GU Peds

Anatomy and Physiology of Kidney

• Two Kidneys

  • Surrounded by adipose tissue

  • Outer cortex

    • Glomeruli

    • Convoluted Tubules of nephron and blood vessel

  • Inner Medulla

    • Renal pyramid

    • Urine leaves papilla of pyramid to collect

    • Minor calyces come together to make major calyces and then the renal pelvis

What is larger the kidney or the stomach in children?

Kidneys

• prone to injury

What causes increased risk of bacterial entry into bladder?

The shorter urethra

What is the difference in GFR for infants?

• Slower

  • Increases risk for dehydration

Describe Bladder Capacity differences

• 30mL in newborn

  • Adult size by 1 year old

Describe Reproductive organs differences

• Immature at birth

• Mature at adolescence

Describe Inspection for GU

• Growth retardation, unusual weight gain

• Lethargy, fatigue, rapid respirations, confusions, developmental delay

• Skin: pruritis, edema, bruising, pallor, dysmorphic features

• Extern genitalia area: infant diaper rash, constant urine dribble, displaced urethral opening, red urethral opening, discharge

• Female: vaginal irritation, labial fusion

• Male: enlargement, discoloration of scrotal sac

• When lying down → abdomen distention, ascites, slack abdominal musculature

Describe Auscultation for GU

• Flow murmur → anemic child w/ renal disorder

• use bell of stethoscope when listening BP to hear softer Korotkoff sounds

Describe Palpation for GU

• Presence of palpable kidneys (enlargement, mass)

• Abdom masses, distended bladder

• Scrotum: distended testicles, masses

Describe CBC

Complete Blood Count

• evaluates Hematocrit, Hemoglobin, WBC count, and platelet count

Used for:

• anemia, infection, thrombocytopenia

Describe BUN

Blood Urea Nitrogen

• indirect measurement of renal function (x2 creatinine levels = 50% reduc in GFR)

Describe Creatinine

• Direct measurement of renal function (x2 creatinine levels = 50% reduc in GFR)

• Diag impaired renal func

Describe Creatinine Clearance

• 24 hr urine collection

• presence of creatinine in urine compared w/ serum level = creatinine clearance

• Diag impaired renal func

Describe Urinalysis

• tests for urine’s color, pH, specific gravity, odor, presence of protein, glucose, ketones, blood, leukocyte esterase, RBC, WBC, bacteria, crystals, casts

• gives preliminary info about Uri Tract

Describe Urine Culture

• Urine plated and evaluated q day for bacteria, final report after 2-3 days, to determine best ATB

• Used for UTI

Describe Total Protein Globulin, Albumin

• protein electrophoresis separates various components into zones by electrical change

• Diagnose, eval, and monitor chronic renal disease

Describe Cystoscopy

• Endoscopic visualization of urethra and bladder

• Used for: hematuria, recurrent UTI, ureteral reflux, bladder capacity

Describe Urodynamic Studies

• measures urine flow during urination

• then US to check how well it emptied

• Used for Dysfunctional voiding

Describe a Voiding Cystourethrogram

VCUG

• bladder filled w/ contrast via catherization, fluoroscopy to demonstrate filling of bladder and collapsing after emptying

• Used for: hematuria, UTI, vesicourethral reflux, suspected structural anomalies

• Insert foley prior

Describe Intravenous Pylogram

• IVP

• Radioplaque contrast injected IV and filtered by kidneys, X-ray films show passage of dye through kidneys, ureters, and bladder

• Used for urinary outlet obstruction, hematuria, trauma to renal system, kidney tumor

• Don’t use for shellfish/iodine allergy

Describe Renal Biopsy

• insert needle through skin and into kidney, tissue is sampled

• Used to diag renal disease or assessment of renal transplant rejection

Describe Renal U/S

• reflected sound waves to visualize kidneys, ureters, and bladder

• Used for assessment of kidney size, cysts, tumors, rejections of kidney transplant

T/F infants and young children have proportionally larger extracellular fluid volume?

True

Do infants/children younger than 2 years have greater or less amount of skin surface area?

• Greater

What does higher respiratory and metabolic rates in early childhood mean for kids?

• More water is lost through the lungs

Why are children at greater risk for fluid and electrolyte imbalance?

• greater amount of body water

• require more fluid intake

• excrete more fluid

Types of Dehydration

• Isotonic

• Hypotonic

• Hypertonic

Describe Isotonic Dehydration

• Electrolyte and water deficits are balanced

• Serum Sodium is in normal limits

• Most common type of dehydration

• Hypovolemic shock is greatest concern

Describe Hypotonic Dehydration

• Electrolyte deficit exceeds water deficit

• Serum Na conc is <130

• Phys signs = severe with smaller fluid losses

Describe Hypertonic Dehydration

• Most dangerous type, water loss in excess of electrolyte loss

• Serum Sodium >150

• Seizures likely to occur

Signs and Symptoms of Dehydration

• Fewer wet diapers than usual

• No tears when crying, inside of mouth dry and sticky

• Lethargy

• Very poor skin turgor

• Increased respiratory rate

• Sunken fontanel, sunken eyes with dark circles

• Abnormal skin color/temp

Restoring F/E Balance

• VS, Urine Specific Gravity

• Ensure diet that supports growth

• Strict records of I/O

• Admin diuretics

• Urine Output is restored, diuresis may be significant

• Monitor for signs of hyperkalemia, hypocalcemia

• Admin packed RBC transfusions

• Dialysis may be necessary

IV Solutions for Isotonic

D5, 0.9% NS, Lactated Ringers

IV Solutions for Hypertonic

D10, D5.9%

IV Solutions for Hypotonic

0.45% NS

Structural Disorders

• Hypospadias/epispadias

• Obstructive uropathy

• Hydronephrosis

• Vesicoureteral reflux

• Bladder Exstrophy

Common Sites of Obstructive Uropathy

• Any obstruction along ureter between kidney, pelvis, and bladder

  • Ureteropelvic (pelvis to ureter)

  • Ureterovesical (lower ureter to bladder)

  • Ureterocele (ureters swells into bladder)

  • Posterior urethral valves (flaps of tissue in proximal urethra, male only)

Describe Vesicoureteral Reflux

Urine flows backward up the ureter

• Occurs when bladder contracts when voiding and occurs in one or both ureters

• if infection is present → kidney exposed to bacteria - pyelonephritis

• increase pressure on kidneys → htn, renal insufficiency, failure

  • Primary and Secondary

Describe Primary VUR

congential abnormality at vesicoureteral junction = valve incompetence

Describe Secondary VUR

structural problems (neurogenic bladder, bladder dysfunction, bladder outlet obstruction)

• grading on severity (1-5)

Vesicoureteral Reflux Assessment

• S/S = fever, dysuria, freq/urgency, nocturia

• hx of UTI, congenital defect

Vesicoureteral Reflux Management

• Prevent infection by emptying bladder, perineal hygiene, ATB regiment

• If severe - surgical correction necessary, monitor hydration and output, bloody urine initially then clear within 2-3 days

Acquired/Functional Disorders

• Urinary tract infection

• Enuresis

• Nephrotic syndrome

• Acute glomerulonephritis

• Hemolytic uremic syndrome

• Renal failure (acute and chronic)

Describe Urinary Tract Infection

Bacterium, virus, or fungus

• Common cause = E-coli (found in perineal and anal region)

• ascend to urethral area via urethra, causing urethritis or cystitis

  • Incre risk in female (shorter urethra)

• If upper tract, urethritis and pyelitis or pyelonephritis may result

UTI Assessment

• neonate/young infant → jaundice, inc RR, irritability, feeding diff, failure to thrive

• infant/children → redness and irritation in perineal area, dysuria, freq, urgency

UTI Managment

• Oral or intravenous ATB

  • 7–14-day course

• Oral fluids - help flush bacteria from bladder

• antipyretics - reduce fever

• heating pad, warm compress = relieve abdomen pain

  • void in warm sitz, tub bath = helps burning when urinating

  • return after ATB course for repeat urine culture

UTI Manifestation in Infants

• Fever/Hypothermia (neonate)

• Irritability

• Dysuria (crying when voiding)

• Change in urine odor or color

• Poor weight gain

• Feeding difficulties

• Malodor

UTI Manifestation in Children

• Abdominal or suprapubic pain

• Voiding freq/urgen

• Dysuria

• New or increased incidence of enuresis

• Malodor

• Fever

UTI Diagnosis

• Based on cultures and sensitivities

• Indicated by suprapubic aspiration

• intensely ill → catherization or SPA is choice

Describe Acute Glomerulonephritis

• Inflammation of glomeruli

• Interference with the glomeruli filtering waste products from blood → rise to acute and chronic manifestations

• S/S

  • Gross hematuria, tea or red urine

  • Edema (periorbital region)

  • Develops HTN and Headache

  • Severe diseases cause ascites

Acute Glomerulonephritis Diagnosis

• Serum Antistreptolysin titer (ASO titer) means exposure to bacteria (if not diagnosed with strepto infect past 2 weeks)

• Serum complement (C3) positive

• Urine microscopic hematuria noted up to 1 year after

• BUN/Creatinine assess renal func

• Nephrotic syndrome can occur if not recover

Acute Glomerulonephritis Management

• no specific treatment

• maintain fluid volume HTN

• antihypertensives (nifedipine, diuretics)

• sodium/fluid restriction

• Urine Output/Color

• Treat infectious sources with ATB

• severe → dialysis

• AVOID NSAIDS with bad renal func

Describe Chronic Glomerulonephritis

• Several glomerular diseases that do not have tendency towards spontaneous recovery

• Advanced pathological dmg to glomeruli silently

• S/S:

  • Decrease in urine output

  • High BP

  • headaches

  • periorbital edema

Chronic Glomerulonephritis Assessment

• Decrease Urine output

• Periorbital edema, increase abdominal girth, swollen labia/scrotum

• Hematuria/proteinuria

• Abnormal BUN and creatinine

Chronic Glomerulonephritis Management

• salt/fluid restriction, low potassium foods

• monitor weight, abdominal girth, electrolytes, acidosis, inadequate renal perfusion

• renal failure → dialysis

• plasma exchange

• loop diuretics

Chronic Glomerulonephritis Diagnosis

• Urinalysis

• Blood Chem

• BUN

• Serum Creatinine

• pH

Describe Nephrotic Syndrome

• excessive protein is excreted into the urine (proteinuria)

  • protein levels 2+

  • hyaline or granular casts

  • microhematuria

  • high specific gravity

• glomerular basement membrane permeability → loss of protein (albumin) in urine (proteinuria) → decreased protein

• decrease protein/albumin in bloodstream

• inc cholesterol

• Complications: anemia, infeciton, poor growth, peritonitis, thrombosis, renal failure

Types of Nephrotic Syndrome

• Congenital, infection, poor growth, peritonitis, thrombosis, renal failure

Nephrotic Syndrome Assessment

• Edema (periorbital, generalized [anasarca], abdominal ascites)

• Skin - stretched/tight appearance, pallor, skin breakdown

• Growth failure and msucle wasting (prolonged illness)

Nephrotic Syndrome Management

• Promote diuresis (diuretics, potassium supplemenetation, monitor UO, weigh daily)

• Preventing infection

  • pneumococcal vaccine, prophylactic ATB

• Encourage adequate nutrition and growth (fluid/sodium restriction, protein rich snacks)

• Minimal Change Nephrotic Syndrome -→ Corticosteroids

• Edematous child → intravenous albumin, diuretics

• Educate parents monitor protein levels with dipstick

Describe Renal Failure

• Where kidneys can’t concentrate urine, conserve electrolytes, or excrete waste products

• Acute or chronic → continues to progress → results in chronic (ESRD)

Describe Acute Renal Failure

• Sudden, reversible decline in renal func

• accum of metabolic toxins and F/E imbalance

• Risk Factors: shock, trauma, burns, urologic abnormalities, renal disease, nephrotoxic meds, severe blood transfusion rxn

• Complications: HTN, pulm edema, CHF, hyperkalemia, metabolic acidosis, hyperphosphatemia, uremia

Acute Renal Failure Assessment

• Nausea, vomiting, diarrhea, lethargy, fever, decreased urine output

• Decreased skin elasticity, dry mucous membranes, edema

• crackles, tachypnea, cardiac rhythm disturbances

• Signs of CHF: edema, bounding pulse, S3 heart sound, adventitious lung sounds, SOB

Acute Renal Failure Management

• Manage HTN, monitor BP, antihtn

• restore F/E: assess urine specific gravity, strict I/O diuretics, monitor for hyperkalemia, polystyrene sulfonate, PRBC transfusion, dialysis

Describe Vulvovaginitis

• inflammation of vulva and vagina

• Causes: bacterial/yeast overgrowth, chemical factors (bubble baths, soaps, perfumes), poor hygiene, tight clothing, persistent scratching

Vulvovaginitis Management

• hygiene

• wash genital area thoroughly daily w/ mild soap and water

• wipe after urinating/bowel movement (front to back)

• cotton underwear

• topical or oral meds

Describe Circumcision

• removal of excess foreskin of penis

• decrease risk of UTI, STI, HIV infection, penile cancer, cervical cancer in female partners

• Complications: alteration in urinary meatus, unintentional removal of excessive amounts of foreskin, damage to glans

Circumcision Management

• Manage pain

• Atraumatic care (restrain infant in padded circumcision chair)

• Postprocedural care: sponge bath, loose diapers, ATB ointment/vaseline

• NOTIFY → excessive bleeding, no void in 6-8 hr after procedure, purulent/serous drainage, red/swollen penile shaft

Describe Epididymis

• inflammation of epididymis

• caused by infection from bacteria

• most common cause of pain in the scrotum

• Rarely occurs before puberty

• If left untreated → scrotal abscess, testicular infarction, infertility

Epididymis Assessments

• Note Hx: swollen scrotum, sexually active, dysuria, urethral discharge, fever lasting days/weeks

• Inspection: edema/erythema

• Palpate: hardened/tender epididymis, inguinal lymph nodes for enlargement

Epididymis Management

• Encourage bed rest with scrotum elevated

• Pain meds (NSAIDS)

• ATB

Describe Testicular Torsion

• Testicle is abnormally attachedto scrotum and twisted

• Needs immediate surgery within 4-8 hrs from symptoms → or ischemia → infertility/testes resection (orchiectomy)

• Common: ages 12-18

Testicular Torsion Assessment

• Sudden, severe scrotal pain (older; sever and persistent)

• Neonate: dusky scrotum, solid mass palpated, prevents light passage, no pain

• Swelling on affected side (hemorrhagic, blue-black)

• Management

  • Surgical corrections

Describe Hemolytic Uremic Syndrome (HUS)

• Preceded by diarrheal illness (hemorrhagic colitis)

• Thrombotic events: leads to occlusion of glomerular capillary loops and glomerulosclerosis → renal failure

• Caused by E. Coli (common)

• Characterized: Hemolytic Anemia, Thrombocytopenia, Acute Renal failure

• transmitted from feces, unpasteurized dairy/fruit, public swimming pools, undercooked ground beef

Hemolytic Uremic Syndrome Assessment

• watery diarrhea → bloody → improves

• cramping/vomiting

• pallor, toxic appearance, edema, oliguria, anura

• neuro: irritability, altered LOC, seizures, posturing, coma

Hemolytic Uremic Syndrome Management

• Contact precaution

• Maintain fluid volume (strict I/O, diuretics, antiHTN, monitor for bleed/fatigue/pallor)

• Prevent hemolytic uremic syndrome: hygiene, swim diapers, cook meat (155F core), wash fruit/veggie, avoid unpasteurized

Describe End-Stage Renal Disease

• Chronic renal failure

  • Results from congenital structural defects (obstructive uropathy), inherited conditions, or acquired

  • Different from chronic renal (results from diabetes or HTN)

End-Stage Renal Disease Assessment

• low birthweight, poor growth

• decrease appetitie/energy levels, dry/itchy skin, bone/joint pain

• Uremia

• Metabolic Acidosis

End-Stage Renal Disease Management

• Dialysis/Renal transplant

• Promote growth and development: protein, sodium/potassium restrictions, meds

Describe Enuresis

• continues incontinence of urine past age of toilet training

  • Primary, Secondary, Diurnal, Nocturnal

Describe Primary Enuresis

• Child who has never achieved voluntary bladder control

Describe Secondary Enuresis

• Urinary incontinence in child who previous demonstrated bladder control over last 3-6 months

Describe Diurnal Enuresis

• Daytime loss of urinary control

Describe Nocturnal Enuresis

• Nighttime bedwetting

• Desmopressin is used for this

Enuresis Assessment

• Elicit description of present illness

• Determine: age, achieve daytime/nighttime dryness, urine holding behaviors, fluid amount before bedtime

Enuresis Management

• inc amt of fluid consumed during days to inc freq or urge to void

• fixed schedule to establish voiding pattern

• educate family it isn’t child fault

• limit fluid/voiding before bedtime

Describe Bladder Extrophy

• Bladder and related structures turned inside out through opening in abdominal wall

• Developmentally abnormality present at birth

• Management: Surgical repair

  • Keep bladder moist and covered w/ sterile plastic bag

Describe Desmopressin

DDAVP is a synthetic form of antidiuretic hormone (ADH) (vasopressin).

Used to reduce UO and help the body retain water.