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.