1. Genitourinary Disorders
Jan Bazner-Chandler
CPNP, CNS, MSN, RN

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

3. 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

4. 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

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

6. 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

7. Assessment: UTI
Neonate: jaundice, fever, failure to thrive, feeding, vomiting
Infant: irritability, poor feeding, vomiting, diarrhea, strong odor to urine
Childhood: vomiting, diarrhea, abdominal or flank pain, fever, enuresis, urgency, frequency, strong odor to urine

8. Diagnosis Urinary Tract Infection
Pyuria – white blood cells in urine
Culture of urine – grows out bacteria
Urosepsis: Blood culture and urine culture grow out the same organism
Pyelonephritis:
Elevated white blood cell count
Elevated C-reactive protein and erythrocyte sedimentation rate

9. Multidisciplinary Interventions
Antibiotic therapy for 7 to 10 days
E-coli most common organism 85%
Amoxicillin or Cefazol or Bactrim or Septra
Increase fluid intake
Frequent voiding
Acetaminophen for pain
Teach proper cleansing

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

11. Voiding Disorders
Delay or difficulty in achieving control after a socially acceptable age.
Enuresis
Nocturnal = at night
Diurnal = during the day
Secondary = relapse after some control

12. Toilet Training Readiness
12 months no control over bladder
18 to 24 months some children show signs of readiness
Some children may not be ready until around 30 months

13. Enuresis
Involuntary discharge of urine after the age by which bladder control should have been established, usually considered to be age of 5 years.

14. Enuresis Familial history Males outnumber females 3:2
5 to 10% will remain enuretic throughout their lives
Rule out UTI, ADH insufficiency, or food allergies

15. Pharmacologic Interventions
Pharmacological intervention:
Desmopressin synthetic vasopressin acts by reducing urine production and increasing water retention and concentration
Tofranil: anticholinrgic effect – FDA approval for treatment of enuresis
Side effect may be dry mouth and constipation
Some CNS: anxiety or confusion
Need to be weaned off

16. Multidisciplinary Interventions
Diet control
Reduce fluids in evening
Control sugar intake
Bladder training
Praise and reward
Behavioral chart to keep track of dry nights
Alarm system

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

18. Ureteral Reflux

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

20. Hydronephrosis

21. Ambiguous Genitalia
Genital appearance that does not permit gender declaration.

22. Agenesis of Scrotum

23. Hypertrophy of Clitoris

24. Extrophy of Bladder
Congenital malformation in which the lower portion of abdominal wall and anterior bladder wall fail to fuse during fetal development.

25. Assessment
Visible defect that reveals bladder mucosa and ureteral orifices through an open abdominal wall with constant drainage of urine.

26. Extrophy of Bladder

27. Extrophy of Bladder

28. Surgical Management
Surgery within first hours of life to close the skin over the bladder and reconstruct the male urethra and penis.
Urethral stents and suprapubic catheter to divert urine
Further reconstructive surgery can be done between 18 months to 3 years of age

29. Multidisciplinary Interventions
Preserve renal function: prevent infection
Attain urinary control
Re-constructive repair
Sexual function

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

31. Hypospadias Most common anomaly of the male phallus
Incomplete formation of the anterior urethral segment
Urethral formation terminates at some point along the ventral fusion line.
Cordee – downward curve of penis.

32. Hypospadias

33. Tight Chordee

34. Hypospadias Repair

35. Newborn Circumcision not recommended.
Foreskin may be needed for reconstructive surgery.

36. Surgical Interventions
Release of tight chordee
Placement of urethra opening at head of penis
Surgery recommended at around six to nine months of age
Long term outcomes:
Leaking at the site
Body image

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

38. Multidisciplinary Interventions
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

39. Testicular Exam
Monthly testicular self-examination is recommended for all males beginning in puberty, but is essential in males with history of undescended testicle.

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

41. Assessment Sudden severe pain in the scrotal area
Highest incidence on left side due to longer cord on that side

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

43. Acute Renal Failure (ARF)
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.

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

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

46. Assessment: 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
Electrolyte imbalance and dehydration

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

48. Goals of Treatment: Acute Renal Failure
Reduce symptoms
Supportive care until renal function returns
Medications – corticosteroids
Dietary restrictions - sodium
Dialysis if indicated

49. Complications of Peritoneal Dialysis
Peritonitis
Pain during infusion of fluids
Leakage around the catheter
Respiratory symptoms
Abdominal fullness from too much fluids
Leakage of fluid to chest from hole in diaphragm

50. Nephrotic Syndrome / nephrosis
Etiology is not know, it is felt to be the result of an alteration of the glomerular membrane, making it permeable to plasma proteins (especially albumin).

51. Generalized Edema

52. Assessment Generalized edema
Edema is worse in scrotum and abdomen (results in ascites)
Dramatic weight gain
Pale, fatigue, anorexic
Urinary output decreased
Urine foamy and frothy with elevated SG

53. Diagnostic evaluation
Proteinuria
* 4+ urine in urine
Hypoalbuminemia
Hypercholesterolemia
* Fat cells in blood
BUN and Creatinine normal unless renal damage

54. Multidisciplinary Interventions
Diuretics (during acute phase lasix would be given after IV albumin)
Fluid restriction if edema severe
Low sodium / high protein diet
Daily weights
Strict intake and output

55. Corticosteroid Therapy
High dose prednisone
Taper when protein loss in urine decreases
Current recommendations to keep on low dose every other day for up to 6 months
If relapse or remission not obtained will try cytotoxic medications

56. Side Effects of Cortisone Therapy
Hirsutism
Moon face with ruddy cheeks
Acne
Dorsocervical fat pads
Ecchymosis (easy bruising)
Truncal obesity
Mood swings – inability to sleep
Increase appetite

57. Moon Face High-dose corticosteroid therapy produces a characteristic
“moon face” appearance.

58. Before and After

59. Nursing Interventions for long tern use
Prednisone prescribed every other day
Instruct to take in the morning
Long Term Use - Prednisone every other day in the am
Take with food: can cause GI upset
Do not stop taking medication until instructed to do so
Medication needs to be tapered
Monitor for infection

60. Glomerulonephritis
Immune complexes become entrapped in the glomerular membrane.
Symptoms appear 1 to 2 weeks after a Strep A skin or throat infection.

61. Clinical Manifestations
Hematuria / red cells casts
Facial edema
Brown or frothy urine
Mild proteinuria
Hypertension

62. Multidisciplinary Interventions
Low sodium / high protein
Anti-hypertensive drugs
Diuretics
Antibiotics if + throat culture or blood culture
Monitor blood pressure
24 hour urine for Creatinine clearance

63. Teaching Culture sore throats
Take antibiotics for full course prescribed
Do not share medications with others in family