1. The Child With a Genitourinary Alteration
Chapter 20
The Child With a Genitourinary Alteration

2. Anatomy of the Genitourinary System

3. Pediatric Differences in the Genitourinary System
Complete maturity of the kidney occurs between 6 and 12 months of age
Before this time, the filtration capacity of the glomeruli is reduced; urine is voided frequently and has a low specific gravity

4. Pediatric Differences in the Genitourinary System
Fluid constitutes a larger fraction of an infant’s and small child’s total body weight
The kidneys are less efficient at regulating electrolyte and acid-base balance and eliminating some drugs from the body
The immaturity of the renal structures predisposes the infant to dehydration and fluid volume excess
Bladder capacity increases from 20 to
50 mL at birth to 700 mL in adulthood

5. Pediatric Differences in the Genitourinary System
Innervation of stretch receptors in the bladder wall does not occur before the age of 2 years
The urethra is shorter in children than in adults and may contribute to the frequency of urinary tract infections in children
Kidneys are more susceptible to trauma in children because they do not have as much fat padding

6. Diagnostic Tests and Assessments of the Renal System
Urine specimen (for urinalysis; may be clean catch or sterile)
Intravenous pyelogram
Radiographs of kidneys, ureters, and bladder
Renal/bladder ultrasound
Cystogram
Computed tomography
Voiding cystourethrogram
Magnetic resonance imaging

7. Serum Blood Tests Hemoglobin and hematocrit Blood urea nitrogen
Creatinine
Serum electrolytes

8. Genitourinary Tract Disorders
Urinary tract infections
Vesicoureteral reflux

9. Urinary Tract Infections
Caused by bacteria ascending from outside the urethra into the bladder
From the bladder, bacteria may continue to ascend into the upper urinary tract
Fecal bacteria most common cause of urinary tract infections (approximately 80%)

10. Urinary Tract Infections
Anatomic and physical factors that predispose to urinary tract infections include:
Females: short urethra, which provides a ready pathway for invasion of organisms
Males: increased incidence in uncircumcised infants younger than 1 year
Urinary stasis
Vesicoureteral reflux
Sexual activity in adolescent girls
Urinary tract obstructions
Constipation
P. 597

11. Urinary Tract Infections
Clinical manifestations in the infant:
Fever or hypothermia in the neonate
Irritability
Dysuria
Change in urine odor or color
Poor weight gain
Feeding difficulties
Clinical manifestations in the child:
Abdominal or suprapubic pain
Voiding frequency
Voiding urgency
Dysuria
New or increased incidence of enuresis
Fever

12. Urinary Tract Infections
Diagnostic evaluation
History
Physical examination
Urinalysis
Urine culture and sensitivity
Therapeutic management
Eliminate current infection
Identify contributing factor
Prevent urosepsis
Preserve renal function

13. Urinary Tract Infections
Nursing considerations
Monitor intake and output
Observe for signs of dehydration in the infant and child
Administer antibiotics as ordered
Obtain daily weights
Encourage frequent voiding in toilet-trained child
Encourage increased fluid intake
Child and family education

14. Vesicoureteral Reflux
Retrograde flow of bladder urine into the ureters
Primary reflux: results from a congenital anomaly that affects the ureterovesical junction
Secondary reflux: result of an acquired condition
Reflux with infection is the most common cause of pyelonephritis in children
Clinical manifestations
See urinary tract infection
May see clinical manifestations of pyelonephritis
P. 598

15. International Classification of Reflux

16. Vesicoureteral Reflux
Divided into categories based on the degree of reflux from the bladder into the upper genitourinary tract structures
Grade I: urine refluxes partway up the ureter
Grade II: urine refluxes all the way up the ureter

17. Vesicoureteral Reflux
Grade III: urine refluxes all the way up the ureter with dilation of the ureter and calyces
Grade IV: urine refluxes all the way up the ureter with marked dilation of the ureter and calyces
Grade V: massive reflux of urine up the ureter with marked tortuosity and dilation of the ureter and calyces

18. Vesicoureteral Reflux
Diagnostic evaluation
Laboratory studies
Urinalysis
Urine cultures
Electrolytes
Blood urea nitrogen
Imaging studies
Plan 3 to 6 weeks after the infection to allow for infectious inflammation to subside
Ultrasound
Voiding cystourethrogram

19. Vesicoureteral Reflux
Therapeutic management
Grades I and II: continuous low-dose antibacterial therapy with frequent urine cultures
Grade III: managed with antibiotic therapy unless complications present
Grade IV and V: may require surgical intervention

20. Vesicoureteral Reflux
Nursing considerations
Explain treatment plan
Explain that medical management may last for years and that adherence to antibiotic therapy and follow-up is important
If surgical intervention is necessary, educate regarding preoperative and postoperative repair

21. Congenital Anomalies
Epispadias
Hypospadias
Cryptorchidism

22. Cryptorchidism
Testes fail to descend through the inguinal canal into the scrotal sac
Exposes the testes to the heat of the body, leading to low sperm counts at sexual maturity

23. Cryptorchidism Greater risk for torsion and trauma
Frequently associated with an inguinal hernia
Clinical manifestations
Testes that are not palpable or not easily guided into the scrotum or
A previously descended testis that ascends into an extrascrotal position

24. Cryptorchidism Diagnostic evaluation
Ultrasound, computed tomographic scan, or magnetic resonance image to determine location
Therapeutic management
Human chorionic gonadotropin hormone is given to induce descent
If testes remain undescended, an orchiopexy is performed in the toddler years

25. Epispadias and Hypospadias
Hypospadias: congenital defect in which the urinary meatus is located on the lower or underside of the shaft
Epispadias: congenital defect in which the urinary meatus is located on the upper side of the penile shaft; less common than hypospadias

26. Epispadias and Hypospadias
Clinical manifestations
Ventral or dorsal placement of the urethral opening
Altered urinary stream
Chordee
Diagnostic evaluation
Based on physical examination

27. Epispadias and Hypospadias
Therapeutic management is surgical intervention usually done in one stage
Release of chordee and lengthening of the urethra
Repositioning of the meatus at the penile tip
Reconstruction of the penis
Usually done between 6 and 12 months of age
No circumcision of infant with hypospadias
Urinary diversion is used after surgery to allow healing (stents or catheters)
Goal of surgery: to make urinary and sexual function as normal as possible and to improve the cosmetic appearance of the penis

28. Nursing Considerations for Children Undergoing Renal Surgery
Provide surgical tour, especially the “wake-up” room
Determine child’s words for penis, urination, etc.
Encourage parents to remain with child as appropriate
Provide support and reassurance
Assist child to turn, cough, and breathe deeply; frequently reposition infants
Perform frequent vital signs monitoring
Teach splinting of incision and incentive spirometry preoperatively

29. Nursing Considerations for Children Undergoing Renal Surgery
Assess and monitor for bladder spasms and incisional pain
Provide analgesics as ordered
Regulate intravenous fluids
Keep accurate intake and output records
Measure daily weights
Teach need to keep skin dry and odor free
Provide written instructions to parents
Provide contact number if problems occur

30. Glomerular Disease
Acute glomerulonephritis
Nephrotic syndrome

31. Pathophysiology of Acute Poststreptococcal Glomerulonephritis and Nephrotic Syndrome

32. Acute Glomerulonephritis vs. Nephrotic Syndrome
Acute glomerulonephritis: disorder that occurs suddenly and are characterized by hematuria, proteinuria, edema, and renal insufficiency
Occurs most frequently in young school-age children, most commonly after a streptococcal infection
Nephrotic syndrome: a kidney disorder characterized by proteinuria, hypoalbuminemia, and edema
Occurs most frequently in children between ages 2 and 6 years

33. Acute Glomerulonephritis vs. Nephrotic Syndrome
Pathophysiology
Streptococcal infection
Formation of antibodies in response to streptococcal bacteria
Antibodies combine with bacterial antigens to form immune complexes
Antigen-antibody complexes become trapped in the glomerulus and activate an inflammatory response in the glomerular basement membrane
Pathophysiology
Insult occurs to the glomerular basement membrane
Damage causes increased permeability and loss of substances that would normally prevent negatively charged proteins from crossing the membrane
Leads to increased clearance rate for albumin (negatively charged protein)
This causes a loss of plasma proteins and proteinuria

34. Acute Glomerulonephritis vs. Nephrotic Syndrome
Inflammation causes damage to the glomerular capillaries and reduces the size of the capillary lumen
Leads to decreased glomerular filtration rate
Leads to renal insufficiency
Causes sodium and fluid retention
Leads to edema and oliguria
Hypoalbuminemia reduces the plasma oncotic pressure
This causes a shifting of fluid from intravascular space to interstitial spaces
Fluid shifts reduce intravascular volume, causing hypovolemia and decreased renal blood flow
In response, renin production is stimulated, causing increased excretion of aldosterone
Renal tubular reabsorption of sodium occurs, which causes water retention and in turn leads to edema

35. Acute Glomerulonephritis vs. Nephrotic Syndrome
Clinical manifestations
Hematuria: tea- or cola-colored urine
Hypertension
Edema (worse in morning)
Usually young school-age child
Clinical manifestations
Proteinuria: frothy urine
Edema
Abdominal pain
Weight gain
Hypovolemia
Normotension
Pallor
Fatigue
Toddler or preschool-age child

36. Acute Glomerulonephritis vs. Nephrotic Syndrome
Diagnostic evaluation
History
Presenting symptoms
Renal ultrasound
Urinalysis
Laboratory results
Elevated blood urea nitrogen
Elevated erythrocyte sedimentation rate
Elevated ASO titer
Elevated creatinine
Electrolyte imbalance
Diagnostic evaluation
History
Clinical manifestations
Laboratory results
Urinalysis (3 to 4+ protein)
Possible microscopic hematuria
Hypoalbuminemia
Elevated cholesterol
Elevated triglycerides
Elevated hemoglobin and hematocrit
Elevated platelets

37. Acute Glomerulonephritis vs. Nephrotic Syndrome
Therapeutic management
Supportive
Antihypertensives
Diuretics
Low-salt diet
Therapeutic management
Prednisone to initiate remission
Diuretics
Possible administration of albumin
Antibiotics to prevent infection
No added salt diet

38. Acute Glomerulonephritis vs. Nephrotic Syndrome
Nursing considerations
Intake and output every shift
Daily weights
Monitor cardiopulmonary status every shift
Fluid restrictions as ordered
Low-salt diet
Cluster care to promote rest
Frequent position changes to decrease pressure on bony prominences (every 2 hours)
Nursing considerations
Position changes every 2 hours
Good daily hygiene
Support and elevate edematous body parts with pillows
Physical activity as tolerated
Antibiotics as ordered
Vital signs every shift
Intake and output every shift

39. Acute Glomerulonephritis vs. Nephrotic Syndrome
Nursing considerations
Good daily hygiene
Monitor for signs of dehydration
Vital signs every shift
Parental education
Nursing considerations
Monitor laboratory values
Observe for signs of dehydration
Daily weights
No added salt diet
Measure abdominal girth daily
Administer diuretics as ordered
Monitor cardiopulmonary status every shift
Parental education

40. Child with Nephrotic Syndrome

41. Hemolytic Uremic Syndrome
An acute renal disease characterized by a triad of manifestations: acute renal failure, hemolytic anemia, thrombocytopenia
Occurs primarily in infants and small children between 6 months and 3 years of age
An important cause of chronic renal failure
Disease usually follows an acute gastrointestinal or upper respiratory infection

42. Hemolytic Uremic Syndrome
Clinical manifestations
Presence of gastrointestinal, urinary tract, or upper respiratory tract infection with diarrhea and/or vomiting
Hemolytic anemia
Edema and ascites
Hypertension
Neurologic involvement (irritability, seizures, lethargy, stupor, coma, cerebral edema)
Rectal bleeding
Purpura
hematuria/proteinuria
Oliguria or anuria

43. Hemolytic Uremic Syndrome
Diagnostic evaluation
Triad of anemia, thrombocytopenia, and renal failure is sufficient for diagnosis
Renal involvement is evidenced by proteinuria, hematuria, and presence of urinary casts
Blood urea nitrogen and serum creatinine levels are elevated
Hemoglobin and hematocrit counts are low
Reticulocyte counts are high

44. Hemolytic Uremic Syndrome
Therapeutic management
Focuses on the complications of acute renal failure and includes the following:
Fluid restriction
Antihypertensive medications
High-calorie, high-carbohydrate diet low in protein, sodium, potassium, and phosphorus
Most consistently effective treatment is early dialysis or continuous hemofiltration
Transfusion of fresh packed red blood cells may be needed to treat severe anemia

45. Hemolytic Uremic Syndrome
Nursing considerations
Parenteral or enteral nutrition as ordered
Dialysis may be required during the acute period to correct electrolyte and fluid balances while eliminating wastes
Monitor intake and output
Daily weights
Maintain fluid restrictions as ordered
Blood pressure as ordered (report changes to prevent complications)
Thorough handwashing
Provide emotional support for child and address parental anxiety
Family education