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Genitourinary Disorders
Jan Bazner-Chandler
CPNP, 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

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

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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
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

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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: anticholinergic 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 Uretheral reflux.jpg

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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
hydronephrosis_series.jpg
Ambiguous Genitalia
.Genital appearance that does not permit gender
declaration.
Agenesis of Scrotum agenesis of scrotum
Hypertrophy of Clitoris cliterol hypertrophy
Extrophy of Bladder

.Congenital malformation in which the lower portion of

abdominal wall and anterior bladder wall fail to fuse
during fetal development.

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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
Extrophy of Bladder msotw9_temp0
Multidisciplinary Interventions

.Preserve renal function: prevent infection

.Attain urinary control
.Re-constructive repair
.Sexual function

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
Long Term Complications
.Urinary incontinence
.Body image
.Inadequate sexual function

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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 hyospadius.jpg
Tight Chordee
hypospadius _cordee.jpg
Hypospadias Repair Hypospadius repair.jpg
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

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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

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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: Acute Renal Failure

.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

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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 / nephrosis

Etiology 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 msotw9_temp0

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+ proteine 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

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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 msotw9_temp0
High-dose
corticosteroid therapy
produces a characteristic
moon face

appearance.

Before and After

msotw9_temp0
msotw9_temp0
Nursing Interventions for long term 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.

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Clinical Manifestations
.Hematuria / red cells casts
.Facial edema
.Brown or frothy urine
.Mild proteinuria
.Hypertension

Teaching
.Culture sore throats
.Take antibiotics for full course prescribed
.Do not share medications with others in family
Multidisciplinary Interventions
.Low sodium / high protein
.Anti-hypertensive drugs
.Diuretics
.Antibiotics if +ve throat culture or blood culture
.Monitor blood pressure
.24 hour urine for Creatinine clearance

Genitourinary Disorders

DISCUSSION

QUESTIONS & ANSWERS