The Child With Genitourinary and Renal Problems

Objectives

Identify the different types of structural disorders affecting the genitourinary tract.
Explain enuresis and the impact it can have on a child.
Describe the various factors that contribute to urinary tract infections in infants and children.
Differentiate glomerulonephritis from nephrotic syndrome.

Nursing Responsibilities

Assessment of kidney and urinary tract system based on:
  - Physical examination
  - History
  - Observation of symptoms
Must be developmentally appropriate.

Normal Characteristics of Urine

Appearance: Clear, pale yellow or deep gold.
Sterility: Sterile at 37 degrees Celsius.
pH Level: Slightly acidic with a median pH of 6.
Urine Production:
- Newborns: 1 to 2 mL/kg/hr.
- Children: 1 mL/kg/hr.
Absent Elements in Normal Urine:
  - Glucose
  - Ketones
  - Protein
  - White blood cells (normal count <1 or 2)
  - Red blood cells (normal count <1 or 2)
  - Casts
  - Nitrites

Diagnostic Studies for GU Tract Disorders

Types of Diagnostic Procedures:
  - Retrograde pyelogram
  - Renal/bladder/testicular ultrasound
  - Renal biopsy
  - Computed tomography (CT scan)
  - Magnetic resonance imaging (MRI)
  - Renal arteriogram
  - Urinalysis
  - Urine culture and sensitivity (C&S)
  - Blood urea nitrogen (BUN)
  - Creatinine
  - Kidneys, ureters, and bladder (KUB) imaging
  - Voiding cystourethrogram (VCUG/VCG)

GU Tract Disorders

**Urinary tract infection (UTI)
Vesicoureteral reflux (VUR)**

Urinary Tract Infection (UTI)

Prevalence: One of the most common conditions in childhood; 10% of children have a febrile UTI in the first 2 years of life.
Risk Factors:
- The most important host factor is urinary stasis.
- Uncircumcised males are at higher risk.
Circumcision Statement:
  - “The health benefits of circumcision in newborn boys outweigh the risks of the procedure. But the American Academy of Pediatrics found the benefits are not great enough to recommend that all newborn boys be circumcised.”
  - Health benefits include prevention of:
    - Urinary tract infections
    - Acquisition of HIV
    - Transmission of some sexually transmitted infections
    - Penile cancer

Classification of UTIs

Types of UTIs:
  - Bacteriuria
  - Asymptomatic bacteriuria
  - Symptomatic bacteriuria
  - Recurrent UTI
  - Persistent UTI
  - Febrile UTI
  - Cystitis
  - Urethritis
  - Pyelonephritis
  - Urosepsis

Etiology and Pathophysiology of UTI

Common Pathogens:
  - Escherichia coli (most common pathogen, 80% of cases)
  - Proteus
  - Pseudomonas
  - Klebsiella
  - Haemophilus
  - Staphylococcus aureus
  - Occasionally, fungal and parasitic pathogens
Anatomic or Physical Causes:
- Short urethra in biological females.
- Uncircumcised biological males.

Clinical Manifestations of UTI in Children

General Symptoms:
  - Incontinence in a toilet-trained child
  - Strong-smelling urine
  - Frequency or urgency.
Symptoms in Infants:
  - Poor feeding
  - Failure to gain weight
  - Frequent urination
  - Screaming/straining during urination
  - Foul-smelling urine
  - Enlarged kidneys or bladder.
Symptoms in Childhood:
  - Poor appetite
  - Incontinence
  - Frequent urination
  - Painful urination
  - Abdominal/back pain
  - Fatigue
  - Pallor.

Urine Collection for UTI

Preferred Methods:
  - Clean-catch specimen is preferred.
  - U-bag for collection from younger children.
  - Urine specimen obtained by catheterization provides more accurate results.
Best Time to Obtain a Urine Sample:
- Urine should be collected when signs of infection are present.

Goals of Treatment for UTI

Treatment Objectives:
  - Eliminate the current infection.
  - Identify contributing factors to reduce risk of recurrence.
  - Prevent systemic infection.
  - Preserve renal function.

Prevention of UTI

Hygiene Practices:
  - Practice perineal hygiene—wiping front to back.
  - Avoid tight clothing or diapers; wear cotton panties.
  - Check for vaginitis.
  - Avoid “holding” urine.
  - Encourage complete bladder emptying with each void.
  - Avoid straining during defecation and prevent constipation.
  - Encourage adequate fluid intake.

Vesicoureteral Reflux (VUR)

Condition:
- Abnormal retrograde flow of bladder urine into the ureters, potentially leading to recurring kidney infections (pyelonephritis).

Therapeutic Management of VUR

Management Strategies:
  - Prevent bacteria from reaching the kidneys.
  - Low-dose antibiotic therapy may be utilized.
  - Urine cultures are not routinely performed unless fever or other symptoms are present.
  - Prognosis: Most children outgrow VUR; severe cases may necessitate surgical intervention.

Voiding Cystourethrogram (VCUG)

Definition:
- Technique to observe the ureters and bladder during voiding to diagnose VUR.

Enuresis

Definition:
- Inability to control bladder function after an age where control of voiding is expected.
Types of Enuresis:
- Primary: Never been free from bedwetting.
- Secondary: Started bedwetting after previously having urinary control.
Risk Factors:
  - Family history.
  - Disorders associated with bladder dysfunction.
  - Biologically male.
  - Emotional factors.

Medication Treatment for Enuresis

Medications Utilized:
  - Oxybutynin chloride (Ditropan):
    - Class: Anticholinergics; reduces bladder contractions.
  - Desmopressin acetate (DDAVP):
    - Class: Antidiuretic hormone; reduces the volume of urine produced.

Other Treatments for Enuresis

Treatment Protocols:
  - Encourage child to void before bed.
  - Fluid intake during the day, but none after 1600 hrs.
  - Avoid caffeine/carbonated drinks after 1600 hrs.
  - Purposeful waking of the child to void during the night.
  - Use positive reinforcement techniques; avoid punishment.
  - Complementary and alternative medicine (CAM) therapy such as hypnotherapy.
  - Bedwetting alarms to assist in training.
  - Avoid constipation.

Common Disorders of the Genitourinary (GU) Tract

Conditions include:
  - Phimosis
  - Cryptorchidism
  - Inguinal hernia
  - Hydrocele
  - Hypospadias
  - Epispadias
  - Chordee
  - Bladder exstrophy
  - Testicular torsion
  - Ambiguous genitalia

Phimosis

Definition:
- Inability to retract the foreskin.

Cryptorchidism

Definition:
- Failure of one or both testes to descend normally through the inguinal canal.
Natural History:
- Most children will have spontaneous descent of their testes within the first year of life.
Risks:
- Decreased sperm production in undescended testes.
- Increased risk of malignancy in adulthood.
Treatment Options:
- Surgical correction (Orchidopexy).
- Older children may receive administration of human chorionic gonadotropin.

Inguinal Hernia

Definition:
- Protrusion of abdominal contents through the inguinal canal into the scrotum.
Clinical Presentation:
- Painless inguinal swelling.
Treatment:
- May resolve spontaneously.
- Surgical closure if not closed by 1 year of age.

Hydrocele

Definition:
- Collection of fluid in the scrotum.
Symptoms:
- Enlarged scrotum and/or pain.
Treatment Options:
- May resolve spontaneously.
- Surgical repair if fluid persists after 1 year.

Hypospadias

Definition:
- Urethral opening located behind the glans penis or anywhere along the ventral surface of the penile shaft.
Treatment Protocols:
  - Male circumcision is not performed prior to surgical correction.
  - Surgery recommended during the first year of life.
  - Goal of surgery: to restore normal urinary and sexual function and improve the appearance of the penis.

Hypospadias Surgery Images

Before and After Visuals:
- ADAM (Figure not included in the original transcript).

Epispadias

Definition:
- Meatal opening located on the dorsal surface.
Characteristics Based on Biological Sex:
  - Biologically Female:
    - Wide urethra
    - Bifid clitoris
    - Possible exstrophy of the bladder
  - Biologically Male:
    - Widened pubic symphysis
    - Broad, spade-like penis
    - Possible exstrophy of the bladder.
Treatment:
- Surgery indicated for males.

Chordee

Definition:
- Ventral curvature of the penis.
Association:
- Often linked with hypospadias.
Treatments:
- Surgical release of the fibrous band causing the deformity.

Bladder Exstrophy

Definition:
- Eversion of the posterior bladder through the anterior bladder wall and lower abdominal wall.
Possible Associations:
- May occur with genital anomalies or anal defects.
Nursing Care Required:
- Cover with a sterile, non-adherent dressing.
Treatment:
- Immediate surgical intervention is required.

Case Study Example

Case of Mike, 12 years old:
  - Symptoms: Discomfort, embarrassment during assessment, was hit by a fast-pitched ball in the right thigh during baseball practice.
  - After the initial sting, he continued playing but later experienced:
    - Nausea
    - Sharp pain in the left testicle radiating toward groin and abdomen.
    - Bruising of the right thigh.
    - Swelling in the scrotum, especially on the left side.

Testicular Torsion

Definition:
- Rotation of the testicle leading to twisting of the spermatic cord.
Clinical Signs:
- Enlargement of the affected testicle.
- Sudden, severe onset of pain.
Treatment:
- Immediate surgical intervention is necessary to prevent complications.

Ambiguous Genitalia

Definition:
- Disorders of sex development where infants are born with discrepancies in external genitalia, gonadal, and chromosomal sex.
Characteristics:
  - Genital appearance may not allow for specific gender declaration.
  - Cause:
    - Genetic mutations may begin around the 7th week of gestation.
Management:
- Requires evaluation by a multidisciplinary team including endocrinology, urology, genetics, surgeons, nurses, and social workers.
- Management can be complex and controversial.

Glomerular Disease

Types:
- Glomerulonephritis
- Nephrotic syndrome.

Glomerulonephritis

Definition:
- Specifically, acute poststreptococcal glomerulonephritis.
Etiology:
- Follows a bacterial or viral infection (specifically Group A beta-hemolytic streptococcus) occurring 10-21 days prior to onset of glomerular inflammation.
Pathophysiology:
- Inflammation of glomerular capillaries leads to leukocyte accumulation and occlusion of the capillary lumen. This decreases plasma filtration, causing excessive water and sodium accumulation, resulting in circulatory congestion, edema, and hypertension.
- Final effect: Impairs filtering of urine.

Clinical Manifestations of Glomerulonephritis

Key Symptoms:
  - Recent upper respiratory infection or streptococcal infection.
  - Cloudy, tea-colored urine.
  - Decreased urine output.
  - Hypertension.
  - Lethargy.
  - Anorexia.
  - Periorbital edema.
  - Hematuria.
  - Generalized edema.
  - Child may appear ill, lethargic, and pale.

Diagnosis of Glomerulonephritis

Diagnostic Tests Include:
  - Urinalysis/ Urine Culture (UA/UC).
  - Elevated creatinine and blood urea nitrogen (BUN).
  - Antistreptolysin O (ASO) titer.

Treatment for Glomerulonephritis

Management Strategies:
  - General supportive measures; most cases treated at home; almost all children fully recover.
  - Diuretics and antihypertensives are used to manage fluid accumulation and hypertension.
  - Antibiotic therapy indicated when persistent streptococcal infection is confirmed.

Nephrotic Syndrome - Minimal Change Nephrotic Syndrome

Pathophysiology:
  - Alterations in the glomerular membrane increase permeability allowing proteins to pass into the urine, leading to massive loss of protein in urine.
  - This condition typically occurs predominantly between ages 2 and 7 years.
  - The cause is often unknown; however, it may be associated with a viral or bacterial infection.

Clinical Manifestations of Nephrotic Syndrome

Key Symptoms:
  - Proteinuria.
  - Weight gain within a few days to weeks.
  - Facial and periorbital edema.
  - Ascites.
  - Edema in ankles.
  - Anorexia.
  - Diarrhea.
  - Irritability.
  - Lethargy.
  - Decreased foamy urine.

Diagnosis of Nephrotic Syndrome

Diagnostic Tools:
  - Urine evaluations (testing for protein/albumin).
  - Elevated glomerular filtration rate (GFR).
  - Serial serum protein/albumin, hemoglobin, and hematocrit evaluations.
  - Renal biopsy may be required.
  - Concerns about acute kidney injury (AKI) due to decreased intravascular volume, interstitial nephritis, and acute tubular necrosis.

Treatment for Nephrotic Syndrome

Main Treatment Goals:
  1. Reduce urinary protein excretion.
  2. Manage fluid retention in tissues.
  3. Prevent infections.
  4. Minimize complications arising from therapies.
Treatment Measures Include:
  - General supportive measures.
  - Dietary and fluid restrictions.
  - Antibiotic therapy for confirmed infections.
  - Medications such as:
    - Corticosteroids (e.g., Prednisone) to stop movement of protein into urine.
    - Diuretics (e.g., Furosemide, Lasix) to eliminate excess fluids from the body.
    - 25% albumin to increase plasma volume and decrease edema.
  - About 80% of affected children recover fully.

Comparison of Nephrotic Syndrome & Glomerulonephritis

Nephrotic Syndrome:
  - Greater than 2+ proteinuria.
  - Microscopic hematuria.
  - Negative ASO and streptococcus titers.
  - Normotensive.
  - Normal electrolyte levels.
  - Edema present.
Glomerulonephritis:
  - 0-2+ proteinuria.
  - Hematuria present.
  - Positive ASO and streptococcus titers.
  - Frequently hypertensive.
  - Edema present.

References

Hockenberry, M.J., Wilson, D., & Rodgers, C.C. (2022). Wong’s Essentials of Pediatric Nursing (11th ed.). St. Louis, MO: Elsevier Mosby.