Genitourinary

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Genitourinary

• Elisa A. Mancuso RNC-NIC, MS, FNS
• Professor of Nursing

2
Kidneys

• Detoxify blood and eliminates waste
• Produce erythropoietin
• Regulate blood pressure
• Maintains fluid and electrolyte balance
• Essential for life process
• Huge blood supply
• ? in accidents/trauma

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Hormones

• Erythropietic Stimulating Factor
• Released when low serum O2
• Stimulates production of RBCs
• ? ESF Anemia and prolonged PT/PTT

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Hormones

• Renin
• ? BP or ?blood volume
• Stimulates production of Angiotension I ?
  Angiotension II
• Vasoconstriction and ? BP
• ?Aldosterone by adrenal cortex
• Reabsorbes Na H2O

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Urinary Assessment

• v Voiding pattern output 1-2ml/kg/hr
• Oliguria
• lt1cc/kg/hr (infants) and lt0.5cc/kg/hr children
• Anuria-
• No production of urine.
• Indicates serious renal dysfunction
• Diuresis-
• ? urinary output.
• R/O hyperglycemia
• Glucose threshold is 160 mg
• ? urination and glycosuria.

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Urinary Assessment

• Color
• Clear/straw
• Darker
• Concentrated from dehydration or bilirubin
• Hematuria-blood
• UTI, stones, trauma or glomerulonephritis
• PH
• ? (Alkalinic) with ?K
• Clarity
• Clear ? Cloudy
• Pyuria indicates infection

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Urinary Assessment

• Pain
• Burning on urination- UTI
• Dull achy pain - kidney disease
• Sharp, colicky pain-kidney stones
• Cystitis
• Suprapubic pain or pain after voiding

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Urinary Function Studies

• Urinalysis- U/A
• C S Culture and sensitivity
• Identify organism
• Specific gravity 1.005-1.020
• Infant lt1.010
• Children 1.010-1.030
• Fluid challenge test
• 20-50cc/kg/hour then v output
• Blood Urea Nitrogen (BUN) 5-18
• Creatinine 0.3-1mg/dl
• most reliable test for glomeruli function
• Glomerular Filtration Rate GFR
• Renal Function 70-160cc/min.
• Infant has lower rate till 2 years of age.

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Renal Function Studies

• Ultrasound- renal or pelvic
• Intravenous Pyelogram IVP
• Renal angiography
• Cystoscopy
• Voiding Cysto Urethra Gram VCUG
• Renal Biopsy

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Urinary Tract Infections

• Ascending infection
• Bacteria ? urethra ? bladder (cystitis)
• Bladder ? ureters ? kidney (pyelonephritis)
• Fecal bacteria causes 80 UTIs
• Peak incidence _at_ 2-6 years of age
• without structural problems

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Etiology

• Girls urethra smaller closer to anus
• ? risk when wipe back to front
• Boys non-circumsized or have phimosis
• Urinary stasis
• Structural defect or obstruction
• Vesicouretal Reflux or Hydronephrosis
• Incomplete bladder empting RT
• Constipation or toilet training (holding it in)
• Sexually active adolescent girls

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Clinical signs

• Burning
• Frequency
• Dysuria
• Suprapubic, flank or abdominal pain
• Incontinence
• Foul smelling urine
• Fever
• Infants may present with high fever, chills,
  vomiting, diarrhea or irritability

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Diagnosis

• UA and C S to identify organism
• Clean catch or bagged urine
• Area must be cleaned properly!
• Urinary catheterization or supra-pubic tap.
  Sterile procedure!
• Repeat CS after medication completed
• To verify med was effective

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Antibiotic Therapy

• Sulfonamides Co-trimoxazole
• (Bactrim DS/Septra/TMP-SMX).
• v Sulfa allergies.
• ? PO intake. Not for infants less than 2 months.
• Cephalosporins Ceclor po/ Rocephin IV/IM.
• Resistant or severe UTIs or pyelonephritis.
• (IV) meds for hospitalized pts.
• Penicillins (PCN) Ampicillin po/IV, amoxicillin,
  augmentin
• ? PCN allergies (Ampicillin and amox not as
  sensitive)
• Repeat Culture to assess efficacy of
  med.

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Analgesic Therapy

• Phenazopyridine HCL (pyridium)
• Antispasmotic.
• Local anesthetic action on urinary mucosa. Only
  use for pain older children gt6years
• SE-orange urine and can stain contact lenses.
• Motrin
• 5-10 mg/kg/dose q 6-8 hr
• Tylenol
• 10-15 mg/kg/dose

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Therapy

• ? Hydration 2 4 liters/day
• Acidic juices cranberry and OJ
• Encourage frequent voiding
• Appropriate hygiene
• Wipe from front to back
• No bubble baths

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Hydronephrosis

• Congenital or Acquired RT reflux or calculi
• Obstruction _at_ ureto-pelvic junction
• Renal pelvis and calyces dilated with urine.
• ? urine flow leads to
• stasis, infections or calculi
• Infants may spontaneously resolve
• Diagnosis
• Renal ultrasound or IVP

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Clinical signs

• Colicky, flank pain
• May radiate to groin
• N/V
• Possible palpable mass
• Pyuria
• Fever

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Therapy

• ? Fluids-2.5 liters/day
• Hygiene
• ? Increase voiding
• Surgery
• Stent _at_ obstruction site

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Polycystic Kidney Disease

• Autosomal dominant disorder 90.
• Disease progresses in adulthood.
• Autosomal recessive
• Severe disease in childhood
• Cyst formation renal enlargement
• Cysts filled with
• glomerular filtrate, solutes and fluids
• Renal blood vessels and nephrons compressed
• Functional tissue is destroyed ?
• kidney failure

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Clinical Signs

• Flank pain
• Hematuria
• Proteinuria
• Nocturia
• Frequent UTIs and renal calculi
• HTN and impaired renal blood flow
• Protruding abdomen

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Therapy

• Renal ultrasound
• IVP
• CT Scan
• ? Fluid Intake 2-2.5 L/day
• Prevents infection
• Antihypertensive Meds
• Beta blockers-atenolol or propanolol
• Ca Channel Blockers-procardia or verapamil
• Dialysis or kidney transplant

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Acute Glomerulonephritis

• Antigen/antibody reaction to infection
• Group A ß hemolytic strep.
• Most common in boys 4 - 7years of age
• Peaks in winter and spring
• Wire Mesh Trap

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Pathophysiology

• Antibodies made against strep toxin
• AG/AB complex trapped in glomerulus
• Leukocytes infiltrate the area
• Adheres to basement membrane
• ? Inflammation ? GFR
• Damaged Glomerulus
• Leakage of RBCs and Protein
• Small hemorrhages on cortical surfaces
• Kidneys become enlarged and pale

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Clinical Signs Symptoms

• Cardinal sign Hematuria 4
• Tea colored urine RT ? ? RBCs being excreted
• Proteinuria 3/4
• Oliguria
• ? Temperature
• ? Na and H2O Re-absorption ? ?? BP
• ? Periorbital/facial edema 3/4 in AM.
• Dependent edema/extremities in PM.
• ? Weight gain
• Circulatory congestion RT pulmonary edema

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Diagnosis

• ASO titers gt250 todd units
• Reflects recent strep infection
• Past 10-14 days
• ? ESR
• ? BUN ? Creatnine
• ? Specific Gravity 1.20-1.30
• ? Albumin Hypoalbunemia
• ? K due to impaired GFR
• ? NH4 (Azotemia)

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Treatment

• Isolation Precautions!
• Bed rest (6-12 weeks)
• Stable electrolytes, BUN BP
• Medications
• PCN 10 day therapy
• only for current strep
• Hydralazine (Apresoline)
• vasodilator (? renal cerebral flow)
• v V/S, BP Neuro status
• Furosemide (Lasix) Loop diurectic
• Inhibits re-absorption of Na Cl
• v Lytes v I0 v weight

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Treatment

• Fluid Balance
• Oliguria Fluid restriction (I O)
• Promote voiding
• Diuresis Improvement ? Dehydration
• Nutrition
• ? Carbohydrates
• ? Na and K
• Moderate protein
• (Protein ? Urea ? ?? BUN)
• Energy for tissue repair

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Nephrotic Syndrome

• Most common glomerular injury in kids
• Idiopathic 85
• Boys 2x gt Girls
• Age 2-4 years
• Viral infection 7 days before onset
• Acquired secondary
• Acute Glomerulonephritis ?Toxic Nephrosis
• Systemic disease SLE or HIV.
• Major presenting symptom of pt with AIDS
• Swiss Cheese Syndrome

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Pathophysiology

• ?? Glomerular Permeability to plasma proteins
• ?? Urinary excretion of protein albumin
• Proteinuria 3/4 Hypoproteinemia (-) N
  balance
• Albuminuria 3/4 Hypoalbuminemia
• ?? Plasma Osmotic Pressure ? ?? Vascular Volume
• Stimulates Renin ? Angiotensin ? ADH
  Aldosterone Na H2O retained ? Edema
• ?? Interstitial Fluid (abdomen extremities)
• Hyperlipidemia (450-1500)
• ?? Serum protein activates hepatic lipid
  synthesis
• Fat streaks in glomeruli ?? GFR
• Lipid granules in urine sparkly

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Signs and symptoms

• Pitting Edema- Presenting symptom
• Periorbital in AM Dependent in PM
• Back, Abdomen Scrotum
• Gradual weight gain
• Ascites
• ? Abd girth ? Respiratory function
• Oliguria
• Dark and frothy (Lipid Granules)
• Skin waxy and white from anemia
• Malnutrition
• ? Intestinal absorption
• (-) N balance
• Blood pressure WNL or ? RT Hypovolemia

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Prognosis

• Self-Limiting Resolves 1-2 weeks
• Prolonged recovery 12 - 18 months
• Exacerbations of symptoms
• Risk of relapse 50 after 5 years
• 80 will have favorable outcome

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Therapy

• Assess V/S for shock! v HR BP
• Strict IO Daily weight
• v urine- protein, albumin SG
• Bed rest
• ? Risk for skin breakdown RT edema
• Sheepskin, reposition q 2h
• Nutrition
• ? Calories, ? Ca, ? Protein ? Na

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Medications

• Prednisone 2mg/kg/day qid
• ? Inflamation Proteinuria
• Diuresis (7-21 days) ? protein excretion
• Monitor SE
• Hyperglycemia ? Growth GI bleeding
• Diuretics
• Furosemide (Lasix) 1-2mg/kg/dose
• Mannitol IV 0.25-0.5 mg/kg/dose q4h
• ? Osmotic Pressure ? GFR
• Reabsorbs H2O, Na Cl
• Salt Poor Albumin (SPA) 5-25 1-2 gm/kg/day
• Plasma expander replenishes albumin

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Hypospadias

• 1-300 births
• 10-15 have 1st degree relative
• Urethral opening located behind glands on ventral
  (underside) surface
• Kids wet their sneakers
• ?? Severity closer to body wall

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Treatment

• No circumcision!
• May use foreskin for repair later
• Urology consult
• Reconstructive surgery _at_ 6-18 mos
• Testosterone prior to ? penile size
• Indwelling catheter ? leg bag
• Home care instructions important

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Epispadias

• Rarer than hypospadias
• Urethral opening located behind glans penis on
  dorsal (upper) surface
• Kids wet their faces
• Same Treatment as for hypospadias

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Cryptochidism

• Failure of 1 or both testes to descend abdomen?
  inguinal canal? scrotal sac
• Inguinal hernia and small scrotal size
• Retractile testes- Reducible
• Overactive cremasteric reflex.
• Manually can be brought down to scrotal sac.

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Therapy

• Wait for 1st birthday for spontaneous descent
• 75 spontaneously descend
• HCG 1000 units IM x 3 doses
• Facilitates descent
• Surgery-orchioplexy
• Bring testes into scrotal sac

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Enuresis

• Unable to control bladder function (Nocturnal bed
  wetting)
• Primary
• Never been dry _at_ night
• Secondary
• Most common, previously dry and now accidents _at_
  night
• Delayed CNS maturation
• Unable to detect bladder fullness and control
  voiding
• UTI
• Family history
• Hypercalciuria
• ?? Ca in urine ? bladder irritation ? painful
  urination

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Therapy

• R/O UTI or ?? Ca
• Behavior modifications
• No drinking at bedtime
• Void prior to bedtime
• Imagery of full bladder
• Medications
• TCAs
• Imipramine (Tofranil) 10-25mg q HS
• Nortrypyline (Pamelor) 10-35 mg q HS
• Antidiuretic
• DDAVP Desmopressin Acetate 0.2-0.6 mg q HS
• Diuretic
• Chlorothiazide (Diuril) 20 mg/kg/24H
• ?? Ca reabsorption

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Testicular Torsion

• 4000 males _at_ peak age 13
• Twisting of spermatic cord
• ?? blood flow to testes
• Testes can survive only 6-12 hours with-out blood
  flow
• Gangrene necrosis sets in
• Surgical emergency

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Signs and symptoms

• Acute onset!
• Severe testicular pain
• Scrotum swollen, red warm
• Abdominal pain N V
• ?Cremasteric reflex
• Surgery
• Untwist and secure cord to prevent further
  torsions
• Orchiectomy
• Remove gangrene testicle