1. GENITO-URINARY SYSTEM
DISORDERS OF THE
GENITO-URINARY SYSTEM
IN CHILDREN

2. Aim To show an in-depth understanding of the
genito-urinary disorders in children and the
process of care in the nursing management

3. Learning Objectives By the end of this session, the student
should be able to:
Understand the anatomy and physiology of the renal system and structure and function
Identify the differences between adult and children GU system
Describe the most common diagnostic investigations and procedures for GU disorders

4. Learning Objectives…con’t
Understand the general assessment of children with genitourinary disorders
Understand the common genitourinary disorders in children
Plan the nursing management for children with GU disorders

5. PAEDIATRIC DIFFERENCES OF KIDNEY DEVELOPMENT
Begins during 1st week of gestation
Completed by end of 1st year after birth
Excretion less than adult
By the age of 6 to 12 months, filtration and absorption is nearly like adults
For healthy infant, the kidneys operate at a functional level appropriate for the size of the body.

6. Function of Kidney Nephron
Glomeruli – filter water and solutes from blood
Tubules – reabsorb needed substances (water, protein, electrolytes, glucose, amino acids) from filtrate and allow unneeded substances to leave the body in urine
Urine formed in the nephron, passes into renal pelvis, through ureter into bladder and out of body through urethra

8. Urine formed in the nephron, passes into renal pelvis, through
ureter into bladder and out of
body through urethra

9. filter water and solutes from blood
Glomeruli :
filter water and solutes from
blood
Tubules :
reabsorb needed
substances (water,
protein, electrolytes,
glucose, amino acids)
from filtrate and allow
unneeded substances to
leave the body in urine

10. Function of Kidney Maintaining body fluid volume and composition
Secretes hormones:-
Renin – helps with the regulation of blood pressure
Erythropoietin – stimulates red blood cell production by the bone marrow
Metabolised Vitamin D – responsible for calcium metabolism

11. Diagnostic Investigations
Urinalysis
CT Scan- an x-ray procedure that combines many x-ray images with the aid of a computer to generate cross-sectional views and, if needed, three-dimensional images of the internal organs and structures of the body. 

12. Blood urea nitrogen (B.U.N) and creatinine -
gross indicator of renal function
(BUN) test measures the amount of nitrogen in blood that comes from the waste product urea.
Urea is made when protein is broken down in body.
Blood urea nitrogen (BUN) and creatinine tests can be used together to find the BUN-to- creatinine ratio (BUN:creatinine). body in the urine.
  A blood urea nitrogen (BUN) test is done to determine :
kidneys are working normally.
kidney disease is getting worse.
See if treatment of kidney disease is working.
See if severe dehydration is present. Dehydration generally causes BUN levels to rise more than creatinine levels. This causes a high BUN-to-creatinine ratio. Kidney disease or blockage of the flow of urine from kidney causes both BUN and creatinine levels to go up.

13. Cystoscopy – bladder and urethra are examined with cystoscope (fibre optic technology)

14. KUB (Kidney, Ureter, Bladder) x-ray Renal Biopsy
Renal Ultrasound

15. Intravenous pyelogram (IVP)
An injection of x-ray contrast media via a needle or cannula into the vein, typically in the arm. The contrast is excreted or removed from the bloodstream via the kidneys, and the contrast media becomes visible on x-rays almost immediately after injection

16. Retrograde Pyelogram
a urologic procedure where the physician injects contrast into the ureter in order to visualize the ureter and kidney. 
Micturating Cystourethrography (MCUG) – serial x-ray of the bladder and urethra after IV infusion of iodine-bound contrast medium ( to detect blockage)

17. COMMON DISORDERS OF THE GENITOURINARY SYSTEM
Urinary tract infection (UTI)
Nephrotic syndrome
Acute Post-Streptococcal Glomerulonephritis (APSGN)
Vesicoureteral reflux
Hypospadias

18. URINARY TRACT INFECTIONS
Definition
UTI is the presence of bacteria in the urine
Infection usually occur at the upper urinary tract or at the lower urinary tract
Incidence
Common age of onset for UTI is 2-6 years
Girl>Boy - Female has shorter urethra
Uncircumcised male prone to develop UTI

19. Causes Causative organisms – E. Coli
Route of entry -bacteria ascending from the area outside of the urethra.
Vesico-ureteral reflux
Infections – URTI, GE
Poor perineal hygiene - fecal organisms are the most common infecting organisms due to the proximity of the rectum to the urethra.
Short female urethra
Vesicoureteral reflux (VUR) is the abnormal flow of urine from the bladder back into the ureters.
VUR is most commonly diagnosed in infancy and childhood after the patient has a urinary tract infection (UTI). About one-third of children with a UTI are found to have VUR. VUR can lead to infection because urine that remains in the child’s urinary tract provides a place for bacteria to grow. But sometimes the infection itself is the cause of VUR.
here are two types of VUR. Primary VUR occurs when a child is born with an impaired valve where the ureter joins the bladder. This happens if the ureter did not grow long enough during the child's development in the womb. The valve does not close properly, so urine backs up (refluxes) from the bladder to the ureters, and eventually to the kidneys. This type of VUR can get better or disappear as the child gets older. The ureter gets longer as the child grows, and the function of the valve improves.
Secondary VUR occurs when there is a blockage anywhere in the urinary system. The blockage may be caused by an infection in the bladder that leads to swelling of the ureter. This also causes a reflux of urine to the kidneys.

20. Urethritis – infection of the urethra
Types of UTI
Urethritis – infection of the urethra
Cystitis – an infection in the bladder that has moved up from the urethra
Pyelonephritis – a urinary infection of the kidney as a result of an infection in the urinary tract

21. Diagram of cystitis

22. Signs & Symptoms of UTI in babies
Unexplained fever (febrile fits)
Poor
growth
Abdominal
pain
Foul-smelling
urine
Signs & Symptoms of UTI in babies
Irritability
Poor feeding
Weight loss
(failure to weight gain)
Vomiting

23. Signs & Symptoms of UTI in older children
Urinary frequency/urgency
Dysuria
Foul-smelling urine
Cloudy urine
Incontinence during day and/or night
Increased irritability
Nausea and vomiting
Low abdominal or flank pain
Fever and chills
Fatigue
Small amount of urine while micturating despite feeling of urgency

24. Signs of serious infections
Central pyrexia but peripherally cold
Poor colour
Pale, grey mottled skin
Quiet and lethargic child
Poor tone
Tachycardic and hypertensive

25. Diagnostic investigations
Obtaining a urine specimen:-
- Urine bag
- Clean catch urine
- Mid-stream urine
- Catheterisation
- Supra-pubic aspiration-draining the bladder by inserting a sterile needle through the skin above the pubic arch and into the bladder.

26. Diagnostic investigations
Ultrasound
Plain x-ray
Micturating Cystourethrogram (MCUG)

27. Nursing care
Obtain urine specimen before antibiotics started, sent for ME/CS
Blood tests
Strict I/O chart
Monitor vital signs esp. body temperature
Administer antibiotics as prescribed (5 days course)
Administer anti-pyretic drugs to reduce fever and pain
Advised to take plenty of fluids to prevent dehydration and to flush the urinary tract
If the child is unable (vomiting) or refuse to take fluids, administer IV fluids as prescribed

28. Nursing Problems
Fever due to increased body temperature related to urinary tract infection.
Alteration in urination (frequency, pain, burning, dribbling and enuresis) related to infection.
Pain related to inflammatory changes in the urinary tract.
Lack of knowledge about UTI and health prevention

29. Nursing interventions
Problem 1: Fever due to increased body temperature related to urinary tract infection
Goal: to reduce fever and maintain normal body temperature
Nursing interventions
Rationales
monitor body temperature every 4º
encourage plenty of fluid intake
administer anti-pyrexial medications as prescribed
maintain bed rest
wear thin loose clothing
give tepid-sponging with luke-warm water
baseline obs.
to maintain hydration
to maintain an optimum body temp.
to reduce the body heat
to reduce body heat

30. Nursing interventions
Problem 2: Alteration in urination (frequency, pain,
burning, dribbling and enuresis) related to infection
Goal: to ensure that the child is comfortable during urination
Nursing interventions
Rationales
assess the urinary frequency, pain or burning sensation during micturation
assess the colour & odour of urine
strict I/O chart
administer antibiotics as prescribed
observe for signs & symptoms of serious infection
as baseline obs.
to observe urinary frequency
to prevent spread of infection
to prevent complications

31. Health teaching to prevent UTI
Ensure the child to pass urine regularly (every 2-3 hours) and take the time to completely empty the bladder
Avoid holding urine for prolonged period of time
Perineal hygiene - wipe from front to back
Avoid tight fitting clothing or diapers; wear cotton panties
Avoid constipation
Encourage fluid intake
Avoid bubble baths

32. Student’s Activity
You are required to do the nursing care plan for problem no. 3 & 4, including nursing interventions and rationales

33. Nephrotic Syndrome
Nephrotic Syndrome

34. What is Nephrotic Syndrome?
Alteration of glomerular membrane permeability with massive proteinuria, hypoalbuminaemia, hyperlipidaemia and oedema

36. Causes
It occurs when the filters in the kidney leak an excessive amount of protein. The level of protein in the blood ↓ and this allows fluid to leak across the blood vessels into the tissues – causing oedema
Nephrotic syndrome are caused by changes in the immune system

37. Pathophysiology
For unknown reason, the glomerular membrane, usually impermeable to large proteins becomes permeable.
Protein, especially albumin, leaks through the membrane and is lost in the urine.
Plasma proteins decrease as proteinuria increase.

38. The colloidal osmotic pressure which holds water in the vascular compartments is reduced owing to decrease amount of serum albumin. This allows fluid to flow from the capillaries into the extracellular space, producing oedema.
Accumulation of fluid in the interstitial spaces and peritoneal cavity is also increased by an overproduction of aldosterone, which causes retention of sodium.
There is increased susceptibility to infection due to decreased gamma-globulin.
Causing generalised oedema

41. Incidence 1 : 50 000 children Males > females
Common age of onset is between 2 to 6 years, but can occur at any age

42. Signs & Symptoms Oedema - initially noted in the periorbital area
- ascites
- intense scrotal oedema
- striae may appear due
to skin overstretching
- pitting oedema
↑ weight
↓ urine output
Proteinuria (foamy urine indicates proteinuria)
Fatigue
Irritable and depression
Severe recurrent infections
Anorexia
Wasting of skeletal muscles

43. Diagnostic investigations
Urinalysis
- protein on dipstick
- haematuria may be absent or microscopic

44. Diagnostic investigations…con’t
Blood test
- total serum protein – low
- serum albumin – low
- cholesterol and lipoproteins – high
Renal function test – often normal
Blood pressure – often normal but 25% hypertension
Renal biopsy

45. Renal biopsy

46. Nursing problems
Generalised oedema due to fluid volume excess related to glomerular dysfunction
Impaired skin integrity related to oedema
Altered urinary pattern related to glomerular dysfunction
Increased susceptibility to infection related to disease process and steroid therapy

47. Nursing problems…con’t
Altered body image (round face) due to side- effects of medication
Inadequate nutritional intake related to large loss of protein from the urine
Knowledge deficit of the disease process and treatment
Anxiety and depression due to the up and down of the course of disease

48. Nursing problem 1 :Generalised oedema due to fluid volume excess related to glomerular dysfunction
Goal : to relieve oedema
Nursing interventions
Administer steroids – prednisolone 2-4mg/kg to control oedema
Observe for side-effects of steroids – Cushing’s syndrome (moon face, abdominal distension, striae, ↑ appetite, ↑ weight, aggravation of adolescent acne)

49. Administer diuretic – frusemide
Administer diuretic – frusemide. Diuretics can cause loss of electrolytes esp. potassium, encourage ↑ potassium food e.g. citrus fruits, date, apricot, banana
Keep the child CRIB during periods of severe oedema
Strict I/O chart – restrict intake of fluid – offer small amount of measured fluid during severe oedema, for infant measure the diaper’s wt.
Measure daily weight and abdominal girth – to check any weight gain due to water retention

50. Nursing problem 2 :Impaired skin integrity related to oedema
Goal : to protect the child from skin breakdown
Nursing intervention
Position the child comfortably in bed so that oedematous skin is well-support with a pillow
Elevate the child’s head to reduce peri- orbital oedema
Provide good skin care – give bath and maintain hygiene esp. genitals and moist area
Change bedding daily and free from creases and sharp objects – to avoid cut

51. Student’s activity
For problems 3 – 9, you are required to look for the nursing interventions yourself.

52. Nursing Management Admission to ward
Explain to parents nature of illness
Blood for FBC/DC, U +E, Creat., Serum lipid, C&S, LFT, serum albumin
For CXR and Echo
Daily urine dipstick for protein, ME and C&S – every morning
Daily BP, weight and abdominal girth
Start on IV infusion

53. Nursing Management…con’t
Administration of IV albumin
Start on steroid therapy – prednisolone given at a dose of 2mg/kg/day divided into 2-3 doses. This regimen is continued until remission is achieved
Remission is achieved when the urine is 0 or trace for protein for 5 to 7 consecutive days
Administer prophylactic antibiotics to reduce infections

54. Nursing Management…con’t
Start on diuretic therapy – frusemide (lasix)
Dietary restriction – provide ↑ protein, high carbohydrate, ↑ potassium diet & no salt diet
Strict I/O chart
Provide careful skin care
Good hygiene
CRIB

55. THE END
Question and Answer

56. VESICO-URETERAL REFLUX
DEFINITION
The backflow or reflux of urine from the bladder into the ureters and possibly the kidneys. The urine returns to the bladder after passing urine.

57. Signs & symptoms for infants
Fever >39ºC
Irritability
Poor feeding
Vomiting
Dysuria as evidenced by crying when passing urine
Change in urine colour or odor

58. Signs & symptoms for children
Abdominal or suprapubic pain
Frequency in passing urine
Urgency in passing urine
Dysuria
New or increased incidence of enuresis

59. Pathophysiology
In normal functioning urinary tract, there is a valve-like mechanism at the junction of the ureter and bladder that prevents urine from refluxing in the ureters
As urine fills the bladder or the bladder contracts during micturating, pressure in the bladder occludes the opening to the ureter
When a defect occur at the vesioco-ureteral junction, VUR occur

61. Diagnostic investigations
MCUG – to visualise the urethra, evaluate degree of reflux and define any abnormalities
Renal scan – to assess renal scarring and function
Urodynamic studies – this is done when there is micturating dysfunction (frequency, urgency, or incontinence) is present
Cystograms
Urine culture
Blood test – serum creatinine

63. International Classification of Reflux
GRADE I: reflux into ureter only – no dilatation
GRADE II: reflux into ureter, pelvis and calyces with no dilaltation and normal calyceal fornices
GRADE III: mild dilatation of ureter and renal pelvis
GRADE IV: moderate dilatation of ureter, pelvis and calyces
GRADE V: gross dilatation of ureter, pelvis and calyces

64. GRADE IV: moderate dilatation of ureter,
pelvis and calyces

65. GRADE V:
gross dilatation
of ureter,
pelvis and calyces

66. - occurs as a result of acquired bladder dysfunction
Reflux can be divided into 2 categories :-
PRIMARY REFLUX
- caused by abnormal position of the ureteral bud on the wolffian duct during development of the urinary tract, resulting in smaller, tunneled segment of the ureter
SECONDARY REFLUX
- occurs as a result of acquired bladder dysfunction

67. Medical management
Daily low dose of prophylactic antibiotic to prevent UTI
Urinalysis and urine ME/CS – every 3 to 4 months to evaluate for UTI
Monitor ↑BP

68. Surgical Management
Surgery – reimplantation of the ureter into the bladder
Indicated due to recurrent UTI despite antibiotics, Grade 5 reflux or progressive renal injury

69. HYPOSPADIAS Definition
Hypospadias is a congenital anomaly in which the actual opening of the urethral meatus is “below” the normal placement on the glans of penis

74. Causes Occurs from incomplete development of the urethra in utero
Exact causes unknown – may be genetic, environmental or hormonal factor

75. Complications
Stenosis of the opening could occur – may lead to UTI or hydronephrosis
May interfere with fertility if left uncorrected
The location of the meatus may make it difficult for the child to urinate standing up

76. Surgical management
The choice of surgical correction is affected primarily by the severity of the defect
Surgery is done when the child’s age is less than 18 months
Reconstruction of the meatal opening is done – Meatal advancement granuloplasty (MAGPI)

78. The goal for surgical correction:-
To enhance the child’s ability to pass urine in the standing position with a straight stream
To improve the physical appearance of the genitalia for psychological reasons
To preserve a sexually adequate organ

79. References
Ashwill, J.W. and Droske, S. C Nursing Care of Children. Principles and Practice. USA: W.B. Saunders.
Brunner, L.S. and Suddarth, D.S The Lippincott Manual of Peadiatric Nursing. (3rd ed.) UK: Chapman & Hall.

80. Question and Answer
The End