340 GU

Altered Genitourinary Function in Children

Development of the Genitourinary System in Infants

  • Nephron Development

    • Nephrons are immature and less efficient in newborns.

    • Glomerular filtration and absorption rates are low due to immature kidneys.

    • Newborns have decreased ability to concentrate urine and reabsorb amino acids.

    • The Loop of Henle is shorter in infants:

    • Reduces the ability to reabsorb sodium and water, causing very dilute urine during the first 3 months of life.

    • Reduced hydrogen ion excretion, lower acid secretion, and low plasma bicarbonate levels make them more vulnerable to acidosis.

Urinary Function in Newborns

  • Bladder Development

    • The newborn bladder functions as an abdominal organ up to about 3-4 months of age.

    • Infants cannot effectively concentrate urine until approximately 1-3 months of age.

  • Sodium Regulation

    • Newborn kidneys are less adaptable to sodium deficiencies and excesses:

    • Vulnerable to fluid volume overload with isotonic saline infusion.

    • Susceptible to sodium deficits from vomiting and diarrhea.

Clinical Signs and Symptoms

Newborns

  • Poor feeding

  • Respiratory distress

  • Poor urinary stream

  • Jaundice

  • Seizures

  • Dehydration

  • Vomiting

Infants

  • Poor feeding

  • Pallor

  • Fever

  • Failure to gain weight

  • Persistent diaper rash

  • Seizures

  • Dehydration

  • Vomiting

Children

  • Frequent urination

  • Painful urination

  • Enlarged kidney or bladder

  • Excessive thirst

  • Foul-smelling urine

  • Poor appetite

  • Pallor

  • Fatigue

  • Enuresis

  • Edema

  • Hematuria

  • Abdominal or back pain

  • Hypertension

  • Tetany

  • Growth failure

Assessment and Measurement Techniques

  • Accurate Measurements

    • Record weight, input & output (I & O), and blood pressure (B/P).

    • Prepare child and parents for tests and collection of specimens.

  • Specific Measurement Techniques:

    • Count diapers.

    • Weigh diapers before and after use.

    • Daily weight of the child.

    • Insertion of a Foley catheter requires careful preparation.

Urine Characteristics in Infants

  • Normal Appearance: Clear

  • Specific Gravity (Sp. Gr.): 1.010-1.030

  • pH range: 4.5-8.0

  • Chemical Composition:

    • Glucose: Negative

    • Protein: Negative

    • Ketones: Negative

    • RBCs: <1-2

    • WBCs: <1-2

    • Nitrite: Negative

  • Normal Volume: 1-2 ml/kg/hr

Diagnostic Procedures

  • Urinary Procedures:

    • Urine Culture & Sensitivity

    • Intravenous Pyelography (IVP)

    • Voiding Cystoureterography (VCUG)

    • Renal Ultrasound

    • Kidney, Ureters, and Bladder (KUB) imaging

    • Cystoscopy

    • Renal Biopsy

Health and Family History Assessment

  • Health History:

    • Focus on renal disease, hypertension, and other renal dysfunctions.

  • Physical Assessment:

    • Abnormal respiratory rate and depth.

    • Hypertension indicators.

    • Presence of fever.

    • Signs of growth retardation.

    • Circulatory congestion signs include:

    • Abdominal distention.

    • Early signs of uremic encephalopathy (changes in consciousness).

    • Check for congenital abnormalities such as:

    • Hypospadias or Epispadias.

    • Ear abnormalities.

Congenital Anomalies in the Genitourinary System

Hypospadias

  • Definition: Urethral opening located on the ventral surface of the penis.

  • Incidence: Unknown, with a wide range of severity.

  • Association: May indicate ambiguous genitalia.

Epispadias

  • Definition: Dorsal placement of urethral opening.

  • Clinical Features:

    • Increased risk of urinary tract infections.

    • Potential interference with procreation.

    • Body image disturbance issues.

Surgical Considerations for Hypospadias

  • Surgical Repair: Typically performed in stages with goals to:

    • Enable child to void in a standing position.

    • Improve physical appearance of the genitalia.

    • Preserve a functionally adequate sex organ.

  • Ideal Timing for Surgery: 6-18 months of age is considered optimal.

  • Rationale: Early intervention enhances results for functionality and aesthetics.

Post-operative Care

  • Post operative Management Includes:

    • Examine every newborn male carefully for signs of abnormalities.

    • Delay circumcision if there is any question.

    • Psychological preparation of parents and child before the procedure.

  • Care Instructions:

    • Use pressure dressing; frequently check the tip of the penis without changing dressing.

    • Catheter/stent care.

    • Employ double diapering technique to manage drainage.

    • Detailed instructions on home care.

Cryptorchidism (Undescended Testes)

  • Definition: Condition where one or both testicles fail to descend into the scrotum, often associated with hypospadias.

  • Types of Cryptorchidism:

    • Undescended: Testes are somewhere along the normal pathway of descent.

    • Ectopic: Testes are positioned outside the normal pathway.

    • Retractile: Testes can be manipulated back into the scrotum.

    • Absent: Testes are non-existent.

Management of Cryptorchidism

  • Diagnosis: Ultrasound or surgical exploration to locate testes.

  • Recommendation: AAP suggests treatment prior to age 1.

  • Medications: Administration of HCG has a 20% success rate for testicular descent.

  • Surgical treatment: Orchiopexy between 6-24 months recommended.

  • Health Education: Educate parents about increased risk of testicular cancer in later decades (ages 30-40).

Urinary Tract Obstruction

  • Definition: An obstruction at any level of the upper or lower urinary tract that leads to the dilation of the affected kidney (Hydronephrosis).

  • Clinical Presentation:

    • Recurrent urinary tract infections (UTIs).

    • Incontinence.

    • Fever.

    • Flank or abdominal pain.

    • Foul-smelling urine.

    • Hematuria.

    • Dysuria.

    • Polyuria, polydipsia, urgency.

    • Anemia.

    • Failure to thrive.

    • Nocturnal enuresis.

Management Strategies

  • Perform surgical correction if indicated.

  • Monitor blood pressure regularly.

  • Prepare parents and children for procedures.

  • Observe closely for post-operative complications.

  • Provide education on caring for catheters and managing the child's condition at home.

Vesicoureteral Reflux (VUR)

  • Description: Condition where urine regurgitates from the bladder into the ureters and kidneys.

  • Grading: VUR severity can be graded from 1-5.

  • Complications: Can result in hypertension, renal insufficiency, or renal failure if untreated.

  • Types of reflux:

    • Primary Reflux: Resulting from an incompetent valvular mechanism at the ureterovesicular junction; may be familial and usually outgrown.

    • Secondary Reflux: Resulting from an acquired condition such as UTI.

Assessment Findings

  • Recurrent UTIs are common in females.

  • A single episode of UTI is notable in males.

  • Family history of VUR increases risk.

  • Risks include kidney scarring and chronic kidney disease.

Diagnostic Procedures

  • Voiding Cystourethrogram (VCUG)

    • Goal: Protect kidneys from scarring.

  • Medical Management:

    • Administer antibiotics until reflux resolves.

  • Surgical Intervention: Necessary when antibiotics fail or when reflux is severe; procedure involves reimplantation of ureters.

Preventive Measures

  • Promote compliance with antibiotic therapy.

  • Instruct child on complete bladder emptying.

  • Educate on proper hygiene habits.

  • Screen for siblings for potential anomalies.

  • Age-appropriate preparation for diagnostic procedures.

Hernias in Children

  • Hernia Definition: Protrusion of a portion of an organ through an abnormal opening.

  • Risks: Dangerous if protrusion is constricted, circulation is impaired, or interferes with function/development of other structures.

  • Common Herniation Areas:

    • Diaphragmatic

    • Abdominal wall

    • Inguinal canal

Congenital Diaphragmatic Hernia

  • Description: Opening between thorax and abdominal cavity due to incomplete fetal development.

  • Effects: Abdominal contents can compress lungs and affect fetal lung development.

Signs and Symptoms

  • Can be detected in utero or present as:

    • Respiratory distress

    • Cyanosis

    • Scaphoid abdomen

    • Impaired cardiac output.

  • Immediate Medical Needs:

    • Intubation

    • GI decompression

    • IV fluid administration

    • Potential surgery required.

Umbilical Hernia

  • Description: Caused by incomplete fusion of the umbilical ring where vessels exit the abdominal wall.

  • Demographics: Most common in low birth weight and premature infants.

  • Geographic Variation: More prevalent in African Americans compared to Caucasians.

  • Size: Variable; most resolve within 3-5 years without treatment, although surgery may be needed.

Inguinal Hernia

  • Pathophysiology: The processus vaginalis persists, allowing abdominal contents to be pushed through the opening.

  • Incidence: 80% of childhood hernias are inguinal.

  • Management: Surgical correction is typically indicated, especially if symptomatic.

Urinary Tract Infections (UTIs)

  • Classifications:

    • Urethritis: Infection of the urethra.

    • Cystitis: Infection of the bladder.

    • Pyelonephritis: Infection involving the kidneys.

Etiology and Risk Factors

  • Causative Agent: E. Coli responsible for 80% of UTIs in females.

  • Demographics: Uncircumcised infant males have higher UTI rates. By age 12 months, UTIs are 10-30 times more common in females.-

  • Other Risk Factors:

    • Constipation

    • Use of bubble baths

    • Presence of pinworms

    • Dysfunctional voiding, urinary stasis

    • Decreased fluid intake

    • Vesicoureteral reflux (VUR)

    • Urologic abnormalities

    • Indwelling catheterization

    • Neurogenic bladder

    • Sexual abuse or intercourse

Clinical Manifestations

Infants

  • Fever

  • Weight loss

  • Failure to thrive (FTT)

  • Vomiting

  • Diarrhea

Children

  • Dysuria

  • Increased frequency and urgency

  • Incontinence

  • Foul-smelling urine

  • Possible hematuria

  • Abdominal pain

  • Fever

Diagnosis

  • Urine Screening:

    • Detection of nitrites, RBCs, WBCs in urine.

  • Urine Culture: > 100,000 colonies of a single bacteria confirms UTI.

Therapeutic Management Goals

  1. Cure the infection.

  2. Identify predisposing factors.

  3. Prevent recurrent infections.

Management Strategies

  • Ensure accurate specimen collection and handling.

  • Administer antibiotics effectively.

  • Encourage fluid intake.

  • Promote comfort measures for the child.

  • Schedule adequate follow-up cultures.

  • Educate preventive strategies for future UTIs.

Involuntary Urination (Enuresis)

  • Definition: Involuntary passage of urine by a child older than 5 years, beyond the age when voluntary control should have been established.

  • Types:

    • Primary Enuresis: Familial tendency, decreased bladder capacity, developmental or maturational lag.

    • Secondary Enuresis: Result of psychological factors, UTI, diabetes.

Management Strategies

  • Conduct a thorough history and physical examination.

  • Collect urine samples for diagnostic purposes.

  • Wait for maturation since most children outgrow by age 10.

  • Implement retention/control exercises.

  • Possible drug therapy options include:

    • Oxybutynin (Ditropan)

    • Imipramine (may have neurologic side effects)

    • DDAVP (nasal spray or tablet).

  • Utilize moisture alarms and behavior modification techniques, emphasizing positive reinforcement.

Hemolytic Uremic Syndrome (HUS)

  • Definition: Combination of hemolytic anemia and thrombocytopenia occurring with acute renal failure, primarily in children aged 6 months to 5 years.

  • Progression: Typically begins with watery diarrhea, leading to hemorrhagic colitis, hemolytic anemia, and thrombocytopenia.

Etiology

  • Causes include bacterial toxins (mostly verotoxin-producing strains of E. coli), chemicals, viruses, and can be idiopathic.

  • Consumption of raw foods, undercooked meats, unpasteurized products, or contaminated drinking water can be contributing factors.

Pathophysiology

  • Microthrombi form in glomerular arterioles occluding the capillary loops, leading to glomerulosclerosis and eventual renal failure.

  • Red blood cells (RBCs) and platelets sustain damage as they navigate through partially obstructed vasculature.

Signs and Symptoms

  • Common symptoms:

    • Vomiting

    • Marked pallor

    • Oliguria or anuria

    • Edema

    • Fatigue

    • Elevated blood pressure (hypertension)

    • Abdominal pain and tenderness

    • Neurological changes including irritability, altered level of consciousness, seizures, or coma.

Laboratory Findings

  • Urinalysis: Positive for blood, protein, pus, and casts.

  • Serum: Elevated BUN and creatinine, moderate to severe anemia, thrombocytopenia, leukocytosis with left shift, hyponatremia, hyperkalemia, hyperphosphatemia.

Chronic Renal Failure (CRF)

Definition

  • A gradual, irreversible decline in renal function leading to the accumulation of metabolic toxins alongside fluid and electrolyte imbalances.

Pathophysiology

  • Glomerular damage leads to the retention of waste products, resulting in hyperkalemia, metabolic acidosis, calcium and phosphorus disturbances, anemia, and growth issues.

Early Signs and Symptoms

  • Often subtle; may include:

    • Loss of energy

    • Decreased appetite

    • Hypertension

    • Headaches, muscle cramps, nausea

    • Weight loss or growth retardation

    • Increased or decreased urine output

    • Facial edema and dental defects

    • Sallow skin

    • Bone or joint pain.

Management Strategies

  • Focus on supportive therapy and potential dialysis or transplant options for end-stage renal failure.

  • Dietary recommendations to minimize excretory demands on the kidney and manage calcium/phosphorus levels include:

  • Control hypertension, prevent infections, and manage complications.

Nutritional Considerations in CRF

Dietary Management

  • Minimize protein to avoid excessive nitrogen waste and possible metabolic acidosis; monitor for the need for sodium bicarbonate.

  • Ensure sufficient caloric intake for growth while maintaining adequate protein of high biological value.

  • May require supplements like vitamin D and iron intake for anemia management.

Complications and Care

  • Monitor and manage fluid and electrolyte disturbances, specifically controlling hypertension and promoting proper nutrition. Feelings of disturbance in body image due to growth fluctuations and conditions like anemia must be supported.

Dialysis Considerations

Dialysis Types

  • Peritoneal Dialysis: Utilizes osmosis and diffusion; performed overnight in early stages.

  • Hemodialysis: Requires catheter insertion in the arm to filter blood completely; utilized in late stages.

Renal Replacement Therapies in Children

  • Renal transplant is the preferred long-term solution, offering a more compatible lifestyle post-transplant compared to dialysis, requiring immunosuppression to prevent rejection.