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

2. 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

3. Anomalies of the Urinary Tract

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. Nursing Care Plan 28-2

18. Nursing Care Plan 28-2 (Continued)

19. 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

20. 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

21. 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

22. 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