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GENITOURINARY SYSTEM 579

• Pyuria

• Mild hematuria

• Mild proteinuria

Management of interstitial nephritis includes any of the following"·32:

• Fluid and nutritional support

• Anti-infective agents (as indicated)

• Dialysis (as indicated)

• Surgery to relieve obstructions (if present)

• Renal transplantation

Nephrolithiasis

Nephrolithiasis is a condition that occurs more commonly in men

and is characrerized by renal calculi (kidney stones) thar form in rhe

renal pelvis. There are three primary types of kidney stOnes, which

are categorized according to the stone-forming substances: calcium

oxalate, struvite (composed of magnesium, ammonium, and phosphate), and uric acid. Many factors contribute to stone formation and include the foliowing8.9•J3•J4:

• High urinary concentration of stone-forming substances

• Presence of crystal growth facilitatOrs

• Metabolic abnormalities

• Dietary factors (low Auid and high protein intake)

• Infection may contribute to the formation of kidney stOnes

• Urinary tract obstruction

• Medications (carbonic anhydrase inhibitors, triamterene, indinavir, and vitamin C)8.9,JJ

Signs and symptoms of kidney stones include rhe following8•9:

• Pain in the Aank or groin, depending on the stone location (Pain

increases greatly as the stone passes through the ureters.)

580 ActrrE CARE HANDBOOK FOR PHYSICAL THERAPISTS

• Hematuria

• Fever

• Variable urine pH

• Variable levels of serum calcium, chloride, phosphate, carbon

dioxide, uric acid, and Cr

Management of kidney stones includes any of the followings.,.33-3s:

• Analgesics

• Hydration and diuretics

• Discontinuation of the aforementioned medications

• Anti-infective agents

• Reduction in dietary consumption of predisposing factors, such

as salt and protein

• Specific therapies aimed at reducing stone formation, including

thiazide diuretics, pyridoxine, magnesium, orthophosphate, and

potassium citrate

• Surgery (as a last resort)

Diabetic Nephropathy

Approximately 20-30% of people with type 'lor type 2 diabetes will

develop diabetic nephropathy," which is characterized by systemic

vascular changes in the kidneys that result in scarring (nephrosclerosis) of the glomeruli and, ultimately, in reduced kidney function.

Pyelonephritis and necrosis of the renal papillae arc also associated

with diabetic nephropathy. Patients who demonstrate poor glycemic

control with resultant vascular disease and hypertension are more

likely to develop diabetic nephropathy. Hypertension can lead to or

result from diabetic nephropathy.8.36,37

Signs and symptoms of diabetic nephropathy include the

following,,36.37:

• Microalbuminuria, oliguria, anuria. Microalbuminuria is a critical screening tool for early detection of nephropathy.

• Peripheral edema.

GENITOURINARY SYSTEM 581

Management of diabetic nephropathy includes any of the

followingR•16.P:

• Strict glycemic control (Refer to Diabetes Mellitus in Chapter 11.)

• Antihypertensive agents (ACE inhibitors, calcium channel

blockers)

• Rc�rriction of protein intake

• Hydration

• Diuretics

• Nutritional support

• Dialysis

• Simultaneous pancreas-kidney transplantation (See Chapter

12.)

Rellal Vascl/lar Abllom,alities

Renal Artery Stenosis or Occlusion

Renal artery stenosis is a narrowing of the renal artery lumen; renal

artery oCc/l/sioll is blockage of the renal artery lumen. Renal artery

stenosis or occlusion can result from any or all of the following:

atherosclerotic disease, diabetes mellirus, subacute bacterial endocarditis, emboli from mitral valve stenosis, and mural thrombi that develop afrer myocardial infarction. Decreased renal perfusion

results in renovascular hypertension as a result of increased renin

production. IUS

Signs and symptoms of renal artery stenosis or occlusion include

the followingS.,,:

• II yperrension

• Microscopic hematuria

• Flank or upper abdominal pain

• Abdominal aortic, renal artery bruits, or both

• Peripheral edema

582 AClITE CARE HANDBOOK FOR PHYSICAL THERAPISTS

Management of renal artery stenosis or occlusion includes any of

the foliowingS,3s:

• Antihypertensive agents (ACE inhibitors)

• Anticoagulation agents

• Analgesics

• Dialysis

• Surgery (bypass grafting, angioplasty with possible stent placement, or nephrectomy in unilateral renovascular disease) Renal Veill Thrombosis

Renal vein thrombosis is an uncommon disorder, resulting in the

accumulation of plaque in the renal vein. Renal vein throll"lbosis can

be caused by dehydration, sepsis, a hypercoagulable state, injury to

the abdomen or back, renal tumors extending into the renal vein, and

nephrotic syndrome, Sudden occlusion of the renal vein results in

renal infarcts.8.39

Signs and symptoms of renal vein thrombosis include the

following7,s.39:

• Flank pain

• Gross hematuria

• Proteinuria

• Oliguria

Renal vein thrombosis can be managed with anticoagulants or

thrombolytic agents.7,8.39

Urillary Tract Dysfrmctioll

Cystitis

Bacteria, viruses, fungi, chemical agents, radiation exposure, and

autoimmune dysfunction are all potential causative factors thar

can lead to cystitis, which is an inAammation of the bladder wall.

Cystitis and urinary tract infections are nor synonymous, as inflammarion of the bladder can occur from noninfectious causes. How-

GENITOURINARY SYSTEM 583

ever, cystitis can occur with prostatitis or pyelonephritis.18 Cystitis

that occurs from noninfectious causes is called interstitial cystitis

and is relatively uncommon.40.41 People who are sexually active or

who have an indwelling catheter, urinary tract obstructions, diabetes mellitus, neurogenic bladder, or poor hygiene are at greater risk of developing cystitisI8

Signs and symptoms of cystitis include the following'8,.o ... :

• Urinary frequency and urgency

• Dysuria

• Hematuria (in more serious cases)

• Nocruria

• Suprapubic pain, low back pain, or both

Management of cystitis includes any of the following'8,.o,4':

• Anti-inflammatory agents, tricyclic antidepressants, antihistamines, immunosuppressives, antispasmodics, calcium channel blocking agents, and interstitial cystitis agents.

• Increased fluid intake.

• Therapeutic hydrodistention with or without intra vesicular

instillation. Therapeutic hydrodistention is performed under general anesthesia, and the bladder is hydrodistended to help identify areas of inflamed epithelium and promote healing of these areas, as

well as to help distend the bladder, which may help with pain

relief. Intravesicular instillation is commonly performed with therapeutic hydrodistention and involves infusion of agents such as anti-inflammatory analgesic agents into the bladder.

• Surgical management with total or subtotal cystectomy, denervation of the bladder, or procedures that increase bladder capaciry (all of these are last-resort measures).

Urinary Calculi

Urinary calculi are stones (llrolithiasis) that can form anywhere in the

urinary tract outside of the kidneys. Formation of stones, symptoms,

and management are similar to that of kidney stones (see Nephrolithiasis for further details on the formation and clinical presentation of