PediatricPediatricGenitourinary Genitourinary

DisordersDisorders

Revised Debbie Perez Revised Debbie Perez 10/0910/09

Pediatric Difference in Pediatric Difference in Urinary Tract:Urinary Tract:

Kidney functionKidney function Bladder capacityBladder capacity Bladder controlBladder control RecoveryRecovery

Urinary Tract InfectionsUrinary Tract Infections

Etiology and PathophysiologyEtiology and Pathophysiology Occur more commonly in girls Occur more commonly in girls

Migration of pathogensMigration of pathogens

Escherichia coli most common cause-Escherichia coli most common cause-Why?Why?

May be bacterial, viral or fungalMay be bacterial, viral or fungal

AssessmentAssessment Typical symptoms of older children & Typical symptoms of older children &

adults:adults: DysuriaDysuria Frequency & urgencyFrequency & urgency BurningBurning Hematuria (usually older child)Hematuria (usually older child)

Symptoms for infants and young children Symptoms for infants and young children can be vague and nonspecific:can be vague and nonspecific: FeverFever Mild abdominal painMild abdominal pain EnuresisEnuresis If severe: High fever, flank pain, vomiting, If severe: High fever, flank pain, vomiting,

malaisemalaise

Diagnostic TestsDiagnostic Tests

Urine for culture and sensitivityUrine for culture and sensitivity Clean catchClean catch Suprapubic aspirationSuprapubic aspiration CatheterizationCatheterization

Positive Urinalysis Positive Urinalysis Bacteria colony count of more than Bacteria colony count of more than

100,000/ml.100,000/ml. Presence of proteinPresence of protein

Therapeutic Therapeutic InterventionsInterventions

Drug TherapyDrug Therapy AntibioticsAntibiotics Analgesics – TylenolAnalgesics – Tylenol AntipyreticAntipyretic

Nursing CareNursing Care Force fluids for rehydrationForce fluids for rehydration Prescribed antibioticsPrescribed antibiotics Promote comfortPromote comfort

Therapeutic Therapeutic InterventionsInterventions

Parent TeachingParent Teaching Change diaper frequentlyChange diaper frequently Teach girls to wipe front to backTeach girls to wipe front to back Discourage bubble bathsDiscourage bubble baths Encourage children to drink periodically Encourage children to drink periodically

during the dayduring the day Bathe dailyBathe daily Adolescent start menstruating – encourage Adolescent start menstruating – encourage

change of pad every 4 hourschange of pad every 4 hours When girls become sexually active – teach to When girls become sexually active – teach to

urinate immediately after intercourseurinate immediately after intercourse

EvaluationEvaluation

Follow upFollow up Return for repeat urinalysis – usually Return for repeat urinalysis – usually

after 72 hours of treatment to be sure after 72 hours of treatment to be sure treatment is workingtreatment is working

Girls who have more than three UTI’s, Girls who have more than three UTI’s, and boys with first UTI should be and boys with first UTI should be referred to urologist for further referred to urologist for further evaluation.evaluation.

Vesicoureteral Vesicoureteral RefluxReflux

PathophysiologyPathophysiology Urinary RefluxUrinary Reflux – – defective defective

ureterovesicular valve that guards the ureterovesicular valve that guards the entrance from the bladder to the entrance from the bladder to the ureter :ureter : Primary reflux – congenital abnormality Primary reflux – congenital abnormality Secondary reflux – repeated UTI’s Secondary reflux – repeated UTI’s Neurogenic bladder – stronger than usual Neurogenic bladder – stronger than usual

bladder pressure.bladder pressure. Backflow – while voiding when bladder Backflow – while voiding when bladder

contracts, urine is swept up the ureterscontracts, urine is swept up the ureters Stasis of urine in ureters or kidneys Stasis of urine in ureters or kidneys

which in turn leads hydronephrosis which in turn leads hydronephrosis

AssessmentAssessment

1.1. FeverFever

2.2. VomitingVomiting

3.3. ChillsChills

4.4. Straining or crying on urination, poor Straining or crying on urination, poor urine stream urine stream

5.5. Enuresis (bedwetting), incontinence in a Enuresis (bedwetting), incontinence in a toilet trained child, frequent urinationtoilet trained child, frequent urination

6.6. Strong smelling urineStrong smelling urine

7.7. Abdominal or back/flank painAbdominal or back/flank pain

Diagnostic TestsDiagnostic Tests

1.1. Urine cultureUrine culture

2.2. Voiding Cystourethrogram Voiding Cystourethrogram

3.3. Renal ultrasoundRenal ultrasound

Therapeutic Therapeutic InterventionsInterventions

Drug TherapyDrug Therapy AntibioticsAntibiotics

PenicillinPenicillin CephalosporinsCephalosporins

Urinary AntisepticsUrinary Antiseptics NitrofurantoinNitrofurantoin

SurgerySurgery Repair of significant anatomical Repair of significant anatomical

anomalies, uretheral implantationanomalies, uretheral implantation

Nursing CareNursing Care

Keep accurate record of intake and Keep accurate record of intake and outputoutput

Secure stents and catheterSecure stents and catheter

Assess vital signsAssess vital signs

Assess comfort levelAssess comfort level

Patient Teaching Patient Teaching

Critical ThinkingCritical Thinking The child is diagnosed with mild reflux The child is diagnosed with mild reflux

and placed on Bactrim (Trimethoprim- and placed on Bactrim (Trimethoprim- sulfamethoxazole). A teaching plan for sulfamethoxazole). A teaching plan for this medication would include which of this medication would include which of the following?the following?

a. avoid exposure to the sun when the child a. avoid exposure to the sun when the child is taking any Sulfonamideis taking any Sulfonamideb. discontinue the medications when the b. discontinue the medications when the

symptoms disappearsymptoms disappearc. mix the medication with food and increase c. mix the medication with food and increase

fluid intake to reflect age/size appropriate fluid intake to reflect age/size appropriate amount amount

d. the medication will turn the urine orange and d. the medication will turn the urine orange and may cause a strong or foul odor to the urinemay cause a strong or foul odor to the urine

EvaluationEvaluation

Follow-up:Follow-up:

Repeat VCUG (voiding Repeat VCUG (voiding cystourethrogram) after a few monthscystourethrogram) after a few months

Test YourselfTest Yourself

Which of the following organisms is Which of the following organisms is the most common cause of UTI in the most common cause of UTI in children?children?

a. staphylococcusa. staphylococcus

b. klebsiellab. klebsiella

c. pseudomonasc. pseudomonas

d. escherichia colid. escherichia coli

Bladder ExstrophyBladder Exstrophy

A rare defect in which the bladder A rare defect in which the bladder wall extrudes through the lower wall extrudes through the lower abdominal wallabdominal wall

Due to failure of abdominal wall to Due to failure of abdominal wall to close in fetal development close in fetal development

Upper urinary tract usually normalUpper urinary tract usually normal 1:400,000 live births1:400,000 live births Treatment is surgical reconstruction Treatment is surgical reconstruction

in stagesin stages

Goals of Surgical Goals of Surgical ReconstructionReconstruction

Bladder and abdominal wall closureBladder and abdominal wall closure Urinary continence, with Urinary continence, with

preservation of renal functionpreservation of renal function Creation of functional and normal – Creation of functional and normal –

appearing gentitalia appearing gentitalia Improvement of sexual functioning Improvement of sexual functioning

Nursing CareNursing Care

Pre-op focus-prevent infectionPre-op focus-prevent infection Post-operative focus – Immobilize to Post-operative focus – Immobilize to

promote healing of surgical sitepromote healing of surgical site Monitor renal function – assess I&O and Monitor renal function – assess I&O and

urine chemistries to detect renal damageurine chemistries to detect renal damage Maintain patency of drainage tubesMaintain patency of drainage tubes AnalgesicsAnalgesics Antibiotics as orderedAntibiotics as ordered Emotional support of parentsEmotional support of parents

Etiology and Etiology and PathophysiologyPathophysiology

Epispadias – rare and often Epispadias – rare and often associated with extrophy of bladder.associated with extrophy of bladder.

HypospadiasHypospadias Occurs from incomplete Occurs from incomplete

development of urethra in utero.development of urethra in utero. Occurs in 1 of 100 male children. Occurs in 1 of 100 male children.

Increased risk if father or siblings Increased risk if father or siblings have defect. have defect.

HypospadiasHypospadias

AssessmentAssessment

Usually discovered during Newborn Physical Assessment

InterventionsInterventions Medical Treatment:Medical Treatment:

Do NOT circumcise infant. May need Do NOT circumcise infant. May need to use foreskin in reconstruction.to use foreskin in reconstruction.

SurgerySurgery Reconstructive – repositions uretheral Reconstructive – repositions uretheral

opening at tip of penisopening at tip of penis Chordee – released and urethra Chordee – released and urethra

lengthened.lengthened.

What do you think?What do you think?

The reason for surgery at about 1 The reason for surgery at about 1 year of age is because:year of age is because:

a. the procedure is less painful for a childa. the procedure is less painful for a child

b. chordee may be reabsorbedb. chordee may be reabsorbed

c. the child has not developed body image c. the child has not developed body image

and castration anxietyand castration anxiety

d. the repair increases the ease of toilet d. the repair increases the ease of toilet training training

Post–op Nursing CarePost–op Nursing Care

Assess bleedingAssess bleeding Maintain urinary drainage Maintain urinary drainage Control Bladder SpasmsControl Bladder Spasms Prophylactic antibioticsProphylactic antibiotics Control PainControl Pain Increase fluid intakeIncrease fluid intake

Do not allow to play on any Do not allow to play on any straddle toys.straddle toys.

Prevent infection Prevent infection Call Dr if: Call Dr if:

temp is over 101temp is over 101 loss of appetiteloss of appetite pus or increased bleeding from stentpus or increased bleeding from stent cloudy or foul smelling urinecloudy or foul smelling urine

CryptorchidismCryptorchidism

Failure of one or both of the Failure of one or both of the testes to descend from testes to descend from abdominal cavity to the abdominal cavity to the

scrotumscrotum

AssessmentAssessment

Therapeutic Therapeutic InterventionsInterventions

Surgery Surgery Orchiopexy done via laproscopyOrchiopexy done via laproscopy Done around 1 year of ageDone around 1 year of age

Nursing Care – Post-opNursing Care – Post-op Assess from bleeding and S/S of infection.Assess from bleeding and S/S of infection. Minimal activity for few day to ensure that the Minimal activity for few day to ensure that the

internal sutures remain intactinternal sutures remain intact Allow opportunity to express fears about Allow opportunity to express fears about

mutilation or castration by playing with puppets mutilation or castration by playing with puppets or dolls.or dolls.

Acute Acute GlomerulonephriGlomerulonephri

tistis

Etiology and Etiology and PathophysiologyPathophysiology

Usual organism: Group A beta-Usual organism: Group A beta-hemolytic streptococcushemolytic streptococcus

Organism not found in kidneyOrganism not found in kidney

Glomeruli become inflamed Glomeruli become inflamed

and scarredand scarred

Edema: renal capillary permeability Edema: renal capillary permeability with renal vascular spasms with renal vascular spasms

glomerular glomerular filtration filtration accumulation of Na+ and H2O in the accumulation of Na+ and H2O in the

blood stream causing increased blood stream causing increased intravascular and interstitial fluid volumeintravascular and interstitial fluid volume

Proteinuria: Protein molecules filter Proteinuria: Protein molecules filter through the damaged glomerulithrough the damaged glomeruli

Hematuria: RBCs can pass through to Hematuria: RBCs can pass through to the urinethe urine

Manifestations Manifestations

Common in boy 5-10 years old. Common in boy 5-10 years old. Occurs Occurs 1-2 weeks after a respiratory 1-2 weeks after a respiratory infection or after impetigo.infection or after impetigo.

Has 2 phases Has 2 phases Edematous phase – 4-10 daysEdematous phase – 4-10 days Diuresis phase- self limitingDiuresis phase- self limiting

AssessmentAssessment

1.1. Renal: Renal:

a. a. Moderate Moderate ProteinuriaProteinuria

b. Sudden onset of b. Sudden onset of hematuriahematuria (tea- (tea-colored, reddish-brown, or smoky) colored, reddish-brown, or smoky) and next develops and next develops oliguriaoliguria

c. Excessive foaming of urinec. Excessive foaming of urine

Assessment Cont…Assessment Cont…

2.2. CardiovascularCardiovascular:: a.a.    EdemaEdema-usually eyes, hands, feet, -usually eyes, hands, feet,

not generalized (dependent edema)not generalized (dependent edema) b.b.    HypertensionHypertension from hypervolemia from hypervolemia

which can lead towhich can lead to c.c.    Cardiac involvement CHF- Cardiac involvement CHF-

orthopnea / dyspnea, cardiac orthopnea / dyspnea, cardiac enlargement, pulmonary edemaenlargement, pulmonary edema

Assessment cont…Assessment cont…

3.Neuro 3.Neuro

a.a. Encephalopathy: Encephalopathy:

headacheheadache

irritability irritability

convulsions convulsions

coma-from cerebral edemacoma-from cerebral edema

Test YourselfTest Yourself

A 6 year old is admitted with R/O A 6 year old is admitted with R/O acute glomerular nephritis which of acute glomerular nephritis which of the following symptoms is the child the following symptoms is the child most likely have?most likely have?a. normal blood pressure, diarrheaa. normal blood pressure, diarrhea

b. periorbital edema, grossly bloody b. periorbital edema, grossly bloody urineurine

c. severe, generalized edema, ascitesc. severe, generalized edema, ascites

d. severe flank pain, vomitingd. severe flank pain, vomiting

Diagnostic TestsDiagnostic TestsUrinalysis-Urinalysis- protein (moderate), protein (moderate), RBC'sRBC's, WBC's, , WBC's,

Specific Gravity elevated. Specific Gravity elevated. *All children should have a urinalysis 2 wks *All children should have a urinalysis 2 wks

after strep infection. after strep infection. Blood-Blood- ASO titer:ASO titer: (antistreptolysin O) (antibody (antistreptolysin O) (antibody

formation against Streptococcus) is elevated, formation against Streptococcus) is elevated, indicating a recent streptococcal infectionindicating a recent streptococcal infection

ESRESR: (erythrocyte sedimentation rate) elevated : (erythrocyte sedimentation rate) elevated showing inflammatory processshowing inflammatory process

BUN:BUN: (urea nitrogen) & creatinine elevated (urea nitrogen) & creatinine elevated indicating glomerular damageindicating glomerular damage

CBC:CBC:WBCs normal range, H&H decreased.WBCs normal range, H&H decreased. Lytes:Lytes: elevated potassium, low serum elevated potassium, low serum

bicarbonatebicarbonate

Therapeutic Therapeutic InterventionsInterventions

1. Depends on the severity of the 1. Depends on the severity of the disease. disease.

No specific treatment, supportive No specific treatment, supportive care. care.

2. Treat at home if normal BP & 2. Treat at home if normal BP & adequate output. adequate output.

3. Must be hospitalized if: 3. Must be hospitalized if: BP increasesBP increases gross hematuriagross hematuria oliguria present. oliguria present.

To monitor for complicationsTo monitor for complications*Rarely develops into acute renal failure*Rarely develops into acute renal failure

Main Goals: Main Goals: Relieve Hypertension and Re-Relieve Hypertension and Re-establish fluid and electrolyte establish fluid and electrolyte

balance:balance: Keep accurate record of I&O. Keep accurate record of I&O. Record characteristics of urine outputRecord characteristics of urine output Check and record specific gravity Check and record specific gravity

with each voidingwith each voiding Monitor vital signs and neuro vital Monitor vital signs and neuro vital

signssigns Monitor and record amount of edema Monitor and record amount of edema

at least once a shift.at least once a shift.

Interventions cont…Interventions cont… Daily weightsDaily weights Bed rest for 4-10 days during Bed rest for 4-10 days during

acute phaseacute phase Oxygen therapyOxygen therapy Diet therapyDiet therapy Drug therapyDrug therapy

Critical ThinkingCritical Thinking

A child is admitted and diagnosed A child is admitted and diagnosed with having AGN, prioritize the with having AGN, prioritize the following nursing diagnoses.following nursing diagnoses.

a. fluid volume excessa. fluid volume excessb. risk for impaired skin integrityb. risk for impaired skin integrity

c. anxietyc. anxiety

d. activity intoleranced. activity intolerance

Critical ThinkingCritical Thinking

When teaching parents about knownWhen teaching parents about known

antecedent infections in acuteantecedent infections in acute

glomerulonephritis, which of the glomerulonephritis, which of the followingfollowing

should the nurse cover?should the nurse cover?a. Herpes simplexa. Herpes simplex

b. Streptococcusb. Streptococcus

c. Varicellac. Varicella

d. Impetigod. Impetigo

Nephrotic Nephrotic SyndromeSyndrome

Chronic renal disorder in Chronic renal disorder in which the basement which the basement

membrane surfaces of the membrane surfaces of the glomeruli are affected, glomeruli are affected,

causing loss of protein in the causing loss of protein in the urine.urine.

Etiology and Etiology and PathophysiologyPathophysiology Insidious onset with periods of remission / Insidious onset with periods of remission /

exacerbations throughout life- No cureexacerbations throughout life- No cure Idiopathic cause (95%) immune response is Idiopathic cause (95%) immune response is

strongly suspected.strongly suspected. Other causes: may develop after acute Other causes: may develop after acute

glomerulonephritis, sickle cell disease, glomerulonephritis, sickle cell disease, Diabetes Mellitus, or drug toxicity.Diabetes Mellitus, or drug toxicity.

Age of onset preschool yrs.- 2-4 yrs, males more Age of onset preschool yrs.- 2-4 yrs, males more commoncommon

Increased permeability which allows protein to Increased permeability which allows protein to leak into the urine (proteinuria).leak into the urine (proteinuria).

Shift of protein out of the vascular system Shift of protein out of the vascular system causes fluid from the plasma to seep into the causes fluid from the plasma to seep into the interstitial spaces and body cavities, interstitial spaces and body cavities, particularly the abdomen (ascites). Edema and particularly the abdomen (ascites). Edema and hypovolemia hypovolemia

AssessmentAssessmentFour most common Four most common

characteristics:characteristics:

1.1. Massive proteinuria Massive proteinuria

2.2. Low serum albumin (KLow serum albumin (K++ normal) normal)

3.3. EdemaEdema

4.4. MalnourishmentMalnourishment

AssessmentAssessment

1.1. HyperlipidemiaHyperlipidemia2.2. Shiny, pale skin Shiny, pale skin 3.3. Brittle hair Brittle hair 4.4. Hypercoagulability (increased risk for Hypercoagulability (increased risk for

thrombosis)thrombosis)5.5. Fatigue Fatigue 6.6. Abdominal pain (ascites)Abdominal pain (ascites)

Ask Yourself?Ask Yourself?

Which of the following signs and Which of the following signs and symptoms are characteristic of symptoms are characteristic of minimal change nephrotic minimal change nephrotic syndrome?syndrome?

a. gross hematuria, proteinuria, fevera. gross hematuria, proteinuria, fever

b. hypertension, edema, fatigueb. hypertension, edema, fatigue

c. poor appetitie, proteinuria, edemac. poor appetitie, proteinuria, edema

d. body image change, hypotensiond. body image change, hypotension

DiagnosticsDiagnostics

Based on historyBased on history Characteristic symptoms Characteristic symptoms Lab findings with serum albumin Lab findings with serum albumin

and sodium decreasedand sodium decreased BUN, Cholesterol and Electrolytes BUN, Cholesterol and Electrolytes

may be orderedmay be ordered Urinalysis reveals massive Urinalysis reveals massive

proteinuria (50 mg/kg/day) (primary proteinuria (50 mg/kg/day) (primary indicator of nephrotic syndrome)indicator of nephrotic syndrome)

Therapeutic Therapeutic InterventionsInterventions RReduce edemaeduce edema

Keep accurate record of I&O. Keep accurate record of I&O. Measure abdominal girth, weigh Measure abdominal girth, weigh dailydaily

Test urine for protein and specific Test urine for protein and specific gravity to see if tx is effectivegravity to see if tx is effective

Diet:Diet: Normal diet for child’s age Normal diet for child’s age

recommended recommended No salt added No salt added High caloricHigh caloric Possible fluid restrictionsPossible fluid restrictions

Diuretics-cautious use Diuretics-cautious use AntihypertensiveAntihypertensive AntibioticAntibiotic AnalgesicsAnalgesics Albumin if resistant to diureticAlbumin if resistant to diuretic Protective IsolationProtective Isolation

TreatmentTreatment

InterventionsInterventions

Provide good skin care – edematous Provide good skin care – edematous tissue fragiletissue fragile

Child / ParentChild / Parent teaching – measures teaching – measures to prevent infections, medication to prevent infections, medication administration, monitoring of intake administration, monitoring of intake and outputand output

Provide rest periodsProvide rest periods

Prognosis:Prognosis:

Usually spontaneous resolution even Usually spontaneous resolution even with relapses (by age 30)with relapses (by age 30)

20% may develop chronic renal 20% may develop chronic renal failurefailure

The EndThe End