Genitourinary Disorders

Jan Bazner-ChandlerCPNP, CNS, MSN, RN

Urinary Tract Infection Most common serious bacterial infection in

infants and children Highest frequency in infancy Uncircumcised males have a ten-fold

incidence

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

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

UTI – Males Infant males

Needs to be investigated VCUG – ureteral reflux Ultrasound of kidneys – hydronephrosis or polycystic

kidneys Higher in un-circumcised males

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

Assessment: UTI Neonate: jaundice, fever, failure to thrive,

feeding, vomiting

Infant: irritability, poor feeding, vomiting, diarrhea, strong odor to urine

Childhood: vomiting, diarrhea, abdominal or flank pain, fever, enuresis, urgency, frequency, strong odor to urine

Diagnosis Urinary Tract Infection

Pyuria – white blood cells in urine Culture of urine – grows out bacteria

Urosepsis: Blood culture and urine culture grow out the same organism

Pyelonephritis: Elevated white blood cell count Elevated C-reactive protein and erythrocyte

sedimentation rate

Multidisciplinary Interventions Antibiotic therapy for 7 to 10 days

E-coli most common organism 85% Amoxicillin or Cefazol or Bactrim or Septra

Increase fluid intake Frequent voiding Acetaminophen for pain Teach proper cleansing

Urethritis Urethral irritation due to chemicals or

manipulation Most common in females Bubble bath, scented wipes, nylon under wear Self-manipulation Child abuse

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

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

Enuresis Involuntary discharge of urine after the age by

which bladder control should have been established, usually considered to be age of 5 years.

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

Pharmacologic 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

Multidisciplinary Interventions Diet control

Reduce fluids in evening Control sugar intake

Bladder training Praise and reward Behavioral chart to keep track of dry nights Alarm system

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

Ureteral Reflux

Hydronephrosis Water on kidney Due to obstruction Congenital anomaly Goals of care to maintain integrity of kidney

until normal urinary flow can be established.

Hydronephrosis

Ambiguous Genitalia Genital appearance that does not permit

gender declaration.

Agenesis of Scrotum

Hypertrophy of Clitoris

Extrophy of Bladder

Congenital malformation in which the lower portion of abdominal wall and anterior bladder wall fail to fuse during fetal development.

Assessment Visible defect that reveals bladder mucosa

and ureteral orifices through an open abdominal wall with constant drainage of urine.

Extrophy of Bladder

Extrophy of Bladder

Surgical Management 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

Multidisciplinary Interventions

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

Long Term Complications Urinary incontinence Body image Inadequate sexual function

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.

Hypospadias

Tight Chordee

Hypospadias Repair

Newborn Circumcision not recommended. Foreskin may be needed for reconstructive

surgery.

Surgical Interventions 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

Cryptorchidism Hidden testicle 3 to 5% of males High incidence in premature infants Goals of treatment:

Preserve testicular function Normal scrotal appearance

Multidisciplinary Interventions 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

Testicular Exam Monthly testicular self-examination is

recommended for all males beginning in puberty, but is essential in males with history of undescended testicle.

Testicular Torsion Rotation of the testicle Spermatic cord twists and obstructs

circulation to the testis Left testicle affected more

Longer cord on left side

Assessment

Sudden severe pain in the scrotal area

Highest incidence on left side due to longer cord on that side

Goals of Treatment Surgical intervention

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

Acute Renal Failure (ARF) 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.

Renal Failure Newborn causes:

Congenital anomalies

Hypotension

Complication of open heart surgery

Renal Failure Childhood causes:

Dehydration

Glomerular nephritis / Nephrotic Syndrome

Nephro-toxicity / drug toxicity

Assessment: 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 Electrolyte imbalance and dehydration

Diagnostic Tests Decrease RBC due to erythropoietin

Urea and Creatinine elevated

GFR (glomerular filtration rate) most sensitive indicator of glomerular function.

Goals of Treatment: Acute Renal Failure Reduce symptoms Supportive care until renal function returns Medications – corticosteroids Dietary restrictions - sodium Dialysis if indicated

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

Nephrotic Syndrome / nephrosisEtiology 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).

Generalized Edema

Assessment Generalized edema Edema is worse in scrotum and abdomen

(results in ascites) Dramatic weight gain Pale, fatigue, anorexic Urinary output decreased Urine foamy and frothy with elevated SG

Diagnostic evaluation Proteinuria

* 4+ urine in urine Hypoalbuminemia Hypercholesterolemia

* Fat cells in blood

BUN and Creatinine normal unless renal damage

Multidisciplinary 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

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

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

Moon Face

High-dosecorticosteroid therapyproduces a characteristic “moon face” appearance.

Before and After

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

Glomerulonephritis Immune complexes become entrapped in the

glomerular membrane.

Symptoms appear 1 to 2 weeks after a Strep A skin or throat infection.

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

Multidisciplinary 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

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