Urology comes from Greek meaning ‘study of urine’. Typically, more males are seen by urologists and there has been an increase in the subspecialities of neurourology and urogynaecology. However, urologists predominantly deal with males and females presenting with a wide range of common conditions affecting the kidneys, bladder, prostate, and male reproductive organs (Figure 1). The symptoms may be linked to benign or malignant conditions or be a symptom, such as urinary incontinence, of an underlying disorder. Conditions affecting the genitourinary system are not always life-threatening, but they can have a major impact of quality of life (QoL). Approximately 90% of men between 50-80 years live with one or more lower urinary tract symptoms, which affect their QoL (The Urology Foundation, 2014).
With more than 750 000 episodes of care in the UK each year (Harrison, 2018), urology as a specialty is faced with high demand. As a result of increased pressure on the specialty, nurses are more frequently engaging in clinical consultations to bridge the gap between workload demands and service provision. Therefore, it is vital to have more nurses with advanced clinical skills—advanced clinical practitioners (ACPs)— to offer patients a better experience. They will undertake systematic assessments of genitourinary symptoms, establish reliable recognition of clinical presentations, make a differential diagnosis with the findings, and formulate an action plan for therapeutic options (Harrison, 2018). Table 1 shows the common reasons for genitourinary symptom assessment.
Table 1. Common reasons for genitourinary symptom assessment
| Urinary retention | This can be acute as a medical emergency, chronic due to incomplete emptying of the bladder, or acute on chronic. Retention accounts for 30 000 hospital admissions each year. Men are significantly more at risk of acute retention than women and it is more common in the 60 to 80-year-old age bracket, secondary to benign prostatic hyperplasia (BPH) (Kuppusamy and Gillatt, 2011). Acute retention in younger males and females is suggestive of neurological impairment (Dougherty and Aeddula, 2021) |
| Urinary tract infection (UTI) | The incidence of UTI is highest in young females and increases with age in both sexes (National Institute for Health and Care Excellence (NICE), 2015a). Incidence is higher older males due to outflow obstruction caused by benign prostate growth, urethral stricture or urinary tract stones (NICE, 2018). Predisposing factors for females are pregnancy, sexual intercourse, vaginal atrophy (post-menopause) and presence of a cystocele (NICE, 2021). It is estimated 10% of males and 20% of females aged over 65 years have asymptomatic bacteriuria (Scottish Intercollegiate Guidelines Network (SIGN), 2012) |
| Urinary tract stones | The prevalence of stone disease continues to increase in the western world, commonly due to lifestyle-associated factors and, in the UK, approximately 6000 patients require hospital admission each year (Knott, 2021). Stones causing an obstruction in the lower urinary tract predispose people to infection, sepsis or kidney impairment |
| Overactive bladder syndrome | Affecting 17% of the population aged over 40 years and defined as urinary urgency with or without urge incontinence, it is usually associated with urinary frequency and nocturia in the absence of other pathology (Reynard et al, 2019). The symptoms are often attributed to bladder outflow obstruction in men |
| Indwelling catheter complications | Up to 50% of people with long-term indwelling catheters experience complications. Urinary catheters increase the risk of infection, urosepsis, urethral trauma and recurrent blockages resulting in hospital admission (Nazarko, 2019) |
Communication
The quality of the communication during nurse–patient consultations can have a considerable impact on patient outcomes (O’Hagan et al, 2014). Therefore, the nurse should use a combination of verbal and non-verbal communication skills, be aware of barriers to effective communication, such as language and cultural differences, speech or hearing impairment, and the setting in which the consultation is taking place. An interpreter or advocate should be offered when appropriate (National Institute for Health and Care Excellence (NICE), 2015a).
Because bothersome lower urinary tract symptoms (LUTS) such as frequent voiding, urinary incontinence or impotence can be distressing and embarrassing to discuss, it is vital to overcome barriers and establish effective communication with the person. Sensitive handling is essential to ask questions that may be intrusive, and anticipating potential embarrassment can facilitate difficult conversation. Therefore, promoting a patient–nurse relationship based on trust can have a direct therapeutic effect and significantly impact the effectiveness of communication and subsequent disclosure of information by the patient (Rasiah et al, 2020).
Many patients worry about undergoing intimate procedures, having tests can be uncomfortable, embarrassing or undignified. Discussing problems can also be difficult: evidence suggests that men are more likely to find discussing problems embarrassing, with 39% unwilling to mention urological concerns. Age can be a factor in potential embarrassment (The Urology Foundation, 2014) and embarrassment can lead to inappropriate use of terminology for body parts or functions (Ali, 2017).
Offering a chaperone (an impartial observer whose name should be documented in the records) for intimate examination of the patient is good practice as it safeguards both parties (Nursing and Midwifery Council, 2018). Considering cultural factors is best practice because in some communities examinations on the opposite sex, genitalia and rectum can be considered intrusive.
The assessment process
The genitourinary consultation should be a structured process that provides the nurse with sufficient information to make a differential diagnosis. The systematic person-centred assessment should include open and closed questions, providing adequate time for the person to respond, explore and expand on the presenting complaint. It is important to seek the reason for presentation or referral, obtain a comprehensive medical history, undertake a physical examination, and initiate or conduct investigations. It may be essential to ask questions of a sensitive nature to obtain an accurate picture of the problem, enable accurate diagnosis and to ensure appropriate management/treatment.
The nurse will require a comprehensive understanding of pathology, pharmacology, comorbidities and progression of disease states affecting the genitourinary system, which will underpin decision-making for subsequent tests and investigations. The nurse should have the skills to recognise red-flag symptoms of weight loss, haematuria or palpable mass, and relate them to potential pathology requiring urgent action. However, consulting with the multidisciplinary team is vital to guarantee patient safety and ensure the best outcomes for the patient.
Patient history
An assessment would begin with finding out what the patient perceives to be the problem, their main concerns and the outcome that they hope to achieve from the consultation (their expectations). Useful questions include:
- What has brought you here today?
- What is the main concern?
Table 2 outlines key symptoms to explore in taking a history of the presenting complaint.
Table 2. History of presenting complaint: genitourinary system
| Key symptoms | Urinary symptoms
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Men
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Women
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Both
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| Classification of lower urinary tract symptoms (NICE, 2015b; 2019) | Storage: urgency with or without leakage, frequency and nocturiaVoiding: weak or intermittent flow, hesitancy, terminal dribble, straining and incomplete emptyingPost-micturition: frequent and bothersome post-micturition dribble | |||
| Example questions to elicit information on urinary symptoms |
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Systemic enquiry
The ACP would go on to assess other body systems that may or may not be linked to the presenting complaint, such as neurological or gastrointestinal system.
Past medical history
- UTI, incontinence, prostate disease, diabetes, bleeding disorders—questioning may indicate gradual disease progression
- Are comorbidities well-controlled?
- Any previous treatment or investigations?
- Surgery, ie transurethral resection of prostate (TURP)
- Any recent surgical instrumentation? (According to Thurtle and Biers (2017) recent urinary instrumentation increases the risk of UTI.)
- Any urogenital conditions such as hypospadias, ambiguous genitalia or polycystic kidney disease.
Allergies to note
- Medication, creams, fixation tape etc
- Latex—some indwelling catheters are made from latex or coated latex.
Prescribed and over-the-counter medication
It is important to ask about medications that the patient is taking.
- Diuretics: may indicate hypertension and account for urinary frequency symptoms
- Alpha blockers: may indicate history of prostate enlargement
- Nephrotoxic: combinations of drugs used to manage comorbidities such as diabetes and hypertension may impair renal function
- Opioids: may induce urinary retention and constipation
- Currently on antibiotics or recurrent usage?
Bowel regime
Ask the patients what their usual regimen is, using the baseline measurement as ‘the rule of 3’; up to three times per day, three times per week or every third day. Record the type of stool using Bristol Stool Scoring Tool. Constipation can increase symptoms of urinary frequency and weaken muscles in the pelvic floor if ‘straining’ is required to initiate defaecation.
For female patients
- Menstrual cycle: is there a link to cyclical pain and worsening premenstrual bladder symptoms?
- Obstetric history: number of pregnancies, any multiple births, were birth weights over 3.6 kg? Such factors can weaken the pelvic floor muscles leading to stress urinary incontinence (SUI).
Family history
- Any history of urological disease?
- Any history of breast cancer? Around 20-25% of men who carry the BRCA2 (breast cancer gene 2) alteration will develop prostate cancer at some point in their life (Oxford Regional Genetic Department, 2014).
Social history and lifestyle habits: questions to ask
- What is your job and pattern of working?
- Do you smoke? How many cigarettes per day? (Smoking is a bladder irritant and increases symptoms of urinary frequency. Smoking can also increase the risk of bladder cancer)
- Do you drink a lot of coffee, ‘energy drinks’ or fizzy drinks? (Drinks containing caffeine, as well as carbonated drinks, act as a bladder irritant and increase symptoms of urinary frequency and urgency)
- Do you drink alcohol? How many units per week? (Alcohol acts as a diuretic by inhibiting the production of vasopressin, increasing symptoms of urinary frequency)
- Any recreational drug use?
- Can you tell me about your diet?
- What is your daily fluid intake?
- Have you been on a foreign holiday recently?
Foreign travel
Recent travel to Egypt or the Middle East may have exposed the person to a parasite that causes urinary schistosomiasis. Presenting symptoms of acute schistosomiasis may include fever, haematuria, pain during voiding or urinary frequency. Further testing of the urine may reveal the presence of eggs, which may also be present in faeces. Cystoscopy may identify eggs in the trigone area of the bladder, just above the bladder neck (Reynard et al, 2019). Alternatively, dehydration during a holiday in a hot climate may lead to the development of kidney stones.
Recreational drug use: ketamine
Ketamine was reclassified from category C drug to category B in 2014 due to new evidence of its chronic toxicity in the bladder (Advisory Council on the Misuse of Drugs, 2013). Ketamine damage can affect the bladder and entire urinary tract. Presentation may be reduced bladder capacity, urinary frequency, urgency, haematuria or suprapubic pain (Misra, 2018).
Physical examination
- Abdominal palpation: assess for tenderness, distended palpable bladder (volume over 300 ml)
- Digital rectal examination (DRE): this is to assess the prostate, anal sphincter tone and presence of blood. The size, consistency and contour of the prostate gland should be recorded. Prostate Cancer UK recommends that assessment takes place after a prostate-specific antigen (PSA) blood test. The level of this protein will be raised if malignancy is detected
- Inspection of the external genitalia for phimosis, hypospadias, penile or urethral trauma
- Pelvic examination (females): record prolapse type and grade, measurement of pelvic floor muscle contraction, urine leakage, evidence of vaginal atrophy, lichen sclerosus.
Tests and investigations
These may include:
- Intraoperative CT/MRI/ultrasound scan to investigate haematuria, chronic retention or recurrent UTI
- Bloods: assessment of renal function by measuring urea and electrolytes and creatinine, plus full blood count for general screening
- Urinalysis/culture
- Cytology
- PCA3 (prostate cancer gene 3) urine test
- Measurement of blood pressure
- Portable bladder ultrasound scan to measure post-void residual volume. A post-void residual less than 100 ml of urine is deemed acceptable (Darrah et al, 2009)
- Cystoscopy is the gold standard for assessing the lower urinary tract
- Photodynamic diagnosis: a light-sensitive drug is put into the bladder prior to cystoscopy to enable primary diagnosis of bladder tumours
- Biopsy: transrectal (under local anaesthetic), or transperineal (under general anaesthetic) fine-needle biopsies taken from all lobes of the prostate gland
- Urodynamics/uroflowmetry
- Bladder diary completed over 3 days to assess bladder behaviour during normal daily activities
- International Prostate Symptom Score (I-PSS) a tool to assess the severity of LUTs in men and their impact on QoL (NICE, 2019).
Urine testing
Appropriate use of urine examinations leads to accurate, fast and cost-effective diagnosis, subsequent management of urological disease, eg evaluating UTI and urinary schistosomiasis, and reveals information on the physiology and pathology of the patient (Musa, 2015).
Urine cytology is not 100% reliable because testing can provide false-positive results in the presence of non-malignant abnormal cells or false negatives when cancer is present in abnormal cells.
A PCA3 urine test is a genetic test used to measure the risk of prostate cancer and to determine elevation of PSA. PCA3 can be detected in urine, and high levels will be present with malignancy. The test may reduce the need for biopsy, but the results will be combined with a rectal examination of the prostate gland and information provided by the scan results.
Uroflowmetry
This is a non-invasive diagnostic screening procedure to measure the volume of urine passed, the flow rate in millilitres per second and the time taken to complete the void. Test results are based on several factors. Voided volume should be in excess of 150 ml; a lower volume may indicate a significant storage problem in men. A normal maximum flow rate (Qmax) for a male would be over 15 ml/second compared with a Qmax of 20-36 ml/second in females. Slow or low flow is indicative of an obstruction and fast or high flow is indicative of weak muscles.
Urodynamics
This is a functional study of the lower urinary tract: it is a diagnostic and prognostic tool for people with incontinence and LUTS. According to Nambiar et al (2017), there is no better test for evaluating bladder function and determining underlying pathology in patients with lower urinary tract conditions or urinary incontinence who do not respond to first-line therapies.
Conclusion
As specialist services are increasingly in demand, specialist nurses and ACPs play a pivotal role is the assessment and subsequent management of patients presenting with genitourinary symptoms. Nurses with advanced skills play a key role in ensuring patients receive expert, efficient and safe patient care. Advanced skills include history taking, physical examination and an understanding of appropriate tests and imaging that will supplement the assessment. Effective communication and consultation skills are essential to promote disclosure of appropriate information to enable a differential diagnosis. The nurse should maintain a comprehensive knowledge of genitourinary symptoms and disease processes because it is important to be able to recognise and relate symptoms to potential pathology.
KEY POINTS
- Urinary symptoms can be bothersome and impact on quality of life
- Many elements in the history can help in the diagnosis of urological problems
- A comprehensive assessment is required that will provide adequate information to formulate a diagnosis
CPD reflective questions
- Are you using the most effective communication skills to gather information?
- In relation to common urology complaints, are your knowledge and skills up to date?
- Do you offer patients a chaperone?