1. Pediatric Genitourinary
Disorders

2. Enuresis Repeated involuntary voiding or incontinence by a
child past the age of toilet training.
about 5-6 years of age
What are the manifestations of enuresis?

3. Enuresis Multitreatment Approach
Fluid Restriction Bladder exercises Timed voiding Enuresis alarms Reward system Medications
What are treatment approaches for enuresis and related nursing care?

4. Urinary Tract
Infection

5. Test Yourself
Which of the following organisms is the most common cause of UTI in children?
a. staphylococcus
b. klebsiella
c. pseudomonas
escherichia coli
All are causative agents, Escherichia coli is the more common cause of first time UTI’s.

6. Urinary Tract Infections
Etiology and Pathophysiology
Tend to occur more in girls than in boys because the urethra is shorter in girls and is located close to the vagina and anus.
Pathogens enter as an ascending infection
Most common causative organism is Escherichia coli

7. Assessment
Typical symptoms of older children and adults – dysuria, frequency, urgency, burning,hematuria – may not be present.
Symptoms not always clear
Fever
Mild abdominal pain
Bedwetting (enuresis)
If gets worse – high fever, flank pain, vomiting, malaise
Many children do not complain of the usual signs and symptoms of a urinary tract infection.
What are the differences between adult S&S and infant-child S&S?

8. Diagnostic Tests Urine for culture and sensitivity A Positive Test
Clean catch
Suprapubic aspiration
Catheterization
A Positive Test
Bacteria colony count is more than /ml.
Proteinuria may also be present indicating presence of bacteria.

9. Therapeutic Interventions
Drug Therapy
Antibiotics – specific to causative organism
Analgesics – Tylenol
Nursing Care
Force fluids – childs choice
Dysuria – sit in warm water in bathtub and void into the water

10. Therapeutic Interventions
Parent Teaching
Change diaper frequently
Teach girls to wipe front to back
Discourage bubble baths
Encourage children to drink periodically during the day
Bathe daily
Adolescent start menstruating – encourage change of pad every 4 hours
When girls become sexually active – teach to urinate immediately after intercourse
What teaching should the nurse include regarding prevention of UTI in infants, children and adolescents?

11. Evaluation
Follow up
Return for repeat urinalysis – usually after 72 hours of treatment to be sure treatment is working
Girls who have more than three UTI’s, and boys with first UTI should be referred to urologist for further evaluation.

12. Vesicoureteral Reflux

13. Common Sites for Obstruction
Stenosis of ureteropelvic valve
Stenosis of ureterovescicular junction
Stenosis of the posterior urethral valve
What are the common sites for obstruction?

14. Vesicoureteral Reflux

15. Pathophysiology
Reflux occurs because the valve that guards the entrance from the bladder to the ureter is defective from:
Primary reflux – congenital abnormal insertion of ureters into the bladder
Secondary reflux – repeated UTI’s cause scarring of valve
Bladder pressure that is stronger than usual, neurogenic bladder
Backflow happens at voiding when bladder contracts, urine is swept up the ureters
Results in stasis of urine in ureters or kidneys which in turn leads to infection or hydronephrosis.
What is the main problem with reflux of urine?

16. Clinical Manifestations
Fever
Vomiting
Chills
Straining or crying on urination, poor urine stream,
Enuresis (bedwetting), incontinence in a toilet trained child, frequent urination.
Strong smelling urine
Abdominal or back/flank pain

17. Diagnostic Tests cystourethrogram Urine culture –
done every 2-3 months
cystourethrogram
renal ultrasound - a non-invasive test in which a transducer is passed over the kidney producing sound waves which bounce off the kidney, transmitting a picture of the organ on a video screen. The test is used to determine the size and shape of the kidney, and to detect a mass, kidney stone, cyst, or other obstruction or abnormalities.

18. Therapeutic Interventions
Drug Therapy
Antibiotics
Penicillin
Cephalosporins
Urinary Antiseptics
Nitrofurantoin
Surgery
Repair of significant anatomical anomalies, uretheral implantation
What is the treatment and nursing care rt Vesicoureteral reflux?

19. Nursing Care following surgery
Keep accurate record of intake and output. Keep records from stents and catheter separate. Decreased output from stent could indicate obstruction.
Secure stents and catheter to prevent displacement.
Assess vital signs for signs of infection.
Assess pain. Handle child gently Administer pain medications
Patient Teaching
- regarding prevention of UTI,
- importance of taking all antibiotics, continue
taking antiseptics even when have no symptoms.

20. Evaluation
Follow-up
Go in for a VCUG (voiding cystourethrogram) after a few months

21. Cryptorchidism Hypospadius / Epispadius
Structural Defects
Cryptorchidism
Hypospadius / Epispadius

22. Cryptorchisism
Failure of one or both of the testes to descend from abdominal cavity to the scrotum
What is cryptorchidism?

23. Etiology and Pathophysiology
Testes usually descend into the scrotal sac during the 7-9 month gestation
They may descend anytime up to 6 weeks after birth. Rarely descend after that time.
Cause unknown
Theories
Inadequate length of spermatic vessels
Lowered testosterone levels

24. Why is it important that the testes are in the scrotal sac?

25. Answer:
The higher temperatures in the abdomen than in the scrotum results in morphologic changes to the testis – mainly concerned with lower sperm counts at sexual maturity.

26. Diagnosed on Newborn Physical Exam
Assessment
Diagnosed on Newborn Physical Exam
Palpate the testes separately between thumb and forefinger, with thumb and forefinger of other hand over the inguinal canal.

27. Therapeutic Interventions
Surgery
Orchiopexy done via laproscopy
Done around 1 year of age
Nursing Care – Post-op
Minimal activity for few day to ensure that the internal sutures remain intact
Allow opportunity to express fears about mutilation or castration by playing with puppets or dolls.
What is important information to be included in post-op care and discharge teaching?

28. Hypospadias
Epispadias

29. Hypospadias Congenital urethral defect in which
the uretheral opening is on the
lower aspect of the penis and not
on the tip.
Compare hypospadius with epispadius.

30. Epispadias
Congenital urethral defect in which the uretheral opening is on the upper aspect of the penis and not on the end

31. Etiology and Pathophysiology
Epispadias – rare and often associated with extrophy of bladder.
Hypospadias
Occurs from incomplete development of urethra in utero.
Occurs in 1 of 100 male children. Increased risk if father or siblings have defect.
Defect ranges from mild (meatus is just below tip); to meatus on the perineum between scrotum, ventral foreskin lacking
May have accompanying chordee (a fibrous band that causes the penis to curve downward),
Undescended testes – found in conjunction with hypospadias
Might interfere with fertility in the mature male if not corrected.

32. Assessment
Usually discovered during
Newborn Physical Assessment

33. Ask Yourself?
Why would the nurse question an order to prepare the infant for a circumcision?

34. Answer:
The nurse would question the order for a circumcision because the foreskin is used in reconstruction and repair of the defect.

35. What is the relation of epispadius or hypospadius to infertility?

36. Answer:
If the urethral opening is not at the end of the penis, then the male will not be able to deposit his sperm at the opening of the os of the cervix.

37. Interventions Medical Treatment: Surgery
Reconstructive – repositions uretheral opening at tip of penis
Stent placed in urethra to maintain patency
Chordee – released and urethra lengthened.

38. The reason for surgery at about 1 year of age is because:
a. children will experience less pain
b. chordee may be reabsorbed
c. the child has not developed body image
and castration anxiety
d. the repair is easier before toilet training
C= answer
Why does the surgery usually take place prior to 1 year of age?

39. Post –op Nursing Care
1. Assess bleeding - Bleeding is controlled post-operatively by the use of pressure dressings. However, a small amount of bleeding for the first several days post-operatively is normal. A few drops of blood or a spot no larger than a quarter on the diaper is acceptable.
2. Maintain urinary drainage – care for catheter – foley / suprapubic, or urethral stent. Use double diapering.
What is the focus of post-operative care for this child? What is the related nursing interventions?

40. A double diapering technique protects the urinary stent after surgery
A double diapering technique protects the urinary stent after surgery. The inner diaper collects stool and the outer diaper collects urine.

41. 3. Control Bladder Spasms - usually due to the presence of the in-dwelling catheters are common post-operatively and are controlled by medications that relax the bladder (ie. Antispasmotics- Pro-Banthine and Ditropan)
4. Control Pain – may be given Tylenol
5. Increase fluids intake – assists in
maintaining hydration and free flow of urine.
6. Do not allow to play on any straddle toys.
7. Prevent infection – no bathing or swimming until
stents removed.
8. Call Dr if:
temp is over 101
loss of appetite
pus or increased bleeding from stent
cloudy or foul smelling urine

42. Acute Postinfectious
Glomerulonephritis

43. Acute Postinfectious Glomerulonephritis
Immune-complex disease which causes inflammation of the glomeruli of the kidney as a result of an infection elsewhere in the body.
Define glomerulonephritis.

44. Etiology and Pathophysiology
Usual organism is Group A beta-hemolytic streptococcus
Organism not found in kidney, but the antigen-antibody complexes become trapped in the membrane of the glomeruli causing inflammation, obstruction and edema in kidney
The glomeruli become inflamed
and scarred, and slowly lose their
ability to remove wastes and excess
water from the blood to make urine.
What is the most common causative organism for this pathology?
Gomerulonephritis is a common complication of what childhood infection?
What role do immune complexes play in the development of glomerulonephritis?

45. Acute Glomerulonephritis
Infection from group A beta-hemolytic Streptococcus causes an immune response that causes inflammation and damage to the glomeruli.
Protein and red blood cells are allowed to pass through the glomeruli.
Blood flow to the glomeruli is reduced due to obstruction with damaged cells and renal insufficiency results, leading to the
retention of sodium, water, and waste.

46. Protein molecules filter through the damaged glomeruli – proteinuria
Decreased glomerular filtration leads to accumulation of sodium and water in bloodstream causing increased intravascular and interstitial fluid volume, or edema
Protein molecules filter through the damaged glomeruli – proteinuria
Damage to glomeruli leads to hematuria.
High B/P, Heart failure may result
Common in boy 5-10 years old. Occurs 1-2 weeks after a Strep respiratory infection or after impetigo.
Has 2 phases
Edematous phase – 4-10 days
Diuresis phase
What assessment findings does the nurse expect in a child with acute glomerulonephritis?

47. Assessment
1. Renal:
a. Moderate Proteinuria
b. Sudden onset of hematuria (tea-colored, reddish-brown, or smoky) and next develops oliguria
c. Excessive foaming of urine
2. Cardiovascular:
a.  Edema-usually eyes, hands, feet, not generalized
b.  Hypertension from hypervolemia which can lead to
c.  Cardiac involvement CHF- orthopnea / dyspnea,
cardiac enlargement, pulmonary edema
3.Neuro
a. Encephalopathy (headache, irritability,
convulsions, coma-from cerebral edema)
. What assessment findings does the nurse expect in a child with acute glomerulonephritis?

48. Test Yourself
A 6 year old is admitted with R/O AGN. Which of the following symptoms would the child most likely have?
a. normal blood pressure, diarrhea
b. periorbital edema, grossly bloody urine
c. severe, generalized edema, ascites
d. severe flank pain, vomiting

49. Diagnostic Tests
Urinalysis- protein (moderate), RBC's, WBC's, Specific Gravity elevated.
*All children should have a urinalysis 2 wks after strep infection.
Blood-
1)     ASO titer (antistreptolysin O) (antibody formation against Streptococcus) is elevated, indicating a recent hemolytic streptococcal infection Normal titer is Todd units; IgG antibodies against Streptococcus may be found
2)     ESR (erythrocyte sedimentation rate) elevated showing inflammatory process
3)     BUN(urea nitrogen)& creatinine elevated indicating glomeruli damage
What diagnostic indicators must the nurse monitor?

50. Therapeutic Interventions
1. Depends on the severity of the disease. No
specific treatment. Bedrest encouraged. Disease
is self-limiting!
2. Treat at home if normal BP & adequate output.
3. Must be hospitalized if:
BP increases
gross hematuria
oliguria present.
This way the child can be monitored closely and prevent complications. Rarely develops into acute renal failure
What are nursing interventions related to care of the child with AGN?
Why are Hbg & Hct levels low in a child with glomerulonephritis?

51. Main Goals: Relieve Hypertension Reestablish fluid and electrolyte balance by:
Keep accurate record of I&O. Be sure that child
does not exceed maximum intake ordered.
Record characteristics of urine output including
presence of proteinuria and hematuria.
Check and record specific gravity with each voiding
Monitor vital signs and neuro vital signs
Monitor and record amount of edema at least once
a shift.
What are nursing interventions related to care of the child with AGN?

52. Limit salt intake with hypertension or edema
Daily weights
Bedrest for 4-10 days during acute phase. Semi-fowlers position to assist with breathing. Quiet play.
Oxygen therpay
Diet therapy
Limit salt intake with hypertension or edema
Limit protein if BUN elevated
Decrease intake of Potassium if output decreased
Drug therapy
Antibiotics
Digitalization
Antihypertensives- vasodilators

53. Critical Thinking
With a diagnosis of AGN, which of these nursing diagnoses should receive priority?
a. fluid volume excess
b. risk for impaired skin integrity
c. risk for injury
d. activity intolerance

54. Critical Thinking When teaching parents about known
antecedent infections in acute
glomerulonephritis, which of the following
should the nurse cover?
A. Herpes simplex
B. Scabies
C. Varicella
D. Impetigo

55. Nephrotic Syndrome

56. Nephrotic Syndrome
Chronic renal disorder in which the basement membrane surfaces of the glomeruli are affected, causing loss of protein in the urine.
The glomeruli membrane has increased permeability permitting albumin and protein to pass through the membrane and excreted in the urine.
Explain the changes in vascular function of the kidney in a client with nephrotic syndrome.
a. What laboratory findings must the nurse monitor specific to this condition?
b. What fluid shift does hypoalbuminemia cause or What is the physiologic basis for the edema present in children with
nephrotic syndrome?
c. Why is the renin-angiotension system stimulated. What is the results of this?

57. Note the contrast between the normal glomerular anatomy and the changes that exist in nephrotic syndrome permitting protein to be excreted in the urine.

58. Clinical Manifestations
Four most common characteristics:
1. Edema - May have periorbital edema
upon rising in morning and shifts
during the day.
2. Massive proteinuria and hypoproteinemia
3. Hypoalbuminemia
4. Hyperlipidemia
What are the clinical manifestations of nephrotic syndrome?

59. Other signs and symptoms
Fatigue
Anorexia
weight gain
Abdominal pain – from large amount of fluid in abdominal

60. Ask Yourself?
Which of the following signs and symptoms are characteristic of minimal change nephrotic syndrome?
a. gross hematuria, proteinuria, fever
b. hypertension, edema, fatigue
c. poor appetitie, proteinuria, edema
d. body image change, hypotension
Answer = C

61. Diagnostic Tests
1. Urinalysis – protein-to-creatitine (PR/CR) ratio of
first morning void to assess for proteinuria. Urine
appears dark and frothy.
2. Blood tests – hypoalbuminemia, elevated
cholesterol and triglycerides, elevated hgb, hct,
platelets

62. Try this
Prednisone is the primary drug used in treating NS. What are the side effects and nursing implications?
What teaching should the nurse include with respect to this medication?

63. Nursing Implications related to Prednisone therapy
Answers:
Nursing Implications related to Prednisone therapy
See Drug Guide on p

64. Complications
Children with Nephrotic Syndrome are prone to infection related to:
Loss of immunoglobins in the urine
Corticosteroid Therapy

65. Therapeutic Interventions
1. Administer medications – assess for side effects
Prednisone, Albumin, Diuretics
2. Prevention of infection – avoid people with infections.
May be placed on protective isolation.
3. Keep accurate record of I&O. Measure abdominal girth, weigh daily.
4.  Test urine for protein and specific gravity to see if treatment is effective
5.  Diet:
Normal diet for child’s age
A “no added salt” diet is recommended during steroid treatment.
6. Promote rest
7. Discharge teaching
When caring for a child with nephrotic syndrome what priority nursing
interventions should the nurse include?