Peds 39 Study Notes on Pediatric Genitourinary Disorders

Chapter 39: The Child With a Genitourinary Disorder

Growth and Development of Genitourinary System #1

  • Anatomy:

    • Comprised of the following components:

    • Kidneys

    • Ureters

    • Urinary Bladder

    • Urethra

  • Functions:

    • Excretes excess water and waste products

    • Maintains balance of electrolytes and acid-base

    • Regulates blood pressure by producing the enzyme renin

    • Produces erythropoietin, a hormone that stimulates the production of red blood cells (RBCs).

Growth and Development of Genitourinary System #2

  • Infants and Children:

    • Emptying the bladder of urine is a reflex action.

    • Between ages 2 and 3, children learn to hold urine and urinate voluntarily.

    • Bladder capacity increases with age.

    • Female urethra is shorter than male urethra, resulting in a higher risk for urinary tract infections (UTIs).

    • Kidneys are located lower in the abdomen compared to adults and have less fat cushion which increases the risk of trauma to the kidneys.

Growth and Development of Genitourinary System #3

  • Urine Output:

    • Average urine output varies by age, fluid intake, and kidney health.

Growth and Development of Genitourinary System #4

  • Kidney Development:

    • Kidneys reach full size and function by adolescence.

    • The reproductive system matures at puberty, leading to the production of necessary reproductive cells:

    • Males: Testes, scrotum, ducts, glands, penis.

    • Females: Ovaries, fallopian tubes, uterus, vagina, external genitalia.

    • Hormonal changes during puberty enable full development of the reproductive system.

Urinary Tract Infections (UTIs) #1

  • Prevalence:

    • Common in the “diaper age”

    • More frequent in females than males, except during the first 4 months of life.

  • Etiology:

    • Caused by various bacteria, with Escherichia coli from the intestinal tract being the most common.

    • Female urethra is shorter and straighter making it more susceptible to contamination with feces.

    • Inflammation may extend into the bladder, ureters, and kidneys.

Urinary Tract Infections (UTIs) #2

  • Clinical Manifestations:

    • Symptoms include:

    • Fever

    • Irritability

    • Vomiting

    • Foul-smelling urine

    • Poor feeding

    • Weight loss

    • Abdominal pain

    • Urgency and increased frequency of urination.

    • There may be little to no fever present.

    • If toilet-trained, may experience incontinence or bedwetting.

    • Acute pyelonephritis: Abrupt onset with high fever lasting 1 or 2 days.

Urinary Tract Infections (UTIs) #3

  • Diagnosis:

    • “Clean catch” urine specimen for microscopic examination and possibly culture; for some cases, a sterile specimen may be required.

  • Treatment:

    • Simple UTI managed with anti-infective agents for 7 to 14 days.

    • Acute pyelonephritis may require hospitalization and intravenous (IV) antibiotics; fluids encouraged.

    • Importance of completing the full course of antibiotics.

    • Renal and bladder ultrasound conducted to check for possible structural defects in cases of recurrent infections.

Question #1

  • Is the following statement true or false?

    • UTIs are more commonly seen in adolescent males than in females.

Answer to Question #1

  • False

    • UTIs are more commonly seen in adolescent females than in males.

    • The female urethra is shorter and straighter, allowing for easier contamination with feces leading to infections by E. coli, which is found in the colon.

    • Males are more commonly infected during the first four months of life, particularly if not circumcised.

Enuresis #1

  • Definition:

    • Continued incontinence of urine beyond the age when control of urination is commonly acquired.

    • Diurnal enuresis: loss of daytime control.

    • Nocturnal enuresis: loss of nighttime control, commonly referred to as bedwetting.

    • It is normal for many children to not acquire complete nighttime control until the ages of 5 to 7 years; occasional bedwetting may be present until ages 9 or 10, particularly more in boys.

    • Enuresis may persist into adulthood.

Enuresis #2

  • Causes:

    • Can be physiologic or psychological in nature:

    • Physiologic Causes: Physical disorders such as diabetes mellitus, sickle cell anemia; small bladder capacity; urinary tract infection (UTI); constipation; lack of awareness/signals to empty bladder due to deep sleep.

    • Psychological Causes: Experiences such as rigorous toilet training before the child was ready, expressing resentment towards family, desire to regress to an earlier developmental stage, and emotional stress.

    • May be a possible sign of sexual abuse.

Enuresis #3

  • Clinical Approach:

    • If a physiologic cause is ruled out, efforts should focus on discovering psychological causes.

  • Family Support: Suggestions for families to help the child achieve control include:

    • Waking the child during the night to go to the toilet.

    • Limiting fluid intake before bedtime.

    • Use of an enuresis alarm.

    • Healthcare professionals should maintain a supportive and understanding attitude towards the concerns of the family and the child.

Acute Poststreptococcal Glomerulonephritis #1

  • Condition Overview:

    • An inflammatory reaction to a specific bacterium known as group A beta-hemolytic streptococcus.

    • An antigen-antibody reaction occurs causing injury to and blockage of the glomeruli, which permits RBCs and proteins to escape into the urine.

    • Peak incidence occurs between ages 5 to 12 years, twice as often in boys compared to girls.

    • The condition resembles nephrotic syndrome.

    • Prognosis is generally excellent, though it can progress to chronic nephritis.

Acute Poststreptococcal Glomerulonephritis #2

  • Clinical Manifestations:

    • Presenting symptoms usually appear 1 to 3 weeks after the onset of streptococcal infection:

    • Grossly bloody urine, which may appear smoky, tea or cola colored; possibility of edema.

    • Hypertension occurs in 50% to 90% of affected individuals.

    • Fever range from 103°F to 104°F (39.4°C to 40°C) at onset, reducing to approximately 100°F (37.8°C).

    • Other symptoms may include slight headache, lethargy, vomiting, oliguria, hematuria, and proteinuria on urinalysis; elevated BUN, serum creatinine level, or ESR.

    • Severe headache, drowsiness, seizures, and vomiting may accompany hypertension.

Acute Poststreptococcal Glomerulonephritis #3

  • Treatment Guidelines:

    • Limit activities until clinical symptoms subside.

    • Antibiotics may be prescribed; antihypertensives or diuretics may be utilized as needed.

    • Dietary restrictions are generally minimal, though extra salt intake may be limited.

    • Symptoms and complications are treated symptomatically.

  • Nursing Care:

    • Bed rest and contact precautions are critical.

    • Monitor the child’s activity level to prevent fatigue.

    • Track intake and output; implement restrictions when output is low.

    • Measure blood pressure and perform urine dipstick tests for protein and blood.

    • If the condition persists for longer than a year, it may indicate a chronic condition.

Nephrotic Syndrome #1

  • Overview:

    • Nephrotic syndrome is not a single condition but encompasses various types of nephrosis.

    • Idiopathic nephrotic syndrome (minimal change nephrotic syndrome [MCNS]) is the most common in children.

    • Early characteristics include edema and proteinuria; the onset of MCNS is insidious with a course of remissions and exacerbations, but the recovery rate is generally good with the cause remaining unknown.

    • Predominantly seen in children under 6 years of age.

Nephrotic Syndrome #2

  • Clinical Manifestations:

    • The initial symptom typically is edema, which starts around the eyes and face in the morning and later shifts to the abdomen, lower extremities, and ankles.

    • Anasarca (generalized edema) may develop, sometimes causing respiratory difficulties with edema shifting positions.

    • Other symptoms may include loss of appetite, fatigue, irritability, and malnutrition.

    • Children affected by nephrotic syndrome are susceptible to infections, with repeat acute respiratory conditions commonly occurring.

Nephrotic Syndrome #3

  • Diagnosis:

    • Laboratory findings show marked proteinuria in urine samples; hematuria is usually absent.

    • Blood tests will typically reveal hyperlipidemia and low levels of serum protein and albumin.

  • Treatment:

    • The management involves a prolonged period of remissions and recurrences, including corticosteroid therapy, daily urine testing, and potentially immunosuppressant therapy.

    • Dietary strategies should be appealing to the child; low salt/high protein content is encouraged, along with support and encouragement from family.

    • Changes in treatment may be necessary if the initial regime is ineffective or complications occur.

Comparison #1: Nephrotic Syndrome vs. Poststreptococcal Glomerulonephritis

  • Assessment Factors:

    • Cause:

    • Nephrotic Syndrome: Idiopathic; possibly hypersensitivity reaction.

    • Poststreptococcal Glomerulonephritis: Immune reaction to group A beta-hemolytic streptococcal infection.

    • Onset:

    • Nephrotic Syndrome: Insidious.

    • Poststreptococcal Glomerulonephritis: Abrupt.

    • Urine Findings:

    • Nephrotic Syndrome: Proteinuria with mild hematuria.

    • Poststreptococcal Glomerulonephritis: Grossly bloody urine.

    • Edema:

    • Nephrotic Syndrome: Marked edema.

    • Poststreptococcal Glomerulonephritis: Mild.

    • Hypertension:

    • Nephrotic Syndrome: Rare to mild.

    • Poststreptococcal Glomerulonephritis: Marked.

    • Hyperlipidemia:

    • Nephrotic Syndrome: Extreme.

    • Poststreptococcal Glomerulonephritis: Rare.

Comparison #2: Additional Assessments

  • Peak Age Frequency:

    • Nephrotic Syndrome: 2-3 years.

    • Poststreptococcal Glomerulonephritis: 5-12 years.

  • Interventions:

    • Nephrotic Syndrome: Bed rest during edema phase; corticosteroids; immunosuppressants if needed.

    • Poststreptococcal Glomerulonephritis: Limited activity; antihypertensives as required; symptomatic therapy.

  • Diet:

    • Nephrotic Syndrome: High protein, low sodium.

    • Poststreptococcal Glomerulonephritis: Normal for age; reduced salt intake if hypertensive.

  • Prevention:

    • Nephrotic Syndrome: None known.

    • Poststreptococcal Glomerulonephritis: Treatment of group A beta-hemolytic streptococcal infections.

Question #2

  • Is the following statement true or false?

    • A presenting symptom for acute poststreptococcal glomerulonephritis is edema that moves depending on the position of the client.

Answer to Question #2

  • False

    • Edema that shifts with position is typically associated with nephrotic syndrome.

    • Nephrotic syndrome often presents with edema around the eyes and face on waking, which then progresses to other areas of the body as the child changes position.

Wilms Tumor (Nephroblastoma)

  • Overview:

    • Most common renal malignancy in children and one of the most common abdominal tumors in early childhood.

    • Arises from remnant embryonic tissue that persists after birth.

    • Often has no symptoms other than an abdominal mass or swelling.

    • Upon diagnosis, clinicians must post signs to avoid abdominal palpation.

    • Treatment:

    • Surgical removal of the tumor and affected kidney as soon as possible, followed by radiation and chemotherapy.

    • Prognosis:

    • Dependent on the stage and extent of the disease.

Hydrocele

  • Description:

    • Collection of peritoneal fluid that occupies the scrotum through a small, fingerlike projection in the inguinal canal, facilitating the descent of the testes.

    • The processus requires closure shortly after birth, and if it fails to close, peritoneal fluid can accumulate, resulting in hydrocele.

    • If hydrocele persists by the end of the first year, corrective surgery is performed.

Cryptorchidism

  • Definition:

    • Refers to the condition where one or both testes do not descend into the scrotum shortly before or after birth.

    • The testes are typically normal in size, but the exact cause remains unclear.

    • If both testes remain undescended, it can lead to:

    • Sterility

    • Increased risk for testicular cancer.

    • Surgical correction known as orchidopexy is often performed when the child is 1 to 2 years old.

    • Prognosis is generally good.

Menstrual Disorders #1

  • Menarche:

    • Refers to the beginning of menstruation, typically occurring between ages 9 and 16.

    • Irregular menstruation is common during the first year.

  • Mittelschmerz:

    • Described as dull, aching abdominal pain during ovulation, typically alleviated by analgesics, heating pads, or warm baths.

    • Each individual may experience this differently.

Menstrual Disorders #2

  • Premenstrual Syndrome (PMS):

    • Symptoms include:

    • Edema

    • Headache

    • Increased anxiety

    • Mild depression

    • Mood swings

    • The exact cause remains unknown, but it may be linked to hormonal changes.

    • Symptoms are often mild and may be alleviated by lifestyle changes.

    • Treatment Options:

    • Dietary supplements

    • Vitamins

    • Herbal preparations

    • Mild analgesics

    • Application of local heat

    • Mild diuretics

    • Oral contraceptive pills.

Menstrual Disorders #3

  • Dysmenorrhea:

    • Classified as:

    • Primary Dysmenorrhea: Part of the normal menstrual cycle without associated pelvic disease.

    • Secondary Dysmenorrhea: Resulting from pelvic pathologic changes, such as pelvic inflammatory disease (PID), fibroids, or endometriosis.

    • Symptoms:

    • Cramping abdominal pain

    • Leg pain

    • Backache

    • Treatment varies depending on the cause; NSAIDs are effective for primary dysmenorrhea.

Menstrual Disorders #4

  • Amenorrhea:

    • Primary Amenorrhea: Refers to a lack of menstruation after age 16; requires diagnostic evaluation for genetic or other abnormalities.

    • Secondary Amenorrhea: Defined as missing 3 or more periods after menarche; can result from discontinuation of contraceptives, pregnancy, physical or emotional stressors, or underlying medical conditions.

    • A complete physical examination is necessary to ascertain cause.

Vaginitis

  • Causes:

    • Associated with various factors including prolonged use of diaphragms or tampons, irritating douches or sprays, hormonal changes from birth control pills, and antibiotic treatment; these can increase the risk for infectious organisms.

  • Common Pathogens:

    • Candida albicans

    • Gardnerella vaginalis

    • Trichomonas, which is a sexually transmitted infection (STI).

Question #3

  • What is a recognized symptom of premenstrual syndrome?

    • a. Intense itching

    • b. Severe abdominal pain

    • c. Weight loss

    • d. Increased anxiety

Answer to Question #3

  • d. Increased anxiety

    • Rationale: Symptoms of premenstrual syndrome include edema leading to weight gain, headaches, increased anxiety, mild depression, and mood swings.