Aim
To show an in-depth understanding of the
genito-urinary disorders in children and the
process of care in the nursing management
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
 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
 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.
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
Urine formed in the nephron,
passes into renal pelvis, through
ureter into bladder and out of
body through urethra
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
 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
 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.

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-tocreatinine ratio (BUN:creatinine). 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.
 KUB (Kidney, Ureter, Bladder) x-ray
 Renal Biopsy
Renal Ultrasound
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
 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)
 Urinary tract infection (UTI)
 Nephrotic syndrome
 Acute Post-Streptococcal
Glomerulonephritis (APSGN)
 Vesicoureteral reflux
 Hypospadias
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
 Girl>Boy - Female has shorter urethra
 Uncircumcised male prone to develop UTI
 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
 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
Unexplained fever
(febrile fits)
Abdominal
pain
Poor
growth
Foul-smelling
urine
Irritability
Poor feeding
Vomiting
Weight loss
(failure to weight gain)
 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
 Central pyrexia but peripherally cold
 Poor colour
 Pale, grey mottled skin
 Quiet and lethargic child
 Poor tone
 Tachycardic and hypertensive

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.



Ultrasound
Plain x-ray
Micturating Cystourethrogram (MCUG)
 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
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
1.
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
• baseline obs.
• to maintain hydration
• to maintain an
optimum body temp.
• to reduce the body
heat
• give tepid-sponging with luke-warm • to reduce body heat
water
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 • as baseline obs.
burning sensation during micturation
• assess the colour & odour of urine
• as baseline obs.
• strict I/O chart
• to observe urinary
frequency
• administer antibiotics as prescribed • to prevent spread
of infection
• to prevent
• observe for signs & symptoms of
complications
serious infection
 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
You are required to do the nursing care plan for
problem no. 3 & 4, including nursing
interventions and rationales
 Alteration of glomerular
membrane permeability with
massive proteinuria,
hypoalbuminaemia,
hyperlipidaemia and oedema
 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
 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.
 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
 1 : 50 000 children
 Males > females
 Common age of onset is between 2 to 6 years,
but can occur at any age
 Oedema
 ↓ urine output
- initially noted in the
periorbital area
- ascites
- intense scrotal
oedema
- striae may appear
due
to skin overstretching
- pitting oedema
 ↑ weight
 Proteinuria (foamy urine





indicates proteinuria)
Fatigue
Irritable and depression
Severe recurrent
infections
Anorexia
Wasting of skeletal
muscles
 Urinalysis
- protein 3+ - 4+ on dipstick
- haematuria may be absent or microscopic
 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
1.
2.
3.
4.
Generalised oedema due to fluid volume
excess related to glomerular dysfunction
Impaired skin integrity related to oedema
Altered urinary pattern related to glomerular
dysfunction
Increased susceptibility to infection related to
disease process and steroid therapy
5.
6.
7.
8.
Altered body image (round face) due to sideeffects 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
Goal : to relieve oedema
Nursing interventions
 Administer steroids – prednisolone 2-4mg/kg
to control oedema
 Observe for side-effects of steroids – Cushing’s
syndrome (moon face, abdominal distension,
striae, ↑ appetite, ↑ weight, aggravation of
adolescent acne)
 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
diaper’s wt.
 Measure daily weight and abdominal girth –
to check any weight gain due to water
retention
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 child’s head to reduce periorbital oedema
 Provide good skin care – give bath and
maintain hygiene esp. genitals and moist
area
 Change bedding daily and free from creases
 For problems 3 – 9, you are required to look for
the nursing interventions yourself.
 Admission to ward
 Explain to parents nature of illness
 Blood for FBC/DC, U +E, Creat., Serum lipid,




C&S, LFT, serum albumin
For CXR and Echo
Daily urine dipstick for protein, ME and C&S –
every morning
Daily BP, weight and abdominal girth
Start on IV infusion
 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
 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
Question and Answer
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.
 Fever >39ºC
 Irritability
 Poor feeding
 Vomiting
 Dysuria as evidenced by crying when passing
urine
 Change in urine colour or odor
 Abdominal or suprapubic pain
 Frequency in passing urine
 Urgency in passing urine
 Dysuria
 New or increased incidence of
enuresis
 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
 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
 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
GRADE IV:
moderate dilatation
of ureter,
pelvis and calyces
GRADE V:
gross dilatation
of ureter,
pelvis and calyces
Reflux can be divided into 2 categories :1.
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
2.
SECONDARY REFLUX
- occurs as a result of acquired bladder
dysfunction
 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
 Surgery – reimplantation of the ureter into the
bladder
 Indicated due to recurrent UTI despite
antibiotics, Grade 5 reflux or progressive renal
injury
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
 Occurs from incomplete development of the
urethra in utero
 Exact causes unknown – may be genetic,
environmental or hormonal factor
 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
 The choice of surgical correction is affected
primarily by the severity of the defect
 Surgery is done when the child’s age is less
than 18 months
 Reconstruction of the meatal opening is done –
Meatal advancement granuloplasty (MAGPI)
The goal for surgical correction: To enhance the child’s 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
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.
The End