chapter 44 genitourinary dysfunction all elsevier items and derived items © 2014, 2010, 2006, 2002,...

Chapter 44

Genitourinary Dysfunction

All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Physical examination History taking Observation of symptoms Laboratory, radiologic, or other evaluation

methods

Renal System Assessment

2All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.

Renal System Assessment (Cont.)


Urinary tract infections Infection of the urinary tract: one of the most common

conditions of childhood Often impossible to localize the infection High incidence of infection among uncircumcised

boys younger than 3 months

Genitourinary Tract Disorders and Defects


Recurrent: repeated episodes Persistent: bacteriuria despite antibiotics Febrile: typically indicates pyelonephritis Cystitis: inflammation of the bladder Pyelonephritis: upper urinary tract and kidneys Urosepsis: bacterial illness; urinary pathogens in

blood

Types of Urinary Tract Infections


A variety of organisms are responsible Escherichia coli (80%) Proteus organisms Pseudomonas organisms Klebsiella organisms Staphylococcus aureus Haemophilus organisms Coagulase-negative staphylococci

Causes of Urinary Tract Infections


Structure of the lower urinary tract is believed to account for the increased incidence of infection in females

Single most important contributing factor is stasis

Vesicoureteral reflux, anatomic abnormalities, dysfunction of the voiding mechanism or bladder compression are conducive to infection

Urinary Tract Infections: Anatomic and Physical Factors


Any child who exhibits the following should be evaluated Incontinence in a toilet-trained child Strong or foul-smelling urine Frequency or urgency

Diagnostic Evaluation of Urinary Tract Infections


Urine culture and sensitivity Suprapubic aspiration Percutaneous kidney taps Bladder washout procedure Ultrasonography Voiding cystourethrography Intravenous pyelography Dimercaptosuccinic acid renal scan

Diagnostic Evaluation of Urinary Tract Infections (Cont.)


Eliminate current infection Penicillins, sulfonamide, cephalosporins,

nitrofurantoin Identify contributing factors to reduce the risk of

recurrence Prevent systemic spread of infection Ensure adequate or increased fluid intake Preserve renal function

Therapeutic Management of Urinary Tract Infections


Instruct parents to observe regularly for signs of infection

Tell patients that simple hygiene habits should be routine

Teach patients to cleanse genital area from front to back

Encourage sexually active adolescent girls to urinate as soon as possible after intercourse

Prevention of Urinary Tract Infections


Structural or functional abnormalities that obstruct normal flow

Backup of the urine above the obstruction causes hydronephrosis

Condition may be acquired, unilateral, bilateral, complete, or incomplete

Early diagnosis and surgical correction are essential

Obstructive Uropathy


Obstructive Uropathy (Cont.)


Defects of the external genitourinary tract Major anomalies of the lower genitourinary tract:

surgical repair required Psychologic problems related to genital surgery

External Defects


Clinical state Proteinuria Hypoalbuminemia Hyperlipidemia Edema Massive urinary protein loss

Nephrotic Syndrome


Nephrotic Syndrome (Cont.)


Primary disease Also known as

• “Idiopathic nephrosis”• “Childhood nephrosis”• “Minimal nephrotic syndrome”

Secondary nephrotic syndrome In association with glomerular damage

Congenital nephrotic syndrome Autosomal recessive disorder

Types of Nephrotic Syndrome


Glomerular membrane Normally impermeable to large proteins Becomes permeable to proteins, especially albumin Albumin lost in urine (hyperalbuminuria) Serum albumin decreased (hypoalbuminemia) Fluid shifts from plasma to interstitial spaces

Pathophysiology of Nephrotic Syndrome


Supportive care Reducing excretion of urinary protein Reducing fluid retention in the tissues Preventing infection Minimizing complications related to sepsis

Therapeutic Management of Nephrotic Syndrome


Risk for infection Loss of appetite Salt restriction Fluid restriction Activity adjustment Family support and home care

Care Management of Nephrotic Syndrome


Primary event or manifestation of another disorder

Acute after streptococcal infection After infection with certain strains of hemolytic

streptococcus Latent period of 10-21 days

Acute Glomerulonephritis


Oliguria, edema, hypertension Hematuria

Bleeding in upper urinary tract causes urine to appear smoky

Proteinuria Increased amount of protein reflects increased

severity of renal disease

Glomerulonephritis Symptoms


Almost all children with a diagnosis of acute poststreptococcal glomerulonephritis recover completely

Specific immunity is conferred Subsequent recurrences are uncommon Some children have been reported to develop

chronic disease

Prognosis of Glomerulonephritis


Manage edema Daily weight measurements Accurate input and output Daily abdominal girth measurements

Nutrition Low sodium Fluid restriction

Susceptibility to infections

Care Management of Glomerulonephritis


Pathophysiology Uncommon acute renal disease

Diagnostic evaluation Anemia, thrombocytopenia, renal failure

Therapeutic management Prognosis

Recovery rate of 95%

Hemolytic-Uremic Syndrome


Also called “nephroblastoma” Malignant renal and intraabdominal tumor of

childhood Three times more common in African American

children Peak age at diagnosis: 3 years More frequent in boys

Wilms’ Tumor


Causes Diagnostic evaluation

Abdominal swelling or mass Therapeutic management

Surgical removal Chemotherapy, radiation, or both

Nursing alert Do not palpate abdomen

Wilms’ Tumor (Cont.)


Acute renal failure (ARF) Inadequate perfusion Kidney disease Urinary tract obstruction

Chronic renal failure (CRF) Long-standing kidney disease Congenital anomaly

Renal Failure


Definition: kidneys suddenly unable to regulate volume and composition of urine

Not common in childhood Principal feature: oliguria

Associated with azotemia, metabolic acidosis, and electrolyte disturbances

Most common pathologic cause: transient renal failure resulting from severe dehydration

Acute Renal Failure


Pathophysiology: usually reversible Diagnostic evaluation

Patient: may be critically ill Laboratory measurements

Therapeutic management Treatment of underlying cause Management of complications Supportive therapy

Acute Renal Failure (Cont.)


Hyperkalemia Hypertension Anemia Seizures Hypervolemia Cardiac failure with pulmonary edema

Complications of Acute Renal Failure


More than 50% of the functional renal capacity is destroyed

Begins when diseased kidneys cannot maintain normal chemical structure of body fluids

Progressive deterioration over months or years Clinical syndrome called “uremia”

Chronic Renal Failure


Congenital renal and urinary tract malformations Vesicoureteral reflux associated with recurrent

urinary tract infections Hereditary disorder Chronic pyelonephritis Chronic glomerulonephritis Anaphylactoid purpura, lupus erythematosus

Potential Causes of Chronic Renal Failure


Pathophysiology Diagnostic evaluation Therapeutic management

Promote maximum renal function Maintain fluid and electrolyte balance Treat systemic complications Promote as normal and active a life as possible

Management of Chronic Renal Failure


The process of separating colloid and crystalline substances through a semipermeable membrane

Methods Peritoneal dialysis Hemodialysis Hemofiltration

Dialysis


The preferred method of dialysis for children Abdominal cavity acts as semipermeable membrane

for filtration Warmed solution enters peritoneal cavity by gravity,

remains for period of time before removal Can be managed at home in some cases

Peritoneal Dialysis


Requires creation of a vascular access and special dialysis equipment

Best suited for children who can be brought to facility three times/week for 4-6 hours

Achieves rapid correction of fluid and electrolyte abnormalities

Hemodialysis


Hemodialysis (Cont.)


From living related donor Usually a parent or sibling

From cadaver donor Primary goal: long-term survival of grafted tissue Role of immunosuppressant therapy

Transplantation


What best describes acute glomerulonephritis?

A. Occurs after a urinary tract infectionB. Occurs after a streptococcal infectionC. Associated with renal vascular disordersD. Associated with structural anomalies of genitourinary

tract

Question


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