Genitourinary Alterations NUR 264 – Pediatrics Angela Jackson, RN, MSN

Developmental Differences Kidney development begins in the first weeks of embryo development Primary function of the kidney prior to birth is to maintain adequate amniotic fluid levels The newborn is unable to dispose of excess water & solutes rapidly or efficiently, which makes them prone to fluid volume excess Loop of Henle is short in newborns, reducing their ability to reabsorb sodium & water resulting in very dilute urine Urea synthesis and excretion are slower in newborn, which decreases concentration ability

Developmental Differences Newborns retain large quantities of nitrogen and essential electrolytes to meet growth needs in first few weeks which decrease concentration ability Hydrogen ion excretion, acid secretion and sodium bicarbonate levels are decrease during the first year of life. Severe metabolic acidosis develops more rapidly Sodium excretion is decreased and kidneys are less able to adapt to sodium deficiency or excess. Inadequate sodium reabsorption from tubules result in increased sodium losses in diarrhea and vomiting

Developmental Differences Newborn’s bladder lies in the abdomen. The bladder is in the pelvis by puberty Control of detrusor & urethral sphincter function to control process of urination by 4 years old Shorter urethra in children contributes to urinary infections The kidneys are less protected in the child compared with the adult because of unossified ribs, less fat padding, and the larger size of the kidney proportional to the abdomen. Bladder capacity increases with age from ml at birth to 700 ml by adulthood Reproductive system is functionally immature until puberty

Vesicoureteral Reflux (VUR) Backflow of urine from the bladder up the ureter to the kidney Occurs when the site where the ureter enters the bladder fails to maintain a unidirectional flow Most common anatomic disorder affecting the genitourinary tract Familial reflux is common Reflux is present in one-third of siblings who have an affected brother or sister Also a high incidence of transmission from parent to child

VUR: Pathophysiology In normal anatomy the ureter extends from the kidney to the bladder. It then passes through the bladder wall for a distance that enables the ureter to act as a sphincter. The ureter at this point functions as a one-way valve to prevent the backflow of urine With VUR, the ureter is not long enough to perform these functions and reflux occurs

VUR: Clinical Manifestations May be asymptomatic Persistent and repeated urinary tract infections Enuresis Flank pain Abdominal pain

VUR: Diagnosis Cystogram Voiding cystourethrogram (VCUG) Reflux is graded on a scale of I to V, with I being the least severe and V the most severe

VUR: Treatment The goals of medical management are : Prevention of UTIs Prevention of kidney damage Treatment includes: Surveillance Antibiotics Surgical management may be necessary if medical management fails

VUR: Nursing Management Education Importance of strict adherence to medical regimen Proper hygiene Preparation for diagnostic studies

Nephrotic Syndrome (NS) Disorder of the kidney characterized by altered glomeruli permeability, resulting in massive loss of protein in the urine Primary, or idiopathic, is the most common type of nephrotic syndrome in children NS affects boys more often than girls (2:1) NS usually occurs between ages 2 and 6, peaking at age 2-3 years

NS: Pathophysiology Primary NS is thought to be an autoimmune response resulting from an antigen-antibody reaction Glomeruli become increasingly permeable to plasma protein, allowing massive urinary protein loss Fluids shift from the intravascular to the interstitial space, resulting in edema Hypoalbuminemia results from urinary loss of protein Lipoprotein production increases, resulting in a rise in cholesterol and triglyceride levels

NS: Clinical Manifestations Proteinuria Weight gain Shifting edema (morning Periorbital edema shifting to generalized edema throughout the day) Oliguria Dark, frothy urine Pallor Irritability Fatigue Normal B/P Anorexia Abdominal pain

NS: Diagnosis Urinalysis reveals massive proteinuria (3+ to 4+) Hypoalbuminemia (serum albumin <2.5gm / dl) Hyperlipidemia

NS: Treatment Corticosteroids Diuretics when severe edema is present Albumin Dietary restrictions Immunosuppressant medications are used when steroid therapy fails

NS: Nursing Management Strict I & O, closely monitor VS, daily weight Reposition frequently Measure abdominal girth Monitor serum and urine electrolytes and protein as ordered Assess for edema and dehydration Monitor skin integrity Monitor for signs and symptoms of infection Administration of medication as ordered Teach parents to test urine for protein with dipstick

Acute Glomerulonephritis (AGN) Acute inflammation of the glomeruli within the kidney Results in acute renal failure Incidence peaks at seven years of age, is unusual in children younger than three Occurs more often in males

AGN: Pathophysiology Usually caused by a bacterial infection of the throat or skin. The most common organism is streptococcus (group A beta) Immune system responds to the bacteria by producing antibodies. The antibody/antigen reaction within the glomeruli forms immune complexes and inflammation occurs, damaging the glomeruli

AGN: Clinical Manifestations Gross hematuria Proteinuria Oliguria Periorbital edema Edema of face, abdomen Pallor, lethargy, irritability, headache Abdominal pain, anorexia, vomiting Dysuria Cloudy, brown colored urine Fatigue Elevated blood pressure ranging from mild to moderate

AGN: Diagnosis Urinalysis shows hematuria, proteinuria and increased specific gravity Elevated blood urea nitrogen and creatinine may be present Electrolytes are normal unless renal failure is present Anemia is present as a result of hemodilution Streptozyme test is positive Urine cultures are negative

AGN: Treatment Goals of treatment are: Identification and treatment of the source of the inflammation Maintenance of fluid and electrolyte balance Maintenance of blood pressure within the normal range

AGN: Treatment (cont.) If child has normal B/P and urine output, may be managed at home Children with generalized edema, oliguria, hypertension, and gross hematuria need to be admitted to the hospital

AGN: Treatment (cont.) Treatment of the hospitalized child includes: Diuretics Antihypertensives Dietary restrictions Antibiotic therapy for treatment of streptococcal infection

AGN: Nursing Management Close monitoring of B/P Strict Intake and Output Daily weights Administration of medications as ordered

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