GenitourinaryGenitourinaryGenitourinaryGenitourinary

Elisa A. Mancuso RNC-NIC, MS, Elisa A. Mancuso RNC-NIC, MS, FNSFNS

Professor of NursingProfessor of Nursing

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

Hormones

Erythropietic Stimulating Factor

• Released when low serum O2 • Stimulates production of RBC’s• ↡ ESF = Anemia and prolonged

PT/PTT

HormonesRenin• ↡ BP or ↡blood volume

• Stimulates production of Angiotension I → Angiotension II

– Vasoconstriction and ↟ BP

• ↑Aldosterone by adrenal cortex– Reabsorbes Na & H2O

Urinary Assessment• √ Voiding pattern & output =

1-2ml/kg/hr Oliguria

<1cc/kg/hr (infants) and <0.5cc/kg/hr childrenAnuria- No production of urine.

Indicates serious renal dysfunctionDiuresis-

↑ urinary output. R/O hyperglycemia Glucose threshold is 160 mg ↑ urination and glycosuria.

Urinary Assessment Color

Clear/strawDarker

Concentrated from dehydration or bilirubin

Hematuria-blood UTI, stones, trauma or glomerulonephritis

PH↑ (Alkalinic) with ↓K+

Clarity Clear → Cloudy “Pyuria” indicates infection

Urinary Assessment

Pain Burning on urination- UTI Dull achy pain - kidney

disease Sharp, colicky pain-kidney

stones Cystitis

Suprapubic pain or pain after voiding

Urinary Function Studies

Urinalysis- U/AC & S = Culture and sensitivity

Identify organismSpecific gravity 1.005-1.020

Infant <1.010 Children 1.010-1.030

Fluid challenge test20-50cc/kg/hour then √ output

Blood Urea Nitrogen (BUN) 5-18Creatinine 0.3-1mg/dl

most reliable test for glomeruli functionGlomerular Filtration Rate GFR

– Renal Function = 70-160cc/min. – Infant has lower rate till 2 years of age.

Renal Function Studies

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

Urinary Tract Infections

Ascending infection Bacteria → urethra → bladder (cystitis) Bladder → ureters → kidney

(pyelonephritis)

Fecal bacteria causes 80% UTI’s Peak incidence @ 2-6 years of age

without structural problems

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

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

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 C&S after medication completed– To verify med was effective

Antibiotic TherapySulfonamides: Co-trimoxazole

(Bactrim DS/Septra/TMP-SMX). √ Sulfa allergies. ↑ PO intake. Not for infants less than 2 months.

Cephalosporins: Ceclor po/ Rocephin IV/IM. Resistant or severe UTI’s or pyelonephritis. (IV) meds for hospitalized pt’s.

Penicillins (PCN): Ampicillin po/IV, amoxicillin, augmentin

✔ PCN allergies (Ampicillin and amox not as sensitive)

Repeat Culture to assess efficacy of med.

Analgesic Therapy Phenazopyridine HCL (pyridium)

Antispasmotic. Local anesthetic action on urinary

mucosa. Only use for pain & older children >6years

SE-orange urine and can stain contact lenses.

Motrin5-10 mg/kg/dose q 6-8 hr

Tylenol 10-15 mg/kg/dose

Therapy

↑ Hydration 2 – 4 liters/day• Acidic juices: cranberry and OJEncourage frequent voiding Appropriate hygiene

– Wipe from front to back– No bubble baths

HydronephrosisCongenital or Acquired RT reflux or

calculi• Obstruction @ 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

Clinical signs

• Colicky, flank pain – May radiate to groin

• N/V• Possible palpable mass• Pyuria • Fever

Therapy

• ↑ Fluids-2.5 liters/day• Hygiene• ↑ Increase voiding • Surgery

– Stent @ obstruction site

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

Clinical Signs

• Flank pain• Hematuria• Proteinuria• Nocturia• Frequent UTI’s and renal calculi• HTN and impaired renal blood

flow• Protruding abdomen

Therapy• Renal ultrasound• IVP• CT Scan• ↑ Fluid Intake 2-2.5 L/day

– Prevents infection

• Antihypertensive MedsBeta blockers-atenolol or propanololCa Channel Blockers-procardia or

verapamil Dialysis or kidney transplant

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”

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 RBC’s and Protein– Small hemorrhages on cortical surfaces

• Kidneys become enlarged and pale

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

Diagnosis• + ASO titers >250 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)

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/S, BP & Neuro status

– Furosemide (Lasix) – Loop diurectic•Inhibits re-absorption of Na & Cl• √ Lytes √ I&0 & √ weight

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

Nephrotic Syndrome• Most common glomerular injury in kids• Idiopathic 85%

– Boys 2x > 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”

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”

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

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

Therapy

• Assess V/S for shock! √ HR & BP• Strict I&O & Daily weight

– √ urine- protein, albumin & SG• Bed rest– ↑ Risk for skin breakdown RT

edema– Sheepskin, reposition q 2h

• Nutrition– ↑ Calories, ↑ Ca+, ↑ Protein & ↓ Na+

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

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

Treatment

•No circumcision!– May use foreskin for repair later

• Urology consult• Reconstructive surgery @ 6-18

mos• Testosterone prior to ↑ penile size• Indwelling catheter → leg bag• Home care instructions important

Epispadias

• Rarer than hypospadias• Urethral opening located behind

glans penis on dorsal (upper) surface

• “Kids wet their faces”

• Same Treatment as for hypospadias

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.

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

EnuresisUnable to control bladder function (Nocturnal

bed wetting)• Primary

– Never been dry @ night

• Secondary– Most common, previously dry and now accidents

@ night

• Delayed CNS maturation – Unable to detect bladder fullness and control

voiding

• UTI• Family history• Hypercalciuria

– ↑↑ Ca in urine → bladder irritation → painful urination

Therapy• R/O UTI or ↑↑ Ca• Behavior modifications

– No drinking at bedtime– Void prior to bedtime– Imagery of full bladder

Medications• TCA’s

– 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

Testicular Torsion

• 4000 males @ 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

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