Pediatric Genitourinary Disorders Revised Debbie Perez 10/09

1. Pediatric Genitourinary DisordersRevised Debbie Perez 10/09

2. Pediatric Difference in Urinary Tract: • Kidney function • Bladder capacity • Bladder control • Recovery

3. Urinary Tract Infections • Etiology and Pathophysiology • Occur more commonly in girls • Migration of pathogens • Escherichia coli most common cause-Why? • May be bacterial, viral or fungal

4. Assessment • Typical symptoms of older children & adults: • Dysuria • Frequency & urgency • Burning • Hematuria (usually older child) • Symptoms for infants and young children can be vague and nonspecific: • Fever • Mild abdominal pain • Enuresis • If severe: High fever, flank pain, vomiting, malaise

5. Diagnostic Tests • Urine for culture and sensitivity • Clean catch • Suprapubic aspiration • Catheterization • Positive Urinalysis • Bacteria colony count of more than 100,000/ml. • Presence of protein

6. Therapeutic Interventions • Drug Therapy • Antibiotics • Analgesics – Tylenol • Antipyretic • Nursing Care • Force fluids for rehydration • Prescribed antibiotics • Promote comfort

7. Therapeutic Interventions • Parent Teaching • Change diaper frequently • Teach girls to wipe front to back • Discourage bubble baths • Encourage children to drink periodically during the day • Bathe daily • Adolescent start menstruating – encourage change of pad every 4 hours • When girls become sexually active – teach to urinate immediately after intercourse

8. Evaluation • Follow up • Return for repeat urinalysis – usually after 72 hours of treatment to be sure treatment is working • Girls who have more than three UTI’s, and boys with first UTI should be referred to urologist for further evaluation.

9. Vesicoureteral Reflux

10. Pathophysiology • Urinary Reflux – defective ureterovesicular valve that guards the entrance from the bladder to the ureter : • Primary reflux – congenital abnormality • Secondary reflux – repeated UTI’s • Neurogenic bladder – stronger than usual bladder pressure. • Backflow – while voiding when bladder contracts, urine is swept up the ureters • Stasis of urine in ureters or kidneys which in turn leads hydronephrosis

11. Assessment • Fever • Vomiting • Chills • Straining or crying on urination, poor urine stream • Enuresis (bedwetting), incontinence in a toilet trained child, frequent urination • Strong smelling urine • Abdominal or back/flank pain

12. Diagnostic Tests • Urine culture • Voiding Cystourethrogram • Renal ultrasound

13. Therapeutic Interventions • Drug Therapy • Antibiotics • Penicillin • Cephalosporins • Urinary Antiseptics • Nitrofurantoin • Surgery • Repair of significant anatomical anomalies, uretheral implantation

14. Nursing Care • Keep accurate record of intake and output • Secure stents and catheter • Assess vital signs • Assess comfort level • Patient Teaching

15. Critical Thinking • The child is diagnosed with mild reflux and placed on Bactrim (Trimethoprim- sulfamethoxazole). A teaching plan for this medication would include which of the following? a. avoid exposure to the sun when the child is taking any Sulfonamide b. discontinue the medications when the symptoms disappear c. mix the medication with food and increase fluid intake to reflect age/size appropriate amount d. the medication will turn the urine orange and may cause a strong or foul odor to the urine

16. Evaluation • Follow-up: • Repeat VCUG (voiding cystourethrogram) after a few months

17. Test Yourself • Which of the following organisms is the most common cause of UTI in children? a. staphylococcus b. klebsiella c. pseudomonas d. escherichia coli

18. Bladder Exstrophy • A rare defect in which the bladder wall extrudes through the lower abdominal wall • Due to failure of abdominal wall to close in fetal development • Upper urinary tract usually normal • 1:400,000 live births • Treatment is surgical reconstruction in stages

19. Goals of Surgical Reconstruction • Bladder and abdominal wall closure • Urinary continence, with preservation of renal function • Creation of functional and normal – appearing gentitalia • Improvement of sexual functioning

20. Nursing Care • Pre-op focus-prevent infection • Post-operative focus – Immobilize to promote healing of surgical site • Monitor renal function – assess I&O and urine chemistries to detect renal damage • Maintain patency of drainage tubes • Analgesics • Antibiotics as ordered • Emotional support of parents

21. Epispadias Hypospadias

22. Etiology and Pathophysiology • Epispadias – rare and often associated with extrophy of bladder. • Hypospadias • Occurs from incomplete development of urethra in utero. • Occurs in 1 of 100 male children. Increased risk if father or siblings have defect.

23. Hypospadias

24. Assessment Usually discovered during Newborn Physical Assessment

25. Interventions • Medical Treatment: • Do NOT circumcise infant. May need to use foreskin in reconstruction. • Surgery • Reconstructive – repositions uretheral opening at tip of penis • Chordee – released and urethra lengthened.

26. What do you think? • The reason for surgery at about 1 year of age is because: a. the procedure is less painful for a child b. chordee may be reabsorbed c. the child has not developed body image and castration anxiety d. the repair increases the ease of toilet training

27. Post–op Nursing Care • Assess bleeding • Maintain urinary drainage • Control Bladder Spasms • Prophylactic antibiotics • Control Pain • Increase fluid intake

28. Do not allow to play on any straddle toys. • Prevent infection • Call Dr if: • temp is over 101 • loss of appetite • pus or increased bleeding from stent • cloudy or foul smelling urine

29. Cryptorchidism Failure of one or both of the testes to descend from abdominal cavity to the scrotum

30. Assessment Diagnosed on Newborn Physical Exam

31. Therapeutic Interventions • Surgery • Orchiopexy done via laproscopy • Done around 1 year of age • Nursing Care – Post-op • Assess from bleeding and S/S of infection. • Minimal activity for few day to ensure that the internal sutures remain intact • Allow opportunity to express fears about mutilation or castration by playing with puppets or dolls.

32. Acute Glomerulonephritis

33. Etiology and Pathophysiology • Usual organism: Group A beta-hemolytic streptococcus • Organism not found in kidney • Glomeruli become inflamed and scarred

34. Edema: renal capillary permeability with renal vascular spasms glomerular filtration • accumulation of Na+ and H2O in the blood stream causing increased intravascular and interstitial fluid volume • Proteinuria: Protein molecules filter through the damaged glomeruli • Hematuria: RBCs can pass through to the urine

35. Manifestations • Common in boy 5-10 years old. Occurs 1-2 weeks after a respiratory infection or after impetigo. • Has 2 phases • Edematous phase – 4-10 days • Diuresis phase- self limiting

36. Assessment 1. Renal: a. Moderate Proteinuria b. Sudden onset of hematuria (tea-colored, reddish-brown, or smoky) and next develops oliguria c. Excessive foaming of urine

37. Assessment Cont… 2. Cardiovascular: • a.Edema-usually eyes, hands, feet, not generalized (dependent edema) • b.Hypertensionfrom hypervolemia which can lead to • c.Cardiac involvement CHF- orthopnea / dyspnea, cardiac enlargement, pulmonary edema

38. Assessment cont… 3.Neuro a.Encephalopathy: headache irritability convulsions coma-from cerebral edema

39. Test Yourself • A 6 year old is admitted with R/O acute glomerular nephritis which of the following symptoms is the child most likely have? a. normal blood pressure, diarrhea b. periorbital edema, grossly bloody urine c. severe, generalized edema, ascites d. severe flank pain, vomiting

40. Diagnostic Tests Urinalysis- protein (moderate), RBC's, WBC's, Specific Gravity elevated. *All children should have a urinalysis 2 wks after strep infection. Blood- • ASO titer: (antistreptolysin O) (antibody formation against Streptococcus) is elevated, indicating a recent streptococcal infection • ESR: (erythrocyte sedimentation rate) elevated showing inflammatory process • BUN: (urea nitrogen) & creatinine elevated indicating glomerular damage • CBC:WBCs normal range, H&H decreased. • Lytes: elevated potassium, low serum bicarbonate

41. Therapeutic Interventions 1. Depends on the severity of the disease. No specific treatment, supportive care. 2. Treat at home if normal BP & adequate output. 3. Must be hospitalized if: • BP increases • gross hematuria • oliguria present. To monitor for complications *Rarely develops into acute renal failure

42. Main Goals: Relieve Hypertension and Re-establish fluid and electrolyte balance: • Keep accurate record of I&O. • Record characteristics of urine output • Check and record specific gravity with each voiding • Monitor vital signs and neuro vital signs • Monitor and record amount of edema at least once a shift.

43. Interventions cont… • Daily weights • Bed rest for 4-10 days during acute phase • Oxygen therapy • Diet therapy • Drug therapy

44. Critical Thinking • A child is admitted and diagnosed with having AGN, prioritize the following nursing diagnoses. a. fluid volume excess b. risk for impaired skin integrity c. anxiety d. activity intolerance

45. Critical Thinking When teaching parents about known antecedent infections in acute glomerulonephritis, which of the following should the nurse cover? a. Herpes simplex b. Streptococcus c. Varicella d. Impetigo

46. Nephrotic Syndrome Chronic renal disorder in which the basement membrane surfaces of the glomeruli are affected, causing loss of protein in the urine.

47. Etiology and Pathophysiology • Insidious onset with periods of remission / exacerbations throughout life- No cure • Idiopathic cause (95%) immune response is strongly suspected. • Other causes: may develop after acute glomerulonephritis, sickle cell disease, Diabetes Mellitus, or drug toxicity. • Age of onset preschool yrs.- 2-4 yrs, males more common • Increased permeability which allows protein to leak into the urine (proteinuria). • Shift of protein out of the vascular system causes fluid from the plasma to seep into the interstitial spaces and body cavities, particularly the abdomen (ascites). Edema and hypovolemia

48. Assessment Four most common characteristics: • Massive proteinuria • Low serum albumin (K+ normal) • Edema • Malnourishment

49. Assessment • Hyperlipidemia • Shiny, pale skin • Brittle hair • Hypercoagulability (increased risk for thrombosis) • Fatigue • Abdominal pain (ascites)

50. Ask Yourself? • Which of the following signs and symptoms are characteristic of minimal change nephrotic syndrome? a. gross hematuria, proteinuria, fever b. hypertension, edema, fatigue c. poor appetitie, proteinuria, edema d. body image change, hypotension