Renal & Urogenital Systems Chapter 9 Pathology

Alterations in Renal Function

Biological Variances 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

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 Kidney function analyzed Watch for allergic reaction to dye.

Renal Biopsy

Cystoscopy Invasive surgical procedure Visualizes bladder and ureter placement.

CT Scan

Treatment Modalities Urinary diversion Intermittent catheterization 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 Musk 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

Ureteral Reflux

Ureteral Reflux Males 6 to 1 Genetic predisposition Present as UTI or FTT Diagnostic tests Antibiotics if indicated Surgery to re-implant ureters

Hydronephrosis

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

Long Term Complications Urinary incontinence Infection Body image Inadequate sexual function

Hypospadias

Cryptorchidism 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.