Chapter 44 Genitourinary Dysfunction All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Physical examination  History taking  Observation of symptoms  Laboratory, radiologic, or other evaluation methods Renal System Assessment 2 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Renal System Assessment (Cont.) 3 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Urinary tract infections  Infection of the urinary tract: one of the most common conditions of childhood  Often impossible to localize the infection  High incidence of infection among uncircumcised boys younger than 3 months Genitourinary Tract Disorders and Defects 4 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Recurrent: repeated episodes  Persistent: bacteriuria despite antibiotics  Febrile: typically indicates pyelonephritis  Cystitis: inflammation of the bladder  Pyelonephritis: upper urinary tract and kidneys  Urosepsis: bacterial illness; urinary pathogens in blood Types of Urinary Tract Infections 5 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 A variety of organisms are responsible  Escherichia coli (80%)  Proteus organisms  Pseudomonas organisms  Klebsiella organisms  Staphylococcus aureus  Haemophilus organisms  Coagulase-negative staphylococci Causes of Urinary Tract Infections 6 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Structure of the lower urinary tract is believed to account for the increased incidence of infection in females  Single most important contributing factor is stasis  Vesicoureteral reflux, anatomic abnormalities, dysfunction of the voiding mechanism or bladder compression are conducive to infection Urinary Tract Infections: Anatomic and Physical Factors 7 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Any child who exhibits the following should be evaluated  Incontinence in a toilet-trained child  Strong or foul-smelling urine  Frequency or urgency Diagnostic Evaluation of Urinary Tract Infections 8 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Urine culture and sensitivity  Suprapubic aspiration  Percutaneous kidney taps  Bladder washout procedure  Ultrasonography  Voiding cystourethrography  Intravenous pyelography  Dimercaptosuccinic acid renal scan Diagnostic Evaluation of Urinary Tract Infections (Cont.) 9 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Eliminate current infection  Penicillins, sulfonamide, cephalosporins, nitrofurantoin  Identify contributing factors to reduce the risk of recurrence  Prevent systemic spread of infection  Ensure adequate or increased fluid intake  Preserve renal function Therapeutic Management of Urinary Tract Infections 10 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Instruct parents to observe regularly for signs of infection  Tell patients that simple hygiene habits should be routine  Teach patients to cleanse genital area from front to back  Encourage sexually active adolescent girls to urinate as soon as possible after intercourse Prevention of Urinary Tract Infections 11 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Structural or functional abnormalities that obstruct normal flow  Backup of the urine above the obstruction causes hydronephrosis  Condition may be acquired, unilateral, bilateral, complete, or incomplete  Early diagnosis and surgical correction are essential Obstructive Uropathy 12 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Obstructive Uropathy (Cont.) 13 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Defects of the external genitourinary tract  Major anomalies of the lower genitourinary tract: surgical repair required  Psychologic problems related to genital surgery External Defects 14 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Clinical state  Proteinuria  Hypoalbuminemia  Hyperlipidemia  Edema  Massive urinary protein loss Nephrotic Syndrome 15 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Nephrotic Syndrome (Cont.) 16 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Primary disease  Also known as “Idiopathic nephrosis” “Childhood nephrosis” “Minimal nephrotic syndrome”  Secondary nephrotic syndrome  In association with glomerular damage  Congenital nephrotic syndrome  Autosomal recessive disorder Types of Nephrotic Syndrome 17 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Glomerular membrane  Normally impermeable to large proteins  Becomes permeable to proteins, especially albumin  Albumin lost in urine (hyperalbuminuria)  Serum albumin decreased (hypoalbuminemia)  Fluid shifts from plasma to interstitial spaces Pathophysiology of Nephrotic Syndrome 18 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Supportive care  Reducing excretion of urinary protein  Reducing fluid retention in the tissues  Preventing infection  Minimizing complications related to sepsis Therapeutic Management of Nephrotic Syndrome 19 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Risk for infection  Loss of appetite  Salt restriction  Fluid restriction  Activity adjustment  Family support and home care Care Management of Nephrotic Syndrome 20 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Primary event or manifestation of another disorder  Acute after streptococcal infection  After infection with certain strains of hemolytic streptococcus  Latent period of days Acute Glomerulonephritis 21 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Oliguria, edema, hypertension  Hematuria  Bleeding in upper urinary tract causes urine to appear smoky  Proteinuria  Increased amount of protein reflects increased severity of renal disease Glomerulonephritis Symptoms 22 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Almost all children with a diagnosis of acute poststreptococcal glomerulonephritis recover completely  Specific immunity is conferred  Subsequent recurrences are uncommon  Some children have been reported to develop chronic disease Prognosis of Glomerulonephritis 23 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Manage edema  Daily weight measurements  Accurate input and output  Daily abdominal girth measurements  Nutrition  Low sodium  Fluid restriction  Susceptibility to infections Care Management of Glomerulonephritis 24 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Pathophysiology  Uncommon acute renal disease  Diagnostic evaluation  Anemia, thrombocytopenia, renal failure  Therapeutic management  Prognosis  Recovery rate of 95% Hemolytic-Uremic Syndrome 25 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Also called “nephroblastoma”  Malignant renal and intraabdominal tumor of childhood  Three times more common in African American children  Peak age at diagnosis: 3 years  More frequent in boys Wilms’ Tumor 26 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Causes  Diagnostic evaluation  Abdominal swelling or mass  Therapeutic management  Surgical removal  Chemotherapy, radiation, or both  Nursing alert  Do not palpate abdomen Wilms’ Tumor (Cont.) 27 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Acute renal failure (ARF)  Inadequate perfusion  Kidney disease  Urinary tract obstruction  Chronic renal failure (CRF)  Long-standing kidney disease  Congenital anomaly Renal Failure 28 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Definition: kidneys suddenly unable to regulate volume and composition of urine  Not common in childhood  Principal feature: oliguria  Associated with azotemia, metabolic acidosis, and electrolyte disturbances  Most common pathologic cause: transient renal failure resulting from severe dehydration Acute Renal Failure 29 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Pathophysiology: usually reversible  Diagnostic evaluation  Patient: may be critically ill  Laboratory measurements  Therapeutic management  Treatment of underlying cause  Management of complications  Supportive therapy Acute Renal Failure (Cont.) 30 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Hyperkalemia  Hypertension  Anemia  Seizures  Hypervolemia  Cardiac failure with pulmonary edema Complications of Acute Renal Failure 31 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 More than 50% of the functional renal capacity is destroyed  Begins when diseased kidneys cannot maintain normal chemical structure of body fluids  Progressive deterioration over months or years  Clinical syndrome called “uremia” Chronic Renal Failure 32 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Congenital renal and urinary tract malformations  Vesicoureteral reflux associated with recurrent urinary tract infections  Hereditary disorder  Chronic pyelonephritis  Chronic glomerulonephritis  Anaphylactoid purpura, lupus erythematosus Potential Causes of Chronic Renal Failure 33 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Pathophysiology  Diagnostic evaluation  Therapeutic management  Promote maximum renal function  Maintain fluid and electrolyte balance  Treat systemic complications  Promote as normal and active a life as possible Management of Chronic Renal Failure 34 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 The process of separating colloid and crystalline substances through a semipermeable membrane  Methods  Peritoneal dialysis  Hemodialysis  Hemofiltration Dialysis 35 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 The preferred method of dialysis for children  Abdominal cavity acts as semipermeable membrane for filtration  Warmed solution enters peritoneal cavity by gravity, remains for period of time before removal  Can be managed at home in some cases Peritoneal Dialysis 36 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 Requires creation of a vascular access and special dialysis equipment  Best suited for children who can be brought to facility three times/week for 4-6 hours  Achieves rapid correction of fluid and electrolyte abnormalities Hemodialysis 37 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Hemodialysis (Cont.) 38 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 From living related donor  Usually a parent or sibling  From cadaver donor  Primary goal: long-term survival of grafted tissue  Role of immunosuppressant therapy Transplantation 39 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

 What best describes acute glomerulonephritis? A. Occurs after a urinary tract infection B. Occurs after a streptococcal infection C. Associated with renal vascular disorders D. Associated with structural anomalies of genitourinary tract Question 40 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.