1. Renal & Urogenital Systems
Chapter 9
Pathology

2. Alterations in Renal Function

3. Biological Variances
Kidneys and tubular system mature throughout childhood reaching full maturity during adolescence.
During first two years of life kidney function is less efficient.

4. Bladder Bladder capacity increases with age 20 to 50 ml at birth
700 ml in adulthood

5. 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

6. Urinalysis Protein Leukocytes Red blood cells Casts Specific Gravity
Urine Culture for bacteria

7. Diagnostic Tests Urinalysis Ultrasound
VCUG – Voiding cysto urethrogram
IVP – Intravenous pyelogram
Cystoscopy
CT Scan
Renal Biopsy

8. VCUG

9. IVP

10. Intra Venous Pyelogram
Kidney function analyzed
Watch for allergic reaction
to dye.

11. Renal Biopsy

12. Cystoscopy Invasive surgical procedure Visualizes bladder and
ureter placement.

13. CT Scan

14. Treatment Modalities Urinary diversion Intermittent catheterization
Stents
Drainage tubes
Intermittent catheterization
Watch for latex allergies
Pharmacological management
Antibiotics
Anticholinergic for bladder spasm

15. Urinary Tract Infection
Most common serious bacterial infection in infants and children
Highest frequency in infancy
Uncircumcised males have a ten-fold incidence

16. 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

17. 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

18. UTI – Males Infant males Needs to be investigated
VCUG – ureteral reflux
Ultrasound of kidneys – hydronephrosis or polycystic kidneys
Higher in un-circumcised males

19. 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

20. Clinical Manifestations: UTI
Urinary frequency
Hesitancy
Dysuria
Cloudy, blood tinged
Musk smell to urine
Temperature
Poor feeding / failure to grow
The neonate may only exhibit 6 & 7

21. 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

22. Urethritis Urethral irritation due to chemicals or manipulation
Most common in females
Bubble bath, scented wipes, nylon under wear
Self-manipulation
Child abuse

23. Ureteral Reflux

24. Ureteral Reflux Males 6 to 1 Genetic predisposition
Present as UTI or FTT
Diagnostic tests
Antibiotics if indicated
Surgery to re-implant ureters

25. Hydronephrosis

26. Hydronephrosis Water on kidney Due to obstruction Congenital anomaly
Goals of care to maintain integrity of kidney until normal urinary flow can be established.

27. 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

28. Diagnostics Ultrasound VCUG: voiding cyto urethrogram
IVP is the first two are positive

29. Goals of treatment To preserve renal function
Temporary urinary diversion may be needed to relieve the pressure.
Nephrectomy if renal damage is not reversible

30. Long Term Complications
Urinary incontinence
Infection
Body image
Inadequate sexual function

31. Hypospadias

32. Cryptorchidism Hidden testicle 3 to 5% of males
High incidence in premature infants
Goals of treatment:
Preserve testicular function
Normal scrotal appearance

33. 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

34. Long-term
Monthly testicular self-examination is recommended for all males beginning in puberty, but is essential in males with history of undescended testicle.

35. Testicular Torsion Rotation of the testicle
Spermatic cord twists and obstructs circulation to the testis
Left testicle affected more
Longer cord on left side

36. Clinical Manifestations
Sudden severe pain in the scrotal area
Highest incidence on left side due to longer cord on that side

37. Goals of Treatment Surgical intervention
To relieve obstruction
Preserve the testicular function
Secure testicle to avoid further twisting

38. 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.

39. Renal Failure Newborn causes: Congenital anomalies Hypotension
Complication of open heart surgery

40. Renal Failure Childhood causes: Dehydration
Glomerular nephritis / Nephrotic Syndrome
Nephro-toxicity / drug toxicity

41. 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

42. Diagnostic Tests Decrease RBC due to erythropoietin
Urea and Creatinine elevated
GFR (glomerular filtration rate) most sensitive indicator of glomerular function.