Genitourinary Disorders in Children

Variation in pediatric anatomy and physiology: Structural differences

• Kidneys large in relation to abdomen

• Urethra is shorter in both male and females compared to adults

Variation in pediatric anatomy and physiology: urinary concentration

• Glomerular filtration rate (GFR) slower

• Less able to concentrate urine and reabsorb amino acids

Variation in pediatric anatomy and physiology: urine output

• Bladder capacity increases to usual adult capacity (270 mL) by 1 year of age

• Infant/toddler voids 9-10 times per day; by age 3, its is same as adult (3-8 times per day)

Variation in pediatric anatomy and physiology: reproductive organs

Immature at birth; gonads not mature until adolescence

Health hx

maternal polyhydramnios, oligohydramnios, diabetes, HTN; chromosome abnormalities, congenital malformations, past medical hx of UTI, parental enuresis, age of toilet training, spinal disturbances, menstrual hx and sexual activity in adolescents

HPI

burning w/ urination, change in voiding pattern, foul-smelling urine, vaginal or urethral discharge, hematuria, masses in abdomen/scrotum/groin, poor growth, fever, trauma

Objective

dysmorphic features, diaper rash, reddened urethral opening, labial fusion, abdominal distention, cardiac flow murmur, undescended testicles, penile abnormalities

Common lab and Diagnostic tests

• CBC: suspect anemia, infection

• Blood urea nitrogen (BUN): indirect measurement of renal function and glomerular filtration in the presence of adequate liver function

• Creatinine (serum): more direct measurement of renal function. Used to dx impaired renal function

• Creatinine clearance (urine and serum): 24-hour urine collection evaluated for presence of creatinine then compared with serum creatinine

  • Discard first void, then begin 24-hr collection. Store on ice. Keep ALL urine. Serum drawn during same period.

• Total protein, globulin, albumin (serum): used to dx, evaluate and monitor chronic renal disease

• Urinalysis (urine): “UA” gives preliminary information about urinary tract

  • pH, specific gravity, ketones, protein, glucose, blood, leukocytes, nitrates

• Urine culture and sensitivity: dx of UTI, 24-48 hr growth of bacteria

• Voiding cystourethrogram (VCUG): bladder is filled with contrast via catheterization, fluoroscopy reveals filling and emptying of bladder

  • Used in hematuria, UTIs, vesicoureteral reflux, suspected structural anomalies

• Intravenous pyelogram (IVP): radiopaque contrast injected via IV, filtered through kidneys, X-rays show intervals of dye passage through kidneys, ureters, bladder

  • Indicated in hematuria, renal system trauma, urinary outlet obstruction

  • Contraindicated in children allergic to iodine or shellfish

  • Ensure adequate hydration before and after test

• Renal Ultrasound: useful to determine kidney size, cysts, tumors

Collecting Urine Specimen: Suprapubic aspiration

neonate/infant, collect sterile sample by inserting needle through abdominal wall into bladder (performed by MD or NP)

Collecting Urine Specimen: Urine Bag

• infants/toddlers not toilet trained

• Urine culture– sterile bag; Urinalysis– clean bag

Collecting Urine Specimen: Sterile Urine Catheterization

• 6 to 8 Fr: Birth to 1 year old

• 8 to 10 Fr: 1 to 8 years old

• 10 to 12 Fr: 8 to 12 years old

• 12 to 14 Fr: 12 years and older

Applying the Urine Bag

1.Cleanse area well and pat dry.

• If culture is to be obtained, cleanse with povidine-iodine (Betadine)

2.Apply benzoin around scrotum or vulvar area to aide with urine bag adhesion

3.Allow benzoin to dry

4.Apply urine bag

• Boys: ensure penis is fully inside bag; a portion of scrotum may not be in bag depending on size

• Girls: Apply narrow portion of bag on perineal space between anal and vulvar areas first for best adhesion, then spread remaining adhesive section

5.Tuck bag downward to discourage leaking

6.Check bag frequently for urine

Bladder exstrophy

• A midline closure defect occurring during the embryonic period of gestation leaves bladder open and exposed outside of abdomen

• Usually diagnosed by prenatal ultrasound

• May have malformed bony pelvis

• Females: may have malformed urethra; Males: may have unformed or malformed penis or normal penis with an epispadias

• Will require surgical repair

Bladder exstrophy Nursing Interventions

• prevent infection and skin breakdown, post-op care

• Protect bladder by covering with sterile bag, supine position, change diaper frequently, sponge baths

• Protect skin with barrier creams, consult ostomy nurse if needed

• Post-op care: keep area clean/diapers changed, catheter care, manage spasms with meds as ordered

• Catheterizing stoma: may have urinary reservoir if bladder removed

• Stoma on abdominal wall is catheterized 4 times per day to empty reservoir

• Urine may be mucus-like, cloudy

• Teach parents to catheterize

Hypospadias

Urethral defect in which opening of meatus is on ventral surface of penis

Epispadias

Urethral defect in which the opening is on the dorsal surface of the penis

Hypospadias & Epispadias: Complications and Surgical repair

• Complications: problems with urine stream, may interfere with deposition of sperm in intercourse à infertile, damage to body image

• Surgical repair between 6mos - 1 yr old. Goal is to provide appropriate placed meatus for normal voiding and ejaculation.

  • The meatus is moved to glans penis and urethra is reconstructed as needed

  • No circumcision until after repair

Hypospadias & Epispadias Post op Care

• Assess for urinary drainage through stent or drainage tube

• Tube must remain taped with penis in an upright position

• Abx, analgesics, antispasmodics

• Double diapering used to protect urethra and stent or catheter after surgery

• Teach parents home catheter care, no tub baths until healed, no straddling or ride-on toys

Urinary Tract Infection (UTI)

• UTI’s more common in females than males because of anatomy

• Infants: fever, irritability, vomiting, FTT. Children: fever, vomiting, dysuria, frequency, hesitancy, urgency, pain

• E. coli most common cause but others include Klebsiella, S. aureus, Proteus

• Urinary stasis, decreased fluid intake

• UTI raises more concern in children than adults. May have VUR

• Untreated bladder infection may allow reflux of infected urine to ureters and kidneys, resulting in pyelonephritis

Urinary tract infection: Labs and Diagnostics

• Labs and Diagnostics

• Urinalysis: may be positive for blood, nitrites, leukocyte esterase, WBCs, or bacteria

• Urine culture: positive for infecting organism

• Renal U/S: may show structural defect

• VCUG: reveals if there is vesicoureteral reflux (VUR)

• Hospitalization may be required

• Age < 3 mos, dehydration, toxic appearance, sepsis

Preventing UTI in Females

• Drink enough fluid (to keep urine flushed through bladder).

• drink cranberry juice to acidify the urine

• avoid colas and caffeine which irriate the bladder

• Urinate frequently and do not "hold" urine (to discourage urinary stasis)

• Avoid bubble baths (they contribute to vulvar and perineal Irritation).

• Wipe from front to back after voiding (to avoid contaminating the urethra with rectal material).]

• wear cotton underwear (to decrease the incidence o perineal irriation.

• avoid wearing tight jeans or pans.

• Wash the perineal area daily with soap and water.

• While menstruating, change sanitary pads frequently to discourage bacterial growth.

• Void immediately after sexual Intercourse.

Vesicoureteral Reflux (VUR)

• VUR is a condition where urine from bladder flows back up into ureters

• Occurs during bladder contraction when voiding

• Graded on severity (Grade I-V), V being most severe

• May occur in one or both ureters

• If urine infected, kidney is exposed to bacteria; pyelonephritis may result

• Increased pressure placed on kidney with reflux can cause renal scarring and lead to HTN, renal insufficiency or failure later in life

• Results from structural or functional abnormality

• Up to 50% of children with UTI have VUR

Vesicoureteral Reflux (VUR) TX

antibiotic prophylaxis, UTI prevention hygiene, surgical intervention in more severe cases

Enuresis

• Enuresis is continued incontinence of urine past the age of toilet training

  • Primary: never achieved voluntary bladder control

  • Secondary: incontinence in a child who previously achieved bladder control

  • Diurnal: daytime loss of bladder control

  • Nocturnal: nighttime bedwetting

• Can be secondary to physical disorder, DM, diabetes insipidus, SCA, urethral obstruction. Must tx physical causes first

Enuresis risk factors

family disruption or other stressors, chronic constipation, excessive family demands R/T toileting patterns, difficult to arouse from sleep, fam hx of enuresis, developmentally delayed

Enuresis Nursing Management

• Educate child and family

  • Increase fluid during day and set a fixed schedule for voiding

  • Suggest books to read that are targeted to children

  • Limit bladder irritants (caffeine, chocolate) and fluid intake after dinner

  • Wear underwear to sleep at home, pull-ups when away from home

• Support and encouragement

  • Reassurance

  • Reward system for dry nights

  • Help with bed changing--- not in a punitive way

• Decreasing nighttime voiding

  • Enuresis alarm system

  • Meds may be prescribed (oxybutynin, imipramine, desmopressin)

Nephrotic syndrome

• Occurs as a result of increased glomerular basement membrane permeability, allowing abnormal loss of protein in the urine

  • Protein loss almost exclusively albumin

• May be congenital, secondary, or idiopathic (most common in children)

• Idiopathic also called minimal change nephrotic syndrome (MCNS)

  • Onset usually by 10 yrs old

Nephrotic syndrome complications

anemia, infection, poor growth, peritonitis, thrombosis, renal failure

Nephrotic syndrome s/sx

n/v, recent weight gain, periorbital edema in morning progressing to generalized edema during day, anasarca, fatigue, fussiness, ascites, skin breakdown R/T edema, increased resp rate or labored, fluid overload

Nephrotic syndrome diagnostics

Marked proteinuria, serum protein and albumin levels low, serum cholesterol/triglycerides high, BUN and creatinine elevated (later stages)

Nephrotic syndrome Nursing Management

• Promote diuresis, administer corticosteroids, IV albumin, K+ supplementation

• Prevent infection

• Encourage adequate nutrition

• Educate family

• Provide emotional support

Acute post-streptococcal glomerulonephritis (APSGN)

• Condition caused by an antibody-antigen reaction secondary to an infection with the nephritogenic strain of group A β-hemolytic streptococcus

• Occurs most often between 5-8 yrs old

Acute post-streptococcal glomerulonephritis (APSGN) S/sx

Fever, lethargy, decreased urine output, tea-colored urine, abdominal pain, HTN, circulatory congestion, facial edema in am ® spreads to extremities during day, proteinuria, hematuria, positive ASO titer

Acute post-streptococcal glomerulonephritis (APSGN) Tx

May resolve with proper tx; If no tx, 50% lead to end-stage renal disease

•Diuretics, antihypertensives

Acute post-streptococcal glomerulonephritis (APSGN) Nursing Management

monitor BP and daily weights, maintain sodium and fluid restrictions if edematous, neuro checks, avoid NSAIDs

Hemolytic-Uremic Syndrome (HUS)

• Defined by 3 features:

  • Hemolytic anemia

  • Thrombocytopenia

  • Acute renal failure

• Usually caused by infection in bloodstream which causes RBC’s to break down and clog kidneys

Hemolytic-Uremic Syndrome (HUS) s/sx

begins with diarrheal illness (E.coli, Shigella), oliguria, irritability, lethargy, seizures, HTN

Hemolytic-Uremic Syndrome (HUS) labs/dx

increase BUN/creatinine, decrease Hgb/Hct, ­increase reticulocyte count, leukocytosis w/ left shift, metabolic acidosis, ­increase K^+,  decrease Na⁺, hematuria, proteinuria

Hemolytic-Uremic Syndrome (HUS) nursing

• contact precautions, monitor fluid volume status, monitor BP, monitor for bleeding, may require dialysis

• PREVENTION!

Circumcision

• Removal of excess foreskin of the penis

• Benefits: decreased incidence of UTI, STIs, AIDS, and penile CA

• Complications: rare; bleeding, penile adhesions, meatal stenosis

• To circumcise or not to circumcise is a personal decision

Circumcision nursing

• Advocate for appropriate pain management

• Post-procedural care

  • Clean with clear water, no alcohol wipes, sponge baths until healing

  • Loose diaper

  • Antibiotic ointment or petroleum jelly to penile head with each diaper change (unless Plastibell used)

Cryptorchidism

• Also known as undescended testicles (unilateral or bilateral)

• Up to 3% of male infants

• If not descended by 12 mos, must be referred for surgical repair- orchiopexy

Cryptorchidism risk factors

prematurity, first-born child, Caesarean birth, LBW, hypospadias

Cryptorchidism complications

Complications associated if not repaired by school-age: sterility, increased risk of testicular cancer

Hydrocele

• fluid in the scrotal sac

• Enlarged scrotum

• Usually benign and resolves by 1 yr old

• Not associated with infertility

Varicocele

• a venous varicosity along the spermatic cord

• Mass on one or both sides, feels “worm-like” on palpation, may have pain

• May have low sperm count or reduced sperm motility

• Refer to urology; surgery may be indicated

Testicular torsion

A testicle rotates and twists the spermatic cord which brings blood to testicle

Testicular torsion s/sx

sudden, severe scrotal pain, significant swelling, and may be blue-black in color

Testicular torsion tx

• Considered a surgical emergency

• If untreated, ischemia results, leading to infertility