Pediatric Genitourinary Disorders

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PediatricGenitourinary Disorders
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Structural Defects

• Exstrophy of the Bladder
• Hypospadius / Epispadius

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Bladder Exstrophy

• The bladder wall extrudes through the abdominal
  wall.

p. 1630
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Exstrophy of the Bladder

• Treatment Surgical Reconstruction
• Usually done 24 - 48 hours after birth
• Goals
• Bladder and abdominal wall closure
• Preserve urinary function and continence
• Creation of normal appearing genitalia
• Improvement of sexual functioning

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Exstrophy of the Bladder

• Pre-op Nursing Care
• Prevent infection and trauma to bladder
• Nursing Interventions
• Cover bladder mucosa with plastic dressing
• Daily cleansing of skin around area

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Exstrophy of the Bladder

• Post-operative nursing care
• Care of the surgical site
• Observe for signs of obstruction
• Positioning / alignment
• Neurovascular assessment of lower extremities
• Monitor renal function
• Promote comfort
• Discharge teaching

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Hypospadias
Epispadias
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• Hypospadias
• Congenital urethral defect in which
• the uretheral opening is on the
• lower aspect of the penis and not
• on the tip.

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• Epispadias
• Congenital urethral defect in which the uretheral
  opening is on the upper aspect of the penis and
  not on the end

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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.
• Defect ranges from mild (meatus is just below
  tip) to meatus on the perineum between scrotum,
  ventral foreskin lacking
• May have accompanying chordee (a fibrous band
  that causes the penis to curve downward),
• Undescended testes found in conjunction with
  hypospadias
• Might interfere with fertility in the mature male
  if not corrected.

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Assessment
Usually discovered during Newborn
Physical Assessment
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Ask Yourself?

• Why would the nurse question an order to prepare
  the infant for a circumcision?

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Answer

• The nurse would question the order for a
  circumcision because the foreskin is used in
  reconstruction and repair of the defect.

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• What is the relation of epispadius or hypospadius
  to infertility?

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Answer

• If the urethral opening is not at the end of the
  penis, then the male will not be able to deposit
  his sperm at the opening of the os of the cervix.
  

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Interventions

• Medical Treatment
• Surgery
• Reconstructive repositions uretheral opening at
  tip of penis
• Stent placed in urethra to maintain patency
• Chordee released and urethra lengthened.

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• The reason for surgery at about 1 year of age is
  because
• a. children will experience less pain
• b. chordee may be reabsorbed
• c. the child has not developed body image
• and castration anxiety
• d. the repair is easier before toilet training
• C answer

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Post op Nursing Care

• 1. Assess bleeding - Bleeding is controlled
  post-operatively by the use of pressure
  dressings. However, a small amount of bleeding
  for the first several days post-operatively is
  normal. A few drops of blood or a spot no larger
  than a quarter on the diaper is acceptable.
• 2. Maintain urinary drainage care for
  catheter foley / suprapubic, or urethral
  stent. Use double diapering see Teaching
  Highlights on p. 1632.
• (see following slide)

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A double diapering technique protects the urinary
stent after surgery. The inner diaper collects
stool and the outer diaper collects urine.
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• 3. Control Bladder Spasms - usually due to the
  presence of the in-dwelling catheters are common
  post-operatively and are controlled by
  medications that relax the bladder (ie.
  Antispasmotics- Pro-Banthine and Ditropan)
• 4. Control Pain may be given Tylenol
• 5. Increase fluids intake assists in
• maintaining hydration and free flow of
  urine.
• 6. Do not allow to play on any straddle toys.
• 7. Prevent infection no bathing or swimming
  until
• stents removed.
• 8. Call Dr if
• temp is over 101
• loss of appetite
• pus or increased bleeding from stent
• cloudy or foul smelling urine

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Obstructive Uropathy
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Common Sites for Obstruction

• Stenosis of ureteropelvic valve
• Stenosis of ureterovescicular junction
• Stenosis of the posterior urethral valve
• (See page 1633)

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Vesicoureteral Reflux
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Pathophysiology

• Reflux occurs because the valve that guards the
  entrance from the bladder to the ureter is
  defective from
• Primary reflux congenital abnormal insertion of
  ureters into the bladder
• Secondary reflux repeated UTIs cause scarring
  of valve
• Bladder pressure that is stronger than usual,
  neurogenic bladder
• Backflow happens at voiding when bladder
  contracts, urine is swept up the ureters
• Results in stasis of urine in ureters or kidneys
  which in turn leads to infection or
  hydronephrosis.

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Clinical Manifestations

• 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

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Diagnostic Tests

• Urine culture
• done every 2-3 months
• cystourethrogram
• renal ultrasound - a non-invasive test in which a
  transducer is passed over the kidney producing
  sound waves which bounce off the kidney,
  transmitting a picture of the organ on a video
  screen. The test is used to determine the size
  and shape of the kidney, and to detect a mass,
  kidney stone, cyst, or other obstruction or
  abnormalities.

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Therapeutic Interventions

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

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Nursing Care

• Keep accurate record of intake and output. Keep
  records from stents and catheter separate.
  Decreased output from stent could indicate
  obstruction.
• Secure stents and catheter to prevent
  displacement.
• Assess vital signs for signs of infection.
• Assess pain. Handle child gently Administer
  pain medications
• Patient Teaching
• - regarding prevention of UTI,
• - importance of taking all antibiotics,
  continue
• taking antiseptics even when have no
  symptoms.

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Evaluation

• Follow-up
• Go in for a VCUG (voiding cystourethrogram) after
  a few months

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Urinary Tract Infection
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Test Yourself

• Which of the following organisms is the most
  common cause of UTI in children?
• a. staphylococcus
• b. klebsiella
• c. pseudomonas
• escherichia coli
• All are causative agents, Escherichia coli is the
  more common cause of first time UTIs. (page
  1635.

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Urinary Tract Infections

• Etiology and Pathophysiology
• Tend to occur more in girls than in boys because
  the urethra is shorter in girls and is located
  close to the vagina and anus.
• Pathogens enter as an ascending infection
• Most common causative organism is Escherichia coli

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Assessment

• Typical symptoms of older children and adults
  dysuria, frequency, urgency, burning,hematuria
  may not be present.
• Symptoms not always clear
• Fever
• Mild abdominal pain
• Bedwetting (enuresis)
• If gets worse high fever, flank pain, vomiting,
  malaise

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Diagnostic Tests

• Urine for culture and sensitivity
• Clean catch
• Suprapubic aspiration
• Catheterization
• A Positive Test
• Bacteria colony count is more than 100.000/ml.
• Proteinuria may also be present indicating
  presence of bacteria.

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Therapeutic Interventions

• Drug Therapy
• Antibiotics specific to causative organism
• Analgesics Tylenol
• Nursing Care
• Force fluids childs choice
• Dysuria sit in warm water in bathtub and void
  into the water

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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

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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 UTIs, and boys
  with first UTI should be referred to urologist
  for further evaluation.

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Enuresis
Repeated involuntary voiding by a child old
enough That bladder control is expected about
5-6 years of age
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EnuresisMultitreatment Approach

• Fluid Restriction
• Bladder exercises
• Timed voiding
• Enuresis alarms
• Reward system
• Medications

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Nephrotic Syndrome
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Nephrotic Syndrome

• chronic renal disorder in which the basement
  membrane
• surfaces of the glomeruli are affected, causing
  loss of protein in the urine. The glomeruli
  membrane has increased permeability permitting
  albumin and protein to pass through the membrane
  and excreted in the urine.

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Note the contrast between the normal glomerular
anatomy and the changes that exist in nephrotic
syndrome permitting protein to be excreted in the
urine.
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Clinical Manifestations

• Four most common characteristics
• 1. Edema - May have periorbital edema
• upon rising in morning and shifts
• during the day.
• 2. Massive proteinuria and hypoproteinemia
• 3. Hypoalbuminemia
• 4. Hyperlipidemia

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Other signs and symptoms

• Fatigue
• Anorexia
• weight gain
• Abdominal pain from large amount of fluid in
  abdominal

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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
• Answer C

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Diagnostic Tests

• 1. Urinalysis protein-to-creatitine (PR/CR)
  ratio of
• first morning void to assess for
  proteinuria. Urine
• appears dark and frothy.
• 2. Blood tests hypoalbuminemia, elevated
• cholesterol and triglycerides,
  elevated hgb, hct,
• platelets

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Try this

• Prednisone is the primary drug used in treating
  NS. What are the side effects and nursing
  implications?
• What teaching should the nurse include with
  respect to this medication?

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Answers

• Nursing Implications related to Prednisone
  therapy
• see drug guide on p. 1641.

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Complications

• Children with Nephrotic Syndrome are prone to
  infection related to
• Loss of immunoglobins in the urine
• Corticosteroid Therapy

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Therapeutic Interventions

• 1. Administer medications assess for side
  effects
• Prednisone, Albumin,
• 2. Prevention of infection avoid people with
  infections.
• May be placed on protective isolation.
• 3. Keep accurate record of IO. Measure
  abdominal girth, weigh daily.
• 4.  Test urine for protein and specific gravity
  to see if treatment is effective
• 5.  Diet
• Normal diet for childs age
• A no added salt diet is recommended during
  steroid treatment.
• 6. Promote rest
• 7. Discharge teaching

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Acute Postinfectious Glomerulonephritis
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Acute PostinfectiousGlomerulonephritis

• Immune-complex disease which causes inflammation
  of the glomeruli of the kidney as a result of an
  infection elsewhere in the body.

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Etiology and Pathophysiology

• Usual organism is Group A beta-hemolytic
  streptococcus
• Organism not found in kidney, but the
  antigen-antibody complexes become trapped in the
  membrane of the glomeruli causing inflammation,
  obstruction and edema in kidney
• The glomeruli become inflamed
• and scarred, and slowly lose their
• ability to remove wastes and excess
• water from the blood to make urine.

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Acute Glomerulonephritis
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• Decreased glomerular filtration leads to
  accumulation of sodium and water in bloodstream
  causing increased intravascular and interstitial
  fluid volume, or edema
• Protein molecules filter through the damaged
  glomeruli proteinuria
• Damage to glomeruli leads to hematuria.
• High B/P, Heart failure may result
• 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

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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
• 2. Cardiovascular
• a.  Edema-usually eyes, hands, feet, not
  generalized
• b.  Hypertension from hypervolemia which can lead
  to
• c.  Cardiac involvement CHF- orthopnea / dyspnea,
  
• cardiac enlargement, pulmonary edema
• 3.Neuro
• a. Encephalopathy (headache, irritability,
• convulsions, coma-from cerebral
  edema)

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Test Yourself

• A 6 year old is admitted with R/O AGN 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

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Diagnostic Tests

• Urinalysis- protein (moderate), RBC's, WBC's,
  Specific Gravity elevated.
• All children should have a urinalysis 2 wks
  after strep infection.
• Blood-
• 1)     ASO titer (antistreptolysin O) (antibody
  formation against Streptococcus) is elevated,
  indicating a recent hemolytic streptococcal
  infection Normal titer is 170-330 Todd units IgG
  antibodies against Streptococcus may be found
• 2)     ESR (erythrocyte sedimentation rate)
  elevated showing inflammatory process
• 3)     BUN(urea nitrogen) creatinine elevated
  indicating glomeruli damage

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Therapeutic Interventions

• 1. Depends on the severity of the disease.
  No
• specific treatment. Bedrest encouraged.
  Disease
• is self-limiting!
• 2. Treat at home if normal BP adequate
  output.
• 3. Must be hospitalized if
• BP increases
• gross hematuria
• oliguria present.
• This way the child can be monitored closely
  and prevent complications. Rarely develops into
  acute renal failure

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Main Goals Relieve Hypertension
Reestablish fluid and electrolyte balance by

• Keep accurate record of IO. Be sure that child
• does not exceed maximum intake ordered.
• Record characteristics of urine output including
• presence of proteinuria and hematuria.
• 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.

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• Daily weights
• Bedrest for 4-10 days during acute phase.
  Semi-fowlers position to assist with breathing.
  Quiet play.
• Oxygen therpay
• Diet therapy
• Limit salt intake with hypertension or edema
• Limit protein if BUN elevated
• Decrease intake of Potassium if output decreased
• Drug therapy
• Antibiotics
• Digiiiitalization
• Antihypertensives- vasodilators

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Critical Thinking

• With a diagnosis of AGN, which of these nursing
  diagnoses should receive priority?
• a. fluid volume excess
• b. risk for impaired skin integrity
• c. risk for injury
• d. activity intolerance

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Critical Thinking

• When teaching parents about known
• antecedent infections in acute
• glomerulonephritis, which of the following
• should the nurse cover?
• A. Herpes simplex
• B. Scabies
• C. Varicella
• D. Impetigo

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Cryptorchidism

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

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Etiology and Pathophysiology

• Testes usually descend into the scrotal sac
  during the 7-9 month gestation
• They may descend anytime up to 6 weeks after
  birth. Rarely descend after that time.
• Cause unknown
• Theories
• Inadequate length of spermatic vessels
• Lowered testosterone levels

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Why is it important that the testes are in the
scrotal sac?
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Answer

• The higher temperatures in the abdomen than in
  the scrotum results in morphologic changes to the
  testis mainly concerned with lower sperm counts
  at sexual maturity.

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Assessment
Diagnosed on Newborn Physical Exam
Palpate the testes separately between thumb and
forefinger, with thumb and forefinger of other
hand over the inguinal canal.
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Therapeutic Interventions

• Surgery
• Orchiopexy done via laproscopy
• Done around 1 year of age
• Nursing Care Post-op
• 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.

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