GU+Pediatric+Round+1

=GU Round 1 = Genitourinary System: media type="youtube" key="zEpUQkQ-uKM" width="560" height="315"

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:

<span style="color: #d12e2e; font-family: 'Times New Roman',Times,serif; font-size: 18.719999313354492px;">Excretory <span style="font-family: 'Times New Roman',Times,serif; font-size: 15.600000381469727px;"> removes wastes - urea, creatinine, uric acid, phosphates, sulfates, nitrates, and phenols along with excess fluid and electrolytes.

<span style="color: #d12e2e; font-family: 'Times New Roman',Times,serif; font-size: 18.719999313354492px;">Nonexcretory <span style="font-family: 'Times New Roman',Times,serif; font-size: 15.600000381469727px;"> - functions include the secretion of renin, erythropoietin, metabolism of carbohydrates and regulation of vitamin D.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">At birth the kidney assumes the role of the placenta. 99% of newborns void within 48 hours post delivery.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">The glomerular filtration rate reaches adult status at age 2.

<span style="color: #d12e2e; font-family: 'Times New Roman',Times,serif; font-size: 18.719999313354492px;">Bladder capacity in ounces <span style="font-family: 'Times New Roman',Times,serif; font-size: 20.280000686645508px;">= child’s age +2, Example - 3 year old has the capacity of 5 ounces.

<span style="color: #d12e2e; font-family: 'Times New Roman',Times,serif; font-size: 18.719999313354492px;">Calculating output for infants <span style="font-family: 'Times New Roman',Times,serif; font-size: 20.280000686645508px;">= 1ml/kg/hour, ex. 5kg infant has 5 ml. urine per hour.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Lower uti- cystitis (Bladder) or urethritis (Ureters) <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Upper UTI- pyelonephritis (Kidneys)
 * <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 150%;">UTI **<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">- most common disorder of the GU tract

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Identification of the site will affect treatment. //<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">*Most common offending organism Escherichia coli, E coli. // <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">In infancy bacteria can enter the urinary tract through the blood. After infancy almost always ascends through the urethra.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Rates for UTI equal among sexes until 3 months of age then 4xs greater in the female. <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Highest rates of UTIs, uncircumcised males < 3 months of age and girls < 1 year. <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Males have a longer urethra and secretions from the prostate have antibacterial properties.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Causes: Anomalies, neurogenic bladder, obstructions, urinary stasis, catheters.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Malodorous urine, dysuria, urinary frequency, fever, vomiting, diarrhea, poor appetite, <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">***Enuresis after bladder control has been achieved*** <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Pyelonephritis fever over 101 F, chills, back pain. <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Urinalysis for presence of bacteria, bacteriuria; or white blood cells, pyuria, send for C&S <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">If pyelonephritis is suspected- elevated white blood cells (WBCs), elevated erythrocyte sedimentation rate (ESR), increased C-reactive protein (CRP)
 * <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 150%;">Manifestations: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Renal scanning to identify abnormalities or intravenous pyelogram, voiding cystourethrogram (VCUG), renal ultrasound to identify vesicoureteral reflux, scarring, hydronephrosis (swelling).

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Treatment: treat the infection, prevent reinfection, correct underlying cause.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">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.

=<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 150%;">Case Study: Urinart Tract Infection =

====//<span style="font-family: 'Times New Roman',Times,serif; font-size: 140%;">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. //====

====<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">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? ====

====<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">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. ====

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Is it possible Sarah has Vesicoureteral Reflux? Explain your rationale.
media type="youtube" key="X19DQyQx2no?version=3" height="481" width="588"

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;"><span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 150%;">Enuresis - involuntary voiding of urine. Incontinence is a structural deformity. <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Enuresis primary, secondary, diurnal, nocturnal or both.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Great impact on child and family’s life <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">15-20% of 5 year olds and 5% of ten year olds.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Primary nocturnal enuresis most common in boys <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Primary diurnal enuresis more common in girls

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Enuresis symptom not disease <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Organic – physical basis <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Nonorganic – functional

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;"><span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Organic causes include: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Developmental delay, <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">urinary tract infections, <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">structural disorders, <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">disorders of the concentrating ability of the kidneys, excessive production of urine polyuria (diabetes mellitus or insipidus) //<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">*Chronic constipation //

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 150%;">Non organic causes <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Sleep arousal problems <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Sleep disorders (sleep apnea) <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Psychological stress <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Inappropriate toilet training <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Family history of UTIs

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Average urinary and bowel control by 2.5-3.5 years old

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">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.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">*Remember that if voiding control has been achieved and the child begins wetting during the day or night, a UTI should be suspected.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">In addition to physical exam, voiding history or diary and tests.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 150%;">Treatment: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Medications- Ditropan, Desmopressin (DDAVP) nasal spray not recommended due to increase in hyponatremia <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Bed-wetting alarms <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Motivational therapies <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Bowel programs <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Identify food irritants

media type="youtube" key="PrLQTrXsbLk" width="560" height="315"

<span style="color: #c93b3b; font-family: 'Times New Roman',Times,serif; font-size: 26px;">GU Structural Defects

<span style="color: #c93b3b; font-family: 'Times New Roman',Times,serif; font-size: 19.5px;">Vesicoureteral Reflux (VUR)

media type="youtube" key="4kdaTbsKhrM" height="377" width="504"

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Urine back-flow from the bladder up the ureters into the kidneys.

<span style="color: #c93b3b; font-family: 'Times New Roman',Times,serif; font-size: 19.5px;">Hypospadias media type="youtube" key="_0jHcpsQo7M" width="560" height="315" <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">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.

<span style="color: #c93b3b; font-family: 'Times New Roman',Times,serif; font-size: 19.5px;">Cryptorchidism (Undescended testes) UDT

media type="youtube" key="JfXfCRrnpPc" width="560" height="315"

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">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.

<span style="color: #c93b3b; font-family: 'Times New Roman',Times,serif; font-size: 19.5px;">Hydrocele <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">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.

<span style="color: #c93b3b; font-family: 'Times New Roman',Times,serif; font-size: 19.5px;">Hernias <span style="color: #c93b3b; font-family: 'Times New Roman',Times,serif; font-size: 19.5px;">media type="youtube" key="R0ZGTsOACtQ" width="560" height="315"

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">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.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">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.

<span style="color: #c93b3b; font-family: 'Times New Roman',Times,serif; font-size: 19.5px;">Inguinal Hernia <span style="color: #c93b3b; font-family: 'Times New Roman',Times,serif; font-size: 19.5px;">media type="youtube" key="Z3YMGrctZR4" width="560" height="315"

media type="youtube" key="Ie-IRRntJKM" height="408" width="546"

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">This video is of medical missions performed by a team led by Dr. Jim Sanchez. His explanation of the video is below.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">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. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">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. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">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!

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">By Dr. Jim Sanchez


 * <span style="color: #e80d27; font-family: 'Times New Roman',Times,serif; font-size: 19.5px;">Vulvovaginitis **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Vulvovaginitis is the most common gynecological condition in prepubescent girls. Doctors believe this is due to low estrogen levels.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">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.


 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Causes **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Many triggers can cause an infection in the vagina and vulval areas. The most common cause is bacteria. The following can also cause vulvoganitis:
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">yeast
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">viruses
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">parasites
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">environmental factors
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">sexually transmitted infections
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">exposure to allergens
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">chemical irritants


 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Symptoms: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">The symptoms of vulvovaginitis vary and depend on their cause: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Irritation of the genital area <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Itching <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Inflammation around the labia and perineal areas <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">An increased, strong-smelling vaginal discharge <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Discomfort while urinating

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">A doctor will diagnose vulvovaginitis by discussing your symptoms and possibly collecting a sample of vaginal discharge to test. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">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.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Depends on the cause
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Treatment: **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">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. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Crushed garlic and coconut oil, both known for their antibacterial properties, may also work as home remedies. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">A pharmacist may be able to advise you on the best product for your symptoms and how to apply the product. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Consult your doctor if the inflammation or discharge isn’t better after a week of home treatment. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">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. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">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. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">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.
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Home remedies: **


 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">This could include: **
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">oral antibiotics
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">antibiotic creams applied directly to the skin
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">antifungal creams applied directly to the skin
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">antibacterial creams applied directly to the skin
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">oral antihistamines, if an allergic reaction is a possibility
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">estrogen creams
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">oral antifungal pills

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Personal hygiene routine to help heal the infection and prevent it from recurring, include taking sitz baths and wiping properly after using the toilet. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Wearing loose clothing and cotton underwear to allow the circulation of air and to reduce moisture. Removing underwear at bedtime may also help. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Proper cleansing is important and may help prevent irritation. This is especially true if the infection is bacterial. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Avoid using bubble baths, perfumed soaps, and washing powders as much as possible. Opt for sitz baths instead. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">You may also find sensitive-skin versions of these products less irritating. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">A cold compress is useful to relieve pain on swollen or tender areas.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px; line-height: 0px; overflow: hidden;">
 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Common STDs **



<span style="color: #d12e2e; font-family: 'Times New Roman',Times,serif; font-size: 17px;">References:

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Hockenberry, M. J., & Wilson, D. (2009). Wong's essentials of pediatric nursing (8th ed.). St. Louis, MO: Mosby Elsevier.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">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

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Undescended testes https://youtu.be/JfXfCRrnpPc

Hypospadias https://youtu.be/_0jHcpsQo7M

Hernias https://youtu.be/Z3YMGrctZR4

Umbilical hernia https://youtu.be/R0ZGTsOACtQ