1. The Child with a Genitourinary Condition
Chapter 29
The Child with a Genitourinary Condition

2. Objectives Define each key term listed.
Name the functional unit of the kidney.
List four urological diagnostic procedures.
Recognize urinary tract anomalies in infants.
Differentiate between nephrosis and acute glomerulonephritis.
Discuss the skin care pertinent to the child with nephrosis.
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3. Objectives (cont.)
Explain any alterations in diet applicable to the child with nephrosis.
Outline the nursing care of a child who is diagnosed as having Wilms’ tumor.
Discuss the impact of genitourinary surgery on the growth and development of children at various ages.
Discuss the impact of undescended testes on fertility.
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4. 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
Produce a substance (ESF) that stimulates RBC formation in bone marrow and renin, which regulates blood pressure
Refer to Figure 29-1 on page 675.
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5. Development of the Reproductive System
Gender is determined at time of fertilization
Tests to diagnose conditions of the reproductive tract
Pap
Blood tests
Cultures
Ultrasound
Pregnancy
Discuss the differences between the male and female reproductive systems.
Refer to Figure 29-3 on page 676.
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6. Sexual Abuse in Children
May be manifested by behaviors, such as
Urinary frequency
Excessive masturbation
Encopresis
Severe nightmare
Bedwetting
Irritation or pain in genital area
Decrease in physical or emotional development
Audience Response Question #1
Adults who commit sexual abuse usually:
1. know the child.
2. are dependent on drugs.
3. are strangers to the child.
4. have sociopathic personalities.
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7. Assessment of Urinary Function
Urological diagnostic procedures UA
Ultrasound
IV pyelogram
CT scan of kidneys
Biopsy
Uroflow
Cystoscopy
Voiding cystourethrography
Cystometrogram
Urethral pressure
Discuss each diagnostic test and how it assists in the assessment of the urinary system.
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8. Terms Commonly Used to Describe Urinary Dysfunction
Dysuria
Frequency
Urgency
Nocturia
Enuresis
Polyuria
Oliguria
Define and describe each dysfunction listed.
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9. Anomalies of the Urinary Tract
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10. Phimosis A narrowing of the preputial opening of the foreskin
Prevents foreskin from being retracted over penis
Corrected by circumcision
Forcible retraction of 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
Refer to Figure 29-5 on page 678.
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11. Epispadias and Hypospadias
Urinary meatus is on the upper surface of the penis
Hypospadias
Congenital defect in which the urinary meatus is located on the lower portion of the shaft
May be accompanied by chordee, a downward curvature of the penis from a fibrous band of tissue
In mild cases surgery is not indicated
Surgery is usually performed before 18 months of age
Routine circumcision is avoided in these children, because foreskin may be useful in the repair
Refer to Figure 29-6 on page 678.
Surgery may be indicated if the child cannot stand to void, which may cause psychological issues, or if there may be difficulties in future sexual relationships.
Audience Response Question #2
Hypospadias must be surgically corrected to preserve proper genitourinary function.
1. True
2. False
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12. Epispadias and Hypospadias (cont.)
Refer to Figure 29-6 on page 678.
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13. Exstrophy of the Bladder
Lower portion of abdominal wall and anterior wall of bladder are missing
Noticeable by fetal sonogram
Bladder lies open and exposed on abdomen
Urine leaks continually from the bladder and skin becomes excoriated
Bladder covered to protect mucosa
Diapers placed under—rather than on the infant—to protect bladder while allowing urinary drainage
Positioned on the back or side so urine drains freely
Ideally, surgical closure performed within 48 hours of birth
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14. Obstructive Uropathy
Calculi, tumors, strictures, and scarring may cause obstruction
Hydronephrosis
Polycystic kidney
Urinary diversion surgery may be performed
Toddler may be unable to attain independence in toilet 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
Discuss the nurse’s approach in assessing a distended bladder.
Discuss characteristics of each of the disorders listed.
Calculi, tumors, strictures, and scarring:
Congenital or acquired
Partial or complete blockage
Hydronephrosis:
Distention of the renal pelvis due to obstruction
Becomes enlarged and cysts form
Polycystic kidney:
Large, fluid-filled cysts form in place of healthy kidney tissue in the fetus.
Caused by inherited autosomal recessive trait.
Kidney damage can result in an inability of the kidneys to concentrate urine, which results in metabolic acidosis.
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15. Health Promotion
The bladder capacity of a child can be approximated by the following formula
Age in years + 2 = Ounces of bladder volume or capacity
Give a scenario in which the students must determine bladder capacity.
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16. Acute Urinary Tract Infection (UTI)
More common in girls
Girls have a shorter urethra, location of urethra is near anus, wearing of close-fitting nylon underwear, bubble baths, retention of urine, and vaginitis
Most caused by E. coli
Normal urine is acidic
Alkaline urine favors pathogens
Terms
Urethritis
Cystitis
Bacteriuria
Pyelonephritis
Ureteritis
Vesicoureteral reflux
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17. Acute Urinary Tract Infection UTI (cont.)
Signs and symptoms depend on the age of the child
Treatment
Infants under 1 year old are usually hospitalized for IV antimicrobials
Older children are treated at home with oral antimicrobials
Parent teaching stresses the need for proper amounts of fluid to maintain sterility and flushing of the bladder
Discuss parental teaching regarding UTIs.
What are the age-dependent symptoms of UTI?
Infants: fever, frequent urination, foul-smelling urine, persistent diaper rash
Older child: urinary frequency, pain during micturition, onset of bedwetting in a previously “dry” child, and abdominal pain may be present
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18. Health Promotion Interventions to prevent UTI
Cleanse perineum with each diaper change
Wipe perineum front to back
Avoid bubble baths
Have child urinate immediately after a bath
Use white cotton underwear
Use loose-fitting pants
Offer adequate fluid intake
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19. Nephrotic Syndrome (Nephrosis)
A number of different types of kidney conditions 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
May be related to a thymus T-cell dysfunction
Prognosis is good in steroid-responsive patients
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20. Nephrotic Syndrome (Nephrosis) (cont.)
Generalized edema
Weight gain
Pale, irritable, listless
Poor appetite
Blood pressure usually normal
Urine exam reveals massive albumin and a few RBCs
Prone to infection when absolute granulocyte counts fall below 1000 cells/mm3 (neutropenia)
Discuss the pathophysiology regarding normal blood pressure in children with nephrosis.
How can medication toxicity occur with this disorder?
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.
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21. Nephrotic Syndrome (Nephrosis) (cont.)
Treatment
Steroids to reduce proteinuria and edema
Steroids mask infection; therefore, it is important to monitor the child for signs of infection
Prevent medication toxicity
Diuretics have not been effective in reducing nephrotic edema
Avoid adding salt to foods whenever edema is present
Fluids generally are not restricted except when massive edema is present
Provide a reason for the ineffectiveness of diuretics with this disorder.
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22. Nephrotic Syndrome (Nephrosis) (cont.)
Nursing care
Supportive care to parents and child
Parent instructed to keep daily record of the child’s weight, urinary protein levels, and medications
No vaccinations or immunizations should be administered while the disease is active or during immunosuppressive therapy
Positioning
Strict monitoring of I&O
Daily weight and protection from infection
Discuss the rationale for monitoring and recording weight, urine protein levels, and medications.
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23. Safety Alert
A child recovering from nephrotic syndrome should not receive any vaccinations or immunizations while the disease is active and during immunosuppressive therapy.
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24. Acute Glomerulonephritis
Allergic reaction (antigen-antibody) to group A beta-hemolytic streptococcal infection
Antibodies produced to fight invading organisms also react against glomerular tissue
Both kidneys usually affected
Mild cases generally recover within a couple of weeks
Discuss the pathophysiology of manifestations:
Periorbital edema upon wakening in the morning
Urine is smoky brown or bloody
Urine output may be decreased
Urine specific gravity is high; albumin, RBC, WBC, and casts may be found on exam
Hyperkalemia, BUN, creatinine, and sedimentation rate are elevated
Hypertension may occur
Audience Response Question #3
Complete the analogy. Nephrosis : generalized edema as acute glomerulonephritis : ____________.
1. pedal edema
2. increased abdominal girth
3. periorbital edema
4. hypotension
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25. Wilms’ Tumor (Nephroblastoma)
Embryonal adenosarcoma is thought to have a genetic basis
Most discovered before age 3 years
One of the most common malignancies of early life
Few or no symptoms during the early stages of growth
Abdominal mass usually found by parent or during routine health checkup
Audience Response Question #4
The most common symptom noted in children with Wilms' tumor is:
1. abdominal pain.
2. hematuria.
3. hypertension.
4. abdominal mass.
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26. Wilms’ Tumor (cont.)
IV pyelogram reveals a growth, tumor compresses kidney tissue, usually encapsulated
May cause hypertension
Until the tumor has been surgically removed, abdominal palpation must not be performed
A sign above the bed and a notation on the chart must clearly state no abdominal palpation
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27. Wilms’ Tumor (cont.) Treatment Nursing care
Combination of surgery, 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
Discuss the rationale regarding combination therapy of radiation and chemotherapy.
Discuss Nursing Care Plan 29-2 on pages
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28. Hydrocele Excessive amount of fluid in sac that surrounds the testicle
Causes scrotum to swell
Chronic hydrocele that persists beyond 1 year is corrected by surgery
Discuss the difference between a simple hydrocele and a hydrocele with herniation.
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29. Cryptorchidism Testes fail to descend into the scrotum
Unilateral form is more common
Testes are warmer in abdomen, sperm cells begin to deteriorate
If both testes are involved, sterility can result
Often accompanied by inguinal hernia
Testes continue to secrete hormones directly into the bloodstream, so secondary sex characteristics are not affected
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30. Cryptorchidism (cont.)
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
What is the importance of a monthly testicular self-exam?
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31. Cryptorchidism (cont.)
Nursing care
Scrotal support
Prevent contamination of suture line
Teach testicular self-exam
Psychological and emotional support
Surgery on “private parts” can be embarrassing
Nurse assures the child that his penis will not be affected
Discuss the rationale for scrotal support following an orchiopexy.
What is a possible result of orchiopexy?
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32. Impact of Urinary or Genital Surgery on Growth and Development
Between 3 and 6 years of age, the child becomes curious about sexual differences and may masturbate
Surgical interventions during this stage of development require guidance and preparation in order to minimize negative impact on growth and development
Give examples of growth and development issues that could occur for children between the ages of 3 and 10.
Give examples of growth and development issues that could occur for and adolescents.
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33. Question for Review
What daily nursing assessment should be omitted in a child diagnosed with a Wilms’ tumor?
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34. Review Objectives Key Terms Key Points Online Resources
Review Questions
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