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

2. Alterations in Renal Function

3. Biological Variances All nephrons are present at birth
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. Growth and Development
Newborn = loss of the perfect child
Toddler = toilet training
Pre-school = curiosity
School age = embarrassment
Adolescent = body image / sexual function

7. Focused Health History
Single umbilical artery
Chromosomal abnormality
Congenital anomalies
Ear tags
Toilet training history
Family history
Growth patterns

8. Urine
Whaley & Wong
Application of urine collection bag.

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

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

11. VCUG

12. IVP

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

14. Renal Biopsy

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

16. CT Scan

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

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

19. 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

20. 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

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

22. 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

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

24. 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

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

26. 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

27. 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

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

29. 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

30. 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

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

32. Ureteral Reflux

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

34. Hydronephrosis

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

36. 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

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

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

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

40. Agenesis of Scrotum

41. Hypertrophy of Clitoris

42. Extrophy of Bladder
Interrupted abdominal development in early fetal life produces an exposed bladder and urethra, pubic bone separation, and associated anal and genital abnormalities.

43. Exstrophy of Bladder Occurs is 1 of 30,000 births
Congenital malformation in which the lower portion of abdominal wall and anterior bladder wall fail to fuse during fetal development.

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

45. Extrophy of Bladder

46. Extrophy of Bladder

47. Treatment
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

48. Goals of Treatment Preserve renal function: prevent infection
Attain urinary control
Re-constructive repair
Sexual function

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

50. Hypospadias
Incomplete formation
of the anterior urethral
segment.

51. 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.

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

53. Tight Chordee
Tight chordee causes
curvature of the penis.

54. Goals of Treatment 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

55. Hypospadias

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

57. 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

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

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

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

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

62. 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.

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

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

65. 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

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

67. Urea or BUN
Urea is normally freely filtered through the renal glomeruli, with a small amount reabsorbed in the tubules and the remainder excreted in the urine.
Decrease or increase in the value does not tell the cause: pre-renal, post-renal or renal.
Elevated BUN just tells you the urea is not being excreted by the kidney not why.

68. Creatinine Creatinine is a very specific indicator of renal function.
If kidney function is decreased / creatinine level with be increased
Conditions that will increase levels: glomerulonephritis, pyelonephritis or urinary blockage

69. Creatinine levels Adult female: 0.5-1.1 mg/dL
Adult male: mg/dL
Adolescent: mg/dL
Child: mg/dL
Infant: mg/dL
Newborn: mg/dL.

70. Goals of Treatment: ARF
Reduce symptoms
Supportive care until renal function returns
Medications – corticosteroids
Dietary restrictions
Dialysis if indicated

71. Nursing Diagnosis Fluid Volume excess
Potential for infection due to invasive procedures
Potential for activity intolerance
Altered nutrition: less than body requirements
Anxiety of patient and family

72. Peritoneal Dialysis
Bowden & Greenberg

73. Peritoneal Dialysis
The child’s own peritoneal cavity acts as the semi-permeable membrane across which water and solutes diffuse.
Often initiated in the ICU.
Dialysis set-ups are available commercially.

74. Peritoneal Dialysis

75. Peritoneal Dialysis
Soft catheter is used to fill the abdomen with a dialysis solution.
The solution contains dextrose that pulls waste and extra fluid into the abdominal cavity.
Dialysis fluid is then drained.

76. Dialysis fluid High glucose concentrate: 2.5 to 4.25%
The osmotic pressure of the glucose in solution draws the fluid from the vascular spaces into the peritoneum, making available for exchange and elimination of excess fluid.

77. 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

78. Hemodialysis
Used in treatment of advanced and permanent kidney failure.
Blood flows through a special filter that removes waste and extra fluids.
The clean blood is then returned to the body.
Done 3 times a week for 3 to 5 hours.

79. Dialysis

80. Nephrotic Syndrome

81. 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).

82. Clinical Manifestations

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

84. Urine Specific Gravity
Normal value
Increased Urine SG
Dehydration – diarrhea – excessive sweating - vomiting
Decreased Urine SG
Excessive fluid intake – pyelonephritis - nephritis

85. Diagnostic evaluation
Proteinuria
* 4+ urine in urine
Hypoproteinemia
Low serum plasma protein
Hyperlipidemia
* Fat cells in blood
BUN and Creatinine normal unless renal damage

86. Goals of Treatment To decrease urinary protein loss Controlling edema
Corticosteroids up to 12 months
Balanced nutrition
Restore normal metabolic function
Prevent or treat any infection

87. 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

88. 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

89. Physiologic Changes: cortisone
Catabolism of protein, leading to capillary weakness and poor wound healing
Decreased absorption of calcium leading to demineralization of bone / osteoporosis
Increased appetite
Salt-retaining activity of cortisol / hypertension

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

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

92. Before and After

93. 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

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

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

96. Management 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

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