available Prostate/PSAScreening/default.htm by subscription: www.uptodate.com 10 Health Canada. First Nations comparable health 24 Verhamme KMC, Sturkenboom CJM, Stricker indicators. Prostate cancer section. c. 2005, January. BHC, et al. Drug-induced urinary retention. Available at: http://www.hc-sc.gc.ca/fniah-spnia/ Incidence, management and prevention. Drug Safety diseases-maladies/2005-01_health-sante_indicat-eng.php 2008;31(5):373-88. Available at: http://www.ncbi. nlm.nih.gov/pubmed/18422378 11 Sartor AO. (2011, January). Risk factors for prostate cancer. UpToDate Online. Available by subscription: 25 Potentially harmful drugs in the elderly: Beers list www.uptodate.com and more. Pharmacists Letter / Prescribers Letter 2007 Updated October 2009;23:1-12. Available at: 12 Meyrier A, Fekete T. (2010, September). Acute and http://www.fmda.org/beers.pdf chronic bacterial prostatitis. UpToDate Online. Available by subscription: www.uptodate.com 26 Afonso AS, Verhamme KM, Stricker BH, et al. Inhaled anticholinergic drugs and risk of acute 13 Public Health Agency of Canada. Canadian guideline urinary retention. BJU Int 2010. Published online on sexually transmitted infections. Ottawa, Ontario: ahead of print 29 September 2010. Available at: Public Health Agency of Canada; 2010, January. http://onlinelibrary.wiley.com/doi/10.1111/j.1464- Syndromic management of sexually transmitted 410X.2010.09600.x/abstract infections: Prostatitis chapter. p. 1-10. Available at: http://www.phac-aspc.gc.ca/std-mts/sti-its/guide- lignesdir-eng.php

2011 Clinical Practice Guidelines for Nurses in Primary Care Genitourinary System 6–37

27 Cunningham GR, Kadmon D. (2010, September). 40 Towards Optimized Practice Program. (2010, Medical treatment of benign prostatic hyperplasia. February). Investigation and management of UpToDate Online. Available by subscription: erectile dysfunction. Available at: http://www. www.uptodate.com topalbertadoctors.org/cpgs.php?search=investigation 28 Uphold C, Graham V. Clinical guidelines in family +management+of+erectile+dysfunction+&x=7&y=8 practice. 4th ed. Gainsville, FL: Barmarrae Books 41 Montague DK, et al. (2007). The management of Inc.; 2003. p. 649-51. erectile dysfunction: an update. American Urological 29 Nurses quick check. 2nd ed. 2009. Epididymitis. Association. Available at: http://www.auanet. Lippincott and Wilkins. p: 266-67. org/content/guidelines-and-quality-care/clinical- guidelines/main-reports/edmgmt/content.pdf 30 Anti-Infective Review panel. Anti-infective guidelines for community-acquired infections. 42 Spark RF. (2010, September). Treatment of male Toronto, ON: MUMS Guideline Clearinghouse; sexual dysfunction. UpToDate Online. Available 2010. p. 77. by subscription: www.uptodate.com 31 Eyre RC. (2010, September). Evaluation of the acute 43 Fekete T, Hooton TM. (2010, September). Approach scrotum in adult men. UpToDate Online. Available to the adult with asymptomatic bacteriuria. by subscription: www.uptodate.com UpToDate Online. Available by subscription: www.uptodate.com 32 Swygard H, Cohen MS, Sena AC. (2010, September). Infectious causes of dysuria in adult 44 Colgan R, Nicolle LE, McGlone A, Hooton TM. men. UpToDate Online. Available by subscription: Asymptomatic bacteriuria in adults. American www.uptodate.com Family Physician 2006:74(6);985-90. Available at: http://www.aafp.org/afp/2006/0915/p985.html 33 Public Health Agency of Canada. Canadian guideline on sexually transmitted infections. Ottawa, Ontario: 45 Hooton TM. (2010, September). Urinary tract Public Health Agency of Canada; 2010, January. infections and asymptomatic bacteriuria in Syndromic management of sexually transmitted pregnancy. UpToDate Online. Available by infections: Epididymitis chapter. p. 1-4. Available subscription: www.uptodate.com at: http://www.phac-aspc.gc.ca/std-mts/sti-its/guide- 46 Hooton TM. (2010, September). Acute cystitis and lignesdir-eng.php asymptomatic bacteriuria in men. UpToDate Online. 34 Public Health Agency of Canada. Canadian guideline Available by subscription: www.uptodate.com on sexually transmitted infections. Ottawa, Ontario: 47 Weintrob AC, Sexton DJ. (2010, September). Public Health Agency of Canada; 2010, January. Asymptomatic bacteriuria in patients with Syndromic management of sexually transmitted diabetes mellitus. UpToDate Online. Available by infections: Epididymitis chapter. p. 3. Available at: subscription: www.uptodate.com http://www.phac-aspc.gc.ca/std-mts/sti-its/guide- 48 Anti-Infective Review panel. Anti-infective lignesdir-eng.php guidelines for community-acquired infections. 35 Nurses quick check. 2nd ed. 2009. Erectile Toronto, ON: MUMS Guideline Clearinghouse; dysfunction. Lippincott and Wilkins. p. 274. 2010. p. 68. 36 Spark RF. (2010, September). Evaluation of male 49 Hooton TM. (2010, September). Acute cystitis in sexual dysfunction. UpToDate Online. Available women. UpToDate Online. Available by subscription: by subscription: www.uptodate.com www.uptodate.com 37 Spark RF. (2010, September). Overview of male 50 Hooton TM. (2010, September). Recurrent urinary sexual dysfunction. UpToDate Online. Available tract infection in women. UpToDate Online. by subscription: www.uptodate.com Available by subscription: www.uptodate.com 38 Cope DW. (2010, September). The sexual history 51 Meyrier A. (2010, September). Urine sampling and and approach to the patient with sexual dysfunction. culture in the diagnosis of urinary tract infection in UpToDate Online. Available by subscription: adults. UpToDate Online. Available by subscription: www.uptodate.com www.uptodate.com 39 Basson R. Male sexual dysfunction. In: Gray J, 52 Fekete T. (2010, September). Urinary tract infection editor. Therapeutic choices. 5th ed. Ottawa, ON: associated with urethral catheters. UpToDate Online. Canadian Pharmacists Association; 2007. p. 887-900. Available by subscription: www.uptodate.com 53 Anti-Infective Review panel. Anti-infective guidelines for community-acquired infections. Toronto, ON: MUMS Guideline Clearinghouse; 2010. p. 64-67, 69, 72-73.

Clinical Practice Guidelines for Nurses in Primary Care 2011 6–38 Genitourinary System

54 Nicolle LE. Urinary tract infection. In: Gray J, editor. 65 Gupta K, Hooton TM, Naber KG, et al. International Therapeutic choices. 5th ed. Ottawa, ON: Canadian clinical practice guidelines for the treatment of acute Pharmacists Association; 2007. p. 1326-36. uncomplicated cystitis and pyelonephritis in women: 55 Epp A, et al. Recurrent urinary tract infection: SOGC A 2010 update by the Infectious Diseases Society of Clinical Practice Guideline Journal of Obstetrics America and the European Society for Microbiology and Gynecology 2010;250:1082-90. Available and Infectious Diseases. CID 2011;52:e103-e120. at: http://www.sogc.org/guidelines/documents/ Available at: http://cid.oxfordjournals.org/ gui250CPG1011E.PDF content/52/5/e103.full.pdf+html 56 Anti-Infective Review panel. Anti-infective 66 Hooton TM. (2010, September). Radiologic guidelines for community-acquired infections. evaluation in acute pyelonephritis. UpToDate Online. Toronto, ON: MUMS Guideline Clearinghouse; Available by subscription: www.uptodate.com 2010 p. 64-73. 67 Anti-Infective Review panel. Anti-infective 57 Gupta K, Hooton TM, Naber KG, et al. Executive guidelines for community-acquired infections. summary: International clinical practice guidelines Toronto, ON: MUMS Guideline Clearinghouse; for the treatment of acute uncomplicated cystitis 2010. p. 84-86. and pyelonephritis in women: A 2010 update 68 Swygard H, Sena AC, Cohen MS. (2010, September). by the Infectious Diseases Society of America Neisseria gonorrhoeae infections in men. UpToDate and the European Society for Microbiology and Online. Available by subscription: www.uptodate.com Infectious Diseases. CID 2011;52:561-4. Available 69 Swygard H, Cohen MS, Sena AC. (2010, September). at: http://www.escmid.org/fileadmin/src/media/ Infectious causes of dysuria in adult men. UpToDate PDFs/4ESCMID_Library/2Medical_Guidelines/ Online. Available by subscription: www.uptodate.com ESCMID_Guidelines/Clin_Infect_Dis-2011- 70 Komaroff AL. (2010, September). Dysuria in adult Gupta-561-4.pdf women. UpToDate Online. Available by subscription: 58 Blondel-Hill E, Fryters S. Bugs & Drugs. www.uptodate.com Recommended empiric therapy of selected infections 71 Zenilman JM. (2010, September). Genital Chlamydia in adult patients. Edmonton, AB: Capital Health; trachomatis infections in men. UpToDate Online. 2006. Available at: http://www.bugsanddrugs.ca/ Available by subscription: www.uptodate.com bugs_drugs_website/web-content/COMBINED_ BandD2006_certified.pdf 72 Public Health Agency of Canada. Canadian guideline on sexually transmitted infections. Ottawa, Ontario: 59 Jepson RG, Craig JC. Cranberries for preventing Public Health Agency of Canada; 2010, January. urinary tract infections. Cochrane Database of Primary Care and Sexually Transmitted Infections Systematic Reviews 2008, Issue 1. Art. No.: chapter. p. 5-8. Available at: http://www.phac-aspc. CD001321. DOI: 10.1002/14651858.CD001321.pub4 gc.ca/std-mts/sti-its/guide-lignesdir-eng.php Available at: http://www2.cochrane.org/reviews/en/ ab001321.html 73 Public Health Agency of Canada. Canadian guideline on sexually transmitted infections. Ottawa, Ontario: 60 Dunphy L, Winland-Brown J, Porter B, Thomas D. Public Health Agency of Canada; 2010, January. Primary care – The art and science of advanced Syndromic management of sexually transmitted practice nursing. 2nd ed. Philadelphia: F.A. Davis infections: Urethritis chapter. p. 1-6. Available at: Company; 2007. p. 581-83. http://www.phac-aspc.gc.ca/std-mts/sti-its/guide- 61 Hooton T. (2010, September) Clinical manifestations; lignesdir-eng.php diagnosis; and treatment of acute pyelonephritis. 74 DuBeau C. (2010, September). Clinical presentation UpToDate Online. Available by subscription: and diagnosis of urinary incontinence. UpToDate www.uptodate.com Online. Available by subscription: www.uptodate.com 62 Uphold C, Graham V. Clinical guidelines in family 75 DuBeau C. (2010, September). Epidemiology, risk practice. 4th ed. Gainsville, FL: Barmarrae Books factors, and pathogenesis of urinary incontinence. Inc.; 2003. UpToDate Online. Available by subscription: 63 Hooton T. (2010, September) Microbiology and www.uptodate.com pathogenesis of acute pyelonephritis. UpToDate 76 DuBeau C. (2010, September). Treatment of urinary Online. Available by subscription: www.uptodate.com incontinence. UpToDate Online. Available by 64 Anti-Infective Review panel. Anti-infective subscription: www.uptodate.com guidelines for community-acquired infections. 77 Clemens JQ. (2010, September). Urinary Toronto, ON: MUMS Guideline Clearinghouse; incontinence in men. UpToDate Online. Available 2010. p. 72-74. by subscription: www.uptodate.com

2011 Clinical Practice Guidelines for Nurses in Primary Care Genitourinary System 6–39

78 Dunphy L, Winland-Brown J, Porter B, Thomas D. 91 Curhan GC. (2010, September). Risk factors for Primary care – The art and science of advanced calcium stones in adults. UpToDate Online. Available practice nursing. 2nd ed. Philadelphia: F.A. Davis by subscription: www.uptodate.com Company; 2007. pp. 567-573. 92 Preminger GM. (2010, September). Management 79 The Canadian Continence Foundation. (2007, May). of ureteral calculi. UpToDate Online. Available Incontinence: A Canadian perspective. Available at: by subscription: www.uptodate.com http://www.continence-fdn.ca/pdf/Research_paper_ 93 Barrisford GW, Steele GS. (2010, September). Acute August2007.pdf urinary retention. UpToDate Online. Available by 80 Grymonpre RE. Urinary incontinence in adults. In: subscription: www.uptodate.com Gray J, editor. Therapeutic choices. 5th ed. Ottawa, 94 Barclay L, Vega C. Management of urinary retention ON: Canadian Pharmacists Association; 2007. reviewed. Medscape Medical News 2008. Available p. 789-803. at: http://www.medscape.org/viewarticle/570959 81 Medications that may cause or worsen urinary 95 Nurses quick check. 2nd ed. 2009. Testicular Torsion. incontinence. UpToDate Online. c. 2011. Available Lippincott and Wilkins. p. 808. by subscription: www.uptodate.com 96 Brenner JS, Ojo A. (2010, September). Causes 82 Farrell SA. The evaluation of stress incontinence of scrotal pain in children and adolescents. prior to primary surgery. Journal of Obstetrics and UpToDate Online. Available by subscription: Gynaecology Canada 2003;25(4):313-18. Available www.uptodate.com at: http://www.sogc.org/guidelines/public/127E-CPG- 97 Eyre RC. (2010, September). Evaluation of the acute April2003.pdf scrotum in adult men. UpToDate Online. Available 83 Nadir NA. (2009, October 20). Urinary incontinence. by subscription: www.uptodate.com EMedicine. Available at: http://emedicine.medscape. 98 Rupp TJ. (2010, September 27). Testicular torsion. com/article/778772-overview EMedicine. Available at: http://emedicine.medscape. 84 Amir B, Farrell SA. SOGC committee opinion on com/article/778086-overview urodynamics testing. Journal of Obstetrics and 99 Dogra V, Bhatt S, Rubens D. Sonographic Gynaecology Canada 2008;30(8):717-21. Available evaluation of testicular torsion. Ultrasound Clinics at: http://www.sogc.org/guidelines/documents/ 2006;1(1):61. gui212CO0808.pdf 85 Magali R, Ross S. Conservative management of urinary incontinence. Journal of Obstetrics and Gynaecology Canada 2006;28(12):1113-18. Available at: http://www.sogc.org/guidelines/ documents/186E-CPG-Decembre2006.pdf 86 Curhan GC, Aronson MD, Preminger GM. (2010, September). Diagnosis and acute management of suspected nephrolithiasis in adults. UpToDate Online. Available by subscription: www.uptodate.com 87 Dunphy L, Winland-Brown J, Porter B, Thomas D. Primary care – The art and science of advanced practice nursing. 2nd ed. Philadelphia: F.A. Davis Company; 2007. p. 583-87. 88 Preminger GM, Curhan GC. (2010, September). The first kidney stone and asymptomatic nephrolithiasis in adults. UpToDate Online. Available by subscription: www.uptodate.com 89 Preminger GM, Curhan GC. (2010, September). Evaluation of the adult patient with established nephrolithiasis and treatment if stone composition is unknown. UpToDate Online. Available by subscription: www.uptodate.com 90 Rose BD, Becker MA. (2010, September). Uric acid nephrolithiasis. UpToDate Online. Available by subscription: www.uptodate.com

Clinical Practice Guidelines for Nurses in Primary Care 2011