Genitourinary Disorders Jan Bazner-Chandler CPNP, CNS, MSN, RN

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 Whaley & Wong Application of urine collection bag.

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 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 Bladder training Reduce fluids in evening Control sugar intake Bladder training Praise and reward Behavioral chart to keep track of dry nights Alarm system

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

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

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 Incomplete formation of the anterior urethral segment.

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 Tight chordee causes curvature of the penis.

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

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.

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 Bowden & Greenberg

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

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

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

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 High-dose corticosteroid therapy produces a characteristic “moon face” appearance.

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