PEDIATRIC GENITOURINARY DISORDERS

____
decreased, venous sample will be increased.
 Normally, the urinary system maintains Normal creatinine clearance rate is 100
the proper balance of fluid and electrolytes in the mL/min, normal urine creatinine is 0.7 to
blood. 1.5 mg/100 mL, while creatinine in blood
 Kidneys, rarely exceeds 1 mg/dL.
particularly the
nephrons, filter blood, 3. Urine Culture
secrete waste products,  Detects presence of bacteria in urine, as in
and reabsorb fluids, UTI.
electrolytes, nutrients, 4. Blood Urea Nitrogen Test
and other essential  Measures the level of urea in blood and is
particles, until urine is used to assess glomerular function, or how
formed. Ureters are well the kidneys can clear this from the
where urine travels bloodstream. Normal value is 5 to 20
down the body. The mg/100 mL.
bladder stores urine.
Urethra, which is 5. Ultrasound, MRI, X-Ray, CT Scan
different in structure  Visualize kidneys, ureter, bladder.
among boys and girls,
expels urine. 6. Cystoscopy
 When  Examination of the bladder and ureter
disease occurs, such as with structural abnormalities openings by direct examination with a
or kidney malfunction, children may be left with cystoscope introduced through the
excessive amounts of fluid in the body or with an urethra, is done to evaluate structures of
imbalance of electrolytes essential to their body’s both bladder and ureter. Radiopaque dye
functioning. may be introduced into the bladder or
 Usually, the disorders involving the ureters so these structures can be
kidneys and urinary tract often are long term. visualized on radiography. This is painful,
so a child may be under conscious
ASSESSMENT sedation. After the procedure, the first
1. Urinalysis voiding may be painful too so once
 Most simple test of kidney function. Please allowed, urge children to drink plenty of
read and review the average urine output in fluids so they urinate frequently and flush
24 hours and characteristics of urine, in out any pathogens introduced at the time
tables 46.1 and 46.2 in your book. of the procedure.
Specimens collected should be fresh
because urine that stands long at room Dialysis is the separation and removal of solutes
temperature may change its composition. from body fluid by diffusion through a semi-
permeable membrane.
2. Creatinine Clearance Rate  Peritoneal Dialysis uses the membrane of
 Glomerular filtration rate is the rate at the peritoneal cavity.
which substances are filtered from the  Hemodialysis uses an outside synthetic
blood to the urine. It is measured by the membrane.
amount of creatinine, the breakdown  Kidney function is necessary for life as it
product of muscle contraction, excreted in cleans our blood, if it deteriorates, some method
24 hours as determined by a 24-hour urine to replace function must be instituted.
sample. A venous blood sample is taken  You will further discuss this in your
during the 24-hour period and compared medical-surgical nursing in your higher years,
with the urine findings, if urine creatinine is
 and here, we will just give you a brief 4. If severe, undetermined sex
background.  If the penis defect is so extensive, sex
determination may be unclear and might
need sex cell karyotyping
PEDIATRIC GENITOURINARY DISORDERS
1. Hypospadias and Epispadias MANAGEMENT:
2. Urinary Tract Infection 1. In the newborn,
3. Vesicoureteral Reflux meatotomy is the
4. Hydronephrosis surgical procedure
5. Glomerulonephritis in which the
6. Nephrotic Syndrome urethra is extended
to a normal
HYPOSPADIAS AND EPISPADIAS position.
2. When the child is
Hypospadias is a 12 to 18 months, adherent chordee may be
urethral defect in which released.
the urethral opening is 3. If the repair will be extensive, all surgery
not at the end of the may be delayed until 3 to 4 years old.
penis but on the ventral
or lower aspect of it.  Minimal defects need no intervention.
 But if surgery is intended, children should
not be circumcised yet, because the
Epispadias is a similar
surgeon may wish to use a portion of the
defect in which the opening
foreskin during repair.
is on the dorsal surface of
the penis.
URINARY TRACT INFECTION
 Bacterial invasion,
 Hypospadias
usually Escherichia
is fairly common, occurring in approximately 1 in 300
coli, that enters the
male newborns.
urinary tract most
 May be familial or may occur from a
often as an
multifactorial genetic focus.
ascending infection
from the perineum.
ASSESSMENT:
 Common in
All male newborns must be inspected at birth for children and girls,
hypospadias or epispadias. This is a part of the routine at a rate of 2% to
physical examination. 8%.
1. Abnormal location of urinary meatus  May be urethritis, cystitis, ureteritis, or
 The degree may be minimal, just near the pyelonephritis. Need vigorous treatment in
glans, or maximal, midway or way far from childhood so they do not spread to involve the
the normal opening near abdomen or kidneys, pyelonephritis, and may damage it’s
scrotum. function.
2. Chordee, in hypospadias  UTIs tend to occur more often in girls than
 Many newborns with hypospadias have an in boys because the urethra is shorter in girls
accompanying chordee, a fibrous band that and it is located close to the vagina and anus.
causes the penis to curve downward.
3. Cryptorchidism, in hypospadias ASSESSMENT:
 Undescended testes is also often found in A. Typical Symptoms: pain or burning on
conjunction with hypospadias. urination, urinary frequency, hematuria
  Sometimes may not be present.  Reflux leads to bladder infection because
B. With Cystitis: low grade fever, mild urine is retained in the ureters after voiding, and
abdominal pain, enuresis stasis of any fluid is subject to infection.
 May be difficult to pinpoint that it’s
UTI. The regurgitation of urine from bladder to ureters,
C. With Pyelonephritis: high fever, abdominal caused by the valve defect can be seen in the
pain, flank pain, vomiting, malaise photo.
 Symptoms are more acute. This backflow of urine happens at micturition or
voiding, when the bladder
Diagnosed through above findings plus contracts.
urinalysis or urine culture. This favors the growth of E.
coli.
MANAGEMENT:
1. Administer antibiotics. ASSESSMENT:
 Oral administration, specific to the causative  First seen with history
organism that was cultured. Remind parents of repeated UTIs.
to finish full prescription so infection will not  A CT scan or
return. cystoscopy can show the
2. Force fluids. ureteral reflux.
 To flush the infection out of the urinary tract.
Cranberry juice acidifies urine and makes it MANAGEMENT:
more resistant to bacterial growth. 1. Majority resolve with maturity without
3. Provide warm baths. need for surgery, but until this occurs, teach
 May void into a tub warm water if with painful double voiding and need for prophylactic
urination. antibiotic.
4. Give mild analgesics, such as  Double voiding is having the child void,
acetaminophen, if needed. then in a few minutes attempt to void
 Tylenol may decrease pain and allow voiding. again, which will help empty the
bladder and prevent recurrent infection
5. Encourage perineal hygiene. from urinary stasis. Prophylactic
 Comfort and prevent further infection or re- antibiotic will prevent bladder
infection. infection.

VESICOURETERAL REFLUX 2. If condition is mild, long-term antibiotics

 Vesicoureteral may be as effective as surgery to reduce renal
reflux refers to scarring from recurrent UTIs.
retrograde flow of urine  This is for those with a lower grade of
from the bladder into the reflux, and not for severe cases.
ureters.
 This reflux 3. If continuous antibiotic therapy does not
occurs because the valve prevent recurrent UTIs, reflux can be
that guards the entrance corrected by cystoscopy with injection of
from the bladder to the Deflux to stabilize ureters.
ureter is defective, either  Deflux is dextranomer-hyaluronic acid
from birth or because of which will stabilize the ureter valves.
scarring from repeated
UTIs, bladder pressure that is stronger than usual, 4. Laparoscopic surgery will correct
or ureters that are implanted at abnormal sites or placement of ureters.
angles.
  This involves reinserting the ureters at  Occurs as an immune complex disease
a more oblique angle, creating the from an antigen-antibody reaction after infection
normal valve effect. with group A beta-hemolytic streptococci.
 Common in boys, 5 to 10 years old.

 The antigen-antibody reaction causes a cascade of

proteins which plug or obstruct glomeruli,
HYDRONEPHROSIS leading to tissue damage.
 Enlargement of the kidney  IgG antibodies against streptococci are detected in
pelvis due to a collection of the bloodstream, proof that the illness follows a
urine from back-pressure streptococcal infection.
in the ureter, generally  There are also chronic and IgA
caused by an obstruction. glomerulonephritis, but we will only confine our
discussion to acute post-streptococcal
 As with vesicoureteral glomerulonephritis.
reflux. So, untreated VR can
cause hydronephrosis. ASSESSMENT:
1. Recent pharyngitis, tonsillitis, otitis media,
ASSESSMENT: or impetigo, within 7 to 14 days or up to 3
1. Repeated UTIs weeks.
2. General irritability  Caused by streptococcus, ideally
3. Crying on voiding should have a urinalysis 2 weeks
4. Elevated blood after the infection to evaluate that
pressure as renin- glomerulonephritis is not occurring.
angiotensin system is
activated 2. Sudden onset of hematuria and
5. Flank or proteinuria. Urinary sediment will
abdominal pain contain white blood cells, epithelial cells,
6. Abdominal and red blood cell casts.
palpation reveals  Hematuria is so gross that urine
abdominal mass, the appears tea-colored, reddish-
dilated kidney pelvis brown, or smoky. There is 1+ to 4+
7. Ultrasound protein in a urinalysis and a 24-
shows enlarged pelvis hour urine specimen may contain as
and point of obstruction much as 1 g protein, normally, urine
Treatment is surgical correction of the obstruction contains none. Blood analysis will
before kidney destruction occurs. also show low protein or
hypoalbuminemia.
 As seen in the photo, hydronephrosis leads to
increased intrarenal pressure, causing decreased 3. After these initial urine changes, the child
circulation, and may end with atrophy of the develops oliguria. Specific gravity of urine
kidney. is elevated.
 This will prevent renal failure which may warrant  This would mean fluid retention,
the need for dialysis. hypervolemia, then leading to
edema.
GLOMERULONEPHRITIS
 Glomerulonephritis 4. Due to hypervolemia, hypertension then
is the inflammation of the occurs. If blood pressure is 160/100 may
glomeruli of the kidney. cause encephalopathy.
  Encephalopathy may show signs of Weigh OD and calculate intake and output are
headache, irritability, seizures, essential.
vomiting, or decreasing levels of  Provide high-protein diet to supplement
consciousness. protein loss among those losing large
quantities of proteins.
5. May have edema, abdominal pain, a low-  Restrict salt to reduce severe edema.
grade fever, anorexia, vomiting, or Dialysis
headache. A few children will not completely recover, but
 As a result of the continuous may develop chronic nephritis resulting to
inflammatory reaction. renal insufficiency.
 Peritoneal dialysis may be required if
6. Excessive plasma fluid may lead to cardiac severe renal problems develop.
involvement with signs of orthopnea,
cardiac enlargement, enlarged liver, NEPHROTIC SYNDROME
pulmonary edema, and a galloping heart  Nephrosis is an
rhythm. There may be abnormal altered glomerular
electrocardiographic results. permeability.
 Prevent heart failure by addressing  This is due to fusion
the circulatory overload. of the glomeruli
membrane surfaces
7. Mild anemia occurs as blood volume which leads to abnormal
continuously expands. loss of protein in urine.
 May be given iron.  Cause is an
immunologic mechanism
8. ESR, BUN, and creatinine increases. due to hypersensitivity
 Sign of inflammation, glomeruli to an antigen–antibody
cannot filter properly. reaction or an
autoimmune process, probably from a T-
 Those in bold letters are classical symptoms of lymphocyte dysfunction.
acute post-streptococcal glomerulonephritis.  Common in boys, mostly 3 years old.

MANAGEMENT: Occurs in three forms:

Medications 1. Congenital, which occurs as an autosomal
The course of acute glomerulonephritis is 1 to 2 recessive disorder.
weeks, and is self-limiting. 2. Secondary, as a progression of
 Antibiotics usually are ineffective because glomerulonephritis, sickle cell anemia, or
the disease is not caused by an active systemic lupus erythematosus (SLE).
infection. 3. Idiopathic, no known cause.
 Furosemide is of little value but may be
tried in edema. In children, the congenital form is rare while the
 Calcium channel blockers may decrease idiopathic is the most common.
blood pressure.
 Digitalis may be given in heart failure.
Rest and Activity
Bed rest is not necessary.
 Encourage quiet activities and avoid
competitive play to not stress the kidneys.
Diet
Figure 46.12 shows the process that results in the
signs and symptoms of nephrotic syndrome. There
are 4 characteristic symptoms, and these are:  In NS, laboratory studies will reveal
1. Proteinuria, the increased glomerular marked proteinuria. A single test will show a 1+ to
permeability leads to protein loss in the 4+ protein, while a 24-hour total urine test will
urine. show up to 15 g protein. In APG, it’s only 1 g.
2. Hypoalbuminemia, the same increased  Also, the protein loss in NS is almost
glomerular permeability subsequently entirely albumin, while proteinuria of G is non-
leads to hypoalbuminemia or low serum specific.
albumin level.  Some children with NS also exhibit
3. Generalized edema, to include periorbital hematuria at the onset, but it is minimal in contrast
edema, ascites, and even scrotal edema in to that seen with G.
boys, the low level of protein in the blood,
causes osmotic pressure to fluid shift from
in to out of the cell. Also, as the blood
volume decreases, the kidneys begin to
conserve sodium and water, adding to the
potential for edema.
4. Hyperlipidemia, increased blood lipid
level. This occurs because the liver
increases production of lipoproteins to
compensate for protein loss. Lipids are too
large to be lost in urine, so they rise in the
blood instead.

MANAGEMENT:
1. Begins with a course of daily
corticosteroids, such as IV methylprednisolone
or oral prednisone which may given at home,
to reduce proteinuria and subsequently the
edema.
 Corticosteroids are anti-inflammatory
drugs which will initially address the
immune mechanism causing an altered
glomerular permeability. An initial dose
 of prednisone is given until diuresis  Strong immunosuppressant agents
without protein loss is accomplished. So which may also be used as
every morning, parents must test urine chemotherapy in cancer.
with a chemical reagent strip and
record. Once a week, must need to 8. Reduce Na, eat high protein foods, avoid
collect 24-hour urine specimen so total fats, monitor fluid intake
protein loss can be measured too.  Diet recommendations.

2. Institute measures to keep child free of

infection while the immune system is
suppressed.
 Due to prolonged use of corticosteroids.

3. In about 1 to 2 months, when protein loss

is accomplished and edema subsides,
prednisone may be given every other day.
 Prednisone has the potential to halt
growth. However, growth is apparently
not delayed when the drug is given on
alternate days.

4. Children who respond poorly to

prednisone may need diuretic therapy with
furosemide (Lasix).
 You might be wondering why diuretics
as not given for edema. Diuretics are
not commonly used here because they
tend to cause hypotension and
hypokalemia, which may further
compound the problem. But if
necessary, always check BP and blood K.

5. IV albumin may be administered to

temporarily correct hypoalbuminemia.
 To temporarily increase albumin and
shift fluid into bloodstream. Not long-
term though as albumin is lost in urine.

6. There are no clear guidelines in treating

hyperlipidemia but may try statins, bile acid
sequestrants, and nicotinic acid.
 Hyperlipidemia may lead to CV diseases
and thromboembolism.

7. If all else fails, a course of

cyclophosphamide (Cytoxan), cyclosporine
(Sandimmune), or mycophenolate mofetil
(CellCept), may be effective in reducing
symptoms or preventing relapses