Genitourinary Dysfunction in Children

Pediatric Differences in the GU System:

By age 1 year: kidneys function at adult level Premature infants: glucose, sodium, bicarbonate,
phosphate reabsorption is decreased Infant: only 20% of nephrons have Loops of Henle long enough to reach medulla, thus cannot concentrate urine as efficiently Bladder moves to pelvic cavity by early childhood Children have shorter urethras predisposing them to UTI Achieve complete bladder control by 4-5 years of age

Urinary Tract Infection

Prevalence: 5% in females, 1% in males Prevalence: Before age 6 months more
common in uncircumcised males Can cause impaired renal function Unexplained fever: obtain urinalysis and urine culture

Etiology
Bacteria ascending from the urethra into the
bladder and to the upper urinary tract Escherichia coli: predominate organism Candida rarely causes infection Obstruction Voiding dysfunction Constipation Vesicoureteral Reflux (VUR) Intercourse

Manifestations
Often vague and nonspecific Fever: 100.4 or higher without evidence of
infection in children age 2-24 months Irritability New or increased enuresis Dysuria Poor weight gain

Diagnostic Evaluation
Urinalysis: hematuria, WBCs, nitrites Urine culture: single-strain of bacteria in a clean

catch urine Use a urine bag to collect sample Consider catheterization for sample May see a suprapubic aspiration for culture Refrigerate urine if it is not processed within 1015 minutes of collection

Nursing Management


Obtain history including elimination patterns VS: particular attention to blood pressure Assess for CVA tenderness Assess for phimosis Antibiotic instructions
3-5 day course Take single dose course at night Prophylaxis in recurrent cases (VUR)

Accurate I and O Encourage fluid intake (PO or IV) Education regarding effects of untreated UTI in children Review symptoms with caregiver Follow-up diagnostic evaluation to confirm treatment efficacy Additional education and evaluation for those who are sexually active

Cryptorchidism
Undescended or hidden testes Begin descent at 26-28 weeks gestation Premature infants have higher incidence Occurs in 5% of healthy full term males Etiology unknown

Associated Risks
Most testes spontaneously descend within
the first year of life If remains undescended:
Increased risk of malignancy Sperm production decreased Inguinal hernia more common

Nursing Interventions
Assessment/Identification!!
Assess in a warm environment Examine the older child sitting and in a frog leg position Milk the testis downward from the groin Assess for a hernia Assess the abdomen

Nursing Interventions
Parental education/reassurance Review the risks of an undescended testes If surgically corrected, postoperative care
Assess site Incentive spirometry Skin integrity Increase activity

Additional Information
Rare: bilaterally undescended testes Elevated FSH and LH with absent

testosterone = absent testes May use CT or MRI to determine location Treatment of choice is surgical correction

Hypospadias and Epispadias

Urethral meatus below or above normal
placement. Epispadias is rare Hypospadias:

2/500 males Increased risk if father or sibling affected Testes undescended in 10% of those affected Assess for stenosis

Manifestations
Altered placement of urethral opening Altered urinary stream Chordee (downward curvature of penis) Assess for obstruction of urine outflow

Therapeutic Management
No circumcision Correction requires surgical intervention Done between 6-12 months of age (ideally
before toilet training) Goal of surgery:
Normalize urinary function Normalize sexual function Cosmetic

Nursing Interventions
Identification through assessment Obtain history:
Urinary tract infection Quality of urine stream Incontinence Family History

Nursing Interventions
Post-operative care:
Pressure dressing for 4 days Stent or catheter for urine drainage Hydration (IV the PO) Assess urine color, odor, clarity Monitor temperature Prophylactic antibiotics Quiet, diversional play Pain management

Nursing Interventions
Extensive family education Restrict activity for 1-2 weeks Continued monitoring for UTI

Glomerulonephritis
Inflammatory injury in the glomerulus Infection, Lupus, Schonlein-Henoch

purpura, vasculitis Sudden onset, self-limiting, resolve Poststreptococcal is the most common

Pathophysiology
Antigen-antibody complex formed Become trapped in the glomerulus Activation of inflammatory response Damage to capillary walls Decrease in GFR; renal insufficiency Large molecules are allowed to pass to
urine

Incidence
Group A beta-hemolytic streptococcal
infection (throat or skin) Young school age children Higher incidence in winter and summer Symptoms appear 8-21 days after infection

Manifestations
Hematuria (smoky, tea colored urine) Edema (orbital, worse in a.m.) Decreased urinary output Hypertension

Relevant Laboratory Tests

Proteinuria (mild) BUN and creatinine elevated in severe

renal insufficiency Dilutional anemia C3 (serum complement) low Antistreptolysin (ASO) titer elevated (only useful for recent infection where the child has not received antibiotics)

Nursing Management

Strict, accurate I and O (hourly) Report oliguria Accurate daily weights Monitor for hypertension Antihypertensive medication if necessary Astute respiratory assessment Fluid restriction (monitor for signs of dehydration) Low-sodium diet Cluster care to provide rest Reassurance the illness is self-limiting

Nephrotic Syndrome
Primary (MCNS): most common Secondary: acquired from systemic

disease (lupus, hepatitis, cancer) Arises from one of 4 types of renal lesions which all affect the basement membrane of the glomerulus

Incidence:
Children ages 2-6 years Slightly higher in boys Prognosis for MCNS is good Symptoms decrease with age

Pathophysiology
Insult to glomerular basement membrane Increased permeability resulting in loss of

plasma proteins Fluid shift to interstitial space Hypovolemia and decreased renal blood flow Renin production stimulated Reabsorption of sodium and water Edema

Pathophysiology (contd)
IgG levels decreased Cholesterol and triglycerides elevated Hypercoagulable

Manifestations
Proteinuria* (frothy urine) Hypoalbuminemia* Edema* (orbital, worse during day) Normotensive Increased weight Respiratory infection Abdominal pain (fluid in peritoneal space)

Manifestations

Often misdiagnosed as allergic rhinitis due to respiratory symptoms and orbital edema

Diagnostic Evaluation

3+ - 4+ urine protein Dark, frothy urine Decreased serum albumin Increased Hgb and Hct Increased serum cholesterol Increased serum triglycerides Negative ASO Evaluate for underlying etiology

Management
Prednisone Diuretics Albumin Antibiotics No-added-salt diet

Nursing Interventions

Assess VS (hypovolemia) Strict I and O Assess for dehydration Daily weights Assess exposure to communicable disease Prophylactic Penicillin Follow labs closely (risk of venous thrombus) Measure abdominal girth Astute assessment of pulmonary status No salt added diet Consider fluid restriction if becomes hypervolemic

Acute Renal Failure

Sudden, severe loss of kidney function Prerenal causes: dehydration,

hypotension, shock, renal artery obstruction, aminoglycosides, contrast dye Postrenal causes: structural abnormalities (tumor, ureterovesical obstruction, neurogenic bladder) Rare in children

Manifestations
Electrolyte and fluid imbalance Increased BUN and creatinine Acid-base imbalance (acidosis) Oliguria (urine output <1cc/kg/hr) Poor feeding Lethargy Seizures

Hemolytic Uremic Syndrome as a cause of ARF

Most common cause of acute renal failure Shigas E-coli Causes an inflammatory process Anemia Thrombocytopenia Acute renal failure Source: improperly cooked meat and contaminated dairy

Laboratory Data in ARF

Azotemia (elevated BUN, creatinine, and
uric acid) Metabolic acidosis (low serum bicarbonate) Increased potassium Increased or decreased sodium

Nursing Goals
Monitoring and maintaining fluid and
electrolyte balance Prevention of Infection Adequate nutrition Parental education (decreasing parent an child anxiety)

Chronic Renal Failure

Irreversible loss of kidney function Progresses to end stage renal disease Common cause: congenital anomaly Rare in children (18/1 million)

Manifestations
All associated with acute renal failure Renal bone disease Poor growth (FTT) Chronic hypertension Neurologic symptoms

Nursing Goals
Adequate nutrition
Na and fluid restriction Protein restriction Potassium restriction Phosphorus restriction Vitamin D High calorie foods

Nursing Goals
Prevention of infection Skin integrity Family education Developmental activites based on childs
age Multidisciplinary approach

Dialysis in children

Hemodialysis 3-4 treatments per week Maintain access (prevent infection, obstruction) Children are more susceptible to fluid shifts Interferes significantly with daily routine Requires a multidisciplinary approach for education and promoting optimal growth and development

The End