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Genitourinary

Genitourinary. Common Genitourinary Disorders. Enuresis Urinary Tract Infection Pyelonephritis Vesicoureteral reflux (VUR) Hydronephrosis Cryptorchidism Hypospadius Exstrophy of Bladder Acute Glomerulonephritis Nephrotic Syndrome Acute Renal Failure. Voiding. Toilet Training.

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Genitourinary

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  1. Genitourinary

  2. Common Genitourinary Disorders • Enuresis • Urinary Tract Infection • Pyelonephritis • Vesicoureteral reflux (VUR) • Hydronephrosis • Cryptorchidism • Hypospadius • Exstrophy of Bladder • Acute Glomerulonephritis • Nephrotic Syndrome • Acute Renal Failure

  3. Voiding

  4. Toilet Training • Myelination of spinal cord necessary before child can control bowel and bladder function; occurs between 12-18 months • However, child is usually not ready until 18-24 months • Waiting until 24-30 months makes the job easier

  5. Toilet TrainingAverage age of unirary continence is 3 years of age Expected Developmental Milestones

  6. Signs of Readiness for Toilet Training • Physical Readiness • Child removes own clothes • Child is willing to let go of toy • Child is able to sit, squat, and walk well • Child has been walking for 1 year • Psychological Readiness • Child notices wet diaper • Child indicates need for diaper change • Child communicates need to go to the bathroom and can get there by self • Child wants to stay dry

  7. Parent Readiness • Requires many toileting sessions a day • Need to be able to give child undivided attention • Patience • Personal choice on toilet or free standing potty chair

  8. EnuresisInvoluntary voiding of urine > 6 yrs • Primary • Never achieved dryness for 3 months • Secondary • Dry for 3-6 months then resumes wetness • Diurnal • Wetting occurs only in daytime • Nocturnal • Wetting occurs only in nightime

  9. Organic causes • Neurological delay • UTI • Structural disorder • Chronic renal failure • Disease with polyuria (DM) • Chronic constipation

  10. Non-organic causes • Sleep arousal problem • Sleep disorders from enlarged tonsils, sleep apnea • Psychological stress • Family history • Inappropriate toilet training

  11. Impact on child • May avoid activities • Sports • Sleepovers • Great source of stress • Concealing wet clothing is difficult • Odor is a concern

  12. Enuresis: Nursing Diagnosis • Situational Low Self-Esteem related to bed- wetting or urinary incontinence • Impaired Social Interaction related to bed- wetting or urinary incontinence • Compromised Family Coping related to negative social stigma and increased laundry load • Risk for Impaired Skin Integrity related to prolonged contact with urine

  13. Treatment • Organic- treat underlying cause • Nonorganic- most will outgrow by late childhood

  14. Treatment • Assess parent and child’s motivation and readiness • If willing to be active participant then management includes: • Alarms • Timed voiding • Bladder exercises • Elimination diets • Behavioral therapy • Medications

  15. Management- Bedwetting Alarms

  16. Medication • DDAVP • Ditropan • Tofranil (Imipramine)

  17. Infections

  18. Urinary Tract Infection (UTI) • Most common infection of GI tract • Fecal bacteria (E. coli) cause most UTI’s • Girls>boys after age 1 • In males uncircumcised>circumcised • Can lead to renal scarring, high blood pressure, End Stage Renal Disease

  19. Risk factors for UTI • Urinary tract obstructions • Voiding dysfunction resulting in urinary stasis • Anatomic differences in younger children • Individual susceptibility to infection • Urinary retention while toilet-training • Bacterial colonization of the prepuce of uncircumcised infants • Infrequent voiding • Sexually active adolescent girls

  20. Symptoms in the Infant • Nonspecific • Fever • Irritability • Dysuria (crying when voiding) • Change in urine odor or color • Poor weight gain • Feeding difficulties

  21. Symptoms in the Child • Abdominal or suprapubic pain • Voiding frequency • Voiding urgency • Dysuria • Fever • Malodorus urine • Hematuria • New or increased incidence of enuresis

  22. Diagnostic tests • Urinealysis (UA) • Macro • Micro • 24 hour • Culture and Sensitivity (C & S) • Specimen collection • Clean catch • Pediatric urine collector • Straight cath • Foley cath

  23. Macroscopic Urinalysis (Dip-Stick)

  24. Urine Culture (Colony Count)

  25. Diagnosis • UA (Urinalysis) • Bacteruria • Pyuria • Urine C&S: colony count = 100,000 • Pyelonephritis • Above UA and C&S findings plus • Elevated WBC • Elevated ESR • Increased CRP

  26. Pyelonephritis • Infection travels to kidneys • Same symptoms of UTI plus: • Higher fever • Back or flank pain (CVAT) • Nausea & vomiting • Look sick

  27. Treatment of UTI • 7-10 day of antibiotics by mouth • Dehydrated child and very young often require IV antibiotics • Increase PO fluids • Analgesia • Antipyretics

  28. Treatment of Pyelonephritis • 7-10 days of IV antibiotics • Increase PO fluids • Analgesia • Antipyretics

  29. Prevention • Proper toilet training • Teach proper wiping • Avoid tight clothing • Wear cotton underwear • Encourage children to avoid “holding” urine • Avoid bubble baths • Don’t force cranberry-increases acidity • Adolescent: urinate immediately after intercourse

  30. Structural Defects

  31. Vesicoureteral reflux (VUR) • Malformed valves at ureters and bladder • Allows a backflow of urine up the ureter into the kidney • Can be congenital abnormality, graded 1-5 • Grade 1-3 frequent UTI • Grade 4- 5: massive ureteral and renal pelvis dilation normal reflux

  32. Etiology and symptoms • Genetic origin • Girls>boys • Symptoms • Frequent UTI’s (most common) • Enuresis • Flank pain • Abdominal pain

  33. Treatment • Prophylactic antibiotics • Teach child to double void • Grades 1-3: will usually resolve on own • Grades 4-5: valve repair • Urine C&S every 2-4 months

  34. Hydronephrosis • Enlargement of the pelvis of the kidney • Caused by • Congenital narrowing of the ureteropelvic junction • Kidney stones • Tumors • Blood clots

  35. Symptoms • Usually free of symptoms initially • May have repeated UTI’s (urinary stasis) • Polyuria • Frequency • Flank pain • Increased BP • Abdominal palpation reveals a mass

  36. Management • If untreated can destroy nephrons • Surgical correction of the obstruction

  37. Cryptorchidism (UDT) • One or both testes fail to descend through the inguinal canal into the scrotal sac • In 85% right testis is affected • The affected side or bilateral scrotum appears flaccid or smaller than normal • Unknown why this fails • Increased abd pressure • Hormonal influences

  38. Cryptorchidism (UDT) • Common in the premature infant and LBW infant • Incidence decreases with age • Many resolve spontaneously by 12 months age • If still present at age 1, descent usually does not occur • Associated with lower sperm production • Increased risk for malignant testicle turoms in adulthood

  39. Management • Observation for first year • HCG- stimulates testosterone production and helps with descent • If testis fail to descend between 1-2 years of age then surgical treatment: Orchiopexy

  40. Surgical Management: usually outpatient • Post op instructions • Loose clothing • Incision Care • Monitor for infection • Analgesia • Ice • Discuss future fertility & cancer risk

  41. Hypospadius • Congenital malformation • Urethral opening is below normal placement on glans of penis (ventral surface-underside) • May also have short chordee (fibrous band of the penis, will cause it to curve downward) Epispadius • dorsal placement of urethral opening

  42. Hypospadius, epispadius, chordee

  43. Etiology and Symptoms • Cause is unknown • Defects in testosterone is possible • Possible genetic origin Symptoms • Urinary stream deflected downward • Prepuce is small-Penis appears to look circumcised • May have chordee, undescended testes and inguinal hernia

  44. Management of both • Out patient surgery to lengthens urethra (meatomy), position meatus at penile tip, release the chordee • Performed btw 12-18 mos of age • No circumcision

  45. Post-op: • Stent for urinary drainage and patency • Double Diapering • Strict I&O • Pain Management • Monitor for Infection • No Hip-Holding, ride-on toys • Possible fertility problems

  46. Exstrophy of Bladder • Bladder lies open and exposed on abdomen (defect in abdominal wall) • Bladder is bright red & unable to contain urine • Surgical closure of abdominal wall, reconstruction of bladder, urethra and genitalia “continent urinary reservoir”

  47. Exstrophy of Bladder

  48. Pre op • Prevent infection • Protect skin integrity • Protect exposed bladder • Parental education (straight catheterization) • Keep infant’s legs flexed

  49. Goals of Surgery • Closure of the bladder and abdominal wall • Urinary continence, with preservation of renal function • Creation of functional and normal-appearing genitalia • Correction to promote later sexual functioning

  50. Post Op • Suprapubic catheter-if unable to restore function • Immobilized Pelvis • Strict I&O • Antispasmotics: Probanthine (Pyridium) • Analgesics • Parental Emotional Support

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