The Child with Genitourinary Dysfunction



The Child with Genitourinary Dysfunction


Barbara A. Montagnino and Patricia A. Ring



image


evolve.elsevier.com/wong/essentials





Genitourinary Dysfunction


image Assessment of kidney and urinary tract integrity and diagnosis of renal or urinary tract disease are based on several evaluative tools. Physical examination, history taking, and observation of symptoms are the initial procedures. In suspected urinary tract diseases or disorders, further assessment by laboratory, radiologic, and other evaluative methods is carried out. Figure 27-1 provides a review of the kidney and nephron structures.



image Animation—Kidney Function



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).



TABLE 27-1


RADIOLOGIC AND OTHER TESTS OF URINARY SYSTEM FUNCTION





















































































TEST PROCEDURE PURPOSE COMMENTS AND NURSING RESPONSIBILITIES
Urine culture and sensitivity Collection of sterile specimen Determines presence of pathogens and the drugs to which they are sensitive Does not require specific parental permission
Send specimen to laboratory immediately after collection
Catheterization, clean-catch, or suprapubic specimen
Renal and bladder ultrasonography Transmission of ultrasonic waves through renal parenchyma, along ureteral course, and over bladder Allows visualization of renal parenchyma and renal pelvis without exposure to external-beam radiation or radioactive isotopes
Visualization of dilated ureters and bladder wall also possible
Noninvasive procedure
Testicular (scrotal) ultrasonography Transmission of ultrasonic waves through scrotal contents and testis Allows visualization of scrotal contents, including testis
Testicular ultrasonography is used to identify masses, and Doppler-enhanced ultrasonography is used to differentiate hyperemia of epididymo-orchitis from ischemia or torsion
Noninvasive procedure
Scout film Flat plate radiograph of abdomen and pelvis for KUB Detects and establishes renal outlines, presence of calculi, or opaque foreign bodies in bladder Prepare as for routine x-ray film
Voiding cystourethrography Contrast medium injected into bladder through urethral catheter until bladder is full; films taken before, during, and after voiding Visualizes bladder outline and urethra, reveals reflux of urine into ureters, and shows complications of bladder emptying Prepare child for catheterization
Radionuclide (nuclear) cystogram Radionuclide-containing fluid injected through urethral catheter until bladder is full; images generated before, during, and after voiding Alternative to voiding cystourethrography in children with allergy to intravesical contrast material
Allows evaluation of reflux, although visualization of anatomic details is relatively poor
Prepare child for catheterization
Reassure patient and parents that allergic response to contrast materials is avoided by use of radionuclide
Radioisotope imaging studies Contrast medium injected intravenously; computer analysis to measure uptake or washout (excretion) for analysis of organ function DTPA radioisotope used to measure GFR; estimate of differential renal function and renal washout to determine presence and location of upper urinary tract obstruction
DMSA radioisotope used to visualize renal scars and differential renal function; does not visualize ureters and bladder
MAG3 radioisotope combines features of DTPA (evaluation of upper urinary tract obstruction) with features of DMSA radioisotope (differential renal function)
Insert or assist with insertion of IV infusion
Monitor IV infusion
Urethral catheterization may accompany DTPA radioisotope scan; prepare child for catheterization when indicated
IVP (IV urography; excretory urography) IV injection of a contrast medium
Medium secreted and concentrated by tubules
X-ray films made 5, 10, and 15 minutes after injection; delayed films (30, 60 minutes, and so on) are obtained if obstruction suspected
Defines urinary tract
Provides information about integrity of kidneys, ureters, and bladder
Retroperitoneal masses visualized when they shift position of ureters
Preparation for test:
Infants up to 2 years of age—no solid food; omit one bottle on morning of examination; perform studies early to avoid withholding of fluids
Children ages 2–14 years—give cathartic evening before examination, nothing orally after midnight, enema (soapsuds) morning of examination
CT Narrow-beam x-rays and computer analysis provide precise reconstruction of area Visualizes vertical or horizontal cross section of kidney
Especially valuable to distinguish tumors and cysts
Noncontrast scan is noninvasive
Contrast-enhanced CT scan preparation similar to that for IVP
Cystoscopy Direct visualization of bladder and lower urinary tract through small scope inserted via urethra Investigation of bladder and lower tract lesions; visualizes ureteral openings, bladder wall, trigone, and urethra Give nothing orally after midnight
Carry out preoperative preparations
Prepare the child for cystoscopy
Retrograde pyelography Contrast medium injected through ureteral catheter Visualizes pelvic calyces, ureters, and bladder Give cathartic if ordered
Give preoperative medication if ordered
Observe for reaction to contrast medium
Monitor vital signs after procedure
Renal angiography Contrast medium injected directly into renal artery via catheter placed in femoral artery (or umbilical artery in newborn) and advanced to renal artery Visualizes renal vascular system, especially for renal arterial stenosis Prepare child for insertion of a spinal needle or perfusion catheter in renal pelvis (anesthetic often required)
Whitaker perfusion test Injection of contrast material through renal pelvis and ureters
Measures pressures in renal pelvis and urinary bladder
Determine presence of obstruction causing upper urinary tract dilation  
Renal biopsy Removal of kidney tissue by open or percutaneous technique for study by light, electron, or immunofluorescent microscopy Yields histologic and microscopic information about glomeruli and tubules; helps distinguish among types of nephritic syndromes
Distinguishes other renal disorders
Nothing orally 4–6 hours before test
Premedicate as ordered
Prepare setup for procedure
Assist with procedure
Take vital signs
Apply pressure to area with pressure dressing and, if feasible, a sandbag
Bed rest for 24 hours
Observe for abdominal pain, tenderness
Monitor input and output
Surgical incision may be required in infants
Urodynamics Set of tests designed to measure bladder filling, storage, and evacuation functions
Uroflowmetry—Test to determine efficiency of urination
Cystometrography—Graphic comparison of bladder pressure as a function of volume
Voiding pressure study—Comparison of detrusor contraction pressure, sphincter electromyelogram, and urinary flow
Determine characteristic of voiding dysfunction
Used to identify type (cause) of incontinence or urinary retention
Especially valuable for voiding dysfunction complicated by urinary infection, urinary retention, or neurogenic bladder dysfunction
Prepare child for urinary catheterization
The bladder will be filled with saline solution, and filling pressures will be recorded; the child may experience fullness, coolness from the saline fluid, and urine leakage during the study
Insertion of needles may be required for sphincter EMG


image


image


CT, Computed tomography; DMSA, dimercaptosuccinic acid; DTPA, diethylenetriamine pentaacetic acid; EMG, electromyography; GFR, glomerular filtration rate; IV, intravenous; IVP, intravenous pyelography; KUB, kidney, ureters, and bladder; MAG3, mercaptoacetyltriglycine.



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.



TABLE 27-2


URINE TESTS OF RENAL FUNCTION












































































































TEST NORMAL RANGE DEVIATIONS SIGNIFICANCE OF DEVIATIONS
Physical Tests
Volume Age related
Newborn—30–60 ml
Children—Bladder capacity (oz) = Age (years) + 2
Polyuria
Oliguria
Osmotic factors (urinary glucose level in diabetes mellitus)
Retention caused by obstructive disease
Inadequate bladder emptying caused by neurogenic bladder or obstructive disorder
Anuria Obstruction of urinary tract; ARF
Specific gravity With normal fluid intake—1.016–1.022
Newborn—1.001–1.020
Others—1.001–1.030
High Dehydration
Presence of protein or glucose
Presence of radiopaque contrast medium after radiologic examinations
Low Excessive fluid intake
  Distal tubular dysfunction
  Insufficient ADH
  Diuresis
Osmolality Newborn—50–600 mOsm/L Fixed at 1.010 Chronic glomerular disease
Thereafter—50–1400 mOsm/L High or low Same as for specific gravity
More sensitive index than specific gravity
Appearance Clear pale yellow to deep gold Cloudy
Cloudy reddish pink to reddish brown
Light
Dark
Red
Contains sediment
Blood from trauma or disease
Myoglobin after severe muscle destruction
Dilute
Concentrated
Trauma
Chemical Tests
pH Newborn—5–7
Thereafter—4.8–7.8
Average—6
Weak acid or neutral
Alkaline
If associated with metabolic acidosis, suggests tubular acidosis
If associated with metabolic alkalosis, suggests potassium deficiency
Urinary infection
Metabolic alkalosis
Protein level Absent Present Abnormal glomerular permeability (e.g., glomerular disease, changes in blood pressure)
Most kidney disease
Orthostatic in some individuals
Glucose level Absent Present Diabetes mellitus
Infusion of concentrated glucose-containing fluids
Glomerulonephritis
Impaired tubular reabsorption
Ketone levels Absent Present Conditions of acute metabolic demand (stress)
Diabetic ketoacidosis
Leukocyte esterase Absent Present Can identify both lysed and intact WBCs via enzyme detection
Nitrites Absent Present Most species of bacteria convert nitrates to nitrites in the urine
Microscopic Tests
WBC count <1 or 2 >5 polymorphonuclear leukocytes/field Urinary tract inflammatory process
Lymphocytes Allograft rejection
Malignancy
RBC count <1 or 2 4–6/field in centrifuged specimen Trauma
Stones
Glomerular injury
Infection
Neoplasms
Presence of bacteria Absent to a few >100,000 organisms/ml in centrifuged specimen UTI
Presence of casts Occasional Granular casts
Cellular casts
 WBC
 RBC
Hyaline casts
Tubular or glomerular disorders
Degenerative process in advanced renal disease
Pyelonephritis
Glomerulonephritis
Proteinuria; usually transient


image


ADH, Antidiuretic hormone; ARF, acute renal failure; RBC, red blood cell; UTI, urinary tract infection; WBC, white blood cell.




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.



Genitourinary Tract Disorders and Defects


Urinary Tract Infection


image Case Study—Urinary Tract Infection


image Infection of the genitourinary tract is one of the most common conditions of childhood. Up to 10% of children will have a febrile urinary tract infection (UTI) during the first 2 years of life (Kanellopoulos, Salakos, Spiliopoulou, and others, 2006). Among febrile boys, circumcision status is important in determining the risk for UTI. Uncircumcised male infants younger than 3 months of age had the highest prevalence of UTI (20.1%) of any group, male or female (Shaikh, Morone, Bost, and others, 2008). Circumcision status should be assessed in male infants with unexplained fever. UTI may involve the urethra and bladder (lower urinary tract) or the ureters, renal pelvis, calyces, and renal parenchyma (upper urinary tract). Because it is often impossible to localize the infection, the broad designation UTI is applied to the presence of significant numbers of microorganisms anywhere within the urinary tract except the distal third of the urethra, which is usually colonized with bacteria.



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:



Bacteriuria—Presence of bacteria in the urine


Asymptomatic bacteriuria—Significant bacteriuria (usually defined as >100,000 colony-forming units [CFUs]) with no evidence of clinical infection


Symptomatic bacteriuria—Bacteriuria accompanied by physical signs of UTI (dysuria, suprapubic discomfort, hematuria, fever)


Recurrent UTI—Repeated episode of bacteriuria or symptomatic UTI


Persistent UTI—Persistence of bacteriuria despite antibiotic treatment


Febrile UTI—Bacteriuria accompanied by fever and other physical signs of UTI; presence of a fever typically implies pyelonephritis


Cystitis—Inflammation of the bladder


Urethritis—Inflammation of the urethra


Pyelonephritis—Inflammation of the upper urinary tract and kidneys


Urosepsis—Febrile UTI coexisting with systemic signs of bacterial illness; blood culture reveals presence of urinary pathogen



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.



Anatomic and Physical Factors

The structure of the lower urinary tract is believed to account for the increased incidence of bacteriuria in females (Rosenthal, 2004). The short urethra, which measures about 2 cm (0.75 inch) in young girls and 4 cm (1.6 inches) in mature women, provides a ready pathway for invasion of organisms. In addition, the closure of the urethra at the end of micturition may return contaminated bacteria to the bladder. The longer male urethra (as long as 20 cm [8 inches] in an adult) and the antibacterial properties of prostatic secretions inhibit the entry and growth of pathogens.



The single most important host factor influencing the occurrence of UTI is urinary stasis. Ordinarily, urine is sterile, but at 37° C (98.6° F), it provides an excellent culture medium. Under normal conditions, the act of completely and repeatedly emptying the bladder flushes away any organisms before they have an opportunity to multiply and invade surrounding tissue. However, urine that remains in the bladder allows bacteria from the urethra to rapidly become established in the rich medium. Incomplete bladder emptying (stasis) may result from reflux (see Vesicoureteral Reflux, p. 909), anatomic abnormalities (especially those involving the ureters), dysfunction of the voiding mechanism, or extrinsic ureteral or bladder compression that may be caused by constipation. The key to preventing UTI is to maintain adequate blood supply to the bladder wall by avoidance of overdistention and high bladder pressure.



Altered Urine and Bladder Chemistry

image Animation—Bladder


image Several mechanical and chemical characteristics of the urine and bladder mucosa help maintain urinary sterility. Increased fluid intake promotes flushing of the normal bladder and lowers the concentration of organisms in the infected bladder. Diuresis also seems to enhance the antibacterial properties of the renal medulla.


Most pathogens favor an alkaline medium. Normally, urine is slightly acidic with a median pH of 6. A urine pH of about 5 hampers but does not eliminate bacterial multiplication. Much has been reported about the use of cranberry products to increase urine acidity in an effort to prevent UTI. Recent review of the literature in adult subjects supports the use of cranberry products in reducing the incidence of UTI in women (Jepson, Mihaljevic, and Craig, 2008). Results of one study in children suggests that daily consumption of concentrated cranberry juice can prevent recurrence of symptomatic UTIs (Ferrara, Romaniello, Vitelli, and others, 2009). Further research that controls for type of cranberry product used, dosing regimens, and patient selection based on age and underlying medical condition is required to clarify unanswered questions before recommendations can be made regarding the use of this supplement, especially in the pediatric population.



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).



Vesicoureteral Reflux

Vesicoureteral reflux refers to the abnormal retrograde flow of bladder urine into the ureters. During voiding, urine is swept up the ureters and then flows back into the empty bladder, where it acts as a reservoir for bacterial growth until the next void. Primary reflux results from congenitally abnormal insertion of ureters into the bladder; secondary reflux occurs as a result of an acquired condition.


It is not clear that reflux necessarily causes infections. What is clear is that reflux is more likely to be associated with recurring kidney infections rather than simple bladder infections (cystitis). In the presence of reflux, infected urine (bacteria) from the bladder has access to the kidney, resulting in kidney infections (pyelonephritis). These children are usually very symptomatic with high fevers, vomiting, and chills. Reflux, when associated with UTI, is the most common cause of renal scarring in children. Renal scarring may occur with the first episode of febrile UTI. Reflux in the presence of sterile urine does not cause renal damage. Therefore, the most important concept in managing VUR is preventing bacteria from reaching the kidneys. VUR is managed conservatively with daily low-dose antibiotic therapy. A urine culture should be done every 2 to 3 months and any time the child has a fever. This method of management requires a motivated, reliable, and cooperative family. Many children outgrow the reflux over a period of years. An annual VCUG is done to assess the status of the reflux.


For children with mild to moderate reflux, a minimally invasive endoscopic option (subtrigonal injection or STING) is an alternative to daily antibiotics or open surgical intervention. A bulking agent—dextranomer–hyaluronic acid polymer (Deflux)—is injected into the mucous membrane of the ureter, making retrograde flow of urine more difficult. Overall cure rates relate to degree of reflux and range from 67.4% to 88.3%, although more than one injection may be needed to achieve resolution (Chen, Yeh, and Chou, 2010).


Indications for open surgical intervention include significant anatomic abnormality at the ureterovesical junction, recurrent UTIs, severe forms of VUR, noncompliance with medical therapy, intolerance to antibiotics, and VUR after puberty in women.




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.



Prevention

Prevention is the most important goal in both primary and recurrent infection, and most preventive measures are simple hygienic habits that should be a routine part of daily care (see Nursing Care Guidelines box). For example, parents are taught to cleanse their infant’s genital areas from front to back to avoid contaminating the urethral area with fecal organisms. Girls are taught to wipe from front to back after voiding and defecating. Children should void as soon as they feel the urge (see Critical Thinking Case Study box).




Sexually active female adolescents are advised to urinate as soon as possible after they have intercourse to flush out bacteria introduced during the activity. Children who have recurrent UTIs or neurogenic bladder are frequently maintained on daily low-dose antibiotics. Giving the dose at bedtime allows the drug to remain in the bladder overnight. The nurse should reinforce the importance of compliance to parents and older children.



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.



Nursing Care Management


Nursing goals in urinary tract obstruction include helping to identify cases, assisting with diagnostic procedures, and caring for children with complications (described elsewhere). Preparing parents and children for procedures is a major nursing responsibility. Preparation for urinary diversion procedures is of special importance (see Preparation for Diagnostic and Therapeutic Procedures, Chapter 22).


Parents and children need emotional support and counseling during the lengthy management of these disorders. Many children are discharged with ureteral drainage systems in place that must be protected from damage, and the danger of infection is a constant concern. Parents are taught to care for the equipment and recognize the signs of possible obstruction or infection within the system. Maintaining adequate urine flow is imperative. Fluids should be encouraged. The tube should be observed frequently for indications of obstruction resulting from sediment, small blood clots, or kinking. The physician should inspect any drainage from around the tube.


Children with external diversional systems need psychologic support and guidance, especially as they reach adolescence and body image concerns assume more prominence. Those with progressive renal deterioration may face the prospect of dialysis or transplantation and the emotions that accompany these procedures.



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

Jan 16, 2017 | Posted by in NURSING | Comments Off on The Child with Genitourinary Dysfunction
Premium Wordpress Themes by UFO Themes