GE

Genitourinary Disorders

Instructor: Sarah Bennett, DNP, CPNP, FNE-A/P

Objectives

By the end of this lecture, students will be able to:

  • Identify common pediatric genitourinary tract disorders and their clinical presentations.

  • Differentiate between primary and secondary enuresis and recognize appropriate nursing interventions.

  • Explain the diagnostic process and nursing management of urinary tract infections (UTIs) in children.

  • Compare structural and acquired genitourinary disorders and describe their treatments.

  • Distinguish between acute glomerulonephritis and nephrotic syndrome based on pathophysiology, symptoms, and management.

  • Apply nursing care priorities to pediatric patients with genitourinary conditions, including monitoring, education, and family support.

Enuresis

Definition and Types

Enuresis refers to involuntary urination. It can be categorized into:

  • Daytime Enuresis: Occurs at least twice a week for a minimum of three months after the age of 5.

  • Nocturnal Enuresis (Bedwetting):

    • Primary Enuresis: The child has never been dry for an extended period.

    • Secondary Enuresis: The child has experienced a period of dryness but has resumed bedwetting.

Evaluation of Other Causes

  • Prior to diagnosing enuresis, it is essential to evaluate for other potential causes, which may include:

    • Adverse effects of medications.

    • Urinary tract infections (UTIs).

History Taking

  • Family History: Inquire about any family history of enuresis.

  • Bladder Dysfunction Disorders: Assess for associated disorders.

  • Males: Consider any life-changing events potentially impacting bowel or urinary control.

  • Diagnostics:

    • Functional Bladder Capacity Screening: Expected bladder capacity in ounces is given by the formula: child's age (up to 14 years) + 2.

    • Record the enuresis pattern.

Nursing Care Interventions

  • Encourage the child to urinate before bedtime.

  • Restrict fluid intake for at least 2 hours prior to sleep.

  • Avoid caffeine in the afternoon.

  • Implement positive reinforcement strategies.

  • Avoid punishing or teasing for wetting incidents.

  • Administer any prescribed medications as directed.

  • Ensure the child has regular, soft, and formed stools.

Medications for Enuresis

  • Desmopressin

  • Imipramine: Rarely used due to potential cardiotoxicity.

  • Oxybutynin

Enuresis Questions

Question 1

A school nurse evaluates a 6-year-old who has started wetting their pants after being continent. Possible causes to consider include:

  • Normal developmental regression.

  • A recent urinary tract infection.

  • Overhydration during the school day.

  • Delayed toilet training.

Question 2

A nurse cares for a child with enuresis prescribed desmopressin. The actions the nurse should take include:

  • Administer the medication nasally.

  • Monitor electrolytes following administration.

  • Avoid encouraging fluids after dinner.

Urinary Tract Infections (UTIs)

Definitions

  • Bacteriuria: The presence of bacteria in the urine.

  • Cystitis: Inflammation of the bladder.

  • Pyelonephritis: Inflammation of the upper urinary tract and kidneys.

Risk Factors for UTIs

  • Structural abnormalities.

  • Poor hygiene.

  • Sexual activity.

  • Constipation.

Presentation of UTI by Age

  • Less than 2 years old:

    • Poor feeding.

    • Vomiting.

    • Failure to thrive (FTT).

    • Foul-smelling urine.

    • Persistent diaper rash.

    • Irritability.

    • Frequency of urination.

    • Fever of unknown origin.

  • Greater than 2 years old:

    • Dysuria, frequency, urgency.

    • Hesitancy during urination.

    • Hematuria.

    • Foul-smelling urine.

    • Enuresis/incontinence.

Diagnosis of UTIs

Urinalysis should include the following assessments:

  • Appearance: Cloudy, hazy, potential presence of mucus, pus, and foul odor.

  • pH: Alkaline.

  • Protein: Negative.

  • Glucose: Negative.

  • Ketones: Negative.

  • Leukocytes: Positive.

  • Nitrites: Positive.

  • Red Blood Cells (RBC): Positive.

  • Urine Culture: Necessary to confirm bacterial presence.

Nursing Management of UTIs

Nursing care should emphasize the following:

  • Encourage frequent voiding and complete bladder emptying.

  • Encourage fluid intake.

  • Monitor urine output carefully.

Medications for UTIs

  • Antibiotics:

    • Augmentin.

    • Trimethoprim/sulfamethoxazole.

    • Nitrofurantoin.

  • Analgesics for pain management:

    • Tylenol.

    • Ibuprofen.

Prevention of UTIs

  • Hygiene Practices:

    • Wipe front to back.

    • Avoid bubble baths.

    • Ensure loose fitting clothing.

    • Change infants' diapers frequently.

  • After Sexual Activity:

    • Encourage adolescents to void post-intercourse.

  • Frequent Urination:

    • Avoid holding urine, and encourage timed voiding.

  • Constipation Management:

    • Use stool softeners as needed.

  • Avoid Douching.

Complications of UTIs

Potential complications include:

  • Progressive Kidney Injury

  • Pyelonephritis: Requires treatment with IV antibiotics until afebrile for 24-36 hours, then transitioned to oral antibiotics.

  • Urosepsis: Febrile UTI with systemic manifestations associated.

Voiding Cystourethrogram (VCUG)

VCUG is a procedure in which contrast media is instilled through a urinary catheter to detect structural abnormalities or injury, utilizing progressive x-rays during urination.

  • Nursing Actions:

    • Assess for potential allergies to contrast media or iodine.

    • Increased risk of infection may occur 72 hours post-procedure.

    • Encourage increased fluid intake.

    • Monitor urine output post-procedure.

Vesicoureteral Reflux

Definition

  • Vesicoureteral reflux is characterized by the backward flow of urine from the bladder into one or both ureters, and possibly up to the kidneys due to improper closure of the ureterovesical valve, increasing the risk of UTIs and kidney damage over time.

Grading and Treatment

  • Grading I-V:

  • Treatment Options:

    • Continuous antibiotic prophylaxis utilizing low doses of Bactrim or nitrofurantoin.

    • Address constipation and manage dysfunctional voiding.

Nursing Implications

  • Monitor for UTIs due to their increased risk.

  • Ensure medication adherence while educating family on hydration and scheduled emptying of the bladder.

  • Emphasize proper hygiene practices.

UTI Question

In planning care for a child with a UTI, the nurse should:

  • Encourage the child to void frequently.

Hypospadias and Epispadias

Definitions

  • Chordee: Ventral curvature of the penis requiring surgical release of the fibrous band.

  • Hypospadias: The urethral meatus is located on the ventral aspect of the penile shaft or scrotum, requiring surgical repair at 6-12 months of age.

  • Epispadias: The urethral meatus is open or exposed on the dorsal aspect of the penis, requiring avoidance of circumcision at birth and surgical correction between 6 months to 1 year.

Medical Management

  • Care following a surgical intervention may include urethral reconstruction with stent or catheter placement post-operatively for several weeks.

Nursing Care Interventions

  • Avoid any stress on the catheter.

  • Expect bloody urine initially following surgery.

Exstrophy of the Bladder

Definition

A significant condition characterized by the externalization of the bladder through the abdominal wall, often accompanied by the separation of the pelvic bones and splaying of the urethra.

Presentation Features

  • Typically presents with:

    • Red appearance of the bladder.

    • Seeping urine potentially causing excoriated skin.

  • External genitalia may show abnormalities such as:

    • For males: undescended testes and a short penis.

    • For females: bifid clitoris, short vagina, and separated labia.

Nursing Actions

  • Maintain coverage with sterile plastic wrap or bags, and apply moisture barrier ointment.

  • Protect the area from infection/stool contamination.

Defects of the GU Tract

Key Conditions

  • Phimosis: A condition involving the narrowing of the foreskin preventing retraction; it is typically expected in infants and resolves with growth without forcible retraction.

  • Cryptorchidism: Failure of one or both testes to descend into the scrotum, requiring orchidopexy between 6-24 months of age, noting that approximately 70% self-resolve by 6 months.

  • Hydrocele: A non-painful collection of peritoneal fluid in the scrotum that can resolve spontaneously; surgery may be necessary if not resolved by 1 year.

Structural vs Acquired Disorders

Structural Disorders

  1. Chordee

  2. Hypospadias/Epispadias

  3. Bladder exstrophy

  4. Phimosis

  5. Cryptorchidism

  6. Hydrocele/Varicocele

  7. Testicular torsion

  8. Ambiguous genitalia

Acquired Disorders

  1. Acute glomerulonephritis

  2. Nephrotic syndrome

  3. Hemolytic uremic syndrome

Testicular Torsion

Overview

A urologic emergency where delayed diagnosis can lead to testicular loss.

Pathophysiology

Involves a congenital deformity known as the Bell clapper deformity, where the testicle twists around the spermatic cord leading to venous occlusion and engorgement, ultimately causing arterial ischemia and infarction.

Treatment Options

  • Manual detorsion as an initial step.

  • Surgical intervention may be necessary if manual detorsion is unsuccessful.

Structural Disorders Question

A nurse assesses a male infant with bladder exstrophy. Expected findings include:

  • Epispadias.

  • Undescended testes.

  • Enlarged scrotal sac.

  • Hypospadias.

  • Widened pubic symphysis.

Acute Glomerulonephritis

Pathophysiology

  • Characterized by inflammation of the glomeruli:

  • Post-infectious immune complex formation occurs typically 10-21 days following infection lasting 1-2 weeks. The most common cause is Acute post-streptococcal glomerulonephritis (ASO titer needed).

Symptoms

  • Edema.

  • Anorexia.

  • Hypertension.

  • Oliguria (severely reduced urine output).

  • Hematuria (may appear cola or tea colored).

  • Proteinuria (not as pronounced as in nephrotic syndrome).

  • Possible cerebral complications.

Diagnostics

  • Includes:

    • Throat culture.

    • Urinalysis.

    • CBC and CMP.

    • ASO titer.

Treatment

  • Management may involve:

    • Administering diuretics and antihypertensives.

    • Providing antibiotics as needed.

    • Monitoring inputs and outputs (I&Os).

    • Restricting sodium and fluid as indicated.

    • Monitoring blood pressure (BP) and heart rate (HR).

Patient Education

  • Encourage rest and teach family members to monitor heart rate and blood pressure.

Complications

Possible complications stemming from acute glomerulonephritis may include:

  • Hypertensive encephalopathy.

  • Circulatory overload.

  • Acute kidney injury.

Nephrotic Syndrome

Overview

Nephrotic syndrome involves abnormal protein loss in urine. There are three types:

  • Congenital: Usually involves a recessive gene and presents with poor response to therapy, often leading to death in the first 1-2 years unless dialysis or transplant occurs.

  • Secondary: Occurs within one week after an immune assault.

  • Idiopathic: Minimal change nephrotic syndrome, accounting for about 80% of cases and associated with frequent relapses.

Symptoms

  • Nausea and vomiting.

  • Weight gain.

  • Periorbital edema.

  • Generalized edema throughout the day.

  • Fatigue.

  • Irritability.

Physical Exam Findings

  • Significant edema.

  • Ascites.

  • Pallor.

  • Increased work of breathing.

  • Variations in blood pressure.

  • Heart murmur and crackles may be audible in the lungs.

Laboratory Tests

  • Urinalysis/24-hour urine collection:

    • Massive proteinuria present.

    • Few red blood cells.

    • Increased specific gravity.

  • Blood Tests:

    • Hypoalbuminemia.

    • Hyperlipidemia indicating elevated lipid levels.

    • Hemoconcentration reflected with elevated hemoglobin, hematocrit, and platelets.

    • Elevated ESR.

Treatment

  • Use of prednisone for a minimum of 3 months with a tapering schedule, monitoring for adverse effects.

  • Furosemide: requiring monitoring for potassium levels to increase intake.

  • Albumin infusions as established.

Nursing Care Interventions

  • Monitor I&Os and implement daily weight measurements on the same scale wearing the same clothing.

  • Encourage rest and elevate the legs and feet to reduce edema.

Differences Between Disorders

  • Acute Glomerulonephritis: Shows hematuria, proteinuria, hypertension, and oliguria with less severe edema, typically following infection and largely manifests in only a single episode. Indicative lab findings include elevated BUN/creatinine and urine albumin levels of 1-2+ with the presence of hematuria.

  • Nephrotic Syndrome: Characterized by proteinuria, hypoalbuminemia, marked edema, and hyperlipidemia. This disorder is commonly idiopathic with a relapsing course. During assessments, BUN/creatinine elevations may not be present, but urine may reflect protein absence of RBCs.

Specific Care Interventions for Nephrotic Syndrome

In planning care for a child with nephrotic syndrome, key interventions include:

  • Weighing the child daily on the same scale.

  • Encouraging ambulation may not be as essential at this point relative to total care needs.

  • Fluid intake may need to be adjusted, avoiding increases unless specifically indicated by healthcare provider.

IV Albumin Considerations

When administering an IV infusion of albumin to a child with nephrotic syndrome, the primary concerns for the nurse should include:

  • Monitoring for increased blood pressure.

  • Monitoring urine output closely.

  • Watch for electrolyte imbalances.

  • The risk of fluid overload should be assessed throughout the procedure.

Clinical Manifestations of Acute Glomerulonephritis

In caring for a child admitted with acute glomerulonephritis, the most likely clinical manifestation would be:

  • Tea-colored urine, indicative of hematuria.

Symptom Assessment in Family Reports

In a scenario where a child with a recent ear infection presents with abnormal urine coloration, headache, and swelling around the eyes, despite past fever, the nurse should suspect:

  • Acute Glomerulonephritis based on symptom interrelation and clinical history.

Prioritization of Assessments in Nephrotic Syndrome

When assessing a hospitalized child diagnosed with nephrotic syndrome, a critical set of assessments to evaluate for hypoalbuminemia includes:

  • Heart and lung sounds to identify changes.

References

  1. Althoff, A., Holman, H. C., Henry, N. J., Phillips, B. C., Johnson, J., Roland, P., Wheless, L., Grace, L., Gearhart, M., Cawley, M. E., & Davis, S. (2023). RN Pediatric Nursing (12.0). Assessment Technologies Institute.

  2. Hockenberry, M., & Wilson, D. (2013). Wong's Essentials of Pediatric Nursing (9th ed.). St. Louis, MO: Elsevier Mosby.

  3. Ricci, S.S., Kyle, T. & Carman, S. (2021). Maternity and Pediatric Nursing. 4th Ed. Wolters Kluwer Publishing.