A number of disorders may occur within the female or male genitalia and internal reproductive organs in chil- dren. These problems may be structural or infectious.
Female Disorders
Disorders of the female reproductive organs that occur in children and adolescents include structural disor- ders, infectious disorders, and menstrual disorders.
Menstrual disorders are discussed in chapter 4 and pelvic inlammatory disease is covered in chapter 5.
Labial Adhesions
Labial adhesion or labial fusion is partial or complete adherence of the labia minora (Fig. 43.11). UTI may result from urinary stasis behind the labia; if the adhesions are left untreated, the vaginal oriice may become inaccessible, presenting dificulty with sexual intercourse in the future.
Nursing Assessment
Younger girls have a higher risk of adhesions (3 months to 4 years) (Nepple & Cooper, 2011). Assess the history for dysuria or urinary frequency. Inspect the genitalia for fusion or adherence of the labia minora.
FIGURE 43.11 Labial adhesions. Note fusion of the labia minora. Copyrighted 2011. UBM Medica LLC.
82486:1111JM
Nursing Management
Administer topical estrogen cream as prescribed, usually once or twice daily. Teach the parents to continue cream application until the labia separate. Encourage use of petroleum jelly daily for 1 month following labial separa- tion to prevent recurrence of adhesion.
Vulvovaginitis
Vulvovaginitis is inlammation of the vulva and vagina.
Inlammation may occur as a result of bacterial or yeast overgrowth or from chemical factors such as bubble bath, soaps, or perfumes found in personal care prod- ucts. Poor hygiene may also cause vulvovaginitis. Tight clothing may cause a heat rash in the perineal area.
Persistent scratching of the irritated area may result in the complication of supericial skin infection.
Nursing Assessment
Elicit a description of the present illness and chief com- plaint. Common signs and symptoms reported during the health history may include itching or burning in the perineal area. Explore the child’s current and past medi- cal history for risk factors, which may include:
• Young age (toilet-trained preschooler)
• Poor hygiene
• Sexual activity
• Immune disorders
• Diabetes mellitus
Inspect the perineum for redness, edema, irritation, rash, or vaginal discharge (note color, consistency, and odor).
Nursing Management
Teach appropriate hygiene (daily and toileting). Girls (or their parents) should wash the genital area thoroughly on a daily basis with mild soap and water. Rinse the area well. Encourage girls to wipe after urinating and after bowel movements to wipe in a front-to-back motion. The girl should wear cotton underwear and should change it at least once a day. Administer topical or oral medica- tions as ordered. Table 43.3 lists treatments related to speciic types of vulvovaginitis.
Male Disorders
Male reproductive disorders include structural disorders and disorders caused by infection or inlammation. Cir- cumcision will also be discussed below.
Nursing Assessment
Elicit a description of the present illness and chief com- plaint. Common signs and symptoms reported during the health history might include:
• Irritation or bleeding from the opening of the prepuce (phimosis)
• Dysuria (phimosis)
• Pain (paraphimosis)
• Swollen penis (paraphimosis)
Determine the onset of symptoms and inspect the penis for irritation, erythema, edema, or discharge.
Take Note!
A swollen, reddened penis (paraphimosis) is a medical emergency and can quickly result in necrosis of the tip of the penis if left untreated.
Nursing Management
Apply topical steroid medication as prescribed for phi- mosis, following gentle retraction to stretch the foreskin back. Topical vitamin E cream may also help to soften the phimotic ring. When surgical intervention is necessary, provide routine postprocedural care and pain manage- ment (refer to the section on circumcision below). Teach the parents and uncircumcised boy proper hygiene, which will help to prevent phimosis and paraphimosis (Teaching Guidelines 43.2).
Circumcision
Circumcision is the removal of the excess foreskin of the penis. Some newborn boys are circumcised shortly after birth before going home from the hospital. Some
Phimosis and Paraphimosis
In phimosis, the foreskin of the penis cannot be retracted. Although this is normal in the newborn, it can be pathologic later. Over time, the prepuce (foreskin) naturally becomes retractable. Local irritation, balanitis, or UTI may occur if urine is retained within the foreskin after voiding. Paraphimosis (Fig. 43.12) is a more seri- ous disorder characterized by retraction of the phimotic prepuce, which causes a constricting band behind the glans of the penis and results in incarceration if left untreated.
Topical steroid cream applied twice a day for 1 month may be prescribed for phimosis. Paraphimosis requires reduction of the prepuce or a small dorsal inci- sion to release the foreskin. Circumcision may be used to treat either condition.
Cause Assessment Findings Treatment
Unhygienic practices Irritation of labia and vaginal opening May have foul brownish-green discharge
if infected with bacteria from rectum
Good hygiene.
Sometimes a mild anti-inlammatory cream is prescribed. Assess for signs and symptoms of UTI, which may occur as a complication.
Candida albicans Red bumpy perineal rash in infants White cottage-cheese–like discharge Intense itching
Antifungal cream or vaginal suppository.
Prevent by ingesting probiotics (found in yogurt and keir) daily and supplementing with a probiotic such as Lactinex when taking antibiotics.
Bordetella, Gardnerella Thin gray vaginal discharge with ishy odor Flagyl (metronidazole) orally.
Trichomonas vaginalis Foul yellow-gray or green vaginal discharge
Flagyl (metronidazole) orally. Sexually transmitted, so can be prevented with the use of condoms.
Adapted from Neinstein, L. S., Gordon, C. M., Katzman, D. K., Rosen, D. S., & Woods, E. R. (2009). Handbook of adolescent health care. Philadelphia, PA: Lippincott Williams & Wilkins.
FIGURE 43.12 Paraphimosis: note the swollen prepuce.
Copyrighted 2011. UBM Medica LLC. 82486:1111JM
TABLE 43.3 VULVOVAGINITIS: TYPES AND TREATMENTS
procedure must not be neglected. Advocate for appropri- ate pain management for the infant undergoing circumci- sion. The American Academy of Pediatrics recommends using a subcutaneous ring block with lidocaine or a dorsal nerve block to the penis. The AAP also recommends the use of EMLA (eutectic mixture of local anesthetic) cream topically to decrease pain during the circumcision (2005).
Playing calming music during the procedure may also help to soothe the infant, providing distraction. A sucrose- dipped paciier may also be used as adjuvant therapy for pain management. To increase a sense of comfort during the procedure, restrain the infant in a padded circumci- sion chair with blankets covering the legs and upper body (Kraft, 2003). This allows the infant to be in a semi-upright position during the procedure while still allowing for a sterile procedural ield. If a padded restraint chair is not available, provide atraumatic care by padding the circumci- sion board and covering the infant as previously described.
Providing Postprocedural Care
Usual care after circumcision depends on the type of appli- ance used (Gomco or Mogen clamp or Plastibell appara- tus). Cleanse the penis with clear water for the irst few days and avoid using alcohol-containing wipes. To avoid irritation to the penis, fasten diapers loosely. Notify the physician or nurse practitioner if excessive redness, active bleeding, or purulent discharge occurs. Assess for the irst void following the procedure, or if performed in the outpa- tient setting instruct parents to call the physician or nurse practitioner if the infant has not voided by 6 to 8 hours after the circumcision. Apply antibiotic ointment or petro- leum jelly to the penile head with each diaper change as prescribed, based on the circumcision method used and the preference of the physician or nurse practitioner.
Take Note!
If excess bleeding occurs after the circumcision, apply direct pressure and notify the physician or nurse practitioner immediately.
Educating the Parents
Instruct parents to give sponge baths until the circumci- sion is healed. Describe the normal granulation tissue that will be present during the healing process. Teach parents to apply ointment or petroleum jelly if indicated.
Instruct the parents to call the physician or nurse practi- tioner if any of the following occur:
• The infant does not urinate within 6 to 8 hours after the procedure.
• Heavy bleeding occurs (more than small spots on the diaper or bleeding that requires direct pressure to stop it).
• There is purulent or serous drainage from the circum- cised area.
• There is redness or swelling of the penile shaft.
parents elect not to have their newborn boy circumcised at that time but may desire it later. Neonatal circumci- sion may be performed in the newborn nursery, hospital unit treatment room, or outpatient ofice. Circumcision is indicated later for the conditions of phimosis and para- phimosis. Circumcision done after the newborn period usually requires general anesthesia.
The beneits of circumcision include a decreased incidence of UTI, sexually transmitted diseases, AIDS, and penile cancer, and in female partners a decreased occur- rence of cervical cancer. Complications of circumcision include alterations in the urinary meatus, unintentional removal of excessive amounts of foreskin, or damage to the glans penis (American Academy of Pediatrics [AAP], 2005).
Whether to circumcise or not is a personal decision and often based on religious beliefs or social or cultural customs. Nurses should support and educate the parents in either case.
Nursing Assessment
Prior to the procedure, assess for normal placement of the urinary meatus on the glans penis (in boys with hypospadias, circumcision should be delayed until eval- uation by the pediatric urologist). After the circumcision, assess for redness, edema, or active bleeding. Note signs of infection, such as purulent drainage. Assess pain level.
Nursing Management
Nursing care of the boy undergoing circumcision focuses on managing pain, providing postprocedural care, and educating the parents.
Managing Pain
Whether circumcision is performed in the obstetric area of the hospital before newborn discharge or in the outpatient setting at a few days of age, pain management during the
Teaching Guidelines 43.2
HYGIENE IN THE UNCIRCUMCISED MALE
• The foreskin does not normally retract in the new- born boy, so do not force it to do so.
• Change the diaper frequently and wash the penis daily with water and mild soap.
• When the infant is older and the foreskin easily retracts, gently retract the foreskin and clean around the glans with water and mild soap once a week.
• Dry the area prior to replacing the foreskin.
• Always replace the foreskin after retraction.
• Teach the preschool-age boy to retract the foreskin and clean the penis during each bath or shower.
cord) is often noted as a swelling of the scrotal sac.
Complications of varicocele include low sperm count or reduced sperm motility, which can result in infertility.
Nursing Assessment
Elicit a description of the present illness and chief com- plaint. The boy with hydrocele will have an enlarged scrotum that may decrease in size when he is lying down. Inspect the scrotum for a luid-illed appearance.
The boy with varicocele will have a mass on one or both sides of the scrotum and bluish discoloration.
Inspect the scrotum for masses; the spermatic vein feels worm-like on palpation. The boy with varicocele may have pain.
Nursing Management
Both hydrocele and painless varicocele require watchful waiting, as these conditions will usually resolve spon- taneously. If they do not resolve, or if the difference in testicular volume is marked in the boy with varicocele, refer the child to a urologist, as surgery may be indi- cated. Reassure parents that hydrocele is not associated with the development of infertility. Varicocele may lead to infertility if left untreated, so instruct parents to seek care if pain occurs or if there is a large difference in tes- ticular size. Either condition may be surgically corrected on an outpatient basis. Provide routine postoperative care following either surgery.
Testicular Torsion
In testicular torsion, a testicle is abnormally attached to the scrotum and twisted. It requires immediate atten- tion because ischemia can result if the torsion is left untreated, leading to infertility. Testicular torsion may occur at any age but most commonly occurs in boys aged 12 to 18 years (Dufour, 2008).
Nursing Assessment
Elicit a description of the present illness and chief com- plaint. Signs and symptoms of testicular torsion include sudden, severe scrotal pain. Inspect the affected side for signiicant swelling, which may appear hemorrhagic or blue-black.
Nursing Management
Surgical correction is necessary immediately. Administer pain medication prior to surgery. Reassure the child and family that surgery will alleviate the problem and is per- formed to restore adequate blood low to the testicle.
After surgical repair, provide routine postoperative care.
Take Note!
If the Plastibell is used, teach parents NOT to use petro- leum jelly, as it may cause the ring to be dislodged. A yel- lowish crust may form that should be allowed to fall of on its own after several days.
Cryptorchidism
Cryptorchidism (also known as undescended testicles) occurs when one or both testicles do not descend into the scrotal sac. Ordinarily the testes, which in the fetus develop in the abdomen, make their descent into the scrotal sac during the seventh month of gestation. The cause for this failure to descend may be mechanical, hormonal, chromo- somal, or enzymatic. The disorder may occur unilaterally or bilaterally. Up to 3% of term male infants exhibit crypt- orchidism (Ashley, Barthold, & Kolon, 2010).
Complications associated with cryptorchidism that is allowed to progress into the school-age years include sterility and an increased risk for testicular cancer in ado- lescence or the young adult years. Therapeutic manage- ment is surgical. An orchiopexy is performed to release the spermatic cord, and the testes are then pulled into the scrotum and tacked into place.
Nursing Assessment
Explore the health history for risk factors such as:
• Prematurity
• First-born child
• Cesarean birth
• Low birthweight
• Hypospadias
Palpate for the presence (or absence) of both testes in the scrotal sac.
Take Note!
A retractile testis is one that may be brought into the scrotum, remains for a time, and then retracts back up the inguinal canal. This should not be confused with true cryptor- chidism.
Nursing Management
If the testes are not descended by 6 months of age, the infant should be referred for surgical repair (Ashley et al., 2010). Postoperatively, observe the incision for signs of bleeding or infection.
Hydrocele and Varicocele
Hydrocele (luid in the scrotal sac) is usually a benign and self-limiting disorder. It is usually noted early in infancy and often resolves spontaneously by 1 year of age. Varicocele (a venous varicosity along the spermatic
Take Note!
Testicular torsion is considered a surgical emer- gency, as necrosis of the testis may occur and gan- grene may set in.
Epididymitis
Epididymitis (inlammation of the epididymis) is caused by infection with bacteria. It is the most common cause of pain in the scrotum. It rarely occurs before puberty, but if it does it may occur as a result of a urethral or bladder infection related to a urogenital anomaly. Thera- peutic management is directed toward eradicating the bacteria. If left untreated, a scrotal abscess, testicular infarction, or infertility may occur.
Nursing Assessment
Note history of painful swelling of the scrotum, which may be gradual or acute. If the boy is sexually active, explore history of sexual encounters prior to the onset of symptoms. Document history of dysuria or ure- thral discharge. Note fever, which may last from days to weeks. On inspection, note edema and erythema of the scrotum. Gently palpate the scrotum for a hardened and tender epididymis. Note urethral discharge if pres- ent. Palpate the inguinal lymph nodes for enlargement.
Urinalysis may be positive for bacteria and white blood cells. The culture of urethral discharge may be positive for a sexually transmitted infection such as gonorrhea or Chlamydia. The complete blood count may reveal an elevated white blood cell count.
Nursing Management
Encourage the boy to rest in bed with the scrotum ele- vated. Ice packs to the scrotum may help with pain relief.
Administer pain medications such as NSAIDs or other analgesics as needed.
Administer antibiotics as prescribed. Educate the boy and his family to complete the entire course of anti- biotics as prescribed to eradicate the infection. Advise the child and family to notify the physician or nurse practitioner if the condition is not improving or if the pain and swelling worsen.
KEY CONCEPTS
Though present at birth, the reproductive organs do not reach functional maturity until puberty.
The short length of the urethra in girls and its proximity to the vagina and anus place the young girl at higher risk for the development of urinary tract infections compared with the adult.
The urinary tract is immature in infants and young children, with a slower glomerular iltration rate and a decreased ability to concentrate urine and reabsorb amino acids compared with the adult.
The expected urine output in the infant and child is 0.5 to 2 mL/kg/hour.
Obtaining a clean or sterile urine specimen is nec- essary for accurate urine culture results.
A urinary catheter must be inserted just prior to the voiding cystourethrogram.
Close monitoring of serum blood counts and elec- trolytes is a critical component of nursing care re- lated to renal disorders.
Certain congenital urologic anomalies may require multiple surgeries as well as urinary diversion;
urine drains through a stoma on the abdominal wall that is either pouched or catheterized.
The treatment for nocturnal enuresis may include the use of desmopressin nasal spray and/or an enuresis alarm to train the child to awaken to the sensation of a illing bladder.
Nephrotic syndrome results in signiicant protein- uria and edema.
Acute glomerulonephritis most often follows a group A streptococcal infection and commonly results in hematuria, proteinuria, and hypertension.
The most common cause of hemolytic-uremic syn- drome is infection with E. coli O157:H7. It can be prevented by adequately cooking ground meat, washing hands and produce well, and making sure that an appropriate chemical balance is maintained in public recreational water sources such as swim- ming pools and water parks.
Corticosteroids can cause gastrointestinal upset. If used on a long-term basis, they should be tapered rather than discontinued abruptly to avoid adrenal crisis.
In children, chronic kidney disease is most often the result of congenital structural defects, or infec- tious, inlammatory, or immune processes that damage the kidney, whereas in adults it usually re- sults from hypertension or diabetes.
Children taking immunosuppressants for nephrotic syndrome or for renal transplant are at increased risk for the development of overwhelming infection.
Peritoneal dialysis may be accomplished at home by the parent. Close attention to sterile technique is needed.
Hemodialysis requires an arteriovenous istula or graft that is accessed with needles three or four
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times per week at a hemodialysis center. This is disruptive to the child’s academic, social, and family lives.
Renal transplantation is the best option for the treatment of end-stage renal disease in children, but vigilant medication administration is needed to prevent organ rejection.
Children with renal failure experience anemia, poor growth, depression, anxiety, and low self- esteem.
The diet for a child with a renal disorder must be individualized according to prescribed sodium, luid, and/or protein restrictions.
Postoperative care for the child undergoing uro- logic surgery includes pain management, avoidance or treatment of bladder spasms, and monitoring of urine output.