Genitourinary Disorders
Alterations in Renal Function
Biological Variances
All nephrons are present at birth
Kidneys and tubular system mature throughout childhood
reaching full maturity during adolescence.
During first two years of life kidney function is less
efficient.
Bladder
Bladder capacity increases with age
20 to 50 ml at birth
700 ml in adulthood
Urinary Output
Urinary output per kilogram of body weight decreases as
child ages because the kidneys become more efficient.
Infants 1-2 mL/kg/hr
Children 0.5 – 1 mL/kg/hr
Adolescents 40 – 80 mL/hr
Growth and Development
Newborn = loss of the perfect child
Toddler = toilet training
Pre-school = curiosity
School age = embarrassment
Adolescent = body image / sexual function
Focused Health History
Single umbilical artery
Chromosomal abnormality
Congenital anomalies
Ear tags
Toilet training history
Family history
Growth patterns
Urine
Urinalysis
Protein
Leukocytes
Red blood cells
Casts
Specific Gravity
Urine Culture for bacteria
Diagnostic Tests
Urinalysis
Ultrasound
VCUG – Voiding cysto urethrogram
IVP – Intravenous pyelogram
Cystoscopy
CT Scan
Renal Biopsy
VCUG
IVP
Intra Venous Pyelogram
Renal Biopsy
Cystoscopy
CT Scan
Treatment Modalities
Urinary diversion
Stents
Drainage tubes
Intermittent catheterization
Watch for latex allergies
Pharmacological management
Antibiotics
Anticholinergic for bladder spasm
Urinary Tract Infection
Most common serious bacterial infection in infants and
children
Highest frequency in infancy
Uncircumcised males have a ten-fold incidence
Etiology
Anatomic abnormalities
Neurogenic bladder – incomplete emptying of bladder
In the older child: infrequent voiding and incomplete
emptying of bladder or constipation
Teenager: sexual intercourse due to friction trauma
UTI - Females
Most common in females
Short urethra
Improper wiping
Nylon under pants
Current guidelines – do ultrasound with first UTI followed
by VCUG if indicated
UTI – Males
Infant males
Needs to be investigated
VCUG – ureteral reflux
Ultrasound of kidneys – hydronephrosis or polycystic kidneys
Higher in un-circumcised males
Un-circumcised males
Instruct parents to gently retract foreskin for cleansing
Do not force the foreskin
Do not leave foreskin retracted or it may act as tourniquet
and obstruct the head of the penis resulting in emergency circumcision
Clinical Manifestations: UTI
Urinary frequency
Hesitancy
Dysuria
Cloudy, blood tinged
Must smell to urine
Temperature
Poor feeding / failure to grow
The neonate may only exhibit 6 & 7
Interventions
Antibiotic therapy for 7 to 10 days
E-coli most common organism 85%
Amoxicillin or Cefazol or Bactrim or Septra
Increase fluid intake
Cranberry juice
Sitz bath / tub bath
Acetaminophen for pain
Teach proper cleansing
Urethritis
Urethral irritation due to chemicals or manipulation
Most common in females
Bubble bath, scented wipes, nylon under wear
Self-manipulation
Child abuse
Voiding Disorders
Delay or difficulty in achieving control after a socially
acceptable age.
Enuresis
Nocturnal = at night
Diurnal = during the day
Secondary = relapse after some control
Toilet Training Readiness
12 months no control over bladder
18 to 24 months some children show signs of readiness
Some children may not be ready until around 30 months
Enuresis
Involuntary discharge of urine after the age by which
bladder control should have been established, usually considered to be age of
5 years.
Enuresis
Familial history
Males outnumber females 3:2
5 to 10% will remain enuretic throughout their lives
Rule out UTI, ADH insufficiency, or food allergies
Interventions
Pharmacological intervention:
Desmopressin synthetic vasopressin acts by reducing urine
production and increasing water retention and concentration
Tofranil: anticholinrgic effect – FDA approval for treatment
of enuresis
Side effect may be dry mouth and constipation
Some CNS: anxiety or confusion
Need to be weaned off
Treatment Enuresis
Diet control
Reduce fluids in evening
Control sugar intake
Bladder training
Praise and reward
Behavioral chart to keep track of dry nights
Alarm system
Ureteral Reflux
Males 6 to 1
Genetic predisposition
Present as UTI or FTT
Diagnostic tests
Antibiotics if indicated
Surgery to re-implant ureters
Hydronephrosis
Water on kidney
Due to obstruction
Congenital anomaly
Goals of care to maintain integrity of kidney until normal
urinary flow can be established.
Clinical Manifestations
History of UTI
Followed by flank pain, fever and chills
Decrease in urinary outflow
Neonate may present as UTI
An older child may be asymptomatic except for failure to
thrive
Diagnostics
Ultrasound
VCUG: voiding cyto urethrogram
IVP is the first two are positive
Goals of treatment
To preserve renal function
Temporary urinary diversion may be needed to relieve the
pressure.
Nephrectomy if renal damage is not reversible
Ambiguous Genitalia
Genital appearance that does not permit gender declaration.
Agenesis of Scrotum
Hypertrophy of Clitoris
Extrophy of Bladder
Interrupted abdominal development in early fetal life
produces an exposed bladder and urethra, pubic bone separation, and associated
anal and genital abnormalities.
Exstrophy of Bladder
Occurs is 1 of 30,000 births
Congenital malformation in which the lower portion of
abdominal wall and anterior bladder wall fail to fuse during fetal
development.
Clinical Manifestations
Visible defect that reveals bladder mucosa and ureteral
orifices through an open abdominal wall with constant drainage of urine.
Extrophy of Bladder
Treatment
Surgery within first hours of life to close the skin over
the bladder and reconstruct the male urethra and penis.
Urethral stents and suprapubic catheter to divert urine
Further reconstructive surgery can be done between 18 months
to 3 years of age
Goals of Treatment
Preserve renal function: prevent infection
Attain urinary control
Re-constructive repair
Sexual function
Long Term Complications
Urinary incontinence
Infection
Body image
Inadequate sexual function
Hypospadias
Most common anomaly of the male phallus
Incomplete formation of the anterior urethral segment
Urethral formation terminates at some point along the
ventral fusion line.
Cordee – downward curve of penis.
Newborn
Circumcision not recommended.
Foreskin may be needed for reconstructive surgery.
Tight Chordee
Goals of Treatment
Release of tight chordee
Placement of urethra opening at head of penis
Surgery recommended at around six to nine months of age
Long term outcomes:
Leaking at the site
Body image
Cryptorchidism (undescended testicles)
Hidden testicle
3 to 5% of males
High incidence in premature infants
Goals of treatment:
Preserve testicular function
Normal scrotal appearance
Treatment
Most testes spontaneously descend.
Surgical procedure, orchiopexy, if testicles do not descend
into the scrotal sac by 6 to 12 months of age
Hormone therapy – human chorionic gondadotropin
Slightly higher risk of testicular cancer if untreated
In the teen or adult the testicle would be removed
Long-term
Monthly testicular self-examination is recommended for all
males beginning in puberty, but is essential in males with history of
undescended testicle.
Testicular Torsion
Rotation of the testicle
Spermatic cord twists and obstructs circulation to the
testis
Left testicle affected more
Longer cord on left side
Clinical Manifestations
Sudden severe pain in the scrotal area
Highest incidence on left side due to longer cord on that
side
Goals of Treatment
Surgical intervention
To relieve obstruction
Preserve the testicular function
Secure testicle to avoid further twisting
Acute Renal Failure
Pre-renal, resulting from impaired blood flow to or
oxygenation of the kidneys.
Renal, resulting from injury to or malformation of kidney
tissues.
Post-renal, resulting from obstruction of urinary flow
between the kidney and urinary meatus.
Renal Failure
Newborn causes:
Congenital anomalies
Hypotension
Complication of open heart surgery
Renal Failure
Childhood causes:
Dehydration
Glomerular nephritis / Nephrotic Syndrome
Nephro-toxicity / drug toxicity
Clinical Manifestation: ARF
Sudden onset
Oliguria
Urine output less than 0.5 to 1 mL/kg/hour
Volume overload due to retained fluid
Hypertension, edema, shortness of breath
Acidosis
Diagnostic Tests
Decrease RBC due to erythropoietin
Urea and Creatinine
elevated
GFR (glomerular filtration rate)
most sensitive indicator of glomerular function.
Urea or BUN
Urea is normally freely filtered through the renal glomeruli,
with a small amount reabsorbed in the tubules and the remainder excreted in
the urine.
Decrease or increase in the value does not tell the cause:
pre-renal, post-renal or renal.
Elevated BUN just tells you the urea is not being excreted
by the kidney not why.
Creatinine
Creatinine is a very specific indicator of renal function.
If kidney function is decreased / creatinine level with be
increased
Conditions that will increase levels: glomerulonephritis,
pyelonephritis or urinary blockage
Creatinine levels
Adult female: 0.5-1.1 mg/dL
Adult male: 0.6-1.2 mg/dL
Adolescent: 0.5-1.0 mg/dL
Child: 0.3-0.7 mg/dL
Infant: 0.2-0.4 mg/dL
Newborn: 0.3-1.2 mg/dL.
Goals of Treatment: ARF
Reduce symptoms
Supportive care until renal function returns
Medications – corticosteroids
Dietary restrictions
Dialysis if indicated
Nursing Diagnosis
Fluid Volume excess
Potential for infection due to invasive procedures
Potential for activity intolerance
Altered nutrition: less than body requirements
Anxiety of patient and family
Peritoneal Dialysis
The child’s own peritoneal cavity acts as the semi-permeable
membrane across which water and solutes diffuse.
Often initiated in the ICU.
Dialysis set-ups are available commercially.
Peritoneal Dialysis
Soft catheter is used to fill the abdomen with a dialysis
solution.
The solution contains dextrose that pulls waste and extra
fluid into the abdominal cavity.
Dialysis fluid is then drained.
Dialysis fluid
High glucose concentrate: 2.5 to 4.25%
The osmotic pressure of the glucose in solution draws the
fluid from the vascular spaces into the peritoneum, making available for
exchange and elimination of excess fluid.
Complications of Peritoneal Dialysis
Peritonitis
Pain during infusion of fluids
Leakage around the catheter
Respiratory symptoms
Abdominal fullness from too much fluids
Leakage of fluid to chest from hole in diaphragm
Hemodialysis
Used in treatment of advanced and permanent kidney failure.
Blood flows through a special filter that removes waste and
extra fluids.
The clean blood is then returned to the body.
Done 3 times a week for 3 to 5 hours.
Dialysis
Nephrotic Syndrome / nephrosis
Etiology is not know, it is felt to be the result of an
alteration of the glomerular membrane, making it permeable to plasma proteins
(especially albumin).
Clinical Manifestations
Generalized edema
Edema is worse in scrotum and abdomen (results in ascites)
Dramatic weight gain
Pale, fatigue, anorexic
Urinary output decreased
Urine dark and frothy with elevated SG
Urine Specific Gravity
1.010 Normal value
Increased Urine SG
Dehydration – diarrhea – excessive sweating - vomiting
Decreased Urine SG
Excessive fluid intake – pyelonephritis - nephritis
Diagnostic evaluation
Proteinuria
* 4+ urine in urine
Hypoproteinemia
Low serum plasma protein
Hyperlipidemia
* Fat cells in blood
BUN and Creatinine normal unless renal damage
Goals of Treatment
To decrease urinary protein loss
Controlling edema
Corticosteroids up to 12 months
Balanced nutrition
Restore normal metabolic function
Prevent or treat any infection
Interventions
Diuretics (during acute phase lasix would be given after IV
albumin)
Fluid restriction if edema severe
Low sodium / high protein diet
Daily weights
Strict intake and output
Corticosteroid Therapy
High dose prednisone
Taper when protein loss in urine decreases
Current recommendations to keep on low dose every other day
for up to 6 months
If relapse or remission not obtained will try cytotoxic
medications
Physiologic Changes: cortisone
Catabolism of protein, leading to capillary weakness and
poor wound healing
Decreased absorption of calcium leading to demineralization
of bone / osteoporosis
Increased appetite
Salt-retaining activity of cortisol / hypertension
Side Effects
Hirsutism
Moon face with ruddy cheeks
Acne
Dorsocervical fat pads
Ecchymosis (easy bruising)
Truncal obesity
Mood swings – inability to sleep
Increase appetite
Moon Face
Before and After
Nursing Interventions for long tern use
Prednisone prescribed every other day
Instruct to take in the morning
Long Term Use - Prednisone every other day in the am
Take with food: can cause GI upset
Do not stop taking medication until instructed to do so
Medication needs to be tapered
Monitor for infection
Glomerulonephritis
Immune complexes become entrapped in the glomerular
membrane.
Symptoms appear 1 to 2 weeks after a Strep A skin or throat
infection.
Clinical Manifestations
Hematuria / red cells casts
Facial edema
Brown or frothy urine
Mild proteinuria
Hypertension
Management
Interventions:
Low sodium / high protein
Anti-hypertensive drugs
Diuretics
Antibiotics if + throat culture or blood culture
Monitor blood pressure
24 hour urine for Creatinine clearance
Teaching
Culture sore throats
Take antibiotics for full course prescribed
Do not share medications with others in family
