9.2 Genitourinary Symptoms

9.2 Genitourinary Symptoms

Domain 3 letter E is genitourinary. Stems mix catheters, perineal skin, anticholinergic side effects, and goals of care. HPCC still wants generic names (oxybutynin, tamsulosin, morphine) and a scaled passing score of 500. Catheter choice is a goals question, not a one-size protocol.

Urinary retention: name the cause before you leave a Foley

Urinary retention in hospice is usually drug-induced, outlet obstruction, constipation, clot, or neurologic.

• Opioids increase sphincter tone and blunt detrusor contraction. New retention after a morphine start is not mysterious.
• Anticholinergics—oxybutynin, scopolamine, tricyclic antidepressants, first-generation antihistamines, atropine-like secretion drugs—relax the detrusor. The same class you use for bladder spasms can cause retention.
• Benign prostatic hyperplasia (BPH) plus an opioid or an anticholinergic is a setup. Tamsulosin (an alpha-1 blocker) may help outlet resistance when goals include voiding without a catheter.
• Fecal impaction mechanically obstructs the urethra and is reversible with a bowel plan (Section 9.1).
• Spinal cord compression (Chapter 8) produces overflow, a sensory level, and often bilateral weakness. Retention here is a neurologic emergency relative to remaining function if dexamethasone and imaging still match goals—not a “Foley and ignore” item.
• Clot tamponade from hematuria fills the bladder with clot; the patient strains and passes little urine.

Assess with a bladder scan or in-and-out catheterization, abdominal exam, rectal exam, medication review, and a spinal screen. A single in-and-out catheter treats an isolated opioid-related episode if you also stop the offending anticholinergic and start a bowel regimen. Recurrent retention, dying with a full bladder that causes agitation, or wound-care needs may justify an indwelling urethral catheter.

Urinary obstruction above the bladder

Ureteral obstruction from cervical, prostate, or retroperitoneal disease causes hydronephrosis, flank pain, and eventually uremia. Ureteral stents or percutaneous nephrostomy reverse obstruction when the patient wants more time, dialysis-level kidney function, or relief of colic that drainage will actually treat. When death is days away, the CHPN action is comfort: treat pain, treat uremic nausea with a dopamine antagonist, treat delirium, and do not send an actively dying patient across town for a nephrostomy that will not change the dying process.

Hematuria

Palliative hematuria ranges from pink urine to clot retention and tamponade. Nursing first moves: continuous bladder irrigation to keep clots from filling the bladder, catheter care, and a calm explanation to the family that color is not always volume loss. Palliative radiation can reduce bleeding from a bladder or prostate tumor when travel, performance status, and remaining weeks make a radiation visit worth the burden. Specialist tools (alum irrigation, cystoscopic clot evacuation) exist when prognosis and goals support a procedure. Transfusion is a goals conversation: a still-ambulatory patient with symptomatic anemia may benefit; an imminently dying patient usually needs presence, dark linens, and anxiolysis more than another unit.

Fistula

Vesicovaginal, rectovaginal, and enterovesical fistulas produce odor, wetness, and devastating shame. Diversion surgery is for selected patients with months of life and reconstructable anatomy. Most hospice care is conservative: barrier films, frequent linen changes, charcoal or metronidazole for odor when bacterial overgrowth is the smell, pouching when the opening can be captured, and social-work and chaplain support. Do not promise that a Foley will dry a vesicovaginal fistula; it may reduce volume, but urine can still leak through the tract.

Incontinence, skin, and choosing a device by goals

Urine on skin macerates the sacrum and perineum and fuels fungal infection. The intervention is dryness plus barrier, not a moral lecture about “being wet.” Device choice follows goals, skin, retention, infection risk, and caregiver capacity—not staff convenience alone, and not a reflex Foley for every incontinent dying person who can still be kept dry with pads and turning.

Indwelling catheters raise infection risk. In hospice the competing harm is skin breakdown, pain, and terminal agitation from retention. Document the goal the catheter serves. A condom catheter is only for a man who is emptying the bladder; it does nothing for retention and can constrict penile skin if poorly fitted.

Decision table: pads versus condom catheter versus Foley

Bladder spasms: oxybutynin with a caution label

Bladder spasms after a catheter, with tumor in the bladder wall, or with radiation cystitis feel like sudden suprapubic cramping and urgency. Oxybutynin and related antimuscarinics reduce detrusor spasm. They also cause dry mouth, constipation, urinary retention (if a catheter is not already draining the bladder), blurred vision, heat intolerance, and delirium—especially in frail older adults and in patients already on scopolamine or a tricyclic. If spasms started after a Foley balloon inflated against a small bladder, try less balloon water or a smaller catheter before stacking anticholinergics. Belladonna-and-opium rectal suppositories appear in some protocols; they are still anticholinergic plus opioid. Non-drug checks: infection, constipation, and catheter tug on the trigone.

When retention and spasm coexist, treat the retention first. Oxybutynin on a full, undrained bladder is the wrong sequence.