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2. THOUGHT OF THE DAY
YESTERDAY’S A PAST…
…..TOMORROW IS A FUTURE….
…. BUT….
TODAY IS A GIFT
…… THAT’S WHY IT’S CALLED PRESENT….!

4. • To show an in-depth understanding of the
genito-urinary disorders in children and the
process of care in the nursing management
Aim

5. By the end of this session, the student
should be able to:
• Understand the anatomy and physiology of the renal
system and structure and function
• Identify the differences between adult and children
GU system
• Describe the most common diagnostic investigations
and procedures for GU disorders
Learning Objectives

6. • Understand the general assessment of
children with genitourinary disorders
• Understand the common genitourinary
disorders in children
• Plan the nursing management for children
with GU disorders
Cont…

8. introduction
• Disorders of kidney and urinary tract are
commonly seen in pediatric units as medical
and surgical problems.
• Incidence: 3 to 6 per 1000 live births

9. Nephron:
• Glomeruli – filter water and solutes from blood
• Tubules – reabsorb needed substances (water,
protein, electrolytes, glucose, amino acids) from
filtrate and allow unneeded substances to leave
the body in urine
• Urine formed in the nephron, passes into renal
pelvis, through ureter into bladder and out of body
through urethra
Function of Kidney

10. • Maintaining body fluid volume and composition
• Secretes hormones:-
 Renin – helps with the regulation of blood
pressure
 Erythropoietin – stimulates red blood cell
production by the bone marrow
 Metabolized Vitamin D – responsible for calcium
metabolism
Cont….

11. Renal System Assessment
• Physical assessment
o Palpation, percussion
• Health history
o Previous UTIs, calculi, retention, pregnancy,
STDs, bladder cancer
o Meds: antibiotics, anticholinergic,
antispasmodics
o Urologic instrumentation
o Urinary hygiene
o Patterns of elimination

12. Diagnostic Studies
• Renal scan
• Cystogram
• Retrograde
Pyelogram
• U/S
• CT
• MRI
• Renal arteriogram
• UA
• Urine C&S
• BUN
• Creatinine
• KUB
• IVP

13. Cystoscopy
(fibre optic technology)

14. • KUB (Kidney, Ureter, Bladder) x-ray
• Renal Biopsy
Renal Ultrasound

15. An injection of x-ray contrast media via a needle
or cannula into the vein, typically in the arm. The contrast
is excreted or removed from the bloodstream via the
kidneys, and the contrast media becomes visible on x-rays
almost immediately after injection
Intravenous Pyelogram (IVP)

16. en
Kidney and Ureter Bladder and Urethra
•Renal agenesis
•Renal hypoplasia
•Horse-shoe kidney
•Poly cystic renal disease
•Ectopic kidney
•Duplication of renal
pelvis and ureter
•Hydronephrosis
•Pelvi-ureteric
obstruction
•Congenital renal
neoplasm
•Bladder and neck
obstruction
•Posterior urethral valves
•Neurogenic bladder
•Hypospadias
•Epispadias
•Phimosis
•Urethral stenosis
•Meatal stenosis

17. Renal agenesis
 Definition :
 “It is the absence of kidney due to failure of
ureteric bud formation.also called Potter’s
Syndrome.”
 Type:
 Bilateral
 Unilateral

19. Renal hypoplasia and dysplasia
• it occurs due to reduction of renal mass affecting
the nephron.
• It may be unilateral or bilateral
• It may be segmental, simple
RENAL DYSPLASIA :
• Disorganization of lung parenchyma with immature
nephron and ductal elements resulting in large or
small kidney.
• It may be multicystic , hypo plastic or aplastic

20. Horse – shoe kidney
• It develops when lower poles of the kidnies are
fused in the midline due to fusion of ureteric
buds during fetal development.
• Child presents with pyuria, albuminuria, vomiting
• Surgery is indicated.

21. Polycystic kidneys
• Commonest congenital anomalies as inherited
autosomal disease.
• It is an complex syndrome
• Resulting from progressive dilatation of specific portion
of the nephron.
Types : (i) infantile
(ii) Adult
Diagnosis : IVP , renal angiography

22. Obstructive lesions of the urinary
tract
• It mainly caused by congenital abnormalities like
pelvi-ureteric junction obstruction and posterior
urethral valves which may lead to irreversible renal
damage.

23. Pelvi – ureteric junction stenosis
• Unilateral or bilateral
• Urinary tract infections and upper abdominal
pain
 Diagnosis : ultrasound, IVP , renal function test
 Management:
• Surgery is indicated for removal of obstruction

24. hydronephrosis
• It is the dilatation of renal pelvis
• Unilateral or bilateral
• Due to obstruction of urine flow in the distal
urinary tract
• Males > females
• Abdominal pain, failure to thrive , anemia,
hypertension, hematuria, renal failure.
 Diagnosis : USG, IVP
 Management :
• Surgical removal or pyeloplasty,percutaneous
nephrostomy

27. Meatal stenosis
• Congenital abnormality
• Due to meatal ulcer and scaring
• Meatal dilatation or meatoplasty

28. Exstrophy of bladder( ectopia vesicae)
• It is a congenital malformation
• Lower portion of the abdominal wall and the anterior
wall of the bladder are missing so that bladder is
everted through the opening and may found on the
lower abdomen with continuous passage of urine to
the outside.
• Male are more commonly affected

29.  Clinical manifestations:
• Urinary dribbling
• Skin excoriation
• Infection and ulceration or the bladder mucosa
• UTI
• Growth failure
 Diagnosis :
• Cystoscopic examination
• X-ray
• USG
• IVP
Cont…

30. Management
• Surgical closure of the bladder within 48 hours
• Urinary conversion before reconstructive surgery
• Orthopedic surgery
• Supportive nursing care
• Pre operative care
• Post operative care
• Follow up

31. epispadias
• Abnormal urethral opening on the dorsal aspect
of penis.
• Due to abnormal development of the
intraumbilical wall and upper wall of urethra.
• Rare in females
 Classification :
o anterior epispadias
o posterior epispadias
o female epispadias – bifid clitoris

33. hypospadias
• it is the congenital abnormal urethral opening on
the ventral aspect( under surface ) of the penis.
• Common in male children.
 Classification :
• Anterior hypospadias(65 to 70%) : it may found
as glandular or coronal or on distal penile shaft
• Middle (10-15%) penile shaft hypospadias.
• Posterior hypospadias(20%) : it may be found on
proximal penile shaft or as penoscrotal,scortal or
perineal type.

34. Problems related to hypospadias :
1. Painful downward curvature of penis
2. Deflected stream of urine
3. Inability void urine while standing
Management :
• surgical reconstruction
• Meatotomy
• Chordee correction
• urethroplasty

36. • The choice of surgical correction is affected
primarily by the severity of the defect
• Surgery is done when the child’s age is less than
18 months
• Reconstruction of the meatal opening is done –
Meatal advancement granuloplasty (MAGPI)
Surgical management

38. phimosis
• Narrow opening of the prepuce that prevents it being
drawn back over the glans penis.
Management:
• Circumcision
• apply Betamethasone cream

39. paraphimosis
• It is the retraction of a phimotic foreskin, behind coronal
sulcus.
• It may develop phimotic child which also need for
surgical management by circumcision or reduction with
application of lubricant under deep sedation.
Clinical features :
• edematous
• Severe pain

41. Wilm’s tumor (nephroblastoma)
• Max wilm’s , German surgeon described this most common
renal tumor of childhood.
• Chromosomal deletions 11 and 16
• Highly malignant embryonal tumor
• Tumor develops in kidney parenchyma ,invading the
surrounding tissues.
Clinical features :
• abdominal mass
• Microscopic hematuria
• Fever
• Pallor
• Superficial vein engorgement

42. Cont…
Clinical staging :
Stage 1 - limited to kidney and can be fully excised
Stage 2 - Regional extension of tumor by penetration
through renal capsule.
Stage 3 – non hematogenous extension of the tumor
confined to the abdomen following surgery.
Stage 4 – hematogenous metastasis to distant organs
Stage 5 – bilateral renal involvement

44. Diagnostic evaluation :
• History
• Physical examination
• X-ray abdomen ,chest
• USG
• CT scan
• MRI
• Renal function test
Management :
• Nephrectomy
• Chemotherapy
• radiotherapy

45. Undescended testis
• Testis cannot be made to reach the bottom of the
scrotum
• It is also known as Cryptorchidism
• 5% of full term male infants may have unilateral or
bilateral testis.
Types :
• Retractile
• Palpable
• impalpable

47. Diagnosis :
• USG
• Laparoscopy
• MRI
Complications :
• Trauma
• Malignant
• Psychological trauma
Management :
• Orcheopexy
• Hormonal treatment

48. Vesico – urethral reflux
• Retrograde flow of bladder urine up the ureter during
voiding.
Causes:
• Insertion of ureter in to the bladder
• Infection
• Edema
Clinical features:
• Dysuria
• Urinary frequency and urgency
• Urine retention
• Cloudy or blood tinged urine

49. • GRADE I: reflux into ureter only – no dilatation
• GRADE II: reflux into ureter, pelvis and calyces with
no dilatation and normal calyceal fornices
• GRADE III: mild dilatation of ureter and renal pelvis
• GRADE IV: moderate dilatation of ureter, pelvis and
calyces
• GRADE V: gross dilatation of ureter, pelvis and
calyces
International Classification of
Reflux

51. GRADE IV:
moderate dilatation
of ureter,
pelvis and calyces

52. GRADE V:
gross dilatation
of ureter,
pelvis and calyces

53. • Daily low dose of prophylactic antibiotic to
prevent UTI
• Urinalysis and urine CS – every 3 to 4 months to
evaluate for UTI
• Monitor ↑BP
Medical management

54. • Surgery – reimplantation of the ureter into the
bladder
• Indicated due to recurrent UTI despite
antibiotics, Grade 5 reflux or progressive renal
injury
Surgical Management

55. Definition:
• UTI is the presence of bacteria in the urine
• Infection usually occur at the upper urinary tract
or at the lower urinary tract
Incidence:
• Common age of onset for UTI is 2-6 years
• Girl>Boy - Female has shorter urethra
• Uncircumcised male prone to develop UTI
URINARY TRACT INFECTIONS

56.  Causative organisms – E. Coli
 Route of entry -bacteria ascending from the area
outside of the urethra.
 Vesico-ureteral reflux
 Infections – URTI,
 Poor perineal hygiene - fecal organisms are the
most common infecting organisms due to the
proximity of the rectum to the urethra.
 Short female urethra
Causes

57. • Urethritis – infection of the urethra
• Cystitis – an infection in the bladder
that has moved up from the urethra
• Pyelonephritis – a urinary infection of
the kidney as a result of an infection
in the urinary tract
Types of UTI

58. Diagram of cystitis

59. Unexplained fever
(febrile fits)
Abdominal
pain
Poor
growth
Foul-smelling
urine
Weight loss
(failure to weight gain)
Irritability
Vomiting
Poor feeding

60. • Urinary
frequency/urgency
• Dysuria
• Foul-smelling urine
• Cloudy urine
• Incontinence during
day and/or night
• Increased irritability
• Nausea and vomiting
• Low abdominal or
flank pain
• Fever and chills
• Fatigue
• Small amount of urine
while micturating
despite feeling of
urgency

61. • Obtaining a urine specimen:-
- Urine bag
- Clean catch urine
- Mid-stream urine Sample
- Catheterization
 Ultrasound
 Plain x-ray
 Micturating Cystourethrogram (MCUG)
Diagnostic investigations

62.  Micturating
Cystourethrogram
(MCUG)

63. 1. Fever due to increased body temperature
related to urinary tract infection.
2. Alteration in urination (frequency, pain,
burning, dribbling and enuresis) related to
infection.
3. Pain related to inflammatory changes in the
urinary tract.
4. Lack of knowledge about UTI and health
prevention
Nursing Problems

64. Problem 1: Fever r/t UTI
Nursing interventions Rationales
• monitor body temperature every 4º
• encourage plenty of fluid intake
• administer anti-pyrexial
medications as prescribed
• maintain bed rest
• wear thin loose clothing
• give tepid-sponging with luke-warm
water
•To Prevent Hi.pyrexia
•to maintain hydration
• to maintain an
optimum body temp.
• to reduce the body
heat
• to reduce body heat
Goal: to reduce fever and maintain normal body temperature

65. Nursing interventions Rationales
• assess the urinary frequency, pain or
burning sensation during micturation
• assess the color & odour of urine
• strict I/O chart
• administer antibiotics as prescribed
• observe for signs & symptoms of
serious infection
• as baseline
observation
• to observe urinary
frequency
• to prevent spread
of infection
• to prevent
complications
Problem 2: Alteration in urination (frequency, pain,
burning, dribbling and enuresis) related to infection
Goal: to ensure that the child is comfortable during urination

66. • Ensure the child to pass urine regularly (every 2-
3 hours) and take the time to completely empty
the bladder
• Avoid holding urine for prolonged period of time
• Perineal hygiene - wipe from front to back
• Avoid tight fitting clothing or diapers; wear cotton
panties
• Avoid constipation
• Encourage fluid intake
Health teaching to prevent UTI

69. • Alteration of glomerular membrane
permeability with massive proteinuria,
hypoalbuminaemia, hyperlipidaemia
and oedema.
Definition

71. • It occurs when the filters in the kidney leak an
excessive amount of protein. The level of protein
in the blood ↓ and this allows fluid to leak across
the blood vessels into the tissues – causing
oedema
• Nephrotic syndrome are caused by changes in
the immune system
Causes

72. • For unknown reason, the glomerular membrane,
usually impermeable to large proteins becomes
permeable.
• Protein, especially albumin, leaks through the
membrane and is lost in the urine.
• Plasma proteins decrease as proteinuria
increase.
Pathophysiology

73. • Accumulation of fluid in the interstitial spaces
and peritoneal cavity is also increased by an
overproduction of aldosterone, which causes
retention of sodium.
• There is increased susceptibility to infection
due to decreased gamma-globulin.
• Causing generalized oedema

76. Signs & Symptoms
• Oedema
- initially noted in the
periorbital area
- ascites
- intense scrotal oedema
- striae may appear due
to skin overstretching
- pitting oedema
• ↑ weight
• ↓ urine output
• Proteinuria (foamy urine
indicates proteinuria)
• Fatigue
• Irritable and depression
• Severe recurrent infections
• Anorexia
• Wasting of skeletal muscles

77. Diagnostic investigations
• Urinalysis
- protein 3+ - 4+ on dipstick
• - hematuria may be absent or microscopic
• Blood test
- total serum protein – low
- serum albumin – low
- cholesterol and lipoproteins – high
• Renal function test – often normal
• Blood pressure – often normal but 25%
hypertension
• Renal biopsy

78. Renal biopsy

79. 1. Generalized oedema due to fluid volume excess
related to glomerular dysfunction
2. Impaired skin integrity related to oedema
3. Altered urinary pattern related to glomerular
dysfunction
4. Increased susceptibility to infection related to disease
process and steroid therapy
Nursing problems

80. 5. Altered body image (round face) due to side-effects of
medication
6. Inadequate nutritional intake related to large loss of
protein from the urine
7. Knowledge deficit of the disease process and
treatment
8. Anxiety and depression due to the up and down of the
course of disease
Cont…

81. Goal : to relieve oedema
Nursing interventions
• Administer steroids – prednisolone 2-4mg/kg to control
oedema
• Observe for side-effects of steroids – Cushing’s
syndrome (moon face, abdominal distension, striae, ↑
appetite, ↑ weight, aggravation of adolescent acne)
Nursing problem 1 :Generalized oedema due to
fluid volume excess related to glomerular dysfunction

82. • Administer diuretic – furosemide. Diuretics can
cause loss of electrolytes esp. potassium,
encourage ↑ potassium food e.g. citrus fruits,
date, apricot, banana
• Strict I/O chart – restrict intake of fluid – offer
small amount of measured fluid during severe
oedema, for infant measure the diaper’s wt.
• Measure daily weight and abdominal girth – to
check any weight gain due to water retention
Cont…

83. Goal : to protect the child from skin breakdown
Nursing intervention
• Position the child comfortably in bed so that
oedematous skin is well-support with a pillow
• Elevate the child’s head to reduce peri-orbital
oedema
• Provide good skin care – give bath and maintain
hygiene esp. genitals and moist area
• Change bedding daily and free from creases and
sharp objects – to avoid cut
Nursing problem 2 :Impaired skin integrity
related to oedema

84. • Admission to ward
• Explain to parents nature of illness
• Blood for , U +E, Creat., Serum lipid, C&S, LFT,
serum albumin
• For CXR and Echo
• Daily urine dipstick for protein, C&S – every
morning
• Daily BP, weight and abdominal girth
• Start on IV infusion
Nursing Management

85. • Administration of IV albumin
• Start on steroid therapy – prednisolone
given at a dose of 2mg/kg/day divided into
2-3 doses. This regimen is continued until
remission is achieved
• Remission is achieved when the urine is 0
or trace for protein for 5 to 7 consecutive
days
• Administer prophylactic antibiotics to
reduce infections
Cont…

86. • Start on diuretic therapy – frusemide (lasix)
• Dietary restriction – provide ↑ protein, high
carbohydrate, ↑ potassium diet & no salt diet
• Strict I/O chart
• Provide careful skin care
• Good hygiene
Cont…

87. Bibliography
1. PARUL DATTA’S ; ‘‘A TEXT BOOK OF PEDIATRIC NURSING’’
SECOND EDITION;PUBLISHED BY NEW CENTRAL
BOOK AGENCY MEDICAL PUBLISHERS (P)
LIMITED;KOLKATA; P.NO.357 TO 372
2.PV BOOKS; ‘‘ A TEXT BOOK OF PEDIATRIC HEALTH NURSING’’
FIFTH EDITION;EDITED BY R.K.GUPTA;P.NO.554 TO 563.
3.WEBPAGE;‘‘WWW.WIKIPEDIA.COM&WWW.ENCYCLOPEDIA.CO
M’’ ;TOPIC OF GENITOURINARY DISORDDER;TEXT AND
PICTURES
BY DR.KIRAN SADHU,R.N.R.M PROFESSOR.