Chapter 39: The Child With a Genitourinary Disorder

Chapter 39: The Child With a Genitourinary Disorder

G & D (Growth & Development) of the Genitourinary System

• Urinary System

  • Emptying the bladder of urine occurs as a reflex action.

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

  • Bladder capacity increases with age.

  • Notable anatomical differences:

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

  • Kidneys are located lower in children compared to adults, with less fat cushion around them, increasing the risk of trauma.

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

  • Kidneys reach full size and functionality by adolescence.

• Reproductive System

  • The reproductive portion matures at puberty, where children produce cells necessary for reproduction.

  • Males: includes testes, scrotum, ducts, glands, and penis.

  • Females: includes ovaries, fallopian tubes, uterus, vagina, and external genitalia.

  • Hormonal changes during puberty contribute to the development of the reproductive system during adolescence.

Urinary Tract Infections (UTIs)

• UTIs are fairly common in the “diaper age,” more prevalent in females than males, except during the first 4 months of life.

• The infections are caused by various bacteria, with Escherichia coli from the intestinal tract being the most common.

• Due to the shorter and straighter female urethra, it is more easily contaminated with feces.

Clinical Manifestations

• Common Symptoms:

  • Fever

  • Irritability

  • Vomiting

  • Foul-smelling urine

  • Poor feeding

  • Weight loss

  • Abdominal pain

  • Urgency

  • Increased urination

  • Occasionally little or no fever

  • In those who are toilet-trained: incontinence or bedwetting (enuresis).

  • Acute Pyelonephritis: abrupt onset with high fever for 1 or 2 days.

Diagnosis

• A “clean catch” urine specimen is utilized for testing, often requiring microscopic examination and possibly a culture. In some cases, a sterile specimen is mandatory.

Treatment

• For Simple UTI:

  • Anti-infective treatment for 7 to 14 days.

• For Acute Pyelonephritis:

  • Hospitalization is required, IV antibiotics administered, encourage fluid intake.

  • It is crucial to complete the entire course of antibiotics.

• Renal and bladder ultrasound may be needed to assess potential structural defects if infections recur.

Enuresis (Urinary Incontinence)

• Defined as the continued incontinence of urine beyond the age when control of urination is commonly expected.

• Types of Enuresis:

  • Diurnal: loss of control during the day.

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

• Many children do not achieve complete nighttime control until the ages of 5 to 7; occasional bedwetting may persist until ages 9 or 10, with boys typically experiencing more difficulty.

• Enuresis may sometimes indicate sexual abuse.

Guidance for Families

• Recommendations for families interested in aiding their child in achieving urination control:

  • Wake the child during the night to encourage toilet use.

  • Limit fluid intake before bedtime.

  • Utilize an enuresis alarm.

  • Healthcare professionals should maintain a supportive and understanding mindset toward concerns from families and children.

Physiological Factors

• Possible physiological causes for enuresis include:

  • Physical disorders such as diabetes mellitus or sickle cell anemia.

  • Small bladder capacity.

  • Urinary tract infections.

  • Constipation.

  • Lack of awareness or the inability to signal bladder fullness due to deep sleep.

Psychological Factors

• Potential psychological contributors include:

  • Rigid toilet training prior to readiness.

  • Resentment towards family.

  • Desire to revert to an earlier developmental stage.

  • Emotional stress.

Acute Poststreptococcal Glomerulonephritis (AGN)

• An inflammatory reaction to group A beta-hemolytic streptococcus.

• The antigen-antibody reaction leads to a response that injures and blocks the glomeruli, permitting red blood cells (RBCs) and protein to escape into urine.

• Peak incidence occurs between the ages of 5 to 12, more frequently in boys.

• Similar presentation to nephrotic syndrome, with an excellent prognosis; however, it can progress to chronic nephritis.

Clinical Manifestations

• Symptoms emerge 1 to 3 weeks following a streptococcal infection, which may include:

  • Grossly bloody urine, described as smoky, tea, or cola-colored.

  • Edema.

  • Hypertension, with fever commonly ranging from 103°F to 104°F at onset and decreasing to about 100°F.

  • Possible symptoms include a slight headache, lethargy, vomiting.

  • Urinalysis often shows oliguria, hematuria, and proteinuria; blood urea nitrogen (BUN), serum creatinine levels, and erythrocyte sedimentation rate (ESR) may be elevated.

  • Headaches, drowsiness, seizures, and vomiting can accompany hypertension.

Treatment

• Activity restriction until clinical manifestations resolve.

• Possible administration of antibiotics, antihypertensives, or diuretics as needed.

• Dietary restrictions are generally minimal, although reducing salt intake may be advised.

• Treatment for complications is typically symptomatic.

Nursing Care

• Bed rest is crucial.

• Upon leaving bed, children should avoid fatigue.

• Monitor input and output (I&O), with intake restrictions based on output.

• Blood pressure monitoring should occur regularly.

• For conditions persisting beyond one year, monitor for chronic conditions.

Nephrotic Syndrome

• Several variants of nephrosis are identified as syndromes, with Minimal Change Nephrotic Syndrome (MCNS) being most common among children.

• Early characteristics of MCNS include edema and proteinuria.

• The onset of MCNS is insidious, characterized by remissions and exacerbations; recovery rates are generally favorable, though the cause is unknown.

Clinical Manifestations

• Initial symptoms typically present as edema around the eyes and face in the morning, later shifting to the abdomen, lower extremities, and ankles.

• Anasarca may develop, leading to respiratory difficulty, with edema shifting when the child changes position.

• Accompanying signs may include frothy urine, lack of appetite, fatigue, irritability, and malnutrition.

• Recurring acute respiratory infections are common due to heightened susceptibility.

Diagnosis

• Laboratory findings may reveal:

  • Marked proteinuria in urine samples (hematuria is usually absent).

  • In blood samples, notable findings may include hyperlipidemia and low serum protein and albumin levels.

Treatment

• Treatment involves a long process of managing remissions and recurrences, including:

  • Corticosteroid therapy, daily urine monitoring, and administration of loop diuretics or immunosuppressant therapy may be necessary.

  • A diet appealing to children, typically low in salt and high in protein, is encouraged along with ongoing support.

Comparison of AGN and Nephrotic Syndrome

Wilms Tumor (Nephroblastoma)

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

• Arises from remnants of embryonic tissue that remain postnatally.

• Early detection may yield no obvious symptoms other than an abdominal mass or swelling.

• Upon diagnosis, signs should be posted to avoid abdominal palpation.

Treatment and Prognosis

• Treatment options include the surgical removal of the tumor and the affected kidney as soon as possible, with potential adjuncts like radiation and chemotherapy.

• Prognostic outcomes depend on the stage and extent of the tumors at the time of diagnosis.

Reproductive System Disorders

• Cryptorchidism: Undescended testes characterized by an inability to palpate testes within the scrotum. Surgery is typically performed at ages 6 and 24 months.

• Varicocele: Elongation, dilation, and tortuosity of the veins of the spermatic cord superior to the testicle. Some males may experience discomfort; varicocelectomy is a potential treatment.

• Hydrocele: Accumulation of peritoneal fluid in the scrotum causing painless swelling and enlarged scrotal sac. In many cases, it resolves spontaneously, though surgical repair may be necessary if resolution does not occur within 1 year.

Menstrual Disorders in Females

• Menarche: Beginning of menstruation typically occurring between ages 9 and 16. Irregular menstruation is common during the first year after menarche.

  • Premenstrual Syndrome (PMS): Symptoms include edema, headache, anxiety, mild depression, mood swings. The exact cause is not known but may be related to hormonal changes. Relief is often achieved through lifestyle adjustments or treatments like dietary supplements, vitamins, herbal preparations, and mild analgesics.

  • Dysmenorrhea: Painful menstruation classified as primary (normal cycle) or secondary (associated with pelvic disease) presenting with cramping abdominal pain, leg pain, and backache, with treatment depending on the cause, often using NSAIDs for primary dysmenorrhea.

  • Amenorrhea: The absence of menstruation; primary (absence of previous menstruation) requires evaluation for genetic abnormalities, tumors, or other issues if not experienced by age 16. Secondary amenorrhea can occur due to missing three or more periods after menarche, often related to lifestyle factors or underlying conditions necessitating a comprehensive physical examination for diagnosis.