Genitourinary Disorders

1
Genitourinary Disorders

• Chapter 7
• Medical Considerations

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
• 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.