DISORDERS OF THE GENITO-URINARY IN CHILDREN

1
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 Objectivescont

• 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

7
(No Transcript)
8
Urine formed in the nephron, passes into renal
pelvis, through ureter into bladder and out of
body through urethra
9
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 (BUNcreatinine). 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
• GirlgtBoy - 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

20
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
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

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

29
Problem 1 Fever due to increased
bodytemperature 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

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. 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
Students 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

35
(No Transcript)
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

39
(No Transcript)
40
(No Transcript)
41
Incidence

• 1 50 000 children
• Males gt 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 3 - 4 on dipstick
• - haematuria may be absent or microscopic

44
Diagnostic investigationscont

• 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

1. Generalised oedema due to fluid volume excess
   related to glomerular dysfunction
2. Impaired skin integrity related to oedema
3. Altered urinary pattern related to glomerular
   dysfunction
4. Increased susceptibility to infection related to
   disease process and steroid therapy

47
Nursing problemscont

• 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
tofluid 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 Cushings
  syndrome (moon face, abdominal distension,
  striae, ? appetite, ? weight, aggravation of
  adolescent acne)

49

• 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 diapers
  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 childs 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
Students 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, CS,
  LFT, serum albumin
• For CXR and Echo
• Daily urine dipstick for protein, ME and CS
  every morning
• Daily BP, weight and abdominal girth
• Start on IV infusion

53
Nursing Managementcont

• 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 Managementcont

• 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 gt39ºC
• 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

60
(No Transcript)
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

62
(No Transcript)
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

• 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

70
(No Transcript)
71
(No Transcript)
72
(No Transcript)
73
(No Transcript)
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 childs age is less than
  18 months
• Reconstruction of the meatal opening is done
  Meatal advancement granuloplasty (MAGPI)

77
(No Transcript)
78

• The goal for surgical correction-
• To enhance the childs 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

1. Ashwill, J.W. and Droske, S. C. 1997. Nursing
   Care of Children. Principles and Practice. USA
   W.B. Saunders.
2. Brunner, L.S. and Suddarth, D.S. 1986. The
   Lippincott Manual of Peadiatric Nursing. (3rd
   ed.) UK Chapman Hall.

80
Question and Answer

• The End