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