GU Round 1

Genitourinary System:


Background information-
Maintains Homeostasis through fluid and electrolyte balance
Excretes waste
In the male the GU system has a reproductive role

Anatomy:
GU composed of kidneys, ureters, bladder and urethra.
Kidneys situated on the posterior abdominal wall behind the intestines.
Bladder close to anterior abdominal wall and as child matures, settles into the pelvis

Kidneys produce urine --->
Urine goes through ureters to the bladder --->
Exists the body via the urethra --->

Kidneys in children are more susceptible to injury

Kidneys have excretory and nonexcretory functions:

Excretory removes wastes - urea, creatinine, uric acid, phosphates, sulfates, nitrates, and phenols along with excess fluid and electrolytes.

Nonexcretory - functions include the secretion of renin, erythropoietin, metabolism of carbohydrates and regulation of vitamin D.

At birth the kidney assumes the role of the placenta. 99% of newborns void within 48 hours post delivery.

The glomerular filtration rate reaches adult status at age 2.

Bladder capacity in ounces = child’s age +2, Example - 3 year old has the capacity of 5 ounces.

Calculating output for infants = 1ml/kg/hour, ex. 5kg infant has 5 ml. urine per hour.

UTI- most common disorder of the GU tract
Lower uti- cystitis (Bladder) or urethritis (Ureters)
Upper UTI- pyelonephritis (Kidneys)

Identification of the site will affect treatment.
*Most common offending organism Escherichia coli, E coli.
In infancy bacteria can enter the urinary tract through the blood. After infancy almost always ascends through the urethra.

Rates for UTI equal among sexes until 3 months of age then 4xs greater in the female.
Highest rates of UTIs, uncircumcised males < 3 months of age and girls < 1 year.
Males have a longer urethra and secretions from the prostate have antibacterial properties.

Causes: Anomalies, neurogenic bladder, obstructions, urinary stasis, catheters.

Manifestations:
Malodorous urine, dysuria, urinary frequency, fever, vomiting, diarrhea, poor appetite,
*Enuresis after bladder control has been achieved*
Pyelonephritis fever over 101 F, chills, back pain.
Urinalysis for presence of bacteria, bacteriuria; or white blood cells, pyuria, send for C&S
If pyelonephritis is suspected- elevated white blood cells (WBCs), elevated erythrocyte sedimentation rate (ESR), increased C-reactive protein (CRP)

Renal scanning to identify abnormalities or intravenous pyelogram, voiding cystourethrogram (VCUG), renal ultrasound to identify vesicoureteral reflux, scarring, hydronephrosis (swelling).

Treatment: treat the infection, prevent reinfection, correct underlying cause.

Usually treated with Bactrim, Septra, Amoxil, a cephalosporin or Furadantin for 7-10 days and then follow-up. Untreated leads to complications scarring, stones, hypertension, renal disease.

Case Study: Urinart Tract Infection


Sarah is 4 years old. Her mother brings her to the clinic stating Sarah has been running a low-grade fever and vomiting. Further she states her daughter doesn’t want to eat and has been complaining that her stomach hurts and it stings when she goes to the bathroom. Sarah seems in fine spirits at the moment. Her vital signs are normal at this time aside from the slight temperature.

What other pertinent questions might the nurse ask when checking Sarah in?

A clean catch urine specimen is obtained. What might the nurse expect to see?

Name some appropriate nursing diagnoses, nursing interventions and outcomes for Sarah and her mother.

Upon inspection of the chart it is noted Sarah was in two weeks ago with the same symptoms. Her urine was sent for a culture and sensitivity, what was the most likely organism responsible for her urinary tract infection?

When you ask the mother about the last office visit she tells you,” Yes, the medicine cleared it right up in three days; I guess I should have saved the rest of the medicine and I could have used it for this infection.

Name some teaching topics for Sarah and her mother.

Is it possible Sarah has Vesicoureteral Reflux? Explain your rationale.








Enuresis- involuntary voiding of urine. Incontinence is a structural deformity.
Enuresis primary, secondary, diurnal, nocturnal or both.

Great impact on child and family’s life
15-20% of 5 year olds and 5% of ten year olds.

Primary nocturnal enuresis most common in boys
Primary diurnal enuresis more common in girls

Enuresis symptom not disease
Organic – physical basis
Nonorganic – functional

Organic causes include:
Developmental delay,
urinary tract infections,
structural disorders,
disorders of the concentrating ability of the kidneys, excessive production of urine polyuria (diabetes mellitus or insipidus)
*Chronic constipation

Non organic causes
Sleep arousal problems
Sleep disorders (sleep apnea)
Psychological stress
Inappropriate toilet training
Family history of UTIs

Average urinary and bowel control by 2.5-3.5 years old

Typical sequence- nocturnal bowel control, daytime bowel control, daytime voiding control and nighttime voiding control. Any child experiencing nighttime wetting after 5 needs an evaluation.

*Remember that if voiding control has been achieved and the child begins wetting during the day or night, a UTI should be suspected.

In addition to physical exam, voiding history or diary and tests.

Treatment:
Medications- Ditropan, Desmopressin (DDAVP) nasal spray not recommended due to increase in hyponatremia
Bed-wetting alarms
Motivational therapies
Bowel programs
Identify food irritants




GU Structural Defects

Vesicoureteral Reflux (VUR)



Urine back-flow from the bladder up the ureters into the kidneys.

Hypospadias

Urinary meatus opening on the underside of the penis. Can be located at any point, close to the tip or close to the scrotum. Also can involve curvature.

Cryptorchidism (Undescended testes) UDT



Testes descend through the inguinal canal into the scrotum. If they do not descend they are observed for the first year. If they still do not descend surgery is required as this can impair fertility and predispose the child to a higher risk of testicular cancer later in life.

Hydrocele
Hydrocele is extra fluid in the scrotal sac. It can be noted at birth due to maternal hormones or positioning. Later development may be due to an inguinal hernia. This often resolves on its on.

Hernias


Hernias are areas where the musculature has not completely formed, has a weak spot or tear. Intestinal contents then protrude through this area and are visible and palpable under the skin. Umbilical hernias are seen around infants umbilicus or belly button. These often resolve by 1 year of age. If they do not surgery can be done.

Inguinal hernias arise from the inguinal canal. The testes pass through this canal to the scrotal sac, if it does not close this leaves an opening in the lower abdominal wall and the intestines can bulge through. Care must be taken that parents are aware that they can become incarcerated or estrangulated.


Inguinal Hernia




This video is of medical missions performed by a team led by Dr. Jim Sanchez. His explanation of the video is below.

The Rotary Club of San Francisco del Monte's (RI District 3780) Operating Room on Wheels since its launching in Sept. 2007 has performed more than 30 surgical missions all over Luzon with more than 3,000 beneficiaries.
To have an idea of the impact of these missions, so far we have done 6 inguinal hernia surgeries under local & peripheral nerve anesthesia on kids inside the surgical van. Because of these promising results, I was invited by the Phil. Children's Medical Center to help them on their 2 scheduled hernia surgical missions last Oct.5. From these 2 missions, 30 patients (out of a total of 71) aged 6-11 yrs. old, underwent herniotomy (and some with concomitant orchidopexy procedure for undescended testis) under local & peripheral nerve anesthesia.
In terms of the economic impact, a case of herniotomy under general anesthesia on a kid will cost at least 60K (private) and 10K (charity) while if it is done under local & peripheral nerve block, it will only cost 20-30K (private) and 3K (charity). In other words, there is a significant reduction in the cost of surgery if the procedure is done under local & peripheral nerve anesthesia, more than 50% reduction for private patients and 70% for charity cases!

By Dr. Jim Sanchez

Vulvovaginitis

Vulvovaginitis is the most common gynecological condition in prepubescent girls. Doctors believe this is due to low estrogen levels.

When puberty begins, the vagina becomes more acidic and the infections usually stop. Prior to puberty, the infection can be treated with daily bathing, steroids, and low-dose, topical antibiotics. The child should also be advised on proper bathroom hygiene. Wearing loose-fitting cotton underwear can keep the infection from occurring again.

Causes

Many triggers can cause an infection in the vagina and vulval areas. The most common cause is bacteria. The following can also cause vulvoganitis:
  • yeast
  • viruses
  • parasites
  • environmental factors
  • sexually transmitted infections
  • exposure to allergens
  • chemical irritants


Symptoms:

The symptoms of vulvovaginitis vary and depend on their cause:
Irritation of the genital area
Itching
Inflammation around the labia and perineal areas
An increased, strong-smelling vaginal discharge
Discomfort while urinating

A doctor will diagnose vulvovaginitis by discussing your symptoms and possibly collecting a sample of vaginal discharge to test.
In most cases, the doctor will need to perform a pelvic examination. A wet prep may be necessary to correctly identify the cause of your inflammation. This involves collecting some vaginal discharge for microscopic evaluation.

Treatment:
Depends on the cause

Home remedies:
If you have had a yeast infection in the past, you may be able to treat vulvovaginitis using over-the-counter products available at any pharmacy. Vaginal creams, suppositories, topical ointments, and oral pills are available to treat vulvovaginitis.
Crushed garlic and coconut oil, both known for their antibacterial properties, may also work as home remedies.
A pharmacist may be able to advise you on the best product for your symptoms and how to apply the product.
Consult your doctor if the inflammation or discharge isn’t better after a week of home treatment.
You may be able to relieve some of the symptoms of your vulvovaginitis by sitting in a sitz bath, a warm, shallow bath in which the water only covers your hip area.
Adding tea tree oil or a trace amount of vinegar or sea salt to the bath may help kill some of the bacteria, if that is what is causing your symptoms.
Be careful not to sit in the bath too long, and use a towel to dry the affected area completely after your bath is complete.

This could include:
  • oral antibiotics
  • antibiotic creams applied directly to the skin
  • antifungal creams applied directly to the skin
  • antibacterial creams applied directly to the skin
  • oral antihistamines, if an allergic reaction is a possibility
  • estrogen creams
  • oral antifungal pills

Personal hygiene routine to help heal the infection and prevent it from recurring, include taking sitz baths and wiping properly after using the toilet.
Wearing loose clothing and cotton underwear to allow the circulation of air and to reduce moisture. Removing underwear at bedtime may also help.
Proper cleansing is important and may help prevent irritation. This is especially true if the infection is bacterial.
Avoid using bubble baths, perfumed soaps, and washing powders as much as possible. Opt for sitz baths instead.
You may also find sensitive-skin versions of these products less irritating.
A cold compress is useful to relieve pain on swollen or tender areas.

Common STDs
STDs_Chart picture.jpeg

Common STDs p. 2.jpeg

References:

Hockenberry, M. J., & Wilson, D. (2009). Wong's essentials of pediatric nursing (8th ed.). St. Louis, MO: Mosby Elsevier.


Montagnino, B. A., & Ring, P. A. (2009). Chapter 27: The child with genitourinary dysfunction. In M. J. Hockenberry & D. Wilson (Eds.), Wong's essentials of pediatric nursing (8th ed., pp. 949-973). St. Louis, MO: Mosby Elsevier.


Kidneys:
https://youtu.be/zEpUQkQ-uKM

Bedwetting:
https://youtu.be/PrLQTrXsbLk

Undescended testes
https://youtu.be/JfXfCRrnpPc

Hypospadias
https://youtu.be/_0jHcpsQo7M

Hernias
https://youtu.be/Z3YMGrctZR4

Umbilical hernia
https://youtu.be/R0ZGTsOACtQ