elsevier items and derived items © 2007, 2002 by saunders, an imprint of elsevier inc. chapter 20...

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc.

Chapter 20Chapter 20

The Child With a The Child With a Genitourinary AlterationGenitourinary Alteration

Elsevier items and derived items © 2007, 2002 by Saunders, an imprint of Elsevier Inc. Slide 2

Anatomy of the Genitourinary System


Pediatric Differences Pediatric Differences in the Genitourinary Systemin the Genitourinary System

Complete maturity of the Complete maturity of the kidney occurs between kidney occurs between 6 and 12 months of age6 and 12 months of age

Before this time, the Before this time, the filtration capacity of the filtration capacity of the glomeruli is reduced; glomeruli is reduced; urine is voided frequently urine is voided frequently and has a low specific and has a low specific gravitygravity


Pediatric Differences in the Genitourinary Pediatric Differences in the Genitourinary SystemSystem

Fluid constitutes a larger fraction of an Fluid constitutes a larger fraction of an infant’s and small child’s total body weightinfant’s and small child’s total body weight

The kidneys are less efficient at regulating The kidneys are less efficient at regulating electrolyte and acid-base balance and electrolyte and acid-base balance and eliminating some drugs from the bodyeliminating some drugs from the body

The immaturity of the renal structures The immaturity of the renal structures predisposes the infant to dehydration and predisposes the infant to dehydration and fluid volume excessfluid volume excess

Bladder capacity increases from 20 to Bladder capacity increases from 20 to 50 mL at birth to 700 mL in adulthood50 mL at birth to 700 mL in adulthood


Pediatric Differences in the Genitourinary Pediatric Differences in the Genitourinary SystemSystem

Innervation of stretch receptors in the Innervation of stretch receptors in the bladder wall does not occur before the age bladder wall does not occur before the age of 2 yearsof 2 years

The urethra is shorter in children than in The urethra is shorter in children than in adults and may contribute to the frequency adults and may contribute to the frequency of urinary tract infections in childrenof urinary tract infections in children

Kidneys are more susceptible to trauma in Kidneys are more susceptible to trauma in children because they do not have as children because they do not have as much fat paddingmuch fat padding


Diagnostic Tests and Diagnostic Tests and Assessments of the Renal SystemAssessments of the Renal System

Urine specimen Urine specimen (for urinalysis; may be clean catch or sterile)(for urinalysis; may be clean catch or sterile)

Intravenous pyelogramIntravenous pyelogram Radiographs of kidneys, ureters, and bladderRadiographs of kidneys, ureters, and bladder Renal/bladder ultrasoundRenal/bladder ultrasound CystogramCystogram Computed tomographyComputed tomography Voiding cystourethrogramVoiding cystourethrogram Magnetic resonance imagingMagnetic resonance imaging


Serum Blood TestsSerum Blood Tests

Hemoglobin and hematocritHemoglobin and hematocrit Blood urea nitrogenBlood urea nitrogen CreatinineCreatinine Serum electrolytesSerum electrolytes


Genitourinary Tract DisordersGenitourinary Tract Disorders

Urinary tract infectionsUrinary tract infections Vesicoureteral refluxVesicoureteral reflux


Urinary Tract InfectionsUrinary Tract Infections

Caused by bacteria ascending from outside Caused by bacteria ascending from outside the urethra into the bladderthe urethra into the bladder

From the bladder, bacteria may continue to From the bladder, bacteria may continue to ascend into the upper urinary tractascend into the upper urinary tract

Fecal bacteria most common cause of urinary Fecal bacteria most common cause of urinary tract infections (approximately 80%)tract infections (approximately 80%)



Anatomic and physical factors that predispose to Anatomic and physical factors that predispose to urinary tract infections include:urinary tract infections include: Females: short urethra, which provides a ready Females: short urethra, which provides a ready pathway for invasion of organismspathway for invasion of organisms Males: increased incidence in uncircumcised Males: increased incidence in uncircumcised infants younger than 1 yearinfants younger than 1 year Urinary stasisUrinary stasis Vesicoureteral refluxVesicoureteral reflux Sexual activity in adolescent girls Sexual activity in adolescent girls Urinary tract obstructionsUrinary tract obstructions ConstipationConstipation



Clinical manifestations Clinical manifestations in the infant:in the infant: Fever or hypothermia Fever or hypothermia

in the neonatein the neonate IrritabilityIrritability DysuriaDysuria Change in urine odor Change in urine odor or coloror color Poor weight gainPoor weight gain Feeding difficultiesFeeding difficulties

Clinical manifestations Clinical manifestations in the child:in the child: Abdominal or suprapubic Abdominal or suprapubic

painpain Voiding frequencyVoiding frequency Voiding urgencyVoiding urgency DysuriaDysuria New or increased New or increased incidence of enuresisincidence of enuresis FeverFever



Diagnostic evaluationDiagnostic evaluation HistoryHistory Physical examinationPhysical examination UrinalysisUrinalysis Urine culture and sensitivityUrine culture and sensitivity

Therapeutic managementTherapeutic management Eliminate current infectionEliminate current infection Identify contributing factorIdentify contributing factor Prevent urosepsisPrevent urosepsis Preserve renal functionPreserve renal function



Nursing considerationsNursing considerations Monitor intake and outputMonitor intake and output Observe for signs of dehydration in the infant Observe for signs of dehydration in the infant

and childand child Administer antibiotics as orderedAdminister antibiotics as ordered Obtain daily weightsObtain daily weights Encourage frequent voiding in toilet-trained childEncourage frequent voiding in toilet-trained child Encourage increased fluid intakeEncourage increased fluid intake Child and family educationChild and family education


Vesicoureteral RefluxVesicoureteral Reflux

Retrograde flow of bladder urine into the uretersRetrograde flow of bladder urine into the ureters Primary reflux: results from a congenital Primary reflux: results from a congenital

anomaly that affects the ureterovesical junctionanomaly that affects the ureterovesical junction Secondary reflux: result of an acquired condition Secondary reflux: result of an acquired condition Reflux with infection is the most common cause Reflux with infection is the most common cause

of pyelonephritis in childrenof pyelonephritis in children

Clinical manifestationsClinical manifestations See urinary tract infection See urinary tract infection May see clinical manifestations of pyelonephritisMay see clinical manifestations of pyelonephritis


International Classification of RefluxInternational Classification of Reflux



Divided into categories based on the degree Divided into categories based on the degree of reflux from the bladder into the upper of reflux from the bladder into the upper genitourinary tract structuresgenitourinary tract structures

Grade I: urine refluxes partway up the ureter Grade I: urine refluxes partway up the ureter Grade II: urine refluxes all the way up the Grade II: urine refluxes all the way up the

ureter ureter



Grade III: urine refluxes all the way up the Grade III: urine refluxes all the way up the ureter with dilation of the ureter and calyces ureter with dilation of the ureter and calyces

Grade IV: urine refluxes all the way up the Grade IV: urine refluxes all the way up the ureter with marked dilation of the ureter and ureter with marked dilation of the ureter and calycescalyces

Grade V: massive reflux of urine up the ureter Grade V: massive reflux of urine up the ureter with marked tortuosity and dilation of the with marked tortuosity and dilation of the ureter and calycesureter and calyces



Diagnostic evaluationDiagnostic evaluation Laboratory studiesLaboratory studies

UrinalysisUrinalysis Urine cultures Urine cultures Electrolytes Electrolytes Blood urea nitrogen Blood urea nitrogen

Imaging studiesImaging studies Plan 3 to 6 weeks after the infection to allow Plan 3 to 6 weeks after the infection to allow

for infectious inflammation to subside for infectious inflammation to subside UltrasoundUltrasound Voiding cystourethrogramVoiding cystourethrogram



Therapeutic managementTherapeutic management Grades I and II: continuous low-dose Grades I and II: continuous low-dose

antibacterial therapy with frequent urine antibacterial therapy with frequent urine culturescultures

Grade III: managed with antibiotic therapy Grade III: managed with antibiotic therapy unless complications presentunless complications present

Grade IV and V: may require surgical Grade IV and V: may require surgical interventionintervention



Nursing considerationsNursing considerations Explain treatment planExplain treatment plan Explain that medical management may last Explain that medical management may last

for years and that adherence to antibiotic for years and that adherence to antibiotic therapy and follow-up is importanttherapy and follow-up is important

If surgical intervention is necessary, educate If surgical intervention is necessary, educate regarding preoperative and postoperative regarding preoperative and postoperative repairrepair


Congenital AnomaliesCongenital Anomalies

EpispadiasEpispadias HypospadiasHypospadias CryptorchidismCryptorchidism


CryptorchidismCryptorchidism

Testes fail to descend through the inguinal Testes fail to descend through the inguinal canal into the scrotal saccanal into the scrotal sac

Exposes the testes to the heat of the body, Exposes the testes to the heat of the body, leading to low sperm counts at sexual leading to low sperm counts at sexual maturitymaturity



Greater risk for torsion and traumaGreater risk for torsion and trauma Frequently associated with an inguinal herniaFrequently associated with an inguinal hernia

Clinical manifestationsClinical manifestations Testes that are not palpable or not easily Testes that are not palpable or not easily

guided into the scrotumguided into the scrotum

oror A previously descended testis that ascends A previously descended testis that ascends

into an extrascrotal positioninto an extrascrotal position



Diagnostic evaluationDiagnostic evaluation Ultrasound, computed tomographic scan, or Ultrasound, computed tomographic scan, or

magnetic resonance image to determine magnetic resonance image to determine locationlocation

Therapeutic managementTherapeutic management Human chorionic gonadotropin hormone is Human chorionic gonadotropin hormone is

given to induce descentgiven to induce descent If testes remain undescended, an orchiopexy is If testes remain undescended, an orchiopexy is

performed in the toddler yearsperformed in the toddler years


Epispadias and HypospadiasEpispadias and Hypospadias

Hypospadias: congenital Hypospadias: congenital defect in which the urinary defect in which the urinary meatus is located on the meatus is located on the lower or underside of the lower or underside of the shaftshaft

Epispadias: congenital Epispadias: congenital defect in which the urinary defect in which the urinary meatus is located on the meatus is located on the upper side of the penile upper side of the penile shaft; less common than shaft; less common than hypospadiashypospadias



Clinical manifestationsClinical manifestations

Ventral or dorsal placement of the urethral Ventral or dorsal placement of the urethral openingopening

Altered urinary streamAltered urinary stream

ChordeeChordee

Diagnostic evaluationDiagnostic evaluation

Based on physical examinationBased on physical examination



Therapeutic management is surgical intervention Therapeutic management is surgical intervention usually done in one stageusually done in one stage Release of chordee and lengthening of the urethraRelease of chordee and lengthening of the urethra Repositioning of the meatus at the penile tipRepositioning of the meatus at the penile tip Reconstruction of the penisReconstruction of the penis Usually done between 6 and 12 months of ageUsually done between 6 and 12 months of age No circumcision of infant with hypospadiasNo circumcision of infant with hypospadias Urinary diversion is used after surgery to allow Urinary diversion is used after surgery to allow healing (stents or catheters)healing (stents or catheters) Goal of surgery: to make urinary and sexual Goal of surgery: to make urinary and sexual function as function as

normal as possible and to improve the cosmetic normal as possible and to improve the cosmetic appearance of the penisappearance of the penis


Nursing Considerations for Children Nursing Considerations for Children Undergoing Renal SurgeryUndergoing Renal Surgery

Provide surgical tour, especially the “wake-up” Provide surgical tour, especially the “wake-up” roomroom

Determine child’s words for penis, urination, etc.Determine child’s words for penis, urination, etc. Encourage parents to remain with child as Encourage parents to remain with child as

appropriateappropriate Provide support and reassuranceProvide support and reassurance Assist child to turn, cough, and breathe deeply; Assist child to turn, cough, and breathe deeply;

frequently reposition infantsfrequently reposition infants Perform frequent vital signs monitoringPerform frequent vital signs monitoring Teach splinting of incision and incentive spirometry Teach splinting of incision and incentive spirometry

preoperativelypreoperatively


Nursing Considerations for Children Nursing Considerations for Children Undergoing Renal SurgeryUndergoing Renal Surgery

Assess and monitor for bladder spasms and Assess and monitor for bladder spasms and incisional painincisional pain

Provide analgesics as orderedProvide analgesics as ordered Regulate intravenous fluidsRegulate intravenous fluids Keep accurate intake and output recordsKeep accurate intake and output records Measure daily weightsMeasure daily weights Teach need to keep skin dry and odor freeTeach need to keep skin dry and odor free Provide written instructions to parentsProvide written instructions to parents Provide contact number if problems occurProvide contact number if problems occur


Glomerular DiseaseGlomerular Disease

Acute glomerulonephritisAcute glomerulonephritis Nephrotic syndromeNephrotic syndrome


Pathophysiology of Acute Pathophysiology of Acute Poststreptococcal Glomerulonephritis and Poststreptococcal Glomerulonephritis and

Nephrotic SyndromeNephrotic Syndrome


Acute Glomerulonephritis vs. Nephrotic Acute Glomerulonephritis vs. Nephrotic SyndromeSyndrome

Acute glomerulonephritis: Acute glomerulonephritis: disorder that occurs disorder that occurs suddenly and are suddenly and are characterized by characterized by hematuria, proteinuria, hematuria, proteinuria, edema, and renal edema, and renal insufficiencyinsufficiency

Occurs most frequently in Occurs most frequently in young school-age children, young school-age children, most commonly after a most commonly after a streptococcal infectionstreptococcal infection

Nephrotic syndrome: Nephrotic syndrome: a kidney disorder a kidney disorder characterized by characterized by proteinuria, proteinuria, hypoalbuminemia, and hypoalbuminemia, and edemaedema

Occurs most frequently in Occurs most frequently in children between ages 2 children between ages 2 and 6 yearsand 6 years



PathophysiologyPathophysiology Streptococcal infectionStreptococcal infection Formation of antibodies in Formation of antibodies in

response to streptococcal response to streptococcal bacteriabacteria

Antibodies combine with Antibodies combine with bacterial antigens to form bacterial antigens to form immune complexesimmune complexes

Antigen-antibody complexes Antigen-antibody complexes become trapped in the become trapped in the glomerulus and activate an glomerulus and activate an inflammatory response in the inflammatory response in the glomerular basement glomerular basement membranemembrane

PathophysiologyPathophysiology Insult occurs to the glomerular Insult occurs to the glomerular

basement membranebasement membrane Damage causes increased Damage causes increased

permeability and loss of permeability and loss of substances that would normally substances that would normally prevent negatively charged prevent negatively charged proteins from crossing the proteins from crossing the membranemembrane

Leads to increased clearance Leads to increased clearance rate for albumin (negatively rate for albumin (negatively charged protein)charged protein)

This causes a loss of plasma This causes a loss of plasma proteins and proteinuriaproteins and proteinuria



Inflammation causes damage to Inflammation causes damage to the glomerular capillaries and the glomerular capillaries and reduces the size of the capillary reduces the size of the capillary lumenlumen

Leads to decreased glomerular Leads to decreased glomerular filtration ratefiltration rate

Leads to renal insufficiencyLeads to renal insufficiency Causes sodium and fluid retentionCauses sodium and fluid retention Leads to edema and oliguriaLeads to edema and oliguria

Hypoalbuminemia reduces the Hypoalbuminemia reduces the plasma oncotic pressureplasma oncotic pressure

This causes a shifting of fluid from This causes a shifting of fluid from intravascular space to interstitial intravascular space to interstitial spacesspaces

Fluid shifts reduce intravascular Fluid shifts reduce intravascular volume, causing hypovolemia and volume, causing hypovolemia and decreased renal blood flowdecreased renal blood flow

In response, renin production is In response, renin production is stimulated, causing increased stimulated, causing increased excretion of aldosteroneexcretion of aldosterone

Renal tubular reabsorption of Renal tubular reabsorption of sodium occurs, which causes sodium occurs, which causes water retention and in turn leads water retention and in turn leads to edemato edema



Clinical manifestationsClinical manifestations Hematuria: tea- or cola-Hematuria: tea- or cola-

colored urinecolored urine HypertensionHypertension Edema (worse in morning)Edema (worse in morning) Usually young school-age Usually young school-age

childchild

Clinical manifestationsClinical manifestations Proteinuria: frothy urineProteinuria: frothy urine EdemaEdema Abdominal painAbdominal pain Weight gainWeight gain HypovolemiaHypovolemia NormotensionNormotension Pallor Pallor FatigueFatigue Toddler or preschool-Toddler or preschool-

age childage child



Diagnostic evaluationDiagnostic evaluation HistoryHistory Presenting symptomsPresenting symptoms Renal ultrasoundRenal ultrasound UrinalysisUrinalysis

Laboratory resultsLaboratory results Elevated blood urea nitrogen Elevated blood urea nitrogen

Elevated erythrocyte Elevated erythrocyte

sedimentation ratesedimentation rate Elevated ASO titerElevated ASO titer Elevated creatinineElevated creatinine Electrolyte imbalanceElectrolyte imbalance

Diagnostic evaluationDiagnostic evaluation HistoryHistory Clinical manifestationsClinical manifestations

Laboratory resultsLaboratory results Urinalysis (3 to 4+ protein)Urinalysis (3 to 4+ protein) Possible microscopic hematuriaPossible microscopic hematuria HypoalbuminemiaHypoalbuminemia Elevated cholesterolElevated cholesterol Elevated triglyceridesElevated triglycerides Elevated hemoglobin and Elevated hemoglobin and

hematocrithematocrit Elevated plateletsElevated platelets



Therapeutic managementTherapeutic management SupportiveSupportive Antihypertensives Antihypertensives DiureticsDiuretics Low-salt dietLow-salt diet

Therapeutic managementTherapeutic management Prednisone to initiate Prednisone to initiate

remissionremission DiureticsDiuretics Possible administration Possible administration

of albuminof albumin Antibiotics to prevent Antibiotics to prevent

infectioninfection No added salt dietNo added salt diet



Nursing considerationsNursing considerations Intake and output every shiftIntake and output every shift Daily weightsDaily weights Monitor cardiopulmonary status Monitor cardiopulmonary status

every shiftevery shift Fluid restrictions as orderedFluid restrictions as ordered Low-salt dietLow-salt diet Cluster care to promote restCluster care to promote rest Frequent position changes to Frequent position changes to

decrease pressure on bony decrease pressure on bony prominences (every 2 hours)prominences (every 2 hours)

Nursing considerationsNursing considerations Position changes every 2 hoursPosition changes every 2 hours Good daily hygieneGood daily hygiene Support and elevate edematous Support and elevate edematous

body parts with pillowsbody parts with pillows Physical activity as toleratedPhysical activity as tolerated Antibiotics as orderedAntibiotics as ordered Vital signs every shiftVital signs every shift Intake and output every shiftIntake and output every shift



Nursing considerationsNursing considerations Good daily hygieneGood daily hygiene Monitor for signs of dehydrationMonitor for signs of dehydration Vital signs every shiftVital signs every shift Parental educationParental education

Nursing considerationsNursing considerations Monitor laboratory valuesMonitor laboratory values Observe for signs of Observe for signs of

dehydrationdehydration Daily weightsDaily weights No added salt dietNo added salt diet Measure abdominal girth dailyMeasure abdominal girth daily Administer diuretics as orderedAdminister diuretics as ordered Monitor cardiopulmonary status Monitor cardiopulmonary status

every shiftevery shift Parental educationParental education


Child with Nephrotic SyndromeChild with Nephrotic Syndrome


Hemolytic Uremic SyndromeHemolytic Uremic Syndrome

An acute renal disease characterized by a An acute renal disease characterized by a triad of manifestations: acute renal failure, triad of manifestations: acute renal failure, hemolytic anemia, thrombocytopeniahemolytic anemia, thrombocytopenia

Occurs primarily in infants and small children Occurs primarily in infants and small children between 6 months and 3 years of agebetween 6 months and 3 years of age

An important cause of chronic renal failureAn important cause of chronic renal failure Disease usually follows an acute Disease usually follows an acute

gastrointestinal or upper respiratory infectiongastrointestinal or upper respiratory infection



Clinical manifestationsClinical manifestations Presence of gastrointestinal, urinary tract, or upper Presence of gastrointestinal, urinary tract, or upper

respiratory tract infection with diarrhea and/or vomitingrespiratory tract infection with diarrhea and/or vomiting Hemolytic anemia Hemolytic anemia Edema and ascitesEdema and ascites Hypertension Hypertension Neurologic involvement (irritability, seizures, lethargy, Neurologic involvement (irritability, seizures, lethargy,

stupor, coma, cerebral edema)stupor, coma, cerebral edema) Rectal bleedingRectal bleeding Purpura Purpura hematuria/proteinuria hematuria/proteinuria Oliguria or anuriaOliguria or anuria



Diagnostic evaluationDiagnostic evaluation Triad of anemia, thrombocytopenia, and renal Triad of anemia, thrombocytopenia, and renal

failure is sufficient for diagnosisfailure is sufficient for diagnosis Renal involvement is evidenced by Renal involvement is evidenced by

proteinuria, hematuria, and presence of proteinuria, hematuria, and presence of urinary castsurinary casts

Blood urea nitrogen and serum creatinine Blood urea nitrogen and serum creatinine levels are elevatedlevels are elevated

Hemoglobin and hematocrit counts are lowHemoglobin and hematocrit counts are low Reticulocyte counts are highReticulocyte counts are high



Therapeutic managementTherapeutic management Focuses on the complications of acute renal Focuses on the complications of acute renal

failure and includes the following:failure and includes the following: Fluid restrictionFluid restriction Antihypertensive medications Antihypertensive medications High-calorie, high-carbohydrate diet low in High-calorie, high-carbohydrate diet low in

protein, sodium, potassium, and phosphorusprotein, sodium, potassium, and phosphorus Most consistently effective treatment is early Most consistently effective treatment is early

dialysis or continuous hemofiltrationdialysis or continuous hemofiltration Transfusion of fresh packed red blood cells Transfusion of fresh packed red blood cells

may be needed to treat severe anemiamay be needed to treat severe anemia



Nursing considerationsNursing considerations Parenteral or enteral nutrition as orderedParenteral or enteral nutrition as ordered Dialysis may be required during the acute period to Dialysis may be required during the acute period to

correct electrolyte and fluid balances while eliminating correct electrolyte and fluid balances while eliminating wasteswastes

Monitor intake and outputMonitor intake and output Daily weightsDaily weights Maintain fluid restrictions as orderedMaintain fluid restrictions as ordered Blood pressure as ordered (report changes to prevent Blood pressure as ordered (report changes to prevent

complications)complications) Thorough handwashingThorough handwashing Provide emotional support for child and address Provide emotional support for child and address

parental anxietyparental anxiety Family educationFamily education

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