Clinical Manifestations

As in most disorders of childhood, the incidence and type of kidney or urinary tract dysfunction change with the age and maturation of the child. In addition, the presenting complaints and the significance of these complaints vary with maturation. For example, a complaint of enuresis has greater significance at age 8 years than at age 4 years. In newborns, urinary tract disorders are associated with a number of obvious malformations of other body systems, including the curious and unexplained but frequent association between malformed or low-set ears and urinary tract anomalies.

Many of the clinical manifestations of renal disease are common to a variety of childhood disorders, but their presence is an indication to obtain further information from the child’s history, family history, and laboratory studies as part of a complete physical examination. Suspected renal disease can be further evaluated by means of radiographic studies and renal biopsy (Table 27-1).

Laboratory Tests

Both urine and blood studies contribute vital information for detection of renal problems. The single most important test is probably routine urinalysis. Specific urine and blood tests provide additional information. Because nurses are usually the persons who collect the specimens for examination and who often perform many of the screening tests, they should be familiar with the test, its function, and factors that can alter or distort the results of the test. The major urine and blood tests are outlined in Tables 27-2 and 27-3.

Nursing Care Management

Nursing responsibilities in the assessment of genitourinary disorders or diseases begin with observation of the child for any manifestations that might indicate dysfunction. Many conditions have specific characteristics that distinguish them from other disorders. These are discussed as appropriate throughout the chapter.

The nurse is generally the one who is responsible for preparing infants, children, and parents for tests and for collection of urine and (sometimes) blood specimens for observation and laboratory analysis (see Preparation for Diagnostic and Therapeutic Procedures, and Collection of Specimens, Chapter 22). An important nursing responsibility is to maintain careful intake and output measurements and blood pressure for most children with genitourinary dysfunction and those who might be at risk for developing renal complications (e.g., children in shock, postoperative patients). For example, any significant degree of renal disease can diminish the glomerular filtration rate (GFR), a measure of the amount of plasma from which a given substance is totally cleared in 1 minute. A number of substances can be used, but the most useful clinical estimation of glomerular filtration is the clearance of creatinine, an end product of protein metabolism in muscle and a substance that is freely filtered by the glomerulus and secreted by renal tubular cells. The nurse’s responsibility in this test is collection of urine, usually a 12- or 24-hour specimen.

Classification

Infection of the urinary tract may be present with or without clinical symptoms. As a result, the site of infection is often difficult to pinpoint with any degree of accuracy. Various terms used to describe urinary tract disorders include:

Etiology

A variety of organisms can be responsible for UTI. Escherichia coli (80% of cases) and other gram-negative enteric organisms are most frequently implicated; these organisms are usually found in the anal and perineal region. Other organisms associated with UTI include Proteus, Pseudomonas, Klebsiella, and Haemophilus spp.; Staphylococcus aureus; and coagulase-negative Staphylococcus organisms. Several factors contribute to the development of UTI in childhood.

Diagnostic Evaluation

The clinical manifestations of UTI depend on the child’s age (Box 27-1). Diagnosis of UTI is confirmed by detection of bacteriuria in urine culture, but urine collection is often difficult, especially in infants and very small children. Several factors may alter a urine specimen, and contamination of a specimen by organisms from sources other than the urine, such as perineal and perianal flora in bag specimens, is the most frequent cause of false-positive results. Unless the specimen is a first morning sample, a recent high fluid intake may indicate a falsely low organism count. Therefore, children should not be encouraged to drink large volumes of water in an attempt to obtain a specimen quickly.

More accurate estimates of bacterial content are obtained from suprapubic aspiration (in children younger than 2 years of age) and properly performed bladder catheterization (as long as the first few milliliters are excluded from collection). The specimen should be taken directly to the laboratory for immediate culture.

Tests to detect bacteriuria are being used with increased frequency in screening for UTI. The dipstick tests for leukocyte esterase or nitrite are quick and inexpensive methods for detecting infection before obtaining final culture results.

Localization of the infection site may involve more specific tests, including percutaneous kidney taps and bladder washout procedures. Other tests, such as ultrasonography, voiding cystourethrogram (VCUG), intravenous pyelogram (IVP), and DMSA (dimercaptosuccinic acid) scan, may be performed after the infection subsides to identify anatomic abnormalities contributing to the development of infection and existing kidney changes from recurrent infection.

Therapeutic Management

The objectives of treatment of children with UTI are to (1) eliminate current infection, (2) identify contributing factors to reduce the risk of recurrence, (3) prevent systemic spread of the infection, and (4) preserve renal function. Antibiotic therapy should be initiated on the basis of identification of the pathogen, the child’s history of antibiotic use, and the location of the infection. Several antimicrobial drugs are available for treating UTI, but all of them can occasionally be ineffective because of resistance of organisms. Common anti-infective agents used for UTI include the penicillins, sulfonamide (including trimethoprim and sulfisoxazole in combination), the cephalosporins, and nitrofurantoin.

If anatomic defects such as primary reflux or bladder neck obstruction are present, surgical correction of these abnormalities may be necessary to prevent recurrent infection. Follow-up study is an important component of medical management because the relapse rate is high and infection tends to recur 1 to 2 months after termination of treatment. The aim of therapy and careful follow-up is to reduce the chance of renal scarring. However, recurrent infection of the urinary bladder predisposes the individual to transient episodes of vesicoureteral reflux (VUR).

Nursing Care Management

Nurses should instruct parents to observe regularly for clues suggesting UTI. Unfortunately, the signs of UTI are not as evident as those of upper respiratory tract infection. Therefore, many cases go undetected because no one thought to investigate this very common problem.

Because infants and young children often are unable to express their feelings and sensations verbally, it is difficult to detect discomfort they may be experiencing from dysuria. A careful history regarding voiding habits, stooling pattern, and episodes of unexplained irritability may assist in detecting less obvious cases of UTI. Consequently, parents should be cautioned to observe for specific clues of UTI in suspected cases.

When infection is suspected, collecting an appropriate specimen is essential. It is the nurse’s responsibility to take every precaution to obtain acceptable clean-voided specimens to avoid the use of other more invasive collecting procedures except when absolutely indicated. Because of the unreliability of a specimen obtained via a urine collection bag, suprapubic aspiration of urine or sterile catheterization should be done in infants and young children who are seen with fever.

Frequently, additional tests are performed to detect anatomic defects. Children are prepared for these tests as appropriate for their age. This includes an explanation of the procedure, its purpose, and what the children will experience (see Preparation for Diagnostic and Therapeutic Procedures, Chapter 22). Sometimes a simple description of the urinary system is helpful. Especially for preschool children, the nurse must clarify that the urinary tract is separate from any sexual function and that the test is for a problem that they did not cause. Children may associate blame for perceived wrongdoing (e.g., masturbation) or unacceptable thoughts with the reason for the illness or the tests. For children younger than 3 to 4 years of age, the procedure can be explained on a doll. For those who are older, a simple drawing of the bladder, urethra, ureters, and kidneys makes the procedure more understandable.

Handling actual equipment when feasible can be helpful in allaying anxiety in children of all ages. Anticipatory instruction on distraction techniques such as deep breathing, storytelling, and imagery may help the child relax and be more cooperative during the actual procedures. If surgery is indicated, facts and understanding of the procedure will help decrease the child’s fear and anxiety concerning more extensive medical-surgical intervention.

Because antibacterial drugs are indicated in UTI, the nurse advises parents of proper dosage and administration. When antiseptics such as nitrofurantoin are used for prolonged therapy to maintain urine sterility, parents need an explanation of the drug’s continued necessity when no signs of infection are present. For all children, an adequate or increased fluid intake is encouraged.

Obstructive Uropathy

Structural or functional abnormalities of the urinary system that obstruct the normal flow of urine can produce renal disorders. When there is interference with urine flow, the backup of urine above the obstruction causes hydronephrosis (dilation of the renal pelvis from distention) with eventual pressure destruction of renal parenchyma, although the dilating ureters form a reservoir that reduces the effect on the kidneys for a long time.

Obstruction may be congenital or acquired, unilateral or bilateral, and complete or incomplete with acute or chronic manifestations. The obstruction can occur at any level of the upper or lower urinary tract (Fig. 27-2). Partial obstruction may not be symptomatic unless there is a water or solute diuresis. Boys are affected more frequently than girls, and malformations should be suspected when patients have some other congenital defects (e.g., prune belly syndrome, chromosomal anomalies, anorectal malformations, defects of the pinna of the ear).

Damage to distal nephrons in chronic uropathy alters the ability to concentrate urine, contributing to increased urine flow and metabolic acidosis occurring from decreased excretion of acid secondary to impaired ability of the distal nephron to secrete hydrogen ions. Partial obstruction results in progressive loss of renal function as a result of irreversible damage to the nephrons. Pooled urine serves as a medium for bacterial growth; therefore, UTIs further increase the extent of renal damage.

Early diagnosis and surgical correction or procedures that divert the flow of urine to bypass the obstruction, such as placement of a temporary percutaneous nephrostomy tube or cutaneous ureterostomy, are essential to prevent progressive renal damage. Medical complications of acute or chronic renal failure (CRF) or infection are managed as described for those disorders.

External Defects

Defects of the external genitourinary tract are serious conditions primarily because of the psychologic impact on the child. Satisfactory surgical repair is successful for the more common disorders and is carried out or initiated as early as possible. The major anomalies of the lower genitourinary tract, their description, and their management are outlined in Table 27-4.

TABLE 27-4

DEFECTS OF THE GENITOURINARY TRACT

DEFECT	THERAPEUTIC MANAGEMENT
Inguinal hernia—Protrusion of abdominal contents through inguinal canal into scrotum	Detected as painless inguinal swelling of variable size Surgical closure of inguinal defect
Hydrocele—Fluid in scrotum	Surgical repair indicated if spontaneous resolution not accomplished in 1 year
Phimosis—Narrowing or stenosis of preputial opening of foreskin	Mild cases—Manual retraction of foreskin and proper cleansing of area Severe cases—Circumcision or vertical division and transverse suturing of foreskin
Hypospadias—Urethral opening located behind glans penis or anywhere along ventral surface of penile shaft	Objectives of surgical correction: Enable child to void in standing position and direct stream voluntarily in usual manner Improve physical appearance of genitalia Produce a sexually adequate organ
Chordee—Ventral curvature of penis, often associated with hypospadias	Surgical release of fibrous band causing the deformity
Epispadias—Meatal opening located on dorsal surface of penis	Surgical correction, usually including penile and urethral lengthening and bladder neck reconstruction (if necessary)
Cryptorchidism—Failure of one or both testes to descend normally through inguinal canal	Detected by inability to palpate testes within scrotum Medical—Administration of human chorionic gonadotropin (older child) Surgical—Orchiopexy Objectives of therapy: Prevent damage to undescended testicle Decrease incidence of malignant tumor formation Avoid trauma and torsion Close inguinal canal Prevent cosmetic and psychologic disability from empty scrotum
Exstrophy of bladder—Eversion of posterior bladder through anterior bladder wall and lower abdominal wall; associated with open pubic arch (a severe defect)	Potential objectives of surgical correction: Preserve renal function Attain urinary control Provide adequate reconstructive repair Improve sexual function (especially in males)
Disorders of Sexual Differentiation
Masculinized female (female pseudohermaphrodite)	Assign gender as female; assign gender while avoiding irreversible surgery, realizing some children may change gender later in life; family participation essential
Incompletely masculinized male (male pseudohermaphrodite)	Assign gender while avoiding irreversible surgery, realizing some children may change gender later in life; family participation essential
True hermaphrodite (both ovaries and testes)	Assign gender while avoiding irreversible surgery, realizing some children may change gender later in life; gender assignment depends on predominant characteristics; family participation essential
Mixed gonadal dysgenesis	Assign gender while avoiding irreversible surgery, realizing some children may change gender later in life; gender assignment depends on predominant characteristics; family participation essential

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