Genitourinary Disorders

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Genitourinary Disorders

• Jan Bazner-Chandler
• CPNP, CNS, MSN, RN

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Alterations in Renal Function
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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.

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Bladder

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

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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

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Growth and Development

• Newborn loss of the perfect child
• Toddler toilet training
• Pre-school curiosity
• School age embarrassment
• Adolescent body image / sexual function

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Focused Health History

• Single umbilical artery
• Chromosomal abnormality
• Congenital anomalies
• Ear tags
• Toilet training history
• Family history
• Growth patterns

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Urine
Whaley Wong
Application of urine collection bag.
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Urinalysis

• Protein
• Leukocytes
• Red blood cells
• Casts
• Specific Gravity
• Urine Culture for bacteria

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Diagnostic Tests

• Urinalysis
• Ultrasound
• VCUG Voiding cysto urethrogram
• IVP Intravenous pyelogram
• Cystoscopy
• CT Scan
• Renal Biopsy

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VCUG
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IVP
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Intra Venous Pyelogram
Kidney function analyzed Watch for allergic
reaction to dye.
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Renal Biopsy
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Cystoscopy
Invasive surgical procedure Visualizes bladder
and ureter placement.
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CT Scan
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Treatment Modalities

• Urinary diversion
• Stents
• Drainage tubes
• Intermittent catheterization
• Watch for latex allergies
• Pharmacological management
• Antibiotics
• Anticholinergic for bladder spasm

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Urinary Tract Infection

• Most common serious bacterial infection in
  infants and children
• Highest frequency in infancy
• Uncircumcised males have a ten-fold incidence

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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

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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

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UTI Males

• Infant males
• Needs to be investigated
• VCUG ureteral reflux
• Ultrasound of kidneys hydronephrosis or
  polycystic kidneys
• Higher in un-circumcised males

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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

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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

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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

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Urethritis

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

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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

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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

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Enuresis

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

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Enuresis

• Familial history
• Males outnumber females 32
• 5 to 10 will remain enuretic throughout their
  lives
• Rule out UTI, ADH insufficiency, or food
  allergies

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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

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Treatment Enuresis

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

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Ureteral Reflux
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Ureteral Reflux

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

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Hydronephrosis
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Hydronephrosis

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

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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

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Diagnostics

• Ultrasound
• VCUG voiding cyto urethrogram
• IVP is the first two are positive

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Goals of treatment

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

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Ambiguous Genitalia

• Genital appearance that does not permit gender
  declaration.

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Agenesis of Scrotum
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Hypertrophy of Clitoris
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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.

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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.

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Clinical Manifestations

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

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Extrophy of Bladder
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Extrophy of Bladder
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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

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Goals of Treatment

• Preserve renal function prevent infection
• Attain urinary control
• Re-constructive repair
• Sexual function

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Long Term Complications

• Urinary incontinence
• Infection
• Body image
• Inadequate sexual function

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Hypospadias
Incomplete formation of the anterior
urethral segment.
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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.

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Newborn

• Circumcision not recommended.
• Foreskin may be needed for reconstructive surgery.

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Tight Chordee
Tight chordee causes curvature of the penis.
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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

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Hypospadias
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Cryptorchidism

• Hidden testicle
• 3 to 5 of males
• High incidence in premature infants
• Goals of treatment
• Preserve testicular function
• Normal scrotal appearance

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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

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Long-term

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

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Testicular Torsion

• Rotation of the testicle
• Spermatic cord twists and obstructs circulation
  to the testis
• Left testicle affected more
• Longer cord on left side

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Clinical Manifestations

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

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Goals of Treatment

• Surgical intervention
• To relieve obstruction
• Preserve the testicular function
• Secure testicle to avoid further twisting

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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.

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Renal Failure

• Newborn causes
• Congenital anomalies
• Hypotension
• Complication of open heart surgery

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Renal Failure

• Childhood causes
• Dehydration
• Glomerular nephritis / Nephrotic Syndrome
• Nephro-toxicity / drug toxicity

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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

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Diagnostic Tests

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

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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.

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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

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Creatinine levels

• Adult female 0.5-1.1 mg/dL
• Adult male 0.6-1.2 mg/dL
• Adolescent 0.5-1.0 mg/dL
• Child 0.3-0.7 mg/dL
• Infant 0.2-0.4 mg/dL
• Newborn 0.3-1.2 mg/dL.

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Goals of Treatment ARF

• Reduce symptoms
• Supportive care until renal function returns
• Medications corticosteroids
• Dietary restrictions
• Dialysis if indicated

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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

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Peritoneal Dialysis
Bowden Greenberg
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Peritoneal Dialysis

• The childs 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.

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Peritoneal Dialysis
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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.

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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.

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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

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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.

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Dialysis
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Nephrotic Syndrome
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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).

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Clinical Manifestations
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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

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Urine Specific Gravity

• 1.010 Normal value
• Increased Urine SG
• Dehydration diarrhea excessive sweating -
  vomiting
• Decreased Urine SG
• Excessive fluid intake pyelonephritis -
  nephritis

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Diagnostic evaluation

• Proteinuria
• 4 urine in urine
• Hypoproteinemia
• Low serum plasma protein
• Hyperlipidemia
• Fat cells in blood
• BUN and Creatinine normal unless renal damage

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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

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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

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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

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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

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Side Effects

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

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Moon Face
High-dose corticosteroid therapy produces a
characteristic moon face appearance.
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Before and After
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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

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Glomerulonephritis

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

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Clinical Manifestations

• Hematuria / red cells casts
• Facial edema
• Brown or frothy urine
• Mild proteinuria
• Hypertension

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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

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Teaching

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