Alteration in Genitourinary function
Lecture 8
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Anatomy and physiology
• The genitourinary is made up of the urinary and
reproductive organs.
• The urinary system of the kidneys, ureters,
bladder and urethra.
• Normal function requires the following:
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Unimpaired renal blood flow.
Adequate glomerular filtration.
Normal Tubular function.
Un obstructed urine flow.
• The functional unit of the kidney is nephron.
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Urinary System Organs
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Nephrons
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Pediatric Differences
• All nephrons are present at birth
• Kidneys and tubular system mature
throughout childhood reaching full maturity
during adolescence.
• During first two years of life kidney function is
less efficient.
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Pediatric Differences
• Kidney begins to reach adult functioning about 1 year of age
• Infants cannot concentrate urine as efficiently as older
children and adults.
• Urine output:
– Infant 2ml/kg/hr
– Children 0.5ml/kg/hr.
– Adolescent 40-80 ml/hr
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Bladder
• Bladder capacity increases with age
• 20 to 50 ml at birth
• 700 ml in adulthood
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Review Genitourinary System
• Maintain fluid & electrolyte balance through
glomerular filtration, tubular reabsorption, and
secretion
• Hormonal functions
– Produces renin in glomerulus—regulates BP
– Produces Erythropoietin—stimulates RBC
production in bone marrow
– Metabolized Vitamin D—to active form which is
important in calcium metabolism
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Urine
Whaley & Wong
Application of urine collection bag.
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Diagnostic Tests
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Urinalysis
Ultrasound
VCUG – Voiding cysto urethrogram
IVP – Intravenous pyelogram
Cystoscopy
CT Scan
Renal Biopsy
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VCUG test
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IVP test
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Renal Biopsy
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Cystoscopy
Invasive surgical procedure
Visualizes bladder and
ureter placement.
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CT Scan
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Urinalysis
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Protein
Leukocytes
Red blood cells
Casts
Specific Gravity
Urine Culture for bacteria
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Treatment Modalities
• Urinary diversion
– Stents
– Drainage tubes
• Intermittent catheterization
– Watch for latex allergies
• Pharmacological management
– Antibiotics
– Anticholinergic for bladder spasm
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Urinary Tract Infections
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Urinary tract infection (UTI)?
• A urinary tract infection is an infection of the
bladder (cystitis) or kidney(s) (pyelonephritis).
• Cystitis is considerably more common than the
more severe and more serious pyelonephritis.
Classification of UTI:
• Urethritis: inflammation of the urethra
• Cystitis: inflammation of the bladder
• Ureteritis: inflammation of the ureters
• Pyelonephritis: inflammation of the upper urinary
tract and kidneys
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Causes urinary tract infections in children
Escherichia coli accounts for 80% of all cases.2
Anatomical factors
– stasis of urine due to incomplete bladder emptying.
– Vesicoureteric reflux (the backward flow of urine from the bladder into
the ureters during voiding)
Physical factors
– The presence of urinary catheters allows ascending infection of the
urinary tract.
– Tight clothing or pants,.
– Bubble baths and shampoos can irritate the ureters in both boys and
girls and increase the risk of developing infection.3
Chemical factors
– An adequate fluid intake promotes flushing of the bladder, thereby
reducing the number of organisms in the urine.
– Urine is slightly acidic and most pathogens favour an alkaline medium.
Certain beverages such as cranberry juice are thought to lower urinary
pH.
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Sign and Symptom
Specific
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Frequency
Urgency
Dysuria
Small volumes of urine passed
Lower abdominal or flank pain
Enuresis in a previously
continent child
Fever
Haematuria
Vomiting
Smell from urine
non-specific
• Failure to thrive
• Vomiting and diarrhoea
• Jaundice
• Pyrexia
• Irritability
• Strong smell from urine
• Persistent nappy rash
• Frequent/infrequent voiding
• Screaming on voiding
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Management
1. Elimination of the current infection
2. Identification of contributing factors in order
to reduce recurrence
3. Prevention of systematic spread of the
infection and the preservation of renal
function.
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Can UTIs in children be prevented
1. Hygiene: Wipe females from front to back during diaper
changes or after using the toilet in older girls. With
uncircumcised males, mild and gentle traction of the
foreskin helps to expose the urethral opening. Most boys
are able to fully retract the foreskin by 4 years of age.
2. Complete bladder emptying:
3. Avoid the carbonated drinks, high amounts of citrus,
caffeine (sodas), and chocolate.
4. Avoid bubble baths
5. Prophylactic antibiotics: Daily low-dose antibiotics under a
doctor's supervision may be used in children with
recurrent UTIs.
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Interventions
• Antibiotic therapy for 7 to 10 days
– E-coli most common organism 85%
– Amoxicillin or Cefazol or Bactrim or Septra
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Increase fluid intake
Cranberry juice
Sitz bath / tub bath
Acetaminophen for pain
Teach proper cleansing
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Enuresis
• Unable to control bladder function although
reached an age at which control of voiding is
expected
• “Nocturnal Enuresis”—Bed wetting
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Pathophys and etiology of Enuresis
• Control of urination is r/t maturation of CNS
• By 5 years, most are aware of bladder fullness
and can control voiding
• Daytime first with nighttime dryness later
• Girls seems to master before boys
• Children with primary enuresis may have delayed
maturations of this part of CNS. They are not able
to “sense” bladder fullness and do not awaken to
void
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Nsg Dx: Enuresis
• low self-esteem r/t bedwetting or urinary
incontinence
• Impaired social interaction r/t bedwetting or
urinary incontinence
• Ineffective family coping r/t negative social
response
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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
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Treatment Enuresis
• Diet control
– Reduce fluids in evening
– Control sugar intake
• Bladder training
– Praise and reward
– Behavioral chart to keep track of dry nights
– Alarm system
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Obstructive uropathy
• Obstructive uropathy is a condition in which
the flow of urine is blocked, causing it to back
up and injury one or both kidneys.
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Ureteral Reflux
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Common causes of obstructive uropathy include:
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Bladder stones
Kidney stones
Benign prostatic hyperplasia (enlarged prostate)
Bladder or ureteral cancer
Colon cancer
Cervical cancer
Uterine cancer
Any cancer that spreads
Problems with the nerves that supply the bladder
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Symptoms may include:
• Mild to severe pain in the middle of the body
(flank pain).
• Fever
• Weight gain or swelling (edema)
• Urge to urinate often
• Decrease in the force of urine stream
• Dribbling of urine
• Not feeling as if the bladder is emptied
• Decreased amount of urine
• Blood in urine
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Treatment
1. Stents or drains placed in the ureter or in a
part of the kidney called the renal pelvis may
provide short-term relief of symptoms.
2. Nephrostomy tubes, which drain urine from
the kidneys through the back, may be used to
bypass the obstruction.
3. A Foley catheter, placed through the urethra
into the bladder, may also be helpful.
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Hypospadias
Incomplete formation
of the anterior urethral
segment.
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Hypospadias
• Incomplete formation of the anterior urethral
segment
• Cordee – downward curve of penis.
• Goal of surgery: to make urinary & sexual
function as normal as possible and improve
appearance of penis
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Nsg Dx: Hypospadius
• Knowledge deficit (parental) r/t diagnosis,
surgical correction, & post-op care
• Risk of infection r/t indwelling catheter
• Impaired physical mobility r/t surgical
procedure of penis
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Extrophy of Bladder
• Interrupted abdominal development in early
fetal life produces an exposed bladder and
urethra, pubic bone separation, and
associated anal and genital abnormalities.
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Extrophy of Bladder
• Occurs is 1 of 400,000 births
• Congenital malformation in which the lower
portion of abdominal wall and anterior
bladder wall fail to fuse during fetal
development.
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Clinical Manifestations
• Visible defect that reveals bladder mucosa and
ureteral orifices through an open abdominal
wall with constant drainage of urine.
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Extrophy of Bladder
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Extrophy of Bladder
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Treatment
• 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
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Goals of Treatment
• Preserve renal function: prevent infection
• Attain urinary control
• Re-constructive repair
• Sexual function
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Long Term Complications
• Urinary incontinence
• Infection
• Body image
• Inadequate sexual function
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Acute Renal Failure
• Sudden interruption of kidney function resulting
from obstruction, reduced circulation, or disease of
the renal tissue
• Results in retention of toxins, fluids, and end
products of metabolism
• Usually reversible with medical treatment
• May progress to end stage renal disease, uremic
syndrome, and death without treatment
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Acute Renal Failure
Causes
– Prerenal
• Hypovolemia, shock, blood loss, embolism, pooling of fluid r/t
ascites or burns, cardiovascular disorders, sepsis
– Intrarenal
• Nephrotoxic agents, infections, ischemia and blockages, polycystic
kidney disease
– Postrenal
• Stones, blood clots, urethral edema from invasive procedures
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Acute Renal Failure
• Subjective symptoms
– Nausea
– Loss of appetite
– Headache
– Lethargy
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Acute Renal Failure
• Objective symptoms
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vomiting
disorientation,
edema,
Increase K+
decrease Na
Increase BUN and
creatinine
Acidosis
uremic breath
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hypertension caused
by hypovolemia,
anorexia
sudden drop in UOP
convulsions, coma
changes in bowels
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Acute Renal Failure
• Diagnostic tests
– BUN, creatinine, sodium, potassium. pH, bicarb. Hgb and
Hct
– Urine studies
– US of kidneys
– KUB
– renal CT/MRI
– Retrograde pyloegram
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Acute Renal Failure
• Medical treatment
– Fluid and dietary restrictions
– Maintain E-lytes
– D/C or change cause
– May need dialysis to jump start renal function
– May need to stimulate production of urine with IV
fluids, Dopomine, diuretics, etc.
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Acute Renal Failure
• Medical treatment
– Hemodialysis
• Subclavian approach
• Femoral approach
– Peritoneal dialysis
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Acute Renal Failure
• Nursing interventions
– Monitor I/O, including all
body fluids
– Monitor lab results
– Watch hyperkalemia
symptoms: malaise, anorexia,
parenthesia, or muscle
weakness, EKG changes
– watch for hyperglycemia or
hypoglycemia if receiving TPN
or insulin infusions
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Maintain nutrition
Safety measures
Mouth care
Daily weights
Assess for signs of heart
failure
– GCS and Denny Brown
– Skin integrity problems
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Chronic Renal Failure
• Results form gradual, progressive loss of renal
function
• Occasionally results from rapid progression of acute
renal failure
• Symptoms occur when 75% of function is lost but
considered chronic if 90-95% loss of function
• Dialysis is necessary R/T accumulation or uremic
toxins, which produce changes in major organs
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Chronic Renal Failure
• Subjective symptoms are relatively same as acute
• Objective symptoms
– Renal
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Hyponaturmia
Dry mouth
Poor skin turgor
Confusion, salt overload, accumulation of K with muscle weakness
Fluid overload and metabolic acidosis
Proteinuria, glycosuria
Urine = RBC’s, WBC’s, and casts
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Chronic Renal Failure
• Lab findings
– BUN – indicator of glomerular filtration rate and is affected
by the breakdown of protein. Normal is 10-20mg/dL.
When reaches 70 = dialysis
– Serum creatinine – waste product of skeletal muscle
breakdown and is a better indicator of kidney function.
Normal is 0.5-1.5 mg/dL. When reaches 10 x normal, it is
time for dialysis
– Creatinine clearance is best determent of kidney function.
Must be a 12-24 hour urine collection. Normal is > 100
ml/min
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Chronic Renal Failure
• Nursing diagnosis
– Excess fluid volume
– Imbalanced nutrition
– Ineffective coping
– Risk for infection
– Risk for injury
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Chronic Renal Failure
• Nursing care
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Frequent monitoring
Hydration and output
Cardiovascular function
Respiratory status
E-lytes
Nutrition
Mental status
Emotional well being
– Ensure proper
medication regimen
– Skin care
– Bleeding problems
– Care of the shunt
– Education to client and
family
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