genitourinary disorders jan bazner-chandler cpnp, cns, msn, rn
TRANSCRIPT
Genitourinary Disorders
Jan Bazner-ChandlerCPNP, CNS, MSN, RN
Urinary Tract Infection Most common serious bacterial infection in
infants and children Highest frequency in infancy Uncircumcised males have a ten-fold
incidence
Etiology Anatomic abnormalities Neurogenic bladder – incomplete emptying of
bladder In the older child: infrequent voiding and
incomplete emptying of bladder or constipation
Teenager: sexual intercourse due to friction trauma
UTI - Females Most common in females
Short urethra Improper wiping Nylon under pants Current guidelines – do ultrasound with first UTI
followed by VCUG if indicated
UTI – Males Infant males
Needs to be investigated VCUG – ureteral reflux Ultrasound of kidneys – hydronephrosis or polycystic
kidneys Higher in un-circumcised males
Un-circumcised males Instruct parents to gently retract foreskin for
cleansing Do not force the foreskin Do not leave foreskin retracted or it may act
as tourniquet and obstruct the head of the penis resulting in emergency circumcision
Assessment: UTI Neonate: jaundice, fever, failure to thrive,
feeding, vomiting
Infant: irritability, poor feeding, vomiting, diarrhea, strong odor to urine
Childhood: vomiting, diarrhea, abdominal or flank pain, fever, enuresis, urgency, frequency, strong odor to urine
Diagnosis Urinary Tract Infection
Pyuria – white blood cells in urine Culture of urine – grows out bacteria
Urosepsis: Blood culture and urine culture grow out the same organism
Pyelonephritis: Elevated white blood cell count Elevated C-reactive protein and erythrocyte
sedimentation rate
Multidisciplinary Interventions Antibiotic therapy for 7 to 10 days
E-coli most common organism 85% Amoxicillin or Cefazol or Bactrim or Septra
Increase fluid intake Frequent voiding Acetaminophen for pain Teach proper cleansing
Urethritis Urethral irritation due to chemicals or
manipulation Most common in females Bubble bath, scented wipes, nylon under wear Self-manipulation Child abuse
Voiding Disorders Delay or difficulty in achieving control after a
socially acceptable age. Enuresis
Nocturnal = at night Diurnal = during the day Secondary = relapse after some control
Toilet Training Readiness 12 months no control over bladder 18 to 24 months some children show signs of
readiness Some children may not be ready until around
30 months
Enuresis Involuntary discharge of urine after the age by
which bladder control should have been established, usually considered to be age of 5 years.
Enuresis
Familial history Males outnumber females 3:2 5 to 10% will remain enuretic throughout their
lives Rule out UTI, ADH insufficiency, or food
allergies
Pharmacologic Interventions Pharmacological intervention:
Desmopressin synthetic vasopressin acts by reducing urine production and increasing water retention and concentration
Tofranil: anticholinrgic effect – FDA approval for treatment of enuresis Side effect may be dry mouth and constipation Some CNS: anxiety or confusion Need to be weaned off
Multidisciplinary Interventions Diet control
Reduce fluids in evening Control sugar intake
Bladder training Praise and reward Behavioral chart to keep track of dry nights Alarm system
Ureteral Reflux Males 6 to 1 Genetic predisposition Present as UTI or FTT Diagnostic tests Antibiotics if indicated Surgery to re-implant ureters
Ureteral Reflux
Hydronephrosis Water on kidney Due to obstruction Congenital anomaly Goals of care to maintain integrity of kidney
until normal urinary flow can be established.
Hydronephrosis
Ambiguous Genitalia Genital appearance that does not permit
gender declaration.
Agenesis of Scrotum
Hypertrophy of Clitoris
Extrophy of Bladder
Congenital malformation in which the lower portion of abdominal wall and anterior bladder wall fail to fuse during fetal development.
Assessment Visible defect that reveals bladder mucosa
and ureteral orifices through an open abdominal wall with constant drainage of urine.
Extrophy of Bladder
Extrophy of Bladder
Surgical Management Surgery within first hours of life to close the
skin over the bladder and reconstruct the male urethra and penis.
Urethral stents and suprapubic catheter to divert urine
Further reconstructive surgery can be done between 18 months to 3 years of age
Multidisciplinary Interventions
Preserve renal function: prevent infection Attain urinary control Re-constructive repair Sexual function
Long Term Complications Urinary incontinence Body image Inadequate sexual function
Hypospadias Most common anomaly of the male phallus Incomplete formation of the anterior urethral
segment Urethral formation terminates at some point
along the ventral fusion line. Cordee – downward curve of penis.
Hypospadias
Tight Chordee
Hypospadias Repair
Newborn Circumcision not recommended. Foreskin may be needed for reconstructive
surgery.
Surgical Interventions Release of tight chordee Placement of urethra opening at head of penis Surgery recommended at around six to nine
months of age Long term outcomes:
Leaking at the site Body image
Cryptorchidism Hidden testicle 3 to 5% of males High incidence in premature infants Goals of treatment:
Preserve testicular function Normal scrotal appearance
Multidisciplinary Interventions Most testes spontaneously descend. Surgical procedure, orchiopexy, if testicles do
not descend into the scrotal sac by 6 to 12 months of age
Hormone therapy – human chorionic gondadotropin
Slightly higher risk of testicular cancer if untreated
In the teen or adult the testicle would be removed
Testicular Exam Monthly testicular self-examination is
recommended for all males beginning in puberty, but is essential in males with history of undescended testicle.
Testicular Torsion Rotation of the testicle Spermatic cord twists and obstructs
circulation to the testis Left testicle affected more
Longer cord on left side
Assessment
Sudden severe pain in the scrotal area
Highest incidence on left side due to longer cord on that side
Goals of Treatment Surgical intervention
To relieve obstruction Preserve the testicular function Secure testicle to avoid further twisting
Acute Renal Failure (ARF) Pre-renal, resulting from impaired blood flow
to or oxygenation of the kidneys. Renal, resulting from injury to or malformation
of kidney tissues. Post-renal, resulting from obstruction of
urinary flow between the kidney and urinary meatus.
Renal Failure Newborn causes:
Congenital anomalies
Hypotension
Complication of open heart surgery
Renal Failure Childhood causes:
Dehydration
Glomerular nephritis / Nephrotic Syndrome
Nephro-toxicity / drug toxicity
Assessment: ARF Sudden onset Oliguria
Urine output less than 0.5 to 1 mL/kg/hour Volume overload due to retained fluid
Hypertension, edema, shortness of breath Acidosis Electrolyte imbalance and dehydration
Diagnostic Tests Decrease RBC due to erythropoietin
Urea and Creatinine elevated
GFR (glomerular filtration rate) most sensitive indicator of glomerular function.
Goals of Treatment: Acute Renal Failure Reduce symptoms Supportive care until renal function returns Medications – corticosteroids Dietary restrictions - sodium Dialysis if indicated
Complications of Peritoneal Dialysis Peritonitis Pain during infusion of fluids Leakage around the catheter Respiratory symptoms
Abdominal fullness from too much fluids Leakage of fluid to chest from hole in diaphragm
Nephrotic Syndrome / nephrosisEtiology is not know, it is felt to be the result of
an alteration of the glomerular membrane, making it permeable to plasma proteins (especially albumin).
Generalized Edema
Assessment Generalized edema Edema is worse in scrotum and abdomen
(results in ascites) Dramatic weight gain Pale, fatigue, anorexic Urinary output decreased Urine foamy and frothy with elevated SG
Diagnostic evaluation Proteinuria
* 4+ urine in urine Hypoalbuminemia Hypercholesterolemia
* Fat cells in blood
BUN and Creatinine normal unless renal damage
Multidisciplinary Interventions Diuretics (during acute phase lasix would be
given after IV albumin) Fluid restriction if edema severe Low sodium / high protein diet Daily weights Strict intake and output
Corticosteroid Therapy High dose prednisone Taper when protein loss in urine decreases Current recommendations to keep on low
dose every other day for up to 6 months If relapse or remission not obtained will try
cytotoxic medications
Side Effects of Cortisone Therapy Hirsutism Moon face with ruddy cheeks Acne Dorsocervical fat pads Ecchymosis (easy bruising) Truncal obesity Mood swings – inability to sleep Increase appetite
Moon Face
High-dosecorticosteroid therapyproduces a characteristic “moon face” appearance.
Before and After
Nursing Interventions for long tern use Prednisone prescribed every other day Instruct to take in the morning
Long Term Use - Prednisone every other day in the am
Take with food: can cause GI upset Do not stop taking medication until instructed
to do so Medication needs to be tapered Monitor for infection
Glomerulonephritis Immune complexes become entrapped in the
glomerular membrane.
Symptoms appear 1 to 2 weeks after a Strep A skin or throat infection.
Clinical Manifestations Hematuria / red cells casts Facial edema Brown or frothy urine Mild proteinuria Hypertension
Multidisciplinary Interventions
Low sodium / high protein Anti-hypertensive drugs Diuretics Antibiotics if + throat culture or blood culture Monitor blood pressure 24 hour urine for Creatinine clearance
Teaching Culture sore throats Take antibiotics for full course prescribed Do not share medications with others in family