Genitourinary System

Diuretics & Hormones

see cardiology unit

Overactive Bladder Agents

*Action:* relieve the symptoms of and overactive bladder (noted by involuntary contractions of the detrusor muscle) *Indications:* urinary urgency, urinary frequency, urge incompetence, nocturia *Side Effects:* -GI distress -nausea -dizziness -photosensitivity -headache -constipation -pulmonary reactions *PT Implications:* be aware of side effects; communicate signs of pulmonary impairments or distress to the MD *Examples:* Ditropan, Detrol

Urinary Anti-Infective Agents

*Action:* treat urinary tract infections; not traditional antibiotics or sulfonamide agents; can be used independently or in combination to treat UTI's *Indications:* cystitis, urinary urgency, burning with urination, urinary tract infection, nocturia *Side Effects:* -GI distress -nausea -dizziness -photosensitivity -headache -constipation -rash

Genitourinary System

*Anatomy & Function* - supported by the pelvic floor consisting of muscle, fascia, and ligament *Genital System* - male/female gonads & associated ducts, external genitalia, & associated hormones that all function for REPRODUCTION *Renal System* - 2 kidneys, 2 ureters, urinary bladder, urethra that function to form and eliminate urine

Management Guidelines for High-Risk Pregnancy

*High-risk pregnancy: based on complications from disease or pathology that place the mother and fetus at risk for illness/death* -(L) sidelying to reduce the pressure on the inferior vena cava (maximizes cardiac output, reduces risk of incompetent cervix, and increases maternal-fetal circulation) -Abdominal exercises may stimulate uterine contractions (modify or discontinue) -Keep exercises simple, slow, smooth, and with minimal exertion -Avoid valsalva maneuver (discontinue activities that increase intraabdominal pressure -Provide instruction on proper body mechanics and postural instructions -Encourage maximum muscle efficiency during each movement -Educate women about cesarean delivery rehabilitation -Monitor and report any uterine contraction, bleeding, or amniotic fluid

Contraindications to Exercise during Pregnancy

*Relative:* -severe anemia -unevaluated maternal cardiac dysrhythmia -chronic bronchitis -poorly controlled type 1 diabetes -extremely morbid obesity or underweight -hx of extremely sedentary lifestyle -intrauterine growth restriction in current pregnancy -orthopedic limitations -poorly controlled seizure disorder/HTN -heavy smoker *Absolute:* -hemodynamically significant heart disease -restrictive lung disease -incompetent cervix/cerclage -multiple gestation at risk for premature labor -persistent second or third trimester bleeding -placenta previa after 26 weeks of gestation -premature labor during current pregnancy -ruptured membranes -preeclampsia/pregnancy-induced hypertension

Results of Pelvic Floor Weakness or Poor Endurance

*Weak or Poor Endurance Pelvic Floor Muscles* > due to: pregnancy, trauma, surgery, repetitive straining, or genetics > leads to: inability to to support pelvic organs leading to *organ prolapse* > affected structures: bladder, uterus, cervix, intestines, and rectum > results in: urgency, frequency, urinary or fecal incontinence due to muscle imbalance during increased intra-abdominal pressure

Renal Failure: Treatment

*treatment of ARF* - management of primary etiology - pharmacological intervention - diuretics - nutritional support - hydration - hemodialysis &/or transfusions if applicable *treatment of CRF* *conservative management*: slowing the process and & assisting the body in its compensation - nutritional support, hydration, avoidance of protein, and pharmacological intervention *renal replacement therapy*: some form of hemodialysis &/or transfusions - peritoneal dialysis: uses peritoneal cavity as a semi-permeable membrane between the dialysate fluid and blood vessels of the abdominal cavity

Lifestyle Modifications to Address Bladder Symptoms

- *daily fluid intake should be 2,500 mL (10 cups)* to regulate excessively high or low fluid intake - *reduce bladder irritants* including carbonated, caffeinated, and alcoholic beverages, spicy foods, citric juices, and artificial sweeteners. Taper caffeine slowly to avoid headaches - schedule voiding for every 3-4 hours to *reduce bladder distention*. Avg person voids *6-8 times in a 24-hr period - *regulate bowel function* to prevent constipation and straining during BMs by monitoring dietary fiber, fluid intake and exercise - avoid fluid intake 2-3 hrs before bedtime to *reduce nocturia* - smoking cessation program may reduce the occurrence of coughing and subsequent bladder leakage - weight loss program, if moderately obese, may decrease pressure on pelvic tissues and organs

Functional Incontinence and At-Risk Populations

- *restricted mobility or dexterity*: difficulty or inability to get to bathroom in timely fashion due to underlying physical disabilities or limitations. i.e. SCI, RA, acute illness - *environmental barriers*: may not be able to reach bathroom due to stairs, lack of handrails, or narrow doorways that do not accommodate WC or RW - *mental and psychological disability*: may not realize they have to urinate or may be confused over location of bathroom - *pharmacological intervention*: may take medications that affect awareness, mobility, and dexterity

Renal Failure

- a condition where the kidneys experience a decrease in glomerular filtration rate and fail to adequately filter toxins and waste from the blood *ETIOLOGY*: typically occurs secondary to DM or HTN; may occur from poison, trauma, and genetics. - Nephrons are damaged and lose their ability to filter the blood *classified as*: - acute (damage occurs quickly) - chronic (damage occurs slowly) - end-stage (nearly total or total failure, dialysis required)

Genitourinary System Support Structure: Primary Function of the Pelvic Floor

- bladder/bowel control and sexual function - support pelvic organs by holding organs in position - made up of type I & II fibers

Neurogenic Bladder

- dysfunction where there is damage to the cerebral control that allows for urinary dysfunction - if urine is not properly released, there may be increase in urinary tract infections and kidney damage *ETIOLOGY* - DM - diminished bladder capacity - hyperactive detruser muscle - CVA - other disease processes - infection - nerve damage *S&S* - frequent UTIs - leakage of urine - inability to empty bladder OR loos of urge to urinate when bladder is full - *DX* to include eval by MD, x-rays, urodynamics to assist with diagnosis *TREATMENT* - dependent on etiology with goal of preventing bladder over distention, UTIs, and renal damage - patient education - bladder techniques - lower abdominal massage - temporary catheterization - pharmacological interventions - timed urination program

Urinary Tract Infection (UTI)

- higher incidence in women and geriatric population - classified as uncomplicated, complicated, recurrent, or chronic *etiology* - bacteria infiltrate urethra (urethritis) or further into bladder (cystitis) - if untreated, can cause kidney infection (pyelonephritis) *S&S* - increased urination - pain &/or burning with urination - cloudy urine - pressure above pubic bone - shakiness - fever - back pain - fatigue *treatment* - early treatment has best results - delayed treatment may allow for serious infection to occur - pharmacological interventions: bacteria-specific antibiotics - drink excess of fluids

Urinary Incontinence

- involuntary loss of urine; great enough to be problematic for person and typically occurs when bladder pressure exceeds sphincter resistance *general treatment* - pelvic floor muscle retraining with biofeedback - lifestyle modifications - bladder retraining - prompted voiding program - urge suppression strategies - myofascial release - visceral mobilization - body mechanics - abdominal stretching & strengthening - pharmacological interventions - surgical intervention for urethral or bladder positioning

Urge Urinary Incontinence

- loss of urine after sudden, intense urge to void due to the detrusor muscle of bladder involuntarily contracting during bladder filling - *most common incontinence in GERIATRIC pop.* *etiology* - detrusor muscle overactivity OR increased sensitivity to acetylcholine - overactive bladder aka "urgency-frequency" syndrome - changes in smooth muscle of bladder - increased afferent activity - idiopathic - association with neurological disorders: MS, SCI, CVA, PD *S&S* - triggered by certain events due to a conditioned reflex - "key-in-the-lock" when arriving home & running water *treatment* - behavior modification - biofeedback - pelvic floor muscle strengthening - bladder retraining - pharmacological intervention if necessary

Stress Urinary Incontinence

- loss of urine due to activities that increase intra-abdominal pressure - sneezing, coughing, laughing, running, jumping

Functional Urinary Incontinence

- loss of urine due to inability of unwillingness to sue bathroom prior to involuntary bladder release *etiology* - decreased level of mental awareness or decrease in mobility - rarely seen without other bladder issue or neurological involvement *S&S* - impaired cognition &/or mobility - experience incontinence secondary to inability to successfully use bathroom to void *treatment* - treatment directed towards underlying issue

Overflow Urinary Incontinence

- loss of urine when the intra-bladder pressure exceeds the urethra's capacity to remain closed due to urinary retention *etiology* - caused by outflow obstruction secondary to narrowed or obstructed urethra that results from a prolapsed pelvic organ, a stricture, an enlarged prostate, chronic constipation or neurological disease *S&S* - difficulty initiating urine stream - stream is weak and presents with post void dribble *treatment* - surgical intervention in obstruction is present - if muscle weakness is present, double voiding and strengthening - intermittent catheterization if other interventions fail

Rehab Considerations for Renal Failure/Dysfunction

- modify treatment plan based on fluid and electrolyte status - standard precautions should be followed at all times for protection - monitor vitals closely, however, avoid placement of BP cuff over fistula - avoid mobilization activities as they are contraindicated during dialysis - energy conservation techniques and pacing skills should be incorporated into therapy

Renal Failure: Chronic

- progressive deterioration in renal function - DM - severe hypertension - glomerulopathies - obstructive uropathy - interstitial nephritis - polycystic kidney disease

Renal Failure: Acute

- sudden decline in renal function - increase in BUN and creatine - oliguria (small amounts of urine), hyperkalemia (high calcium), sodium retention - *prerenal etiology* is secondary to a decrease in blood flow typically due to shock, hemorrhage, burn or pulmonary embolism - *postrenal etiology* is secondary to obstruction distal to kidney due to neoplasm, kidney stone or prostate hypertrophy - *intrarenal etiology* is secondary to primary damage of renal tissue due to toxins, internal ischemia or vascular disorders

Renal Failure: S&S

- symptoms based on severity of condition INCLUDE: - nausea - vomiting - lethargy - weakness - hiccups - anorexia - ulceration within GI tract - sleep disorders - headache - peripheral neuropathy - anemia - pruritus (itching) - osteomalacia - ecchymosis (escape of blood vessels into tissue) - pulmonary edema - seizures - coma

Hemodialysis

- treatment process for patients with advanced and permanent kidney failure *kidney failure* creates excess waste, increased blood pressure, retention of excess bodily fluids, and decrease in RBC production *hemodialysis* removes the blood from the body along with waste, excess sodium, and fluids - the process cleanses the blood and returns in to the body - on average, *3 times per week for 3-5 hours* required to complete treatment - *side effects* include; anemia, renal osteodystrophy (dystrophic bone growth), pruritus, sleep disorders ("restless legs"), dialysis-related amyloidosis (abnormal protein build-up)

Pelvic Floor Muscle Exercises

-Assess pelvic floor muscles for strength -Factors to consider: position, endurance, and repetitions -Introduce new positions transitioning from gravity assisted to standing as strengthening and awareness of pelvic floor muscles increase -Goal should be for patients to perform contractions with functional tasks -80 to 100 contractions per day (combine quick, long hold, and functional contractions) *Quick contractions:* important for withstanding increased intraabdominal pressure -begins with 3x10 quick contractions daily (hold 2s; rest 4s) *Long hold contractions:* for endurance training and important for maintaining proper posture and pelvic support -begin with 3 sets of 5 long hold contractions daily (hold 5s; rest 10s; gradually increase the contraction time to 10s) *NOTE: make sure patient fully relaxes after each contraction*

Back Pain During Pregnancy

-Reported in 70% of pregnant women -Caused by physical changes associated with pregnancy (i.e. weight gain, altered muscle tone, increased lordosis, changes in COG, laxity within pelvic ligaments -Excessive bending , lifting, and walking can produce back pain especially if there is a history of back pain or obesity *Minor Back Pain:* -education related to body mechanics, postural awareness, and stretching and strengthening to provide balance within musculature *Severe Back Pain:* -should not be dismissed as a side effect -etiology may include pregnancy induced osteoporosis, disk disease or herniated disk, vertebral OA, and septic arthritis -patients with both minor and severe back pain should be examined to determine if the source of the pain is mechanical, muscular, joint , or discogenic

Exercise & Pregnancy

-Should be encouraged to continue physical activity -Moderate rate during a low risk pregnancy -50-60% of their maximal heart rate for ~30 mins -NWB activities are preferred due to the continuous change of COG -Loose clothing is advised to allow for adequate heat loss, and adequate fluids are required during exercise -Women should avoid becoming overtired and should not exercise in the supine position after the first trimester

Recommendations for Exercise in Pregnancy and Post-Partum from American College of Obstetricians and Gynecologists

-continue to exercise; mild-moderate exercise routines -regular exercise (3x/week) is preferable to intermittent -avoid exercising in supine position after 1st trimester (decreased cardiac output) -prolonged periods of motionless standing should be avoided -be aware of decreased oxygen available for aerobic exercise during pregnancy; modify intensity if needed -stop exercising when fatigued; do NOT exercise to exhaustion -non weight bearing exercises will minimize the risk of injury and facilitate continuation of exercise during pregnancy -pregnancy requires an extra 300kcal per day in order to maintain metabolic homeostasis (ensure an adequate diet) -adequate hydration, appropriate clothing, and optimal environmental surroundings during exercise -many physiological and morphological changes of pregnancy persist for 4-6 weeks post-partum; routines should be resume gradually

Physiological and Postural Changes during Pregnancy

-weight gain= 25-35 -uterus ascends into the abdominal cavity becoming an abdominal organ -ribs expand to accomodate the uterine ascent; respiratory diaphragm elevates 4 cm -increased depth of respiration; tidal volume; and minute ventilation -increased oxygen consumption (15-20%), blood volume (40-50%), and cardiac output (30-60%) -hypotension in supine position during pregnancy from pressure on the inferior vena cava -abdominals become overstretched; ligaments become lax secondary to hormonal changes -joints may become hypermobile

Piriformis Syndrome

Persistent, severe radiating low back pain and buttock pain. -spans from sacrum to the hip and posterior thigh *Etiology:* -during pregnancy the piriformis may shorten or spasm due to postural changes and hip lateral rotation while walking *Signs & Symptoms:* -sciatic paresthesia due to nerve entrapment *Treatment:* -manual techniques for correcting pelvic or sacral alignment such as MET, joint mobs, self-correction techniques, heat application, deep tissue massage, myofascial release, strain-counterstrain, abdominal strengthening, stretching exercises

Diastasis Recti

Separation of the rectus abdominis muscle along the linea alba that can occur during pregnancy. -testing for diastasis recti should be performed on all pregnant women prior to prescribing exercises that require the use of the abdominals *Etiology:* -unknown -theory: biomechanical and hormonal changes in women -therapist note how many fingers fit into the separation and modify treatment accordingly *Signs & Symptoms:* -therapist detects a separation greater than the width of two fingers when the woman lifts her head and shoulders of the plinth *Treatment:* -stabilization and support with abdominal strengthening exercises, postural awareness exercises, and body mechanics training -newborns can also have disastasis recti secondary to incomplete development (usually resolves itself)