The urinary tract and renal disorders discussed below include structural disorders, UTI, enuresis, and acquired disorders that result in altered renal function.
defect in which the opening is on the dorsal surface of the penis. In either case, the opening may be near the glans of the penis, midway along the penis or near the base. If left uncorrected, the boy may not be capable of appropriately aiming a urinary stream from a stand- ing position. In addition, the abnormal placement of the urethral opening may interfere with the deposition of sperm during intercourse, leaving the man infer- tile. Also, if left uncorrected, the boy’s self-esteem and body image may be damaged by the abnormal appear- ance of his genitalia (Pfeil & Lindsay, 2010). For these reasons, the defect is usually repaired sometime after about 1 year of age. The goal of surgical correction for either condition is to provide for an appropriately placed meatus that allows for normal voiding and ejac- ulation. The meatus is moved to the glans penis and the urethra is reconstructed as needed. Most repairs are
Providing Postoperative Care
Nursing management in the postoperative period focuses on preventing infection. Keep the infant supine and quickly change soiled diapers to prevent contamination of the incision with stool. Surgical reconstruction of the bladder within the pelvic cavity and reconstruction of a urethra are done if enough bladder tissue is present.
An indwelling urethral catheter or suprapubic tube will allow urinary drainage, allowing the bladder to rest in the initial postoperative period. Ensure that catheters drain freely and do not become kinked. Sometimes tubes or catheters used in the postoperative period require irri- gation. Refer to the institution’s policy and the surgeon’s orders for speciics related to urinary catheter irrigation.
Manage bladder spasms with oxybutynin (Ditro- pan) or belladonna and opioid (B & O) suppositories as ordered. Note blood-tinged urine upon return from surgery, with clearing of urine within hours to days. If orthopedic surgery is also involved in the repair due to a malformed pubic arch, follow through with recom- mended positioning or bracing to prevent further sepa- ration of the pubic arch.
Catheterizing the Stoma
If bladder tissue is insuficient for repair, then the bladder is removed and a continent urinary reservoir is created.
The ureters are connected to a portion of the small intes- tine that is separated from the gastrointestinal (GI) tract, thus creating a urinary reservoir. The intestines are reanas- tomosed to leave the GI tract intact and separate from the GU tract. A stoma is created on the abdominal wall; it pro- vides access to the urinary reservoir (Fig. 43.1). The stoma is catheterized about four times per day to empty the res- ervoir of urine. Urine from an intestine-based urinary res- ervoir tends to be mucus-like and is often cloudier than urine from a urinary bladder. Teach parents the procedure for catheterizing the urinary reservoir and instruct them to call the child’s urologist or physician or nurse practitioner if signs or symptoms of UTI occur.
Take Note!
Children with congenital urologic malformations are at high risk for the development of latex allergy (Beh- rman, 2011). Latex allergy can result in anaphylaxis. Primary prevention of latex allergy is warranted in all children with uro- logic malformations, so use latex-free gloves, tubes, and cath- eters in these children.
Hypospadias/Epispadias
Hypospadias is a urethral defect in which the opening is on the ventral surface of the penis rather than at the end of the penis (Fig. 43.2). Epispadias is a urethral
FIGURE 43.1 The abdominal stoma allows for urinary continence and requires catheterization.
A B
FIGURE 43.2 (A) Hypospadias: the urethral opening is located on the ventral side of the penis. (B) Epispadias: the urethral opening is located on the dorsal side of the penis.
with the penis in an upright position to prevent stress on the urethral incision. The penile dressing is usually a compression type, used to decrease edema and bruis- ing. Administer antibiotics if prescribed. Assess for pain, which is usually not extensive, and administer analgesics or antispasmodics (oral oxybutynin or B & O supposi- tory) as needed for bladder spasms.
Take Note!
Bladder spasms may also be managed efectively through the use of epidural analgesia, which is being used more frequently in the postoperative period in the pediat- ric population (Ellis, Martelli, LaMontagne, & Splinter, 2007).
Double diapering is a method used to protect the urethra and stent or catheter after surgery; it also helps keep the area clean and free from infection. The inner diaper contains stool and the outer diaper contains urine, allowing separation between the bowel and bladder out- put. Nursing Procedure 43.2 details the double-diapering technique. Change the outside (larger) diaper when the child is wet; change both diapers when the child has a bowel movement.
Educating the Family
If the child is to be discharged with the urinary catheter in place (which is common), teach the parents how to care for the catheter and drainage system. Have parents dem- onstrate their ability to irrigate the catheter should a mucus plug occur. Tub baths are generally prohibited until it is time to remove the penile dressing. Roughhousing, ride-on accomplished in one surgery. More extensive recon-
structions may require two stages.
Nursing Assessment
Note history of an unusual urine stream. Inspect the penis for placement of the urethral meatus: it may be slightly off center of the glans or may be present some- where along the shaft of the penis. Inspect for chordee, a ibrous band causing the penis to curve downward.
Palpate for the presence or absence of testicles in the scrotal sac, because cryptorchidism (undescended tes- ticles) often occurs with hypospadias, as do hydrocele and inguinal hernia.
Nursing Management
The newborn with hypospadias or epispadias should not undergo circumcision until after surgical repair of the urethral meatus. In more extreme cases, the surgeon may need to use some of the excess foreskin while recon- structing the meatus. Nursing management of the infant who has undergone a hypospadias or epispadias repair focuses on providing routine postoperative care and par- ent education.
Providing Postoperative Care
Postoperatively, assess urinary drainage from the ure- thral stent or drainage tube, which allows for discharge of urine without stress along the surgical site. Ensure that the urinary drainage tube remains carefully taped
NURSING PROCEDURE 43.2
Double Diapering
1. Cut a hole or a cross-shaped slit in the front of the smaller diaper.
2. Unfold both diapers and place the smaller diaper (with the hole) inside the larger one.
3. Place both diapers under the child.
4. Carefully bring the penis (if applicable) and cath- eter/stent through the hole in the smaller diaper and close the diaper.
5. Close the larger diaper, making sure the tip of the catheter/stent is inside the larger diaper.
Cut slit
Larger diaper Smaller diaper Pictures and text adapted from Mount Nittany Medical Center. (2009). When your child needs surgery for hypospadias.
Retrieved July 7, 2012, from http://www.mountnittany.org/articles/healthsheets/11952
Disorder Site Illustration Ureteropelvic
junction (UPJ) obstruction
Junction of the upper ureter with the pelvis of the kidney
Urinary tract with unilateral hydronephrosis and narrowing of the UPJ on that side
Site of obstruction Renal pelvis
Kidney Ureter Bladder
Ureterovesical junction (UVJ) obstruction
Junction of the lower ureter and the bladder
Urinary tract with unilateral hydronephrosis and dilated ureters with narrowing of the UVJ on that side
Kidney
Bladder
Ureter
Obstruction
Ureterocele Ureter swells into the bladder Bladder with cystic pouch where ureters insert (unilateral)
Hydroureter
Ureterocele
Posterior urethral valves (males only)
Flaps of tissue in the proximal urethra
Distended proximal urethra, bladder, ureters, and hydronephrosis
Renal pelvis Kidney
Ureter Thickened bladder walls with dilated bladder
Posterior valves
Adapted from Liu, D. B., & Edmondson, J. D. (2011). Antenatal hydronephrosis. Retrieved April 1, 2012, from http://emedicine.med- scape.com/article/1016305-overview; and Lum, G. M. (2011). Kidney & urinary tract. In W. W. Hay, M. J. Levin, J. M. Sondheimer, &
R. R. Deterding (Eds.), Current pediatric diagnosis and treatment (20th ed.). New York, NY: McGraw-Hill.
TABLE 43.1 COMMON SITES OF OBSTRUCTIVE UROPATHY
Nursing Management
Surgical correction is speciic to the type of obstruction and generally consists of removal of the obstruction, reimplantation of the ureters as necessary, and, occa- sionally, creation of a urinary diversion. Postoperatively, assess urine output via vesicostomy, nephrostomy, supra- pubic tube, or urethral catheter for color, clots, clarity, and amount. Encourage luids once the child can tolerate them orally. Administer analgesics and/or antispasmod- ics as needed for bladder spasms. Teach parents care of vesicostomy or drainage tubes, with which the child may be discharged.
Take Note!
Upon return from surgery, most children have intra- venous luids without added potassium infusion.
Potassium is withheld from the intravenous luid until ade- quate urine output is established postoperatively to avoid the development of hyperkalemia should the kidneys fail to func- tion properly (Browne, Flanigan, McComiskey, & Pieper, 2013).
Hydronephrosis
Hydronephrosis is a condition in which the pelvis and calyces of the kidney are dilated (Fig. 43.3). Hydrone- phrosis may occur as a congenital defect, as a result of obstructive uropathy, or secondary to vesicoureteral relux. Congenital hydronephrosis may be revealed on prenatal ultrasound. Complications of hydronephrosis include renal insuficiency, hypertension, and eventually renal failure.
Nursing Assessment
For a full description of the assessment phase of the nursing process, refer to page 1551. Assessment indings pertinent to hydronephrosis are discussed below.
toys, or any activity involving straddling is not allowed for 2 to 3 weeks.
Obstructive Uropathy
Obstructive uropathy is an obstruction at any level along the upper or lower urinary tract. This discussion will focus on congenital structural defects, though obstruc- tion can also occur as a result of other disease processes (acquired obstructive uropathy). The most common sites of obstruction are listed in Table 43.1. The defect may be unilateral or bilateral and can cause partial or complete obstruction of urine low, resulting in dilation of the affected kidney (hydronephrosis). Complications include recurrent UTI, renal insuficiency, and progressive dam- age to the kidney resulting in renal failure.
Nursing Assessment
For a full description of the assessment phase of the nursing process, refer to page 1551. Assessment indings pertinent to obstructive uropathy are discussed below.
Health History
Elicit a description of the present illness and chief com- plaint. Common signs and symptoms reported during the health history might include:
• Recurrent UTI
• Incontinence
• Fever
• Foul-smelling urine
• Flank pain
• Abdominal pain
• Urinary frequency (needing to void often)
• Urinary urgency (urge to void immediately)
• Dysuria (dificulty or pain with voiding)
• Hematuria (blood in the urine)
Explore the child’s current and past medical history for risk factors such as:
• “Prune belly” syndrome
• Chromosome abnormalities
• Anorectal malformations
• Ear defects
Physical Examination and Laboratory and Diagnostic Tests
Palpate the abdomen for the presence of an abdominal mass (hydronephrotic kidney). Assess the blood pres- sure; elevation may occur if renal insuficiency is present.
Many cases of obstructive uropathy may be diagnosed with prenatal ultrasound if the obstruction has been sig- niicant enough to cause hydronephrosis or dilatation elsewhere along the urinary tract.
Normal Kidney Distended Kidney Renal pelvis
Ureter Bladder Obstruction
FIGURE 43.3 Hydronephrosis.
of the valve. Secondary VUR is related to other structural or functional problems such as neurogenic bladder, blad- der dysfunction, or bladder outlet obstruction. As many as 70% of all children diagnosed with UTI have VUR (Nelson & Koo, 2012).
VUR is graded according to its severity, from grade I, which is characterized by minor dilatation of the proxi- mal ureter, to grade V, which is characterized by severe dilatation of the ureter and pelvis of the kidney. Grade I and II VUR cases usually resolve spontaneously, but grade III through V cases are generally associated with recurrent UTIs, hydronephrosis, and progressive renal damage (Nelson & Koo, 2012).
The goal of therapeutic management of VUR is pre- vention of pyelonephritis and subsequent renal scarring, which may contribute to the development of hypertension later in life (Nelson & Koo, 2012). Management includes antibiotic prophylaxis and hygiene/voiding practices to prevent UTI. Serial urine cultures are used to determine recurrence of UTI. Biannual, annual, or biennial radio- nuclide VCUGs are performed to determine the status of VUR.
Grade III, IV, and V cases usually warrant surgical intervention. The ureters are resected from the bladder and reimplanted elsewhere in the bladder wall to regain functionality.
Take Note!
The keys to prevention of long-term sequelae such as hypertension in children with urologic conditions are early diagnosis and intervention, prevention of infection, and close clinical follow-up. Nurses play a key role in monitoring and education.
Nursing Assessment
For a full description of the assessment phase of the nursing process, refer to page 1551. Assessment indings pertinent to VUR are discussed below.
Health History
Elicit a description of the present illness and chief com- plaint. The infant may be asymptomatic, but signs and symptoms reported during the health history might include:
• Failure to thrive
• Intermittent hematuria
• Presence of an abdominal mass
• Signs and symptoms associated with a UTI such as fever, vomiting, poor feeding, and irritability
Explore the child’s current and past medical history for risk factors such as:
• Maternal oligohydramnios or polyhydramnios (con- genital hydronephrosis)
• Elevated levels of serum α-fetoprotein (congenital hydronephrosis)
Physical Examination and Diagnostic and Laboratory Tests
Monitor the blood pressure of infants and children suspected of having hydronephrosis. Palpation of the abdomen may reveal enlarged kidney(s) or a distended bladder. A voiding cystourethrogram (VCUG) will be per- formed to determine the presence of a structural defect that may be causing the hydronephrosis. Other diagnostic tests, such as a renal ultrasound or an intravenous pyelo- gram, may also be performed to clarify the diagnosis.
Nursing Management
Teach the parents signs and symptoms of UTI and sep- sis, as these complications may occur. Explain to the parents that they should observe the child for adequacy of urine output and hydration status. Teach the parents to perform appropriate perineal hygiene and to avoid using irritants in the genital area. The infant or child with hydronephrosis will need follow-up with a pediatric nephrologist or urologist.
Vesicoureteral Reflux
Vesicoureteral relux (VUR) is a condition in which urine from the bladder lows back up the ureters. This relux of urine occurs during bladder contraction with voiding (Fig. 43.4). Relux may occur in one or both ureters. If relux occurs when the urine is infected, the kidney is exposed to bacteria and pyelonephritis may result. The increased pressure placed upon the kidney with relux can cause renal scarring and lead to hyper- tension later in life and, if severe, renal insuficiency or failure.
Primary VUR results from a congenital abnormality at the vesicoureteral junction that results in incompetence
FIGURE 43.4 Note retrograde low of urine up the ureter upon bladder contraction.
output via the Foley catheter; urine should be bloody initially, clearing within 2 to 3 days. If ureteral stents are present, monitor urine output from those as well.
Administer analgesics for incisional pain relief and anti- spasmodics or B & O suppositories as needed for blad- der spasms. Encourage ambulation and advancement of diet as ordered to promote return of appropriate bowel function. Teach parents that prophylactic antibiotics will be given until 1 to 2 months after surgery, when the VCUG demonstrates absence of relux.
Take Note!
When caring for the child who has undergone urologic surgery, avoid manipulating the Foley or suprapu- bic catheter: catheter manipulation contributes to bladder spasms.
Urinary Tract Infection
UTI is an infection of the urinary tract, most commonly affecting the bladder. UTI occurs most often as a result of bacteria ascending to the bladder via the urethra.
The incidence of UTI in children is nearly 3% and is most common in infants and young children. It occurs more frequently in males than females during infancy, but after 1 year of age it is more common in females (Fisher, 2012). One explanation for the more com- mon occurrence in females is that the female’s shorter urethra allows bacteria to have easier access to the bladder. The urethra is also located quite close to the vagina and anus in females, allowing spread of bacteria from those areas. The sexually active female adoles- cent is at risk for the development of UTI, as bacte- ria may be forced into the urethra by pressure from intercourse. The adolescent male may be somewhat protected from UTI by the antibacterial properties of prostate secretions.
UTI presents differently in infants than it does in children. Infants may exhibit fever, irritability, vomiting, failure to thrive, or jaundice. Children may also experi- ence fever and vomiting, but also may have dysuria, fre- quency, hesitancy, urgency, and/or pain.
Pathophysiology
E. coli most commonly causes UTI, as it is usually found in the perineal and anal region, close to the urethral opening. Other organisms include Klebsiella, Staphylo- coccus aureus, Proteus, Pseudomonas, and Haemophi- lus. Numerous factors may contribute to bacterial pro- liferation. Urinary stasis contributes to the development of a UTI once the bacteria have gained entry. Urine that remains in the bladder after voiding allows bacteria to grow rapidly. A decreased luid intake also contrib- utes to bacterial growth, as the bacteria become more
Health History
Elicit a description of the present illness and chief com- plaint. Common signs and symptoms reported during the health history might include:
• Fever
• Dysuria
• Frequency or urgency
• Nocturia
• Hematuria
• Pain in the back, abdomen, or lank
Explore the child’s current and past medical history for risk factors such as:
• Recurrent UTI in the female
• Single episode of UTI in the male
• Congenital defect
• Family history of VUR
For the child who is receiving ongoing follow-up for VUR, determine whether UTIs have occurred since the last visit, as well as the name and dose of prophylactic antibiotic.
Physical Examination
Monitor the blood pressure for elevation. Palpate the abdomen for presence of a mass (if hydronephrosis is present). VCUG may be used to diagnose VUR.
Nursing Management
Nursing management for the child with VUR includes preventing infection and providing postoperative care.
Preventing Infection
When VUR is present, the goal is to avoid urine infection so that infected urine cannot gain access to the kidneys.
Initially, most cases of VUR are managed medically.
Teach the child to empty the bladder completely. Teach the child and parents appropriate perineal hygiene as well as toileting hygiene to prevent recurrence of UTI. Teach parents about the antibiotic therapy pre- scribed; the child will be maintained on a low daily dose to prevent UTI. The drug is most effective when given at bedtime because of urinary stasis overnight.
Inform parents of the schedule for serial urine cultures and follow-up VCUG.
Providing Postoperative Care
If VUR is severe or if UTI is recurrent, surgical correction will be necessary. In the irst 24 to 48 hours after surgery, maintain the intravenous luid rate at 1.5 times mainte- nance to encourage a high urinary output. Monitor urine