GENITOURINARY
HENDRA , DR .Sp.RAD
KIDNEYS
Detoxify blood and eliminates waste
Produce erythropoietin
Regulate blood pressure
Maintains fluid and electrolyte balance
Essential for life process
Huge blood supply
in accidents/trauma
HORMONES
Erythropietic Stimulating Factor
Released when low serum O2
Stimulates production of RBCs
ESF = Anemia and prolonged PT/PTT
HORMONES
Renin
BP or blood volume
Stimulates production of Angiotension I
Angiotension II
Vasoconstriction and BP
Aldosterone by adrenal cortex
Reabsorbes Na & H2O
URINARY ASSESSMENT
Voiding pattern & output = 1-2ml/kg/hr
Oliguria
<1cc/kg/hr (infants) and <0.5cc/kg/hr children
AnuriaNo production of urine.
Indicates serious renal dysfunction
Diuresis urinary output.
R/O hyperglycemia
Glucose threshold is 160 mg
urination and glycosuria.
URINARY ASSESSMENT
Color
Clear/straw
Darker
Concentrated from dehydration or bilirubin
Hematuria-blood
UTI, stones, trauma or glomerulonephritis
PH
(Alkalinic) with K+
Clarity
Clear Cloudy
Pyuria indicates infection
URINARY ASSESSMENT
Pain
Burning on urination- UTI
Dull achy pain - kidney disease
Sharp, colicky pain-kidney stones
Cystitis
Suprapubic pain or pain after voiding
URINARY FUNCTION STUDIES
Urinalysis- U/A
C & S = Culture and sensitivity
Identify organism
Specific gravity 1.005-1.020
Infant <1.010
Children 1.010-1.030
Fluid challenge test
20-50cc/kg/hour then output
Blood Urea Nitrogen (BUN) 5-18
Creatinine 0.3-1mg/dl
most reliable test for glomeruli function
Glomerular Filtration Rate GFR
Renal Function = 70-160cc/min.
Infant has lower rate till 2 years of age.
RENAL FUNCTION STUDIES
Ultrasound- renal or pelvic
Intravenous Pyelogram IVP
Renal angiography
Cystoscopy
Voiding Cysto Urethra Gram VCUG
Renal Biopsy
URINARY TRACT INFECTIONS
Ascending infection
Bacteria urethra bladder (cystitis)
Bladder ureters kidney (pyelonephritis)
Fecal bacteria causes 80% UTIs
Peak incidence @ 2-6 years of age
without structural problems
ETIOLOGY
Girls urethra smaller & closer to anus
risk when wipe back to front
Boys non-circumsized or have phimosis
Urinary stasis
Structural
defect or obstruction
Vesicouretal Reflux or Hydronephrosis
Incomplete bladder empting RT
Constipation
or toilet training (holding it in)
Sexually active adolescent girls
CLINICAL SIGNS
Burning
Frequency
Dysuria
Suprapubic, flank or abdominal pain
Incontinence
Foul smelling urine
Fever
Infants may present with high fever,
chills, vomiting, diarrhea or irritability
DIAGNOSIS
UA and C & S to identify organism
Clean catch or bagged urine
Area
must be cleaned properly!
Urinary catheterization or supra-pubic tap.
Sterile procedure!
Repeat C&S after medication completed
To verify
med was effective
ANTIBIOTIC THERAPY
Sulfonamides: Co-trimoxazole
(Bactrim DS/Septra/TMP-SMX).
Sulfa allergies.
PO intake. Not for infants less than 2 months.
Cephalosporins: Ceclor po/ Rocephin IV/IM.
Resistant or severe UTIs or pyelonephritis.
(IV) meds for hospitalized pts.
Penicillins (PCN): Ampicillin po/IV, amoxicillin, augmentin
PCN allergies (Ampicillin and amox not as sensitive)
Repeat Culture to assess efficacy of med.
ANALGESIC THERAPY
Phenazopyridine HCL (pyridium)
Antispasmotic.
Local anesthetic action on urinary mucosa. Only use for
pain & older children >6years
SE-orange urine and can stain contact lenses.
Motrin
5-10 mg/kg/dose q 6-8 hr
Tylenol
10-15 mg/kg/dose
THERAPY
Hydration 2 4 liters/day
Acidic juices: cranberry and OJ
Encourage frequent voiding
Appropriate hygiene
Wipe
from front to back
No bubble baths
HYDRONEPHROSIS
Congenital or Acquired RT reflux or calculi
Obstruction @ ureto-pelvic junction:
Renal
pelvis and calyces dilated with urine.
urine flow leads to
stasis, infections or calculi
Infants may spontaneously resolve
Diagnosis
Renal
ultrasound or IVP
CLINICAL SIGNS
Colicky, flank pain
May
radiate to groin
N/V
Possible palpable mass
Pyuria
Fever
THERAPY
Fluids-2.5 liters/day
Hygiene
Increase voiding
Surgery
Stent @ obstruction
site
POLYCYSTIC KIDNEY DISEASE
Autosomal dominant disorder 90%.
Disease progresses in adulthood.
Autosomal recessive
Severe disease in childhood
Cyst formation & renal enlargement
Cysts filled with
glomerular filtrate, solutes and fluids
Renal blood vessels and nephrons compressed
Functional tissue is destroyed
kidney failure
CLINICAL SIGNS
Flank pain
Hematuria
Proteinuria
Nocturia
Frequent UTIs and renal calculi
HTN and impaired renal blood flow
Protruding abdomen
THERAPY
Renal ultrasound
IVP
CT Scan
Fluid Intake 2-2.5 L/day
Prevents
infection
Antihypertensive Meds
Beta blockers-atenolol or propanolol
Ca Channel Blockers-procardia or verapamil
Dialysis or kidney transplant
ACUTE GLOMERULONEPHRITIS
Antigen/antibody reaction to infection
Group
A hemolytic strep.
Most common in boys 4 - 7years of age
Peaks in winter and spring
Wire Mesh Trap
PATHOPHYSIOLOGY
Antibodies made against strep toxin
AG/AB complex trapped in glomerulus
Leukocytes
infiltrate the area
Adheres to basement membrane
Inflammation = GFR
Damaged Glomerulus
Leakage
of RBCs and Protein
Small hemorrhages on cortical surfaces
Kidneys become enlarged and pale
CLINICAL SIGNS & SYMPTOMS
Cardinal sign = Hematuria 4+
Tea
colored urine RT RBCs being excreted
Proteinuria +3/+4
Oliguria
Temperature
Na+ and H2O Re-absorption BP
Periorbital/facial edema +3/+4
Dependent edema/extremities in
Weight gain
in AM.
PM.
Circulatory congestion RT pulmonary edema
DIAGNOSIS
+ ASO titers >250 todd units
Reflects
recent strep infection
Past 10-14 days
ESR
BUN & Creatnine
Specific Gravity 1.20-1.30
Albumin = Hypoalbunemia
K+ due to impaired GFR
NH4 (Azotemia)
TREATMENT
Isolation Precautions!
Bed rest (6-12 weeks)
Stable
electrolytes, BUN & BP
Medications;
PCN
10 day therapy
only for + current strep
Hydralazine
(Apresoline)
vasodilator ( renal & cerebral flow)
V/S, BP & Neuro status
Furosemide
(Lasix) Loop diurectic
Inhibits re-absorption of Na & Cl
Lytes I&0 & weight
TREATMENT
Fluid Balance
Oliguria
= Fluid restriction (I =O)
Promote voiding
Diuresis = Improvement Dehydration
Nutrition
Carbohydrates
Na+ and K+
Moderate protein
(Protein Urea BUN)
Energy for tissue repair
NEPHROTIC SYNDROME
Most common glomerular injury in kids
Idiopathic 85%
Boys 2x > Girls
Age 2-4 years
Viral infection 7 days before onset
Acquired secondary
Acute Glomerulonephritis Toxic Nephrosis
Systemic disease SLE or HIV.
Major presenting symptom of pt with AIDS
Swiss Cheese Syndrome
PATHOPHYSIOLOGY
Glomerular Permeability to plasma proteins
Urinary excretion of protein & albumin
Proteinuria +3/+4 = Hypoproteinemia (-) N balance
Albuminuria +3/+4 = Hypoalbuminemia
Plasma Osmotic Pressure Vascular Volume
Stimulates Renin Angiotensin ADH & Aldosterone
Na & H2O retained Edema
Interstitial Fluid (abdomen & extremities)
Hyperlipidemia (450-1500)
Serum protein activates hepatic lipid synthesis
Fat streaks in glomeruli & GFR
Lipid granules in urine sparkly
SIGNS AND SYMPTOMS
Pitting Edema- Presenting symptom
Periorbital in AM Dependent in PM
Back, Abdomen & Scrotum
Gradual weight gain
Ascites
Abd girth & Respiratory function
Oliguria
Dark and frothy (Lipid Granules)
Skin waxy and white from anemia
Malnutrition
Intestinal absorption
(-) N balance
Blood pressure WNL or RT Hypovolemia
PROGNOSIS
Self-Limiting: Resolves 1-2 weeks
Prolonged recovery 12 - 18 months
Exacerbations
of symptoms
Risk of relapse = 50% after 5 years
80% will have favorable outcome
THERAPY
Assess V/S for shock! HR & BP
Strict I&O & Daily weight
urine- protein, albumin & SG
Bed rest
Risk for skin breakdown RT edema
Sheepskin, reposition q 2h
Nutrition
Calories, Ca+, Protein & Na+
MEDICATIONS
Prednisone 2mg/kg/day qid
Inflamation & Proteinuria
Diuresis (7-21 days) protein excretion
Monitor SE:
Hyperglycemia
Growth GI bleeding
Diuretics
Furosemide (Lasix) 1-2mg/kg/dose
Mannitol IV 0.25-0.5 mg/kg/dose q4h
Osmotic Pressure GFR
Reabsorbs H2O, Na & Cl
Salt Poor Albumin (SPA) 5-25% 1-2 gm/kg/day
Plasma expander & replenishes albumin
HYPOSPADIAS
1-300 births
10-15% have 1st degree relative
Urethral opening located behind glands on ventral
(underside) surface
Kids wet their sneakers
Severity closer to body wall
TREATMENT
No circumcision!
May
use foreskin for repair later
Urology consult
Reconstructive surgery @ 6-18 mos
Testosterone prior to penile size
Indwelling catheter leg bag
Home care instructions important
EPISPADIAS
Rarer than hypospadias
Urethral opening located behind glans penis on
dorsal (upper) surface
Kids wet their faces
Same Treatment as for hypospadias
CRYPTOCHIDISM
Failure of 1 or both testes to descend abdomen
inguinal canal scrotal sac
Inguinal hernia and small scrotal size
Retractile testes- Reducible
Overactive cremasteric reflex.
Manually
sac.
can be brought down to scrotal
THERAPY
Wait for 1st birthday for spontaneous descent
75%
spontaneously descend
HCG 1000 units IM x 3 doses
Facilitates
descent
Surgery-orchioplexy
Bring
testes into scrotal sac
ENURESIS
Unable to control bladder function (Nocturnal bed
wetting)
Primary
Secondary
Most common, previously dry and now accidents @ night
Delayed CNS maturation
Never been dry @ night
Unable to detect bladder fullness and control voiding
UTI
Family history
Hypercalciuria
Ca in urine bladder irritation painful urination
THERAPY
R/O UTI or Ca
Behavior modifications
No drinking at bedtime
Void prior to bedtime
Imagery of full bladder
Medications
TCAs
Imipramine (Tofranil) 10-25mg q HS
Nortrypyline (Pamelor) 10-35 mg q HS
Antidiuretic
DDAVP Desmopressin Acetate 0.2-0.6 mg q HS
Diuretic
Chlorothiazide (Diuril) 20 mg/kg/24H
Ca reabsorption
TESTICULAR TORSION
4000 males @ peak age 13
Twisting of spermatic cord
blood flow to testes
Testes can survive only 6-12 hours with-out
blood flow
Gangrene & necrosis sets in
Surgical emergency
SIGNS AND SYMPTOMS
Acute onset!
Severe testicular pain
Scrotum swollen, red & warm
Abdominal pain N & V
Cremasteric reflex
Surgery
Untwist
and secure cord to prevent further torsions
Orchiectomy
Remove gangrene testicle
