The Child with a Genitourinary Condition Chapter 28 The Child with a Genitourinary Condition

Development of the Urinary Tract Consists of two kidneys, two ureters, the urinary bladder, and urethra Function is to rid body of waste products and maintain body fluid homeostasis

Anomalies of the Urinary Tract

Phimosis A narrowing of the preputial opening of the foreskin Prevents foreskin from being retracted over penis Corrected by circumcision Forcible retraction of a tight foreskin is avoided because it can lead to paraphimosis Foreskin cannot be returned to its normal position Swelling and impaired circulation caused by constriction

Hypospadias and Epispadias Hypospadias: a congenital defect in which the urinary meatus is located on the lower portion of the shaft More common May be accompanied by chordee, a downward curvature of the penis from a fibrous band of tissue Epispadias: urinary meatus is on the upper surface of the penis Less common In mild cases surgery is not indicated Surgery may be indicated if child will not be able to stand to void or if it may cause psychological issues or difficulties in future sexual relationships Surgery is usually performed before 18 months of age Routine circumcision is avoided in these children, because foreskin may be useful in the repair

Exstrophy of the Bladder Lower portion of the abdominal wall and the anterior wall of the bladder are missing Bladder lies open and exposed on the abdomen Urine leaks continually from the bladder, skin becomes excoriated Noticeable by fetal sonogram Bladder is covered to protect its mucosa but allow for urinary drainage Diapers are generally placed under rather than around the infant Positioned on the back or side so urine drains freely Surgical close is ideally performed during the first 48 hours after birth

Obstructive Uropathy Calculi, tumors, strictures, and scarring may cause obstruction May be congenital or acquired Blockage may be partial or complete Hydronephrosis is the distention of the renal pelvis because of an obstruction Becomes enlarged and cysts form Polycystic kidney is a condition where large, fluid-filled cysts form in place of healthy kidney tissue in the fetus Inherited autosomal recessive trait Kidney damage can result in an inability of the kidney to concentrate urine, results in metabolic acidosis Surgery is done for urinary diversion Toddler may be unable to attain independence in diet training School-age child suffers from being different, may have a distorted body image Adolescent may have lowered self-esteem and is concerned about sexuality

Acute Urinary Tract Infection (UTI) More common in girls than boys Most are caused by Escherichia coli Terms Urethritis Cystitis Bacteriuria Pyelonephritis Ureteritis Vesicoureteral reflux Girls have a shorter urethra, location of urethra is near anus, wearing of close-fitting nylon underwear, bubble baths, retention of urine, and vaginitis Normal urine is acidic Alkaline urine favors pathogens

UTI (Continued) Signs/symptoms are age dependent Treatment Infants: fever, frequent urination, foul-smelling urine, persistent diaper rash Older child: urinary frequency, pain during micturition, onset of bed-wetting in a previously “dry” child, and abdominal pain may be present Treatment Infants under 1 year are usually hospitalized for IV antibiotics Older children are treated at home with oral antibiotics Parent teaching stresses the need for proper amounts of fluid to maintain sterility and flushing of the bladder

Nephrotic Syndrome (Nephrosis) A number of different types of kidney conditions that are distinguished by the presence of marked amounts of protein in the urine, edema, and hypoalbuminemia More common in boys Seen more in children 2 to 7 years of age Prognosis is good in steroid-responsive patients

Nephrotic Syndrome (Nephrosis) (Continued) Edema Generalized edema, also known as ascites Child gains weight Pale, irritable, and listless, poor appetite Blood pressure is usually normal Urine examination reveals massive albumin and a few RBCs Working units of the kidneys that filter the blood become damaged and allow albumin and blood cells in the urine Level of protein in blood falls, called hypoalbuminemia Treatment Steroids to reduce proteinuria and ultimately edema Prevent medication toxicity Steroids mask infection, therefore it is important to monitor the child for signs of infection

Nephrotic Syndrome (Nephrosis) (Continued) Diuretics have not been effective in reducing nephrotic edema Diet—avoid adding salt to foods whenever edema is present Fluids are generally not restricted except when massive edema is present

Nephrotic Syndrome (Nephrosis) (Continued) Nursing care includes: Supportive care to the parents and child throughout the disease Instructing parent to keep a daily record of the child’s weight, urinary protein levels, and medications No vaccinations or immunizations are given during the acute phase of the illness Positioning Frequent turning to prevent respiratory tract infections HOB elevated to prevent eyelid edema Strict monitoring of I&O Daily weight and protection from infection

Acute Glomerulonephritis Allergic reaction (antigen-antibody) to group A beta-hemolytic streptococcal infection Antibodies produced to fight the invading organisms also react against the glomerular tissue Both kidneys are usually affected Mild cases generally recover within a couple of weeks Manifestations Periorbital edema upon wakening in the morning Urine is smoky brown or bloody Urine output may be decreased albumin, RBCs, WBCs may be found on examination Hyperkalemia Elevated BP may occur

Wilms’ Tumor, Also Known as Nephroblastoma One of the most common malignancies of early life Embryonal adenosarcoma, thought to have a genetic basis Most discovered before the age of 3 years Few or no symptoms during the early stages of growth Abdominal mass usually found by parent or during routine health checkup IV pyelogram reveals a growth; tumor compresses kidney tissue, usually encapsulated May cause hypertension

Wilms’ Tumor (Continued) Treatment Combination of surgery and radiation and chemotherapy Affected kidney and tumor are removed as soon as possible after diagnosis confirmed Nursing care Preoperative Avoid abdominal examination by caregivers Routine postoperative care, see Nursing Care Plan 28-2

Nursing Care Plan 28-2

Nursing Care Plan 28-2 (Continued)

Hydrocele Excessive amount of fluid in the sac that surrounds the testicle and causes the scrotum to swell A chronic hydrocele that persists beyond 1 year is corrected by surgery

Cryptorchidism Testes fail to lower in the scrotum Unilateral form is more common Testes are warmer in abdomen, sperm cells begin to deteriorate If both testes involved, sterility can result Inguinal hernia often accompanies this condition Secondary sex characteristics are not affected because the testes continue to secrete hormones directly into the bloodstream

Cryptorchidism (Continued) Treatment Hormonal management before surgery consists of the administration of human chorionic gonadotropin (hCG) May precipitate descent of the testes into the scrotal sac Orchiopexy improves the condition; fertility rate among these patients may be reduced Increased risk of testicular tumors as the child reaches adulthood

Cryptorchidism (Continued) Nursing Scrotal support Prevent contamination of suture line Teach testicular self-examination Psychological and emotional support Surgery on “private parts” can be embarrassing Nurse assures the child that his penis will not be affected