The Child With a Genitourinary Alteration Chapter 20 The Child With a Genitourinary Alteration

Anatomy of the Genitourinary System

Pediatric Differences in the Genitourinary System Complete maturity of the kidney occurs between 6 and 12 months of age Before this time, the filtration capacity of the glomeruli is reduced; urine is voided frequently and has a low specific gravity

Pediatric Differences in the Genitourinary System Fluid constitutes a larger fraction of an infant’s and small child’s total body weight The kidneys are less efficient at regulating electrolyte and acid-base balance and eliminating some drugs from the body The immaturity of the renal structures predisposes the infant to dehydration and fluid volume excess Bladder capacity increases from 20 to 50 mL at birth to 700 mL in adulthood

Pediatric Differences in the Genitourinary System Innervation of stretch receptors in the bladder wall does not occur before the age of 2 years The urethra is shorter in children than in adults and may contribute to the frequency of urinary tract infections in children Kidneys are more susceptible to trauma in children because they do not have as much fat padding

Diagnostic Tests and Assessments of the Renal System Urine specimen (for urinalysis; may be clean catch or sterile) Intravenous pyelogram Radiographs of kidneys, ureters, and bladder Renal/bladder ultrasound Cystogram Computed tomography Voiding cystourethrogram Magnetic resonance imaging

Serum Blood Tests Hemoglobin and hematocrit Blood urea nitrogen Creatinine Serum electrolytes

Genitourinary Tract Disorders Urinary tract infections Vesicoureteral reflux

Urinary Tract Infections Caused by bacteria ascending from outside the urethra into the bladder From the bladder, bacteria may continue to ascend into the upper urinary tract Fecal bacteria most common cause of urinary tract infections (approximately 80%)

Urinary Tract Infections Anatomic and physical factors that predispose to urinary tract infections include: Females: short urethra, which provides a ready pathway for invasion of organisms Males: increased incidence in uncircumcised infants younger than 1 year Urinary stasis Vesicoureteral reflux Sexual activity in adolescent girls Urinary tract obstructions Constipation P. 597

Urinary Tract Infections Clinical manifestations in the infant: Fever or hypothermia in the neonate Irritability Dysuria Change in urine odor or color Poor weight gain Feeding difficulties Clinical manifestations in the child: Abdominal or suprapubic pain Voiding frequency Voiding urgency Dysuria New or increased incidence of enuresis Fever

Urinary Tract Infections Diagnostic evaluation History Physical examination Urinalysis Urine culture and sensitivity Therapeutic management Eliminate current infection Identify contributing factor Prevent urosepsis Preserve renal function

Urinary Tract Infections Nursing considerations Monitor intake and output Observe for signs of dehydration in the infant and child Administer antibiotics as ordered Obtain daily weights Encourage frequent voiding in toilet-trained child Encourage increased fluid intake Child and family education

Vesicoureteral Reflux Retrograde flow of bladder urine into the ureters Primary reflux: results from a congenital anomaly that affects the ureterovesical junction Secondary reflux: result of an acquired condition Reflux with infection is the most common cause of pyelonephritis in children Clinical manifestations See urinary tract infection May see clinical manifestations of pyelonephritis P. 598

International Classification of Reflux

Vesicoureteral Reflux Divided into categories based on the degree of reflux from the bladder into the upper genitourinary tract structures Grade I: urine refluxes partway up the ureter Grade II: urine refluxes all the way up the ureter

Vesicoureteral Reflux Grade III: urine refluxes all the way up the ureter with dilation of the ureter and calyces Grade IV: urine refluxes all the way up the ureter with marked dilation of the ureter and calyces Grade V: massive reflux of urine up the ureter with marked tortuosity and dilation of the ureter and calyces

Vesicoureteral Reflux Diagnostic evaluation Laboratory studies Urinalysis Urine cultures Electrolytes Blood urea nitrogen Imaging studies Plan 3 to 6 weeks after the infection to allow for infectious inflammation to subside Ultrasound Voiding cystourethrogram

Vesicoureteral Reflux Therapeutic management Grades I and II: continuous low-dose antibacterial therapy with frequent urine cultures Grade III: managed with antibiotic therapy unless complications present Grade IV and V: may require surgical intervention

Vesicoureteral Reflux Nursing considerations Explain treatment plan Explain that medical management may last for years and that adherence to antibiotic therapy and follow-up is important If surgical intervention is necessary, educate regarding preoperative and postoperative repair

Congenital Anomalies Epispadias Hypospadias Cryptorchidism

Cryptorchidism Testes fail to descend through the inguinal canal into the scrotal sac Exposes the testes to the heat of the body, leading to low sperm counts at sexual maturity

Cryptorchidism Greater risk for torsion and trauma Frequently associated with an inguinal hernia Clinical manifestations Testes that are not palpable or not easily guided into the scrotum or A previously descended testis that ascends into an extrascrotal position

Cryptorchidism Diagnostic evaluation Ultrasound, computed tomographic scan, or magnetic resonance image to determine location Therapeutic management Human chorionic gonadotropin hormone is given to induce descent If testes remain undescended, an orchiopexy is performed in the toddler years

Epispadias and Hypospadias Hypospadias: congenital defect in which the urinary meatus is located on the lower or underside of the shaft Epispadias: congenital defect in which the urinary meatus is located on the upper side of the penile shaft; less common than hypospadias

Epispadias and Hypospadias Clinical manifestations Ventral or dorsal placement of the urethral opening Altered urinary stream Chordee Diagnostic evaluation Based on physical examination

Epispadias and Hypospadias Therapeutic management is surgical intervention usually done in one stage Release of chordee and lengthening of the urethra Repositioning of the meatus at the penile tip Reconstruction of the penis Usually done between 6 and 12 months of age No circumcision of infant with hypospadias Urinary diversion is used after surgery to allow healing (stents or catheters) Goal of surgery: to make urinary and sexual function as normal as possible and to improve the cosmetic appearance of the penis

Nursing Considerations for Children Undergoing Renal Surgery Provide surgical tour, especially the “wake-up” room Determine child’s words for penis, urination, etc. Encourage parents to remain with child as appropriate Provide support and reassurance Assist child to turn, cough, and breathe deeply; frequently reposition infants Perform frequent vital signs monitoring Teach splinting of incision and incentive spirometry preoperatively

Nursing Considerations for Children Undergoing Renal Surgery Assess and monitor for bladder spasms and incisional pain Provide analgesics as ordered Regulate intravenous fluids Keep accurate intake and output records Measure daily weights Teach need to keep skin dry and odor free Provide written instructions to parents Provide contact number if problems occur

Glomerular Disease Acute glomerulonephritis Nephrotic syndrome

Pathophysiology of Acute Poststreptococcal Glomerulonephritis and Nephrotic Syndrome

Acute Glomerulonephritis vs. Nephrotic Syndrome Acute glomerulonephritis: disorder that occurs suddenly and are characterized by hematuria, proteinuria, edema, and renal insufficiency Occurs most frequently in young school-age children, most commonly after a streptococcal infection Nephrotic syndrome: a kidney disorder characterized by proteinuria, hypoalbuminemia, and edema Occurs most frequently in children between ages 2 and 6 years

Acute Glomerulonephritis vs. Nephrotic Syndrome Pathophysiology Streptococcal infection Formation of antibodies in response to streptococcal bacteria Antibodies combine with bacterial antigens to form immune complexes Antigen-antibody complexes become trapped in the glomerulus and activate an inflammatory response in the glomerular basement membrane Pathophysiology Insult occurs to the glomerular basement membrane Damage causes increased permeability and loss of substances that would normally prevent negatively charged proteins from crossing the membrane Leads to increased clearance rate for albumin (negatively charged protein) This causes a loss of plasma proteins and proteinuria

Acute Glomerulonephritis vs. Nephrotic Syndrome Inflammation causes damage to the glomerular capillaries and reduces the size of the capillary lumen Leads to decreased glomerular filtration rate Leads to renal insufficiency Causes sodium and fluid retention Leads to edema and oliguria Hypoalbuminemia reduces the plasma oncotic pressure This causes a shifting of fluid from intravascular space to interstitial spaces Fluid shifts reduce intravascular volume, causing hypovolemia and decreased renal blood flow In response, renin production is stimulated, causing increased excretion of aldosterone Renal tubular reabsorption of sodium occurs, which causes water retention and in turn leads to edema

Acute Glomerulonephritis vs. Nephrotic Syndrome Clinical manifestations Hematuria: tea- or cola-colored urine Hypertension Edema (worse in morning) Usually young school-age child Clinical manifestations Proteinuria: frothy urine Edema Abdominal pain Weight gain Hypovolemia Normotension Pallor Fatigue Toddler or preschool-age child

Acute Glomerulonephritis vs. Nephrotic Syndrome Diagnostic evaluation History Presenting symptoms Renal ultrasound Urinalysis Laboratory results Elevated blood urea nitrogen Elevated erythrocyte sedimentation rate Elevated ASO titer Elevated creatinine Electrolyte imbalance Diagnostic evaluation History Clinical manifestations Laboratory results Urinalysis (3 to 4+ protein) Possible microscopic hematuria Hypoalbuminemia Elevated cholesterol Elevated triglycerides Elevated hemoglobin and hematocrit Elevated platelets

Acute Glomerulonephritis vs. Nephrotic Syndrome Therapeutic management Supportive Antihypertensives Diuretics Low-salt diet Therapeutic management Prednisone to initiate remission Diuretics Possible administration of albumin Antibiotics to prevent infection No added salt diet

Acute Glomerulonephritis vs. Nephrotic Syndrome Nursing considerations Intake and output every shift Daily weights Monitor cardiopulmonary status every shift Fluid restrictions as ordered Low-salt diet Cluster care to promote rest Frequent position changes to decrease pressure on bony prominences (every 2 hours) Nursing considerations Position changes every 2 hours Good daily hygiene Support and elevate edematous body parts with pillows Physical activity as tolerated Antibiotics as ordered Vital signs every shift Intake and output every shift

Acute Glomerulonephritis vs. Nephrotic Syndrome Nursing considerations Good daily hygiene Monitor for signs of dehydration Vital signs every shift Parental education Nursing considerations Monitor laboratory values Observe for signs of dehydration Daily weights No added salt diet Measure abdominal girth daily Administer diuretics as ordered Monitor cardiopulmonary status every shift Parental education

Child with Nephrotic Syndrome

Hemolytic Uremic Syndrome An acute renal disease characterized by a triad of manifestations: acute renal failure, hemolytic anemia, thrombocytopenia Occurs primarily in infants and small children between 6 months and 3 years of age An important cause of chronic renal failure Disease usually follows an acute gastrointestinal or upper respiratory infection

Hemolytic Uremic Syndrome Clinical manifestations Presence of gastrointestinal, urinary tract, or upper respiratory tract infection with diarrhea and/or vomiting Hemolytic anemia Edema and ascites Hypertension Neurologic involvement (irritability, seizures, lethargy, stupor, coma, cerebral edema) Rectal bleeding Purpura hematuria/proteinuria Oliguria or anuria

Hemolytic Uremic Syndrome Diagnostic evaluation Triad of anemia, thrombocytopenia, and renal failure is sufficient for diagnosis Renal involvement is evidenced by proteinuria, hematuria, and presence of urinary casts Blood urea nitrogen and serum creatinine levels are elevated Hemoglobin and hematocrit counts are low Reticulocyte counts are high

Hemolytic Uremic Syndrome Therapeutic management Focuses on the complications of acute renal failure and includes the following: Fluid restriction Antihypertensive medications High-calorie, high-carbohydrate diet low in protein, sodium, potassium, and phosphorus Most consistently effective treatment is early dialysis or continuous hemofiltration Transfusion of fresh packed red blood cells may be needed to treat severe anemia

Hemolytic Uremic Syndrome Nursing considerations Parenteral or enteral nutrition as ordered Dialysis may be required during the acute period to correct electrolyte and fluid balances while eliminating wastes Monitor intake and output Daily weights Maintain fluid restrictions as ordered Blood pressure as ordered (report changes to prevent complications) Thorough handwashing Provide emotional support for child and address parental anxiety Family education