Genitourinary disorders

1. Genitourinary disorders Islamic University Nursing College

2. Genitourinary Tract • Main function of GU is • Maintaining the composition and volume of the body fluids in equilibrium • Production of certain hormonal substance (e.g., erythropoietin) • Remove wastes from bloodstream

3. Genitourinary Tract • The nephrons increase in number throughout gestation and reach their full complement by birth but still immature and less effective • Glomerular filtration and absorption are relatively low at birth and do not reach adult values until 1-2 years

4. Genitourinary Tract • Loop of Henle (site of the urine concentrating mechanism) is short in the newborn which reduces the ability of the newborn to reabsorb sodium and water . Concentrating ability reaches adult levels by around 3rd month of age • Amount of urine excreted in 24 hours depends on : fluid intake, state of kidney health, and age

5. GU: Diagnostic tests: urine analysis

6. GU: Diagnostic tests • Urine Culture (suprapubic aspiration) • Glomerular filtration rate: measured by the creatinine clearance test (100ml/min) • BUN: • is used to measure the amount of urea nitrogen in the blood • tests glomerular function (N= 5 – 20 mg/ 100ml) • Serum creatinine: 0.7 – 1.5 mg/ 100ml

7. GU: Diagnostic tests • Sonography & MRI • To visualize the sizes of kidneys, ureters • differentiate between solid or cystic masses. • X-ray: KUB • IVP: intravenous pyelogram • CT scan: size & density of kidneys, adequacy of urine flow • Cystoscopy : evaluate stenosis • Voiding Cystourethrogram (VCUG): evaluate reflux in ureters • Renal biopsy

8. Genitourinary Tract: Assessment • Chief concern: • Burning or cries during urination • Blood in urine/ Frequency of urination • Abdominal pain/ Flank pain • Enuresis • Periorbital edema • Poor appetite • Strong urine odor • Diaper rash • Family history (Renal disease) • Pregnancy history(Nephrotoxic drugs) • Past illnesses (Recurrent UTI)

9. Urinary Tract Infection (UTI) • UTI is the presence of significant numbers of microorganisms anywhere within the urinary tract • May present without clinical manifestations • Peak incidence between 2-6 years of age • Female has greater risk of developing UTI • The likelihood of reoccurrence in female is 50% • Prevalence of UTI in infants is 2% in boys and 3.7% in girls

10. Urinary Tract Infection (UTI) • Escherichia coli (80% of cases) and other gram-negative enteric-organisms are most commonly causative agents • A number of factors contribute to the development of UTI including: • Anatomy of UT • Physical properties of UT • Chemical conditions properties of the host’s urinary tract

11. Factors contributing to UTI • Shorter urethra in females • Uncircumcised males • Incomplete bladder emptying (reflux, stenosis) • Altered urine and bladder chemistry/ sterility: • Adequate fluid intake promote urine sterility • Use of cranberry juice increased urine acidity and so prevent UTI • Extrinsic factors: • Poor hygiene, use of bubble bath, hot tubs • Bladder neck obstruction, chronic constipation, tight clothing/ diapers • Altered Normal. flora: antimicrobial agents • Catheters

12. UTI: Assessment • Any child with fever, dysuria, urgency should be evaluated for UTI • Clean – catch urine for culture & sensitivity • UTI, urine is positive for proteinuria due to bacterial growth • Hematuria due to mucosal irritation • Increase WBC • Urine pH is more alkaline (>7)

13. Gastrointestinal Tract: clinical manifestation • Cystitis (infection of bladder): • low grade fever (LGF) • Mild abdominal pain • Enuresis (preschooler) • Pyelonephritis (kidneys): • Symptoms are more acute • High fever • Flank or abdominal pain • Vomiting • Malaise

14. UTI: Clinical Manifestations

15. UTI: Management • Identify contributing factors to • eliminate the infection • reduce the risk of recurrence • Prevent urosepsis • Preserve renal function • 7-10 days antibiotics matching organism sensitivity (penicillins, sulfonamide, cephalosporins, tetracyclines) • Mild analgesics/ antipyretics • Increase fluid intake: flush out infection • Clean – catch urine after 72 hrs to assess effectiveness • For recurrent UTI, prophylactic antibiotics for 6 months

16. UTI: Nursing Care • Education regarding prevention & treatment • Instruct parents to observe for clues that suggest UTI: • Incontinence in a toilet-trained child • Strong-smelling urine • Frequency

17. Cryptorchidism (Crptorchism) • is failure of one or both testes to descend normally through the inguinal canal into the scrotum • Absence of testes within the scrotum can be a result of • Undescended (cryptorchid) testes, • Retractile testes (withdrawal of the testes) • Anorchia (absence of testes) • Actopic : emerges outside the inguinal ring

18. Cryptorchidism (Crptorchism) • Cryptorchid testes are often accompanied by congenital hernias and abnormal testes, and they are at risk for subsequent torsion • Unknown cause, but this problem is believed to be partly inherited Risk Factors • Prematurity; Low birth weight; Twin • Down syndrome (fetus); Hormonal abnormalities (fetus) • Toxic exposures in the mother • Mother younger than 20 or older than 35 years of age • A family history of undescended testes

19. Cryptorchidism (Crptorchism) • CM • Non-palpable testes • Affected hemiscrotum will appear smaller than the other • In retractile testes :Intermittently observing the testes in the scrotum , thus hands should be warm when examining the baby in a warm room • Management • Retractile testis can be manipulated into the scrotum. • By 1 year of age, cryptorchid testes will descend spontaneously in approximately 75% of cases in both full-term and preterm infants • In true undescended testes rarely descend spontaneously after 1 year of age and need a surgery

20. Cryptorchidism (Crptorchism) • Surgical repair is done to • prevent damage to the undescended testicle & decrease the incidence of tumor formation, • avoid trauma and torsion & prevent the cosmetic and psychologic handicap of an empty scrotum • Postoperative care: • prevention of infection • instructing parents in home care of the child about: • pain control; carefully cleansing the operative site of stool and urine • Observation of the wound for complications; Activity restriction

21. Vesicoureteral Reflux (VUR) • Retrograde flow of urine from the bladder up the ureters and possibly to the kidneys during micturation • The cause may be • a defective bladder valve (UTI) • incorrect placement of ureters • Severity of VUR depends on the degree/grade of VUR

22. Vesicoureteral Reflux (VUR) • Grading system depends on the extend of the VUR , dilatation of ureter and calyces (part of the kidney where urine collects)

23. Vesicoureteral Reflux (VUR) • Primary reflux: congenital anomaly affects the ureterovesical junction • Secondary reflux: occurs as a result of an acquired condition, UTI, neuropathic bladder dysfunction • Radiological Tests • Renal/Bladder Ultrasound • Voiding Cystourethrogram (VCUG) • Management • Spontaneous resolution over time 20-30% • Continuous low-dose antibacterial therapy (prophylactic antibiotics) • Frequent urine cultures • Surgical correction for grades IV & V, anatomical abnormalities, recurrent UTI

24. Vesicoureteral Reflux (VUR) • Nursing Diagnosis • High risk for injury related to possibility of kidney damage from chronic infection (pyelonephritis) • Anxiety related to unfamiliar procedures • Altered family processes related to illness of a child • Nursing Interventions • Administration of antibiotics • Education • Prevention • Perineal hygiene; Complete bladder emptying; Frequent voiding

25. Hypospadias/Epispadias • Is a condition in which the urethral opening is located below the glans penis or anywhere along the ventral surface of the penile shaft • mild cases the meatus is just below the tip of the penis. • severe malformations the meatus is located on the perineum between the halves of the scrotum • Management • Surgical repair • Circumcision delayed to save the foreskin for repair • Surgical correction by 1 year old, before toilet training

26. Acute Glomerulonephritis (AGN) • Inflammation of the Glomeruli occurs as an immune complex disease after infection • Common in school age children • 1-2 weeks After Streptococcal Infection (sore throat) antibodies are formed, an immune complex reaction is then occurs after a period of time which become trapped in the glomerular capillary loop

27. Acute Glomerulonephritis (AGN) • Clinical manifestations • Tea-colored urine • Anorexia • Joint stiffness & pain • Lab Results • Urine analysis: ↑ WBC, epithelial cells, RBC casts • Proteinuria • Serum: ↑ BUN, creatinine, ESR, decreased Hgb • Hypoalbuminemia • Serum ASO titers may be elevated

28. Acute Glomerulonephritis (AGN) • Management • Usually resolves spontaneously, treatment is focused on relief of symptoms. • Antibiotics, such as penicillin to destroy any streptococcal bacteria that remain in the body. • Antihypertensive medications and diuretic medications to control swelling and high BP • Dietary salt restriction may be necessary to control swelling and high blood pressure • > 90% recover from AGN

29. Acute Glomerulonephritis (AGN) • Complications • Acute/chronic renal failure • Hyperkalemia • Nephrotic syndrome • Chronic glomerulonephritis • Hypertension • Congestive heart failure or pulmonary edema (inspiratory crackles)

30. Acute Glomerulonephritis (AGN) • Nursing Diagnosis • Fluid volume excess r/t decreased U.O. • Risk for impaired skin integrity r/t edema and decreased activity • Anxiety r/t hospitalization, knowledge deficit of disease • Management • No added salt diet & Fluid restriction • Q4h BP & Daily weights • I & O

31. Nephrotic Syndrome (NS) • Unknown cause of high proteinuria as a result of damage to the Glomerular Capillary Wall leading to low serum albumin and edema • NS is a sign of a disease that damages the glomeruli in the kidney • Forms of NS • Primary: Minimal Change Nephrotic Syndrome (MCNS) • Idiopathic • 80% of all cases • Good prognosis • Secondary to another disorder • Congenital: autosomal recessive gene

33. Nephrotic Syndrome (NS) • Clinical Manifestations • weight gain • Puffiness of face, periorbital at morning which subsides during the day • swelling of abdomen, scrotum & lower extremities is more prominent • Respiratory difficulty (pleural effusion) • Edema of intestinal mucosa cause diarrhea, loss of appetite, poor intestinal absorption • Decrease urine volume/dark, frothy • Irritable, easily fatigued

34. Nephrotic Syndrome (NS) • Diagnostic test • Marked proteinuria +1 - +4 • Minimal hematuria • Reduce serum albumin < 2 g/dl • Increase serum cholesterol: > 450-1500mg/dl • Increase SG • Elevated ESR

35. Nephrotic Syndrome (NS) • Managements • Reduce urinary protein excretion • Maintain a protein-free urine • Reduce edema & Prevent infection • Minimize complications • General measures: • Daily weight & bed rest during edema, change position Q 2hrs to decrease pressure on body and reduce edema • Antibiotics with infections • Diet: restricted salt during massive edema, high protein diet • Corticosteroids: prednisone (side effect ↑ chance for infection) • Immunosuppressants (do not administer immunization) • Albumin (plasma expander) and lasix

36. Nephrotic Syndrome (NS) • Nursing Diagnosis • Fluid volume excess related to fluid accumulation in tissues • Risk for fluid volume deficit (intravascular) r/t proteinuria, edema, and effects of diuretics • Risk for impaired skin integrity r/t edema and decreased circulation • Risk for infections r/t urinary loss of gammaglobulins • Anxiety (parental) r/t caring for child with chronic disease and hospitalization

37. Nephrotic Syndrome (NS) • Interventions • Assess I & O • Assess changes in edema • Measure abd girth • Measure edema around eyes / & dependent areas • Weigh daily note degree of pitting • Test urine for specific gravity and albumin (hyperalbuminuria ) • Administer corticosteroids (to reduce excretions of urinary protein) • Administer diuretics (relieve edema) • Limit fluids as indicated

39. Renal Failure (RF) • Renal failure is the inability of the kidneys to excrete waste material, concentrate urine, and conserve electrolytes • Could be acute or chronic renal failure

40. Acute Renal Failure (ARF) • ARF is an abrupt decline in glomerular and tubular function • Could be caused by Escherichia coli (which is usually contracted from eating improperly cooked meat or contaminated dairy products) • Classic sign is Elevated blood urea nitrogen level

41. Acute Renal Failure (ARF) • Clinical manifestations • Azotemia: accumulation of nitrogenous waste (Blood Urea Nitrogen (BUN)) within the blood • circulatory congestion/ hypervolemia • electrolytes abnormalities: • Increased K(potassium level > 7mEq/L) & phosphate • Decreased Na+ (seizures) & calcium • metabolic acidosis, hypertension • oliguria: output < 1ml/kg/hr; Anuria: no urinary output in 24 hours • Nausea, Vomiting, Drowsiness

42. Acute Renal Failure (ARF): Prevention • recognize patients at risk (postoperative states, cardiac surgery, septic shock) • prevent progression from pre-renal to renal • preserve renal perfusion • isovolemia, • cardiac output, • normal blood pressure • avoid nephrotoxins (aminoglycosides, NSAIDS)

43. Acute Renal Failure (ARF): Management • Treat the underlying disease • Management of the complications • Provision of supportive therapy • Strictly monitor intake and output (weight, urine output, insensible losses, IVF) & monitor serum electrolytes • Adjust medication dosages according to GFR • Nutrition • provide adequate caloric intake • limit protein intake to control increases in BUN • minimize potassium and phosphorus intake • limit fluid intake • If adequate caloric intake can not be achieved due to fluid limitations, some form of dialysis should be considered

44. Chronic Renal Failure • Progressive deterioration of kidneys functions over months or years produces a variety of clinical and biochemical disturbances that eventually culminate in the clinical syndrome known as uremia • Uremia is a retention of nitrogenous products that produce toxic symptoms • Renal damage is judged by elevated serum creatinine (Normal 0.4- 1.2 d/L) • Renal function is compromised when creatinine is above 1.2 • The end-stage renal disease (ESRD), is irreversible

45. Chronic Renal Failure • Uremia • Retention of waste products • Water and sodium retention • Hyperkalemia • Metabolic acidosis • Anemia • Calcium & phosphorus disturbances • Growth disturbance

46. Chronic Renal Failure • Uremic symptoms can affect every organ system, • Neurological system: cognitive impairment, personality change, asterixis (motor disturbance that affects groups of muscles), seizures • GI: nausea, vomiting, food distaste • Blood-forming system–anemia due to erythropoetin deficiency, easy bruising and bleeding due to abnormal platelets • Pulmonary system–fluid in the lungs, with breathing difficulties • Cardio: chest pain due to pericarditis & pericardial effusion • Skin –generalized itching

47. Chronic Renal Failure: Management • Peritoneal Dialysis/Hemodialysis • is required when the glomerular filtration rate decreases below 10% to 15% of normal • Restrict protein intake • Calcium and Vitamin D, Antihypertensives, Diuretics, Bicarbonate, Antiepileptics, Antihistamines • Transplantation