Pediatric
Genitourinary
Disorders
Revised Marlene Meador10/11
Pediatric Difference in Urinary
Tract:
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Kidney function
Bladder capacity
Bladder control
Recovery
Urinary Tract Infections
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Etiology and Pathophysiology
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Occur more commonly in girls
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Migration of pathogens
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Escherichia coli most common cause-Why?
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May be bacterial, viral or fungal
Assessment
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Typical symptoms of older children & adults:
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Dysuria
Frequency & urgency
Burning
Hematuria (usually older child)
Symptoms for infants and young children can be
vague and nonspecific:
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Fever
Mild abdominal pain
Enuresis
If severe: High fever, flank pain, vomiting, malaise
Diagnostic Tests

Urine for culture and sensitivity
Clean catch
 Suprapubic aspiration
 Catheterization
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Positive Urinalysis
Bacteria colony count of more than 100,000/ml.
 Presence of protein
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Therapeutic Interventions
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Drug Therapy
Antibiotics
 Analgesics – Tylenol
 Antipyretic
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Nursing Care
Force fluids for rehydration
 Prescribed antibiotics
 Promote comfort
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Therapeutic Interventions
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Parent Teaching
 Change diaper frequently
 Teach girls to wipe front to back
 Discourage bubble baths
 Encourage children to drink periodically during the day
 Bathe daily
 Adolescent start menstruating – encourage change of pad
every 4 hours
 When girls become sexually active – teach to urinate
immediately after intercourse
Evaluation

Follow up
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Return for repeat urinalysis – usually after 72 hours
of treatment to be sure treatment is working
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Girls who have more than three UTI’s, and boys
with first UTI should be referred to urologist for
further evaluation.
Enuresis
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Difficulty with urination control
Nocturnal – Enuresis at night
Diurnal – Enuresis during the day
Primary – Never having experienced a period of
dryness
Secondary – Occurs when a 6-12 month of
dryness has preceded the onset of enuresis
Risk Factors
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Physical
Bladder capacity
Urinary tract abnormality
Neurologic alterations
Obstructive sleep apnea
Constipation
UTI
Pinworm infestation
Diabetes mellitus
Voiding dysfunction
Risk Factors
Emotional
 Family disruption
 Inappropriate pressure during training
 Inadequate attention to voiding cues
 Decreased self-esteem
 Sexual abuse
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Diagnosis
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Diagnosis is based on history and symptoms
Urinalysis and culture are done
Measurement of urine flow and bladder capacity
with voiding cystourethrogram
Treatment
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Limit fluids after supper and void before bed
Imagery
Let child keep record of progress
Rewards can be used
Behavioral use of alarm that detects moisture
Imipramine HCL – Tricyclic Antidepressant
Despropressin acetate – tablet or nasal spray which has
antidiuretic effect
Address the emotional side with all involved
Nursing Diagnoses
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Situational low self-esteem related to bedwetting or urinary incontinence
Impaired social interaction related to bedwetting 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
Vesicoureteral Reflux
Pathophysiology

Urinary Reflux – defective ureterovesicular
valve that guards the entrance from the
bladder to the ureter :
Primary reflux – congenital abnormality
 Secondary reflux – repeated UTI’s
 Neurogenic bladder – stronger than usual bladder
pressure.
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Backflow – while voiding when bladder
contracts, urine is swept up the ureters
Stasis of urine in ureters or kidneys which in
turn leads to hydronephrosis
Assessment
1.
2.
3.
4.
5.
6.
7.
Fever
Vomiting
Chills
Straining or crying on urination, poor urine stream
Enuresis (bedwetting), incontinence in a toilet trained
child, frequent urination
Strong smelling urine
Abdominal or back/flank pain
Diagnostic Tests
1. Urine culture
2. Voiding Cystourethrogram
3. Renal ultrasound
Therapeutic Interventions
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Drug Therapy
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Antibiotics
Penicillin
 Cephalosporins
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Urinary Antiseptics
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Nitrofurantoin
Surgery
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Repair of significant anatomical anomalies,
uretheral implantation
Nursing Care
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Keep accurate record of intake and output
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Secure stents and catheter
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Assess vital signs
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Assess comfort level
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Patient Teaching
Evaluation
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Follow-up:
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Repeat VCUG (voiding cystourethrogram) after a
few months
Test Yourself

Which of the following organisms is the most
common cause of UTI in children?
a.
b.
c.
d.
staphylococcus
klebsiella
pseudomonas
escherichia coli
Bladder Exstrophy
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A rare defect in which the bladder wall extrudes
through the lower abdominal wall
Due to failure of abdominal wall to close in fetal
development
Upper urinary tract usually normal
1:400,000 live births
Treatment is surgical reconstruction in stages
Goals of Surgical Reconstruction
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Bladder and abdominal wall closure
Urinary continence, with preservation of renal
function
Creation of functional and normal – appearing
gentitalia
Improvement of sexual functioning
Nursing Care
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Pre-op focus-prevent infection
Post-operative focus – Immobilize to promote healing
of surgical site
Monitor renal function – assess I&O and urine
chemistries to detect renal damage
Maintain patency of drainage tubes
Analgesics
Antibiotics as ordered
Emotional support of parents
Etiology and Pathophysiology
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Epispadias – rare and often associated with
extrophy of bladder.
Hypospadias
 Occurs from incomplete development of
urethra in utero.
 Occurs in 1 of 100 male children. Increased
risk if father or siblings have defect.
Hypospadias
Assessment
Usually discovered during
Newborn Physical Assessment
Interventions
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Medical Treatment:
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Do NOT circumcise infant. May need to use
foreskin in reconstruction.
Surgery
Reconstructive – repositions uretheral opening at
tip of penis
 Chordee – released and urethra lengthened.
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What do you think?
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The reason for surgery at about 1 year of age is
because:
a. the procedure is less painful for a child
b. chordee may be reabsorbed
c. the child has not developed body image
and castration anxiety
d. the repair increases the ease of toilet training
Post–op Nursing Care
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Assess bleeding
Maintain urinary drainage
Control Bladder Spasms
Prophylactic antibiotics
Control Pain
Increase fluid intake
Do not allow to play on any straddle
toys.
 Prevent infection
 Call Dr if:
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temp is over 101
 loss of appetite
 pus or increased bleeding from stent
 cloudy or foul smelling urine
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Cryptorchidism
Failure of one or both of the testes to
descend from abdominal cavity to the
scrotum
Assessment
Therapeutic Interventions
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Surgery
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Orchiopexy done via laproscopy
Done around 1 year of age
Nursing Care – Post-op
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Assess from bleeding and S/S of infection.
Minimal activity for few day to ensure that the internal
sutures remain intact
Allow opportunity to express fears about mutilation or
castration by playing with puppets or dolls.
Acute
Glomerulonephritis
Etiology and Pathophysiology
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Usual organism: Group A beta-hemolytic
streptococcus
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Organism not found in kidney
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Glomeruli become inflamed
and scarred
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Edema: renal capillary permeability with
renal vascular spasms
glomerular filtration
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accumulation of Na+ and H2O in the blood
stream causing increased intravascular and
interstitial fluid volume
Proteinuria: Protein molecules filter through
the damaged glomeruli
Hematuria: RBCs can pass through to the
urine
Manifestations
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Common in boy 5-10 years old. Occurs 1-2
weeks after a respiratory infection or after
impetigo.
Has 2 phases
 Edematous phase – 4-10 days
 Diuresis phase- self limiting
Assessment
1. Renal:
a. Moderate Proteinuria
b. Sudden onset of hematuria (tea-colored,
reddish-brown, or smoky) and next develops
oliguria
c. Excessive foaming of urine
Assessment Cont…
2. Cardiovascular:
 a. Edema-usually eyes, hands, feet, not
generalized (dependent edema)
 b. Hypertension from hypervolemia which can
lead to
 c. Cardiac involvement CHF- orthopnea /
dyspnea, cardiac enlargement, pulmonary
edema
Assessment cont…
3.Neuro
a. Encephalopathy:
headache
irritability
convulsions
coma-from cerebral edema
Test Yourself

A 6 year old is admitted with R/O acute
glomerular nephritis which of the following
symptoms is the child most likely have?
a.
b.
c.
d.
normal blood pressure, diarrhea
periorbital edema, grossly bloody urine
severe, generalized edema, ascites
severe flank pain, vomiting
Diagnostic Tests
Urinalysis- protein (moderate), RBC's, WBC's, Specific
Gravity elevated.
*All children should have a urinalysis 2 wks after strep
infection.
Blood ASO titer: (antistreptolysin O) (antibody formation against
Streptococcus) is elevated, indicating a recent streptococcal
infection
 ESR: (erythrocyte sedimentation rate) elevated showing
inflammatory process
 BUN: (urea nitrogen) & creatinine elevated indicating
glomerular damage
 CBC:WBCs normal range, H&H decreased.
 Lytes: elevated potassium, low serum bicarbonate
Therapeutic Interventions
1. Depends on the severity of the disease.
No specific treatment, supportive care.
2. Treat at home if normal BP & adequate output.
3. Must be hospitalized if:
BP increases
 gross hematuria
 oliguria present.
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To monitor for complications
*Rarely develops into acute renal failure
Main Goals:
Relieve Hypertension and Re-establish
fluid and electrolyte balance:
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Keep accurate record of I&O.
Record characteristics of urine output
Check and record specific gravity with each
voiding
Monitor vital signs and neuro vital signs
Monitor and record amount of edema at least
once a shift.
Interventions cont…
 Daily weights
 Bed rest for 4-10 days during acute
phase
 Oxygen therapy
 Diet therapy
 Drug therapy
Critical Thinking
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A child is admitted and diagnosed with having
AGN. Prioritize the following nursing
diagnoses.
a. fluid volume excess
b. risk for impaired skin integrity
c. anxiety
d. activity intolerance
Critical Thinking
When teaching parents about known
antecedent infections in acute
glomerulonephritis, which of the following
should the nurse cover?
a.
b.
c.
d.
Herpes simplex
Streptococcus
Varicella
Impetigo
Nephrotic Syndrome
Chronic renal disorder in which the
basement membrane surfaces of the
glomeruli are affected, causing loss of
protein in the urine.
Etiology and Pathophysiology
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Insidious onset with periods of remission / exacerbations
throughout life- No cure
Idiopathic cause (95%) immune response is strongly suspected.
Other causes: may develop after acute glomerulonephritis,
sickle cell disease, Diabetes Mellitus, or drug toxicity.
Age of onset preschool yrs.- 2-4 yrs, males more common
Increased permeability which allows protein to leak into the
urine (proteinuria).
Shift of protein out of the vascular system causes fluid from
the plasma to seep into the interstitial spaces and body cavities,
particularly the abdomen (ascites). Edema and hypovolemia
Assessment
Four most common characteristics:
1. Massive proteinuria
2. Low serum albumin (K+ normal)
3. Edema
4. Malnourishment
Assessment
1.
2.
3.
4.
5.
6.
Hyperlipidemia
Shiny, pale skin
Brittle hair
Hypercoagulability (increased risk for thrombosis)
Fatigue
Abdominal pain (ascites)
Ask Yourself?

Which of the following signs and symptoms are
characteristic of minimal change nephrotic
syndrome?
a.
b.
c.
d.
gross hematuria, proteinuria, fever
hypertension, edema, fatigue
poor appetitie, proteinuria, edema
body image change, hypotension
Diagnostics
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Based on history
Characteristic symptoms
Lab findings with serum albumin and sodium
decreased
BUN, Cholesterol and Electrolytes may be
ordered
Urinalysis reveals massive proteinuria (50
mg/kg/day) (primary indicator of nephrotic
syndrome)
Therapeutic Interventions
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Reduce edema
Keep accurate record of I&O. Measure
abdominal girth, weigh daily
Test urine for protein and specific gravity to
see if tx is effective
Diet:
 Normal diet for child’s age recommended
 No salt added
 High caloric
 Possible fluid restrictions
Treatment
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Diuretics-cautious use
Antihypertensive
Antibiotic
Analgesics
Albumin if resistant to diuretic
Protective Isolation
Interventions
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Provide good skin care – edematous tissue
fragile
Child / Parent teaching – measures to prevent
infections, medication administration,
monitoring of intake and output
Provide rest periods
Prognosis:
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Usually spontaneous resolution even with
relapses (by age 30)
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20% may develop chronic renal failure
If you have any questions or
concerns regarding this
presentation please contact
Marlene Meador RN, MSN, CNE
mmeador@austincc.edu