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Genitourinary Disorders

Genitourinary Disorders. Jan Bazner-Chandler CPNP, CNS, MSN, RN. Alterations in Renal Function. Biological Variances. All nephrons are present at birth Kidneys and tubular system mature throughout childhood reaching full maturity during adolescence.

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Genitourinary Disorders

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  1. Genitourinary Disorders Jan Bazner-Chandler CPNP, CNS, MSN, RN

  2. Alterations in Renal Function

  3. Biological Variances • All nephrons are present at birth • 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. Growth and Development • Newborn = loss of the perfect child • Toddler = toilet training • Pre-school = curiosity • School age = embarrassment • Adolescent = body image / sexual function

  7. Focused Health History • Single umbilical artery • Chromosomal abnormality • Congenital anomalies • Ear tags • Toilet training history • Family history • Growth patterns

  8. Urine Whaley & Wong Application of urine collection bag.

  9. Urinalysis • Protein • Leukocytes • Red blood cells • Casts • Specific Gravity • Urine Culture for bacteria

  10. Diagnostic Tests • Urinalysis • Ultrasound • VCUG – Voiding cysto urethrogram • IVP – Intravenous pyelogram • Cystoscopy • CT Scan • Renal Biopsy

  11. VCUG

  12. IVP

  13. Intra Venous Pyelogram Kidney function analyzed Watch for allergic reaction to dye.

  14. Renal Biopsy

  15. Cystoscopy Invasive surgical procedure Visualizes bladder and ureter placement.

  16. CT Scan

  17. Treatment Modalities • Urinary diversion • Stents • Drainage tubes • Intermittent catheterization • Watch for latex allergies • Pharmacological management • Antibiotics • Anticholinergic for bladder spasm

  18. Urinary Tract Infection • Most common serious bacterial infection in infants and children • Highest frequency in infancy • Uncircumcised males have a ten-fold incidence

  19. 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

  20. 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

  21. UTI – Males • Infant males • Needs to be investigated • VCUG – ureteral reflux • Ultrasound of kidneys – hydronephrosis or polycystic kidneys • Higher in un-circumcised males

  22. 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

  23. Clinical Manifestations: UTI • Urinary frequency • Hesitancy • Dysuria • Cloudy, blood tinged • Must smell to urine • Temperature • Poor feeding / failure to grow • The neonate may only exhibit 6 & 7

  24. 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

  25. Urethritis • Urethral irritation due to chemicals or manipulation • Most common in females • Bubble bath, scented wipes, nylon under wear • Self-manipulation • Child abuse

  26. 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

  27. 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

  28. Enuresis • Involuntary discharge of urine after the age by which bladder control should have been established, usually considered to be age of 5 years.

  29. 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

  30. 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

  31. Treatment Enuresis • Diet control • Reduce fluids in evening • Control sugar intake • Bladder training • Praise and reward • Behavioral chart to keep track of dry nights • Alarm system

  32. Ureteral Reflux

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

  34. Hydronephrosis

  35. Hydronephrosis • Water on kidney • Due to obstruction • Congenital anomaly • Goals of care to maintain integrity of kidney until normal urinary flow can be established.

  36. 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

  37. Diagnostics • Ultrasound • VCUG: voiding cyto urethrogram • IVP is the first two are positive

  38. Goals of treatment • To preserve renal function • Temporary urinary diversion may be needed to relieve the pressure. • Nephrectomy if renal damage is not reversible

  39. Ambiguous Genitalia • Genital appearance that does not permit gender declaration.

  40. Agenesis of Scrotum

  41. Hypertrophy of Clitoris

  42. Extrophy of Bladder • Interrupted abdominal development in early fetal life produces an exposed bladder and urethra, pubic bone separation, and associated anal and genital abnormalities.

  43. Exstrophy of Bladder • Occurs is 1 of 30,000 births • Congenital malformation in which the lower portion of abdominal wall and anterior bladder wall fail to fuse during fetal development.

  44. Clinical Manifestations • Visible defect that reveals bladder mucosa and ureteral orifices through an open abdominal wall with constant drainage of urine.

  45. Extrophy of Bladder

  46. Extrophy of Bladder

  47. Treatment • 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

  48. Goals of Treatment • Preserve renal function: prevent infection • Attain urinary control • Re-constructive repair • Sexual function

  49. Long Term Complications • Urinary incontinence • Infection • Body image • Inadequate sexual function

  50. Hypospadias Incomplete formation of the anterior urethral segment.

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