1. Pediatric Genitourinary Disorders Revised Debbie Perez 10/10

2. Pediatric Difference in Urinary Tract: Kidney function Kidney function Bladder capacity Bladder capacity Bladder control Bladder control Recovery Recovery

3. Urinary Tract Infections Etiology and Pathophysiology Etiology and Pathophysiology Occur more commonly in girls Occur more commonly in girls Migration of pathogens Migration of pathogens Escherichia coli most common cause-Why? Escherichia coli most common cause-Why? May be bacterial, viral or fungal May be bacterial, viral or fungal

4. Assessment Typical symptoms of older children & adults: Typical symptoms of older children & adults: Dysuria Dysuria Frequency & urgency Frequency & urgency Burning Burning Hematuria (usually older child) Hematuria (usually older child) Symptoms for infants and young children can be vague and nonspecific: Symptoms for infants and young children can be vague and nonspecific: Fever Fever Mild abdominal pain Mild abdominal pain Enuresis Enuresis If severe: High fever, flank pain, vomiting, malaise If severe: High fever, flank pain, vomiting, malaise

5. Diagnostic Tests Diagnostic Tests Urine for culture and sensitivity Urine for culture and sensitivity Clean catch Clean catch Suprapubic aspiration Suprapubic aspiration Catheterization Catheterization Positive Urinalysis Positive Urinalysis Bacteria colony count of more than 100,000/ml. Bacteria colony count of more than 100,000/ml. Presence of protein Presence of protein

6. Therapeutic Interventions Drug Therapy Drug Therapy Antibiotics Antibiotics Analgesics – Tylenol Analgesics – Tylenol Antipyretic Antipyretic Nursing Care Nursing Care Force fluids for rehydration Force fluids for rehydration Prescribed antibiotics Prescribed antibiotics Promote comfort Promote comfort

7. Therapeutic Interventions Parent Teaching Parent Teaching Change diaper frequently Change diaper frequently Teach girls to wipe front to back Teach girls to wipe front to back Discourage bubble baths Discourage bubble baths Encourage children to drink periodically during the day Encourage children to drink periodically during the day Bathe daily Bathe daily Adolescent start menstruating – encourage change of pad every 4 hours Adolescent start menstruating – encourage change of pad every 4 hours When girls become sexually active – teach to urinate immediately after intercourse When girls become sexually active – teach to urinate immediately after intercourse

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

9. Enuresis Difficulty with urination control Nocturnal – Enuresis at night Diurnal – Enuresis during the day Primary – Never having experienced a period of dryness Secondary – Occurs when a 6-12 month of dryness has preceded the onset of enuresis

10. Risk Factors Physical   Bladder capacity   Urinary tract abnormality   Neurologic alterations   Obstructive sleep apnea   Constipation   UTI   Pinworm infestation   Diabetes mellitus   Voiding dysfunction

11. Risk Factors Emotional   Family disruption   Inappropriate pressure during training   Inadequate attention to voiding cues   Decreased self-esteem   Sexual abuse

12. Diagnosis Diagnosis is based on history and symptoms Urinalysis and culture are done Measurement of urine flow and bladder capacity with voiding cystourethrogram

13. Treatment Limit fluids after supper and void before bed Imagery Let child keep record of progress Rewards can be used Behavioral use of alarm that detects moisture Imipramine HCL – Tricyclic Antidepressant Despropressin acetate – tablet or nasal spray which has antidiuretic effect Address the emotional side with all involved

14. Nursing Diagnoses Situational low self-esteem related to bed- wetting or urinary incontinence Situational low self-esteem related to bed- wetting or urinary incontinence Impaired social interaction related to bed- wetting or urinary incontinence Impaired social interaction related to bed- wetting or urinary incontinence Compromised family coping related to negative social stigma and increased laundry load Compromised family coping related to negative social stigma and increased laundry load Risk for impaired skin integrity related to prolonged contact with urine Risk for impaired skin integrity related to prolonged contact with urine

15. Vesicoureteral Reflux

16. Pathophysiology Pathophysiology Urinary Reflux – defective ureterovesicular valve that guards the entrance from the bladder to the ureter : Urinary Reflux – defective ureterovesicular valve that guards the entrance from the bladder to the ureter : Primary reflux – congenital abnormality Primary reflux – congenital abnormality Secondary reflux – repeated UTI’s Secondary reflux – repeated UTI’s Neurogenic bladder – stronger than usual bladder pressure. Neurogenic bladder – stronger than usual bladder pressure. Backflow – while voiding when bladder contracts, urine is swept up the ureters Backflow – while voiding when bladder contracts, urine is swept up the ureters Stasis of urine in ureters or kidneys which in turn leads to hydronephrosis Stasis of urine in ureters or kidneys which in turn leads to hydronephrosis

17. Assessment 1. Fever 2. Vomiting 3. Chills 4. Straining or crying on urination, poor urine stream 5. Enuresis (bedwetting), incontinence in a toilet trained child, frequent urination 6. Strong smelling urine 7. Abdominal or back/flank pain

18. Diagnostic Tests 1. Urine culture 2. Voiding Cystourethrogram 3. Renal ultrasound

19. Therapeutic Interventions Drug Therapy Drug Therapy Antibiotics Antibiotics Penicillin Penicillin Cephalosporins Cephalosporins Urinary Antiseptics Urinary Antiseptics Nitrofurantoin Nitrofurantoin Surgery Surgery Repair of significant anatomical anomalies, uretheral implantation Repair of significant anatomical anomalies, uretheral implantation

20. Nursing Care Keep accurate record of intake and output Keep accurate record of intake and output Secure stents and catheter Secure stents and catheter Assess vital signs Assess vital signs Assess comfort level Assess comfort level Patient Teaching Patient Teaching

21. Evaluation Follow-up: Follow-up: Repeat VCUG (voiding cystourethrogram) after a few months Repeat VCUG (voiding cystourethrogram) after a few months

22. Test Yourself Which of the following organisms is the most common cause of UTI in children? Which of the following organisms is the most common cause of UTI in children? a. staphylococcus b. klebsiella c. pseudomonas d. escherichia coli

23. Bladder Exstrophy A rare defect in which the bladder wall extrudes through the lower abdominal wall A rare defect in which the bladder wall extrudes through the lower abdominal wall Due to failure of abdominal wall to close in fetal development Due to failure of abdominal wall to close in fetal development Upper urinary tract usually normal Upper urinary tract usually normal 1:400,000 live births 1:400,000 live births Treatment is surgical reconstruction in stages Treatment is surgical reconstruction in stages

24. Goals of Surgical Reconstruction Bladder and abdominal wall closure Bladder and abdominal wall closure Urinary continence, with preservation of renal function Urinary continence, with preservation of renal function Creation of functional and normal – appearing gentitalia Creation of functional and normal – appearing gentitalia Improvement of sexual functioning Improvement of sexual functioning

25. Nursing Care Pre-op focus-prevent infection Pre-op focus-prevent infection Post-operative focus – Immobilize to promote healing of surgical site Post-operative focus – Immobilize to promote healing of surgical site Monitor renal function – assess I&O and urine chemistries to detect renal damage Monitor renal function – assess I&O and urine chemistries to detect renal damage Maintain patency of drainage tubes Maintain patency of drainage tubes Analgesics Analgesics Antibiotics as ordered Antibiotics as ordered Emotional support of parents Emotional support of parents

27. Etiology and Pathophysiology Epispadias – rare and often associated with extrophy of bladder. Epispadias – rare and often associated with extrophy of bladder. Hypospadias Hypospadias Occurs from incomplete development of urethra in utero. Occurs from incomplete development of urethra in utero. Occurs in 1 of 100 male children. Increased risk if father or siblings have defect. Occurs in 1 of 100 male children. Increased risk if father or siblings have defect.

28. Hypospadias

29. Assessment Usually discovered during Newborn Physical Assessment

30. Interventions Medical Treatment: Medical Treatment: Do NOT circumcise infant. May need to use foreskin in reconstruction. Do NOT circumcise infant. May need to use foreskin in reconstruction. Surgery Surgery Reconstructive – repositions uretheral opening at tip of penis Reconstructive – repositions uretheral opening at tip of penis Chordee – released and urethra lengthened. Chordee – released and urethra lengthened.

31. What do you think? The reason for surgery at about 1 year of age is because: The reason for surgery at about 1 year of age is because: a. the procedure is less painful for a child b. chordee may be reabsorbed c. the child has not developed body image and castration anxiety and castration anxiety d. the repair increases the ease of toilet training

32. Post–op Nursing Care Post–op Nursing Care Assess bleeding Assess bleeding Maintain urinary drainage Maintain urinary drainage Control Bladder Spasms Control Bladder Spasms Prophylactic antibiotics Prophylactic antibiotics Control Pain Control Pain Increase fluid intake Increase fluid intake

33. Do not allow to play on any straddle toys. Do not allow to play on any straddle toys. Prevent infection Prevent infection Call Dr if: Call Dr if: temp is over 101 temp is over 101 loss of appetite loss of appetite pus or increased bleeding from stent pus or increased bleeding from stent cloudy or foul smelling urine cloudy or foul smelling urine

34. Cryptorchidism Failure of one or both of the testes to descend from abdominal cavity to the scrotum

35. Assessment Assessment

36. Therapeutic Interventions Surgery Surgery Orchiopexy done via laproscopy Orchiopexy done via laproscopy Done around 1 year of age Done around 1 year of age Nursing Care – Post-op Nursing Care – Post-op Assess from bleeding and S/S of infection. Assess from bleeding and S/S of infection. Minimal activity for few day to ensure that the internal sutures remain intact 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. Allow opportunity to express fears about mutilation or castration by playing with puppets or dolls.

37. Acute Glomerulonephritis

38. Etiology and Pathophysiology Etiology and Pathophysiology Usual organism: Group A beta-hemolytic streptococcus Usual organism: Group A beta-hemolytic streptococcus Organism not found in kidney Organism not found in kidney Glomeruli become inflamed Glomeruli become inflamed and scarred and scarred

39. Edema: renal capillary permeability with renal vascular spasms glomerular filtration Edema: renal capillary permeability with renal vascular spasms glomerular filtration accumulation of Na+ and H2O in the blood stream causing increased intravascular and interstitial fluid volume accumulation of Na+ and H2O in the blood stream causing increased intravascular and interstitial fluid volume Proteinuria: Protein molecules filter through the damaged glomeruli Proteinuria: Protein molecules filter through the damaged glomeruli Hematuria: RBCs can pass through to the urine Hematuria: RBCs can pass through to the urine

40. Manifestations Common in boy 5-10 years old. Occurs 1-2 weeks after a respiratory infection or after impetigo. Common in boy 5-10 years old. Occurs 1-2 weeks after a respiratory infection or after impetigo. Has 2 phases Has 2 phases Edematous phase – 4-10 days Edematous phase – 4-10 days Diuresis phase- self limiting Diuresis phase- self limiting

41. 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

42. Assessment Cont… 2.Cardiovascular: a. Edema-usually eyes, hands, feet, not generalized (dependent edema) a. Edema-usually eyes, hands, feet, not generalized (dependent edema) b. Hypertension from hypervolemia which can lead to b. Hypertension from hypervolemia which can lead to c. Cardiac involvement CHF- orthopnea / dyspnea, cardiac enlargement, pulmonary edema c. Cardiac involvement CHF- orthopnea / dyspnea, cardiac enlargement, pulmonary edema

43. Assessment cont… 3.Neuro a. Encephalopathy: headacheirritabilityconvulsions coma-from cerebral edema

44. Test Yourself A 6 year old is admitted with R/O acute glomerular nephritis which of the following symptoms is the child most likely have? A 6 year old is admitted with R/O acute glomerular nephritis which of the following symptoms is 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

45. Diagnostic Tests Urinalysis- protein (moderate), RBC's, WBC's, Specific Gravity elevated. *All children should have a urinalysis 2 wks after strep infection. *All children should have a urinalysis 2 wks after strep infection.Blood- ASO titer: (antistreptolysin O) (antibody formation against Streptococcus) is elevated, indicating a recent streptococcal infection ASO titer: (antistreptolysin O) (antibody formation against Streptococcus) is elevated, indicating a recent streptococcal infection ESR: (erythrocyte sedimentation rate) elevated showing inflammatory process ESR: (erythrocyte sedimentation rate) elevated showing inflammatory process BUN: (urea nitrogen) & creatinine elevated indicating glomerular damage BUN: (urea nitrogen) & creatinine elevated indicating glomerular damage CBC:WBCs normal range, H&H decreased. CBC:WBCs normal range, H&H decreased. Lytes: elevated potassium, low serum bicarbonate Lytes: elevated potassium, low serum bicarbonate

46. Therapeutic Interventions 1. Depends on the severity of the disease. 1. Depends on the severity of the disease. No specific treatment, supportive care. No specific treatment, supportive care. 2. Treat at home if normal BP & adequate output. 2. Treat at home if normal BP & adequate output. 3. Must be hospitalized if: 3. Must be hospitalized if: BP increases BP increases gross hematuria gross hematuria oliguria present. oliguria present. To monitor for complications *Rarely develops into acute renal failure

47. Main Goals: Relieve Hypertension and Re-establish fluid and electrolyte balance: Keep accurate record of I&O. Keep accurate record of I&O. Record characteristics of urine output Record characteristics of urine output Check and record specific gravity with each voiding Check and record specific gravity with each voiding Monitor vital signs and neuro vital signs Monitor vital signs and neuro vital signs Monitor and record amount of edema at least once a shift. Monitor and record amount of edema at least once a shift.

48. Interventions cont… Daily weights Daily weights Bed rest for 4-10 days during acute phase Bed rest for 4-10 days during acute phase Oxygen therapy Oxygen therapy Diet therapy Diet therapy Drug therapy Drug therapy

49. Critical Thinking A child is admitted and diagnosed with having AGN. Prioritize the following nursing diagnoses. A child is admitted and diagnosed with having AGN. Prioritize the following nursing diagnoses. a. fluid volume excess a. fluid volume excess b. risk for impaired skin integrity c. anxiety d. activity intolerance

50. Critical Thinking When teaching parents about known antecedent infections in acute glomerulonephritis, which of the following should the nurse cover? a. Herpes simplex b. Streptococcus c. Varicella d. Impetigo

51. Nephrotic Syndrome Chronic renal disorder in which the basement membrane surfaces of the glomeruli are affected, causing loss of protein in the urine.

52. Etiology and Pathophysiology Insidious onset with periods of remission / exacerbations throughout life- No cure Insidious onset with periods of remission / exacerbations throughout life- No cure Idiopathic cause (95%) immune response is strongly suspected. Idiopathic cause (95%) immune response is strongly suspected. Other causes: may develop after acute glomerulonephritis, sickle cell disease, Diabetes Mellitus, or drug toxicity. Other causes: may develop after acute glomerulonephritis, sickle cell disease, Diabetes Mellitus, or drug toxicity. Age of onset preschool yrs.- 2-4 yrs, males more common Age of onset preschool yrs.- 2-4 yrs, males more common Increased permeability which allows protein to leak into the urine (proteinuria). Increased permeability which allows protein to leak into the urine (proteinuria). Shift of protein out of the vascular system causes fluid from the plasma to seep into the interstitial spaces and body cavities, particularly the abdomen (ascites). Edema and hypovolemia Shift of protein out of the vascular system causes fluid from the plasma to seep into the interstitial spaces and body cavities, particularly the abdomen (ascites). Edema and hypovolemia

53. Assessment Four most common characteristics: 1. Massive proteinuria 2. Low serum albumin (K + normal) 3. Edema 4. Malnourishment

54. Assessment 1. Hyperlipidemia 2. Shiny, pale skin 3. Brittle hair 4. Hypercoagulability (increased risk for thrombosis) 5. Fatigue 6. Abdominal pain (ascites)

55. Ask Yourself? Which of the following signs and symptoms are characteristic of minimal change nephrotic syndrome? 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

56. Diagnostics Based on history Based on history Characteristic symptoms Characteristic symptoms Lab findings with serum albumin and sodium decreased Lab findings with serum albumin and sodium decreased BUN, Cholesterol and Electrolytes may be ordered BUN, Cholesterol and Electrolytes may be ordered Urinalysis reveals massive proteinuria (50 mg/kg/day) (primary indicator of nephrotic syndrome) Urinalysis reveals massive proteinuria (50 mg/kg/day) (primary indicator of nephrotic syndrome)

57. Therapeutic Interventions Reduce edema Reduce edema Keep accurate record of I&O. Measure abdominal girth, weigh daily Keep accurate record of I&O. Measure abdominal girth, weigh daily Test urine for protein and specific gravity to see if tx is effective Test urine for protein and specific gravity to see if tx is effective Diet: Diet: Normal diet for child’s age recommended Normal diet for child’s age recommended No salt added No salt added High caloric High caloric Possible fluid restrictions Possible fluid restrictions

58. Diuretics-cautious use Diuretics-cautious use Antihypertensive Antihypertensive Antibiotic Antibiotic Analgesics Analgesics Albumin if resistant to diuretic Albumin if resistant to diuretic Protective Isolation Protective Isolation Treatment

59. Interventions Provide good skin care – edematous tissue fragile Provide good skin care – edematous tissue fragile Child / Parent teaching – measures to prevent infections, medication administration, monitoring of intake and output Child / Parent teaching – measures to prevent infections, medication administration, monitoring of intake and output Provide rest periods Provide rest periods

60. Prognosis: Usually spontaneous resolution even with relapses (by age 30) Usually spontaneous resolution even with relapses (by age 30) 20% may develop chronic renal failure 20% may develop chronic renal failure

61. The End