Disorders of the Urinary Tract System

Patent Urachus

Total failure of urachus to obliterate -> urine discharge from umbilicus. Occurs commonly in males than females

Urachus

a tubular structure that is a remnant of embryonic development, which extends from the umbilicus to the apex of the bladder

Exstrophy of the Bladder

a midline closure defect that occurs during the embryonic period of gestation (first 8 weeks). As a result, the bladder lies open and exposed on the abdomen. occurs more frequently in males than females at a ration of 2:1

- Can be revealed by fetal sonogram

- There is no anterior wall of the bladder and no interior skin covering on the lower anterior abdomen. The bladder appears bright red and continually drains urine from the open surface

- In females, the urethra may also be abnormally formed.

- In males, the penis is often unformed or malformed. Pelvic bone defects and urachal defects may be present.

- Children may demonstrate a "waddling" gait from the effect of the non-fused pubic arch

Assessment for Exstrophy of the bladder

- Surgical closure of the bladder and if necessary, the anterior abdominal wall with construction of a urethra

- The bladder is surgically removed and ureterocecal implantation (ureters directed into the small intestine) or a continent urinary reservoir (artificial bladder) is constructed.

Therapeutic Management for Exstrophy of the bladder

- Keep the exposed bladder covered by a sterile plastic bowel bag.

- To prevent skin of the abdomen from excoriation due to the constant irritation of urine, protect it with a substance such as A & D ointment.

- To reduce pressure and prevent further separation of the symphysis , the orthopedic physician may ask the infant's legs be flexed and brought together and wrapped in Ace bandages to hold them in position. If it is done, do not separate the infant's legs to apply diapers, just place them under the child instead.

- Be certain to change diapers promptly after defecation so feces are not brought forward to the open bladder.

- Position the infant on his or her back

- Sponge bathe rather tub bathe the infant

Preoperative Care for Exstrophy of the bladder

- Position the infant on his or her back or an infant chair to prevent feces from coming forward and contaminating the incision line.

- Suprapubic or indwelling catheter for urine drainage will be inserted to allow the newly constructed bladder to rest.

- Immediately after surgery, urine draining from the catheter may be blood-stained, but this should be clear after the first few hour.

- Children may notice sharp painful bladder contractions for the first few days after surgery (analgesic and antispasmodic- to keep the child comfortable).

- The child may be fitted with an external fixation device after an osteotomy to hold the pubic bone sin approximation until they fuse.

- After the second-stage urethra repair, children can be expected to experience some stress incontinence (loss of urine on physical exertion) from the constructed urethra.

- Kegel's exercises can help strengthen the perineal muscles.

Postoperative Care for Exstrophy of the bladder

Hypospadias

a urethral defect in which the urethra opening is not at the end of the penis but on the ventral (lower) aspect of the penis. The meatus may be near the glans, midway back or at the base of the penis. Occurring approximately 1 in 300 male newborns. Tends to be familial or may occur from a multifactorial genetic focus

- Inspect all male newborns at birth

- May have accompanying short chordee- a fibrous band that causes the penis to curve downward (often called a cobra-head appearance)

- Should not be circumcised because at the time of the repair the surgeon may wish to use a portion of the foreskin for the repair.

- A meatotomy can be performed to establish better urinary function

- When the child is older (12-18 months) adherent chordee may be released.

- If the repair well be extensive, all surgery may be delayed until the child is 3-4 years.

- To encourage penis growth and make the procedure easier, the child may have testosterone cream applied to the penis or receive daily injections of testosterone.

- After surgical repair, a urethral urinary drainage catheter will be inserted to allow urine output

- Analgesic such as acetaminophen (Tylenol) and antispasmodic such as oxybutynin (Ditropan)

Assessment of Hypospadias

Urinary tract infection

microbial infection of any part of the urinary tract. Occur more often to females than males. Common cause of nosocomial or health care-acquired infection. E. choli is a frequent offender

- Pain on urination, frequency, burning and hematuria

- Low grade fever

- Mild abdominal pain

- Enuresis (bedwetting)

- Pyelonephritis infection (high fever, abdominal or flank pain, vomiting and malaise)

- Proteinuria

- Presence of red blood cells (hematuria)

- pH more than 7 (alkaline)

Assessment for UTI

uprapubic aspiration, clean-catch technique, or catheterization

Methods of collecting Urine culture for UTI

- Antibiotic

- Drink plenty of fluids to flush the infection

- Cranberry juice recommended as highly recommended as being effective in acidifying urine and more resistant to bacterial growth

- Mild analgesic

Therapeutic Management for UTI

- Urge to urinate every 4 hours to prevent statis of urine in ureters

- Drink plenty of fluids

- To wipe from front to back after moving bowels or urinating

- Wear cotton underwear

- Wash the vulva daily

- Change sanitary pads at least every 4 hours

- Urinate immediately after intercourse

- If antibiotic is prescribed make sure to take it for the full prescribed course.

Preventing UTI's in Females

vesicoureteral reflux

retrograde flow of urine from the bladder into the ureters. This reflux of urine occurs with micturition (voiding) when the bladder contracts because the valve that guards the entrance from the bladder to the ureter is defective either from birth or because of scarring from repeated UTIs; bladder pressure is stronger than usual; or ureters are implanted at unusual angles or too low on the bladder wall. Based on diagnostic studies, it is graded from I to V by degree of reflux, with grade V being the most serious

VCUG (Voiding Cysto-Urethrogram)

uses x-rays and a contrasting agent to evaluate your child's urethra and bladder size, shape, and capacity. This procedure uses x-rays and a contrasting agent that is administered by catheter into your child's bladder.

VCUG, CT scan, MRI, Cystoscopy, and Cystography with contrast material

Diagnostic tests to confirm vesicoureteral reflux

Grade I: urine reflux into the ureter only

Grade II: urine reflux into the ureter and the renal pelvis (where the ureter meets the kidney), without distention (swelling with fluid, or hydronephrosis)

Grade III: reflux into the ureter and the renal pelvis, causing mild swelling

Grade IV: results in moderate swelling

Grade V: results in severe swelling and twisting of the ureter

Gradings of the degree of Vesicourethral Reflux

- It resolve with maturity without a need for surgery.

- Must be treated to decrease the possibility of glomerular scarring from infection or back pressure

- Teaching double voiding (having the child void and then in a few minutes attempt to void again) may help to empty the bladder more fully and prevent recurrent infection from urinary stasis.

- Some girls need to remain on prophylactic antibiotics for a lengthy time to prevent bladder infection from reoccurring

Therapeutic management for vesicourethral reflux

Enuresis

involuntary passage of urine past the age when a child should be expected to have attained bladder control. May be nocturnal, diurnal or both. Found frequently in boys than girls. It also tends to be familial

- Ask how parent's have tried to correct the problem; identify whether it is primarily a problem for the child or the parents

- Assess whether there are stresses in the family, such as parents who expect more mature behavior of a child than he or she can handle

- If the child wet sonly when he or she is engrossed in interesting activity, he or she may simply need more frequent reminding to empty the bladder.

- If a child wets only on nights when he or she exceptionally tired or troubled, a functional rather than an organic cause is suggested.

- If the child has symptoms other than bedwetting such as abdominal pain, burning or frequency, UTI is suggested

Assessment for Enuresis

- If stress factors have been identified, an attempt should be made to correct these.

- Caution parents of children with sickle cell anemia not to restrict fluid this way because increased sickling of cells occurs with dehydration.

- Synthetic antidiuretic hormone administered intranasally or orally

Imipramine (Tofranil) an anticholinergic drug that inhibits urination

- Alarm bells that ring when children wet at night are effective in some children.

- Bladder-stretching exercises- drinking a large quantity of water and then refraining from voiding as long as possible- to increase the functional size of the bladder. A bladder that can hold 300-350ml of fluid will generally be large enough to contain urine during a night's sleep

Therapeutic Management for Enuresis

Postural (Orthostatic) Proteinuria

Proteinuria found during the day but not at night when a recumbent position is assumed. Phenomenon is apparently attributable to the effect of gravity on glomerular function. Needs no therapy. Be sure to document the condition because some of these children develop some form of kidney disorder later in life.

Kidney Agenesis

Absence of one or both kidneys at birth. Is suggested when the volume of amniotic fluid on sonogram or birth is less than normal (oligohydramnios). Will not void urine.

Potter's Syndrome

Bilateral renal agenesis: Oligohydramnios, limb deformities, facial deformities, and pulmonary hypoplasia. Caused by malformations in the ureteric bud

Renal Hypoplasia

incomplete development of the kidney, usually with fewer than five calyces or lobes. Have poor kidney function, may develop hypertension from stenosis of the renal arteries

If bilateral, the child may need kidney transplant in later life to maintain kidney function and prevent kidney function

Acute Renal Failure

Condition that occurs when something, such as a blockage, toxins, or sudden loss of blood flow causes a change in the filtering function of the kidneys

Chronic Renal Failure

Gradual and progressive loss of kidney function. Results from extensive kidney disease

- Oliguria: Urine output <1 mL/kg/hr indicates impaired kidney function.

- Azotemia: Early sign marked by nitrogen waste buildup in the blood.

- Uremia: Advanced azotemia with toxic symptoms like confusion.

- BUN Levels: Toxic: 80-100 mg/dL (needs urgent treatment) Very low (<10 mg/dL): May indicate complete renal shutdown.

- Fixed Specific Gravity: At 1.010, showing kidneys can't concentrate/dilute urine.

- Hyperkalemia: Elevated potassium causes muscle weakness, irregular pulse, low BP.

- Acidosis: H⁺ ion retention leads to metabolic acidosis.

- Phosphorus-Calcium Imbalance: High phosphorus lowers calcium.

- Hypocalcemia causes tetany, seizures, and long-term bone issues (osteodystrophy).

Assessment for Acute Renal Failure

- IV therapy (with potassium) is needed to replace plasma volume

- Diuretic such as furosemide (Lasix) to increase urine production

- Low protein, potassium and sodium and high in carbohydrate diet

- Limit fluid intake

Therapeutic Management for Acute Renal Failure

- Loss of nephron function (kidneys can't concentrate urine); results to polyuria possibly manifested by enuresis

- Oliguria and anuria

- Inability to excrete H+ ions leads to acidosis

- Kidneys responsible for synthesizing Vitamin D to its active form. With poor kidney function, Vitamin D cannot be used

- Anemia

- Pruritus

Assessment for Chronic Renal Failure

- Low protein, low phosphorus, low potassium diet to prevent rapid urea and phosphate buildup.

- Take aluminum hydroxide gel with meals to bind phosphorus in the intestines and prevent absorption

- Meat and fluid intake is restricted

- Needs supplemental calcium

- Recombinant human erythropoietin to stimulate RBC formation

Therapeutic Management for Chronic Renal Failure