Pediatric Alterations - GU

Orchidopexy

A surgery to move a testicle that has not descended or moved down to its proper place in the scrotum

Hypospadias (Treatment)

Meatotomy - Urethra is extended to a normal position, straightening of the Chordee and then the extension of the Urinary Tube out to the tip of the Penis (Want the child to look normal, Urinate normally, and be sexually adequate) Performed before 18 months, 6-9 months recommended. About 10% will require another operation to manage complications (Normally completed in one outpatient surgery)

Nephrotic Syndrome (Idiopathic - Primary)

Most Common. Progression of Glomerulonephritis. "Minimal Change Disease" Etiology - Immune Response. Immune System is threatened. Secondary results from a Systemic type of infection or invasion

Wilm's Tumor (Etiology)

Most common intra-abdominal tumor in childhood. 6% of childhood cancers are this type of tumor (500 cases/year). Presents at age 2-3 years. Slightly higher incidence rate in African-American. Girls more than boys and unilateral more than bilateral.

Enuresis (Inorganic Factors)

Non-physiological /Physical (Sleep schedule, Sleep disorders such as Tonsils and Adenoids obstruct oxygen, may sleep more soundly or less soundly)

Vesicoureteral Reflux (Pathophysiology)

Normally ureters enter the muscular Bladder at an angle and travel through the bladder mucosa before opening into the interior of the bladder. When bladder pressure rise during urination and during the accumulation of Urine, the length of this mucosal segment of ureter becomes compressed and acts like a valve to prevent back flow urine into ureter and Kidney. In VUR it this mucosal segment of the Ureter does not work.

Wilm's Tumor (Unfavorable)

Not responsive to treatments. Does metastasize to the Brain, Lung, Liver, Bones, or to the unaffected Kidney

Nephrotic Syndrome (Diuretics)

Not that effective because of the Protein Imbalance. Must correct the Protein Imbalance

Cryptorchidism (Treatment)

Orchidopexy. Should be performed during the 2nd year of life (Between 5 - 18 months) and possibly hormone therapy

Bladder Exstrophy (Treatment)

Surgical. Closure is completed within the first 48 hours of life. (Until this happens will place a sterile bag, Wee Bag, to cover and protect it) Can usually be closed without disrupting the Boney Pelvis. Can re-route the urine and have an ileostomy. 2 part surgery and the Genitalia may be in traction as much as three weeks. Continence to correct the Reflux that can happen

Enuresis (Medications)

Synthetic Anti-Diuretic Hormone (Intranasaly) DDAVP, Ditropan (Decrease Bladder Spasm), Tofranil (inhibits Urination - give 1 hr before bed), Ditropan (Decrease Urinary output)

Hypospadias (Clinical Manifestations)

The Prepuce is abnormally small and may look like it has already been circumcised. Associated conditions may include a Chordee, undecended Testes and Inguinal Hernia

Vesicoureteral Reflux (VUR)

The abnormal back flow of urine from the bladder into the Ureters, and possibly the Kidneys. Prevalence is less than 1%. Found in 29-50% of children following UTIs and is the most common raiographic abnormality associated with UTIs in children. May be genetic

Tunica Vaginalis

Thin pouch that holds Testes in the Scrotum

Hydrocele (Diagnosis)

Trans-illumination

Vesicoureteral Reflux (Surgical Management)

Try medical first. Dilate the Ureters, divert the urine to allow the Kidney's and ureters to recover better. Reconstruct Ureters back into the bladder for sufficient length (Ureteroneocystostomy - Reimplantation of the ureter into the bladder) and Subureteric Injection of Polytetrafluoroethylene

Bladder Exstrophy

Gap in the anterior wall of the bladder and the abdominal wall were the anterior/posterior bladder has been exposed on the abdomen. "Mid-line Closure" Defect. (Umbilicus is low set and located just above the bladder)

Nephrotic Syndrome (Glomeruli)

Increases its permeability in response to the inflammation and increases its permeability to Protein. The Protein then goes into the Urine causing the fluid in the Vascular system to switch from Intravascular to Interstitial (Edema) which causes a person to become Hypovolemic (Does not have volume in their vascular system)

Hydrocele (Communicating)

Indicates a massive fluctuation in size. Getting smaller at night and larger during activity. Tunic Vaginalis doesn't close completely allowing fluid to flow in and out.

Hypospadias (Nursing Management - Post-op)

Indwelling Cath. or Stent patency, Assess for pain( Analgesic administration -Tylenol), wound and UTI (Antibiotic administration) and Bladder Spasms (Antispsmotic for bladder spasms -Dirtopan), Monitor I & O, Discharge Teaching

Urethritis

Infection confined to the Urethra

Urinary Tract Infection (UTI)

Infection of one or more structures of the urinary Tract and can be classified as Lower Urinary Tract Infection (Cystitis, Urethritis) or Upper Urinary Tract Infection (Pyelonephritis)

Pyelonephritis

Infection of the Kidney and Renal Pelvis

Glomerulonephritis

Inflammation of the Glomeruli, filtering unit in the Kidney, of the Kidney

Cystitis

Inflammation of the Urinary Bladder. Causes are Bacteria, Virus, Fungus (Most common is E-Coli)

Wilm's Tumor (Nursing Intervention)

Intake/Output, pain control (Esp. first 24 hr), watch out for Nausea, vomiting, constipation, wound care for large Abdominal incision, education regarding the need for long-term follow up

Anatomy of the GU

Kidneys, Ureters, Bladder, and Urethra

Vesicoureteral Reflux (Medical Management)

Long term use of antibiotics, and on occasion use of Ditropan - anticholinergic (helps with bladder spasms and pressure)

Cystitis (Clinical Manifestations)

Low grade fever, Mild Abdominal pain, Enuresis, Burning Urination, Pressure, Frequency

Hypoalbuminemia

Low levels of albumin in the blood

Urinary Tract Infection (Clinical Manifestation)

Malodorous Urine, Dysuria, Urinary Frequency, Fever More Serious - Vomiting, Diarrhea, Irritability, Poor Feeding, or Loss of Appetite. Tap on their flank area on their back, will come off the table because it is so painful

Phimosis (Treatment)

Manual stretching, under anesthesia. Topical Steroids, and Circumcision

Nephrotic Syndrome (Nursing Management)

Measure Intake/Output, Prevent Infection, Fluid and Electrolyte balance, take daily weight (How much fluid are they holding onto), Skin breakdown and watch for s/s of Dehydration and Hypovolemia

Aniridia (Wilm's Tumor)

Congenital absence of the Iris

Phimosis (Physiological)

Foreskin, prepuce, is adherent to the glans at birth but disappears as the infant ages, usually by age 5. About 44% of boys have a fully retractable Foreskin by age 10

Proteinuria

A condition in which urine contains an abnormal amount of protein.

Wilm's Tumor (Pathophysiology)

A fragile thin membrane capsule that may be easily torn or broken usually encloses the tumors.

Wilm's Tumor (Diagnosis)

Abdominal Ultrasound, CT scan of the Abdomen and the Chest, maybe a MRI, CBC, Urinalysis, Blood Chemistry, and Liver function tests are preformed.

Wilm's Tumor (Clinical Manifestations)

Abdominal/Flank Mass (Deep) which presents on one side and seldom crosses the mid-line. Slightly moveable. Painless, although some children experience pain, microscopic or gross Hematuria, Hypertension, and general Malaise

Epispadias Presentation (Female)

Abnormal opening from the Bladder neck to the area above the normal Urethral opening, Widened Pubic Bone, Bladder Exstrophy (may/may not be present), Bifid Clitoris, Rudimentary Labid (underdeveloped), Urinary Incontinence, Reflux Nephropathy, and UTI

Epispadias Presentation (Male)

Abnormal opening from the Pubic Symphysis to the area above teh tip of the penis, Widened Pubic Bone, Bladder Exstrophy (may/may not be present), Short, widened penis with Chordee, Urinary Incontinence, Reflux Nephropathy, and UTI

Cryptorchidism (Where could the Testicles be if not in Scrotum?)

Above the Groin, In the Groin area, Close to top of Scrotum, and when they descend, In the Scrotum

Wilm's Tumor

Also called Nephroblastoma. Tumor that arises in the Kidney. It is a Renal Embryoma, meaning that the tumor is derived from undifferentiated primitive cells. Two types - Favorable and Unfavorable. Rapid growing type of cancer

Hydrocele (Treatment)

Surgery if persists longer than 12 - 18 months. (Small incision into inguinal canal, drain fluid, close opening)

Bladder Exstrophy (Medical Management)

Continuous low dose antibiotics, Liberal fluid intake (Want it to keep working), Voiding regiment, and increase fecal bulk (Do not want constipation to interfere with this at all)

Cystitis (Treatment)

Antibiotics - Penicillin, Amoxicilian, Sulfa, Bactrum

Urinary Tract Infection (Medication)

Antibiotics such as Trimethoprim in combination with Sulfamethoxazole (Bactrim, Septra), Amoxicillin (Amoxil), Cephalosporin, or Nitrofurantoin (Furadantin) given for 7-10 days

Hypospadias (Nursing Management - Pre-op)

Assess for evidence of other genitourinary defects, Educate caregivers on Hypospadias, the surgical procedure, and what to expect following surgery

Nephrotic Syndrome (Cytoxan)

Belongs to a class of drugs known as Alkylating agents, which have been used to treat some types of cancer. It is also considered an immunosuppressant

Hypospadias

Birth defect in which the Urinary Meatus is not at the tip of the penis but on the lower aspect of (Ventral Surface). 7/1,000 male births in US. Can also be on the scrotum or the perineum (Extremely Rare) Can occur in females, generally not a big deal

Nephrotic Syndrome (Congenital)

Born with Nephrotic Syndrome

Epispadas (Tests)

CBC, Serum Electrolytes, Pelvic X-Ray, Intravenous Pyelogram (IVP), Ultrasound of the Urogenital System

Epispadias (Etiology)

Causes are unknown. Believed to be related to improper development of the pubic bone. Epispadias is often associated with Bladder Exstrophy, but can happen without it also

Vesicoureteral Reflux (Back flow)

Causes inflammation and infection of the Ureters which can turn into scar tissue

Nephrotic Syndrome - NS

Clinical entity characterized by Proteinuria (exceeding 3.5 G/dL), Hypoproteinemia, Hypoalbuminemia, Edema, and Hyperlipidemia. There are three forms - Congenital, Secondary, and Idiopathic (Primary)

Ureters

Come down from the Kidneys and empty into the bladder

Hypoproteinemia

Decrease in the amount of protein in the blood to an abnormally low level

Enuresis

Defined as involuntary voiding of Urine beyond the expected age at which voluntary control should be achieved after successful toilet training (Approx. 5-7 yrs) Related to bed wetting. Most is Nocturnal and the Cause is generally unknown

Chordee

Downward curvature of the Penis and an incomplete Foreskin

Bladder Exstrophy (Occurs and Diagnosis)

During the embryonic period. Sometime during the first 8 weeks. Can be diagnosed by a Fetal Sonogram (Ultrasound) and be prepared for, but most often not diagnosed until the baby is born

Urinary Tract Infection (Treatment)

Eradicate the infection, Prevent reinfection (Identifying contributing cause), Correct underlying cause, Preserve Renal function

Hypospadias (Etiology)

Exact etiology unknown. POSSIBLY has something to do with abnormal endocrine function (Some affected boys have defects in their Testosterone metabolism or the receptors of Testosterone -> Potential link with taking Loratadine - Claritin) during pregnancy. Genetic Predisposition (Father or Brother may have also)

Cryptorchidism

Failure of one, or both Testicles, to descend into Scrotum. "Undescended Testes". high incidence seen in premature infants. S/S Scrotum remains small, flat, and under developed (If disorder present, they will have a higher risk of Testicular Cancer and Infertility)

Bladder Exstrophy (Goal of Treatment)

Have and acceptable appearance of the abdominal wall and genitalia while preserving the Kidney and bladder functions and support

Hyperlipidemia

High Lipid levels

Urinary Tract Infection (Etiology)

Higher incidence in males during their first life (Uncircumcised). After 1st year, it is more in females due to decrease size of the Urethra

Enuresis (Psycosocial Problems)

History of UTI, Inappropriate Potty Training, Parents/Grandparents very demanding

Anomalies of the GU

Hypospadias, Epispadias, Phimosis, Exstrophy of the Bladder, Vesicoureteral Reflux

Urinary Tract Infection (Pathophysiology)

In infancy, bacterial frequently enter the Urinary Tract through the blood and cause infections. After infancy, almost all UTI occur when bacteria enter the Urinary Tract by ascending through the Urethra. Males are less susceptible because of the longer Urethra and the Prostate glands secretions that contain Antibacterial Properties. Structural anomalies and abnormal function of the Urinary Tract have an important role in the pathogenesis of UTI

Phimosis (Predisposes)

Paraphimosis - Condition in which the foreskin is trapped behind the glans penis and can not be pulled down to cover the head of the penis

Urethra

Pathway to outside from the bladder

Intravenous Pyelogram (IVP)

Performed to visualize the structures of the Urinary System and the Bladder on an X-Ray

Nephrotic Syndrome (Clinical Manifestation)

Periorbital Swelling (Around Eyes), General Swelling including in the extremities especially in the Feet and Ankles, Swollen Abdomen, Weight Gain, Poor appetite, High B/P

Vesicoureteral Reflux (Presentation)

Persistent and repeated UTIs, may have Enuresis, Flank and Abdominal pain

Phimosis (2 Types)

Physiological and Pathological

Epispadias

Rare congenital defect in which the opening of the Urethra is in an abnormal spot, dorsal or superior surface in males and females present with separation of labia and a Bifid Clitoris. May be a mild form of Bladder Exstrophy. Less common than Hypospadias and more common in males than females

Nephrotic Syndrome (Treatment)

Reduce Protein in the Urine, and subsequently Edema, with Steroids. (Can also give Albumin), Educate about Cushing's Syndrome (Can get with the use of Steroids), Cytoxan and Kidney transplant

Hemihypertrophy (Wilm's Tumor)

Relative increase in size of one-half of the body as compared to the other

Wilm's Tumor (Treatment)

Surgical - Removal of the tumor, Nephrectomy (Removal of the Kidney), Chemo, and Radiation (can contribute to the decrease in the growth of the spine and Scoliosis)

Epispadias (Treatment)

Surgical. (Incontinence is not uncommon and may require a second operation) Completed within the first 48 hours after birth, unless child is not stable. Goal is to preserve the bladder and the function of the bladder, possibly cosmetic construction. Initially during the surgery the Bladder and Abdominal wall are closed

Kidneys

Responsible for filtration

Wilm's Tumor (Favorable)

Responsive to treatment such as radiation and chemotherapy. Favorable prognosis - 92% survival rate

Hydrocele

Result from fluid accumulation in the Tunica Vaginalis. Common in infancy, about 10-20% in full term males. Two types: Non-Communicating and Communicating

Stenosis (Preputial Ring) - Phimosis

Resultant inability to retract a fully differentiated foreskin

Phimosis

Results from tightening of the foreskin over the head of the penis that prevents the foreskin from being pulled back. Present when the foreskin cannot be retracted at an age when it should normally be retractable. (In newborns, is normal but should resolve withing a few months) Usually associated with scarring, causes difficulty in voiding

Nephrotic Syndrome (Secondary)

Results in renal malfunctioning as a result of systemic diseases such as Sickle Cell, Hepatitis, Systemic Lupus Erythematosus, Lead Poisoning, Childhood Cancer or its therapies, or other diseases that ultimately put a stress on the renal system and therefore producing the inflammation

Enuresis (Nursing Management)

See if there are stressors, limit PO intake at night, Alarms on the bed that wake the child when they start to Urinate, Motivational Tools, Bladder stretching exercises, May need to take baths in evening and in the morning, Limit Irritating Foods (Caffeine, Carbonated Drinks, Certain Food Colorings)

Enuresis (Organic Factors)

Something physically/physiologically going on (Neuro Delay - unable to hold it, UTI, Small Bladder for their age, Renal Failure, Excessive infection of Urine -> Diabetes, Chronic Constipation)

Bifid Clitoris

Split into two parts

Nephrotic Syndrome (Hypovolemia)

State of decreased Blood Volume. Because of the state of Hypovolemia, the Liver begins to produce Lipoproteins. Cholesterol begins to rise, Triglycerides begin to rise, everything is under assault. Clots form, blood flow begins to slow, blood flow to Kidneys decrease, and Kidneys begin to fail

Bladder

Stores urine, allowing urination to be infrequent and voluntary.

Vesicoureteral Reflux (Treatment - Surgical)

Subureteric Injection - Teflon, under Cytoscope

Hydrocele (Non-Communicating)

Tunica Vaginalis is not patent and the Hydrocele will actually disappear spontaneously i the first 6 months of life

Nephrotic Syndrome (Diagnosis)

UA (For Protein), RBC Casts, Serum Albumin, Serum Cholesterol, Triglycerides, Hemoglobin, Hematocrit, Platelet Count, Electrolytes, BUN, and Creatinine

Cystitis (Diagnosis)

UA and Urine C&S

Urinary Tract Infection (Diagnosis)

UA and Urine Culture with Sensitivity (Urine C&S)

Wilm's Tumor (Causes)

Unknown. but has been seen in rare anomalies such as Aniridia, Hemihypertrophy, and Urinary defects

Hypospadias (Nursing Management - Discharge Teaching)

Urine will be blood-tinged fro sever days, double diaper, limit activity for 2 weeks, no riding toys, call if decreased UOP (Urinary Out Put) or s/s of infection

Bladder Exstrophy (Description)

Variable in size and generally has a soft, pliable membrane at birth. Bright red and continually drains urine. (Skin can becom excoriated by the urine and should be protected with A&D ointment - At risk for UTI)

Vesicoureteral Reflux (Diagnosis - VCUG)

Voiding Cystourethrogram - Catherterize and fill the bladder with contrast medium (Helps to visualize Bladder outline and Urethra. Shows Reflux of Urine into Ureters and kidney), X-Rays before, during, and after voiding. Diagnosis made 2-3 yrs old