Genitourinary Disorders

1. Genitourinary Disorders Jan Bazner-Chandler CPNP, CNS, MSN, RN

2. Urinary Tract Infection • Most common serious bacterial infection in infants and children • Highest frequency in infancy • Uncircumcised males have a ten-fold incidence

3. 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

4. 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

5. UTI – Males • Infant males • Needs to be investigated • VCUG – ureteral reflux • Ultrasound of kidneys – hydronephrosis or polycystic kidneys • Higher in un-circumcised males

6. 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

7. 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

8. 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

9. 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

10. Urethritis • Urethral irritation due to chemicals or manipulation • Most common in females • Bubble bath, scented wipes, nylon under wear • Self-manipulation • Child abuse

11. 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

12. 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

13. Enuresis • Involuntary discharge of urine after the age by which bladder control should have been established, usually considered to be age of 5 years.

14. 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

15. Pharmacologic Interventions • Pharmacological intervention: • Desmopressin synthetic vasopressin acts by reducing urine production and increasing water retention and concentration • Tofranil: anticholinrgic 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

16. 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

17. Ureteral Reflux • Males 6 to 1 • Genetic predisposition • Present as UTI or FTT • Diagnostic tests • Antibiotics if indicated • Surgery to re-implant ureters

18. Ureteral Reflux

19. Hydronephrosis • Water on kidney • Due to obstruction • Congenital anomaly • Goals of care to maintain integrity of kidney until normal urinary flow can be established.

20. Hydronephrosis

21. Ambiguous Genitalia • Genital appearance that does not permit gender declaration.

22. Agenesis of Scrotum

23. Hypertrophy of Clitoris

24. Extrophy of Bladder • Congenital malformation in which the lower portion of abdominal wall and anterior bladder wall fail to fuse during fetal development.

25. Assessment • Visible defect that reveals bladder mucosa and ureteral orifices through an open abdominal wall with constant drainage of urine.

26. Extrophy of Bladder

27. Extrophy of Bladder

28. 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

29. Multidisciplinary Interventions • Preserve renal function: prevent infection • Attain urinary control • Re-constructive repair • Sexual function

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

31. 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.

32. Hypospadias

33. Tight Chordee

34. Hypospadias Repair

35. Newborn • Circumcision not recommended. • Foreskin may be needed for reconstructive surgery.

36. 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

37. Cryptorchidism • Hidden testicle • 3 to 5% of males • High incidence in premature infants • Goals of treatment: • Preserve testicular function • Normal scrotal appearance

38. 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

39. Testicular Exam • Monthly testicular self-examination is recommended for all males beginning in puberty, but is essential in males with history of undescended testicle.

40. Testicular Torsion • Rotation of the testicle • Spermatic cord twists and obstructs circulation to the testis • Left testicle affected more • Longer cord on left side

41. Assessment • Sudden severe pain in the scrotal area • Highest incidence on left side due to longer cord on that side

42. Goals of Treatment • Surgical intervention • To relieve obstruction • Preserve the testicular function • Secure testicle to avoid further twisting

43. 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.

44. Renal Failure • Newborn causes: • Congenital anomalies • Hypotension • Complication of open heart surgery

45. Renal Failure • Childhood causes: • Dehydration • Glomerular nephritis / Nephrotic Syndrome • Nephro-toxicity / drug toxicity

46. Assessment: ARF • 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

47. Diagnostic Tests • Decrease RBC due to erythropoietin • Urea and Creatinine elevated • GFR (glomerular filtration rate) most sensitive indicator of glomerular function.

48. Goals of Treatment: Acute Renal Failure • Reduce symptoms • Supportive care until renal function returns • Medications – corticosteroids • Dietary restrictions - sodium • Dialysis if indicated

49. 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

50. 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).