Dr.

Ghada Abu Shosha

 Genitourinary (GU) disorders in children and
adolescents may occur as a result of abnormalities in
fetal development, infectious processes, trauma,
neurological deficit, genetic influences, or other causes.
 Bladder capacity is about 30 ml in the newborn; it
increases to the usual adult capacity of about 270 ml
by 1 year of age.

 The expected urine output in the infant and child is

0.5 to 2 ml/kg/hour with the average 1-year-old
voiding about 400 to 500 ml per day.
 The average urine output for a teenager is about 800 to
1,400 ml per day.

 The infant and toddler may void as 9 or 10 times per

day. By age 3 the average number of voids per day is
the same as the adult’s (three to eight).
 Structural Disorders:

 Hypospadias & Epispadias.

 Hypospadias and epispadias are congenital anomalies

involving the abnormal location of the urethral meatus

in males.
 Both defects result when the urethral folds fail to fuse

completely over the urethral groove.

 With hypospadias, the urethral meatus can be located
anywhere along the course of the anterior urethra on
the ventral surface of the penile shaft, from the
perineum to the tip of the glans.

 Most cases are mild, with the meatus slightly off

center from the tip of the penis; in severe cases, the
meatus is located on the scrotum.
 In epispadias, the meatal opening is located on the
dorsal surface of the penile shaft.
 If Hypospadias or Epispadias left uncorrected, the
boy may not be capable of appropriately aiming a
urinary stream from a standing position.

 The abnormal placement of the urethral opening may

interfere with the deposition of sperm during
intercourse, leaving the man infertile. Also, if left
uncorrected, the boy’s self-esteem and body image
may be damaged by the abnormal appearance of his
genitalia.
 Surgical treatment to provide an appropriately placed
meatus that allows for normal voiding and ejaculation.

 Most repairs are accomplished in one surgery. More

extensive reconstructions may require two stages.
 History of an unusual urine stream.
 Inspect the penis for placement of the urethral meatus.
 Palpate for presence or absence of testicles in the

scrotal sac, because cryptorchidism (undescended

testicles) often occurs with hypospadias.
 The newborn with hypospadias or epispadias should
not undergo circumcision until after surgical repair of
the urethral meatus.

 Providing routine postoperative care and parent

education.
 Hydronephrosis is a condition in which the pelvis and
calyces of the kidney are dilated. Hydronephrosis
may occur as a congenital defect, as a result of
obstructive uropathy, or secondary to vesicoureteral
reflux.
 Congenital hydronephrosis may be revealed on

prenatal ultrasound.
 Complications include renal insufficiency,

hypertension, and renal failure.

 Health history:
 The infant may be asymptomatic.
 Signs and symptoms may include: failure to thrive,

intermittent hematuria, presence of an abdominal mass,

signs and symptoms associated with UTI such as fever,
vomiting, poor feeding, and irritability.
 Monitor the blood pressure
 Palpation of the abdomen may reveal enlarged
kidney(s) or distended bladder.
 A voiding cystourethrogram (VCUG) will be
performed to determine the presence of a structural
defect that may be causing the hydronephrosis.
 Renal ultrasound
 An intravenous pyelogram.
 Teach the parents signs and symptoms of UTI and
sepsis, as these complications may occur.
 The parents 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.
 Follow up with a pediatric nephrologist or urologist.
 Vesicoureteral reflux (VUR) is a condition in which
urine from the bladder flows back up the ureters. This
reflux of urine occurs during bladder contraction with
voiding.
 Reflux may occur in one or both ureters. If reflux

occurs when the urine is infected, the kidney is exposed

to bacteria and pyelonephritis may result.
 The increased pressure placed upon the kidney with

reflux can cause renal scarring and lead to hypertension

later in life and, if severe, renal insufficiency or failure.
 Primary VUR results from a congenital abnormality
at the vesicoureteral junction that results in
incompetence of the valve.
 Secondary VUR is related to other structural or

functional problems such as neurogenic bladder,

bladder dysfunction, or bladder outlet obstruction.
 As many as 30% to 40% of all children diagnosed

with UTI have primary VUR.

 VUR is graded according to its severity:
 Grade I – reflux into non-dilated ureter
 Grade II – reflux into the renal pelvis and calyces without
dilatation
 Grade III – mild/moderate dilatation of the ureter, renal pelvis
and calyces.
 Grade IV – dilation of the renal pelvis and calyces with
moderate ureteral tortuosity
 Grade V – gross dilatation of the ureter, pelvis and calyces;
ureteral tortuosity; loss of papillary impressions.
 Grade I & II VUR cases usually resolve
spontaneously, but grade III to V cases are generally
associated with recurrent UTI, hydronephrosis, and
progressive renal damage.

 The goal of therapeutic management of VUR is

prevention of pyelonephritis and renal scarring.
 Ureteral reimplantation surgery is a surgical procedure
where the connection between the ureter and the
bladder is reconstructed to prevent VUR.
 Endoscopic treatment is an option for some children
who have lower grades of VUR. The procedure is
performed on an outpatient basis under general
anesthesia.

 The doctor inserts a small telescope into the bladder

through the urethra (the tube connects the bladder to
the outside) and injects a small amount of gel-like
material under the opening of the ureter. The injected
material partially closes the opening and prevents the
urine from going backwards toward the kidney.
 Nephrotic syndrome is a set of symptoms related to
kidney dysfunction occurs as a result of increased
glomerular basement membrane permeability, which
allows abnormal loss of protein in the urine.
 Generally occurs in three forms:
1. Congenital
2. Idiopathic
3. Secondary
 Congenital Nephrotic syndrome is an inherited
disorder, rare, poor prognosis.
 Nephrotic syndrome may occur secondary to another

condition such as systemic lupus erythematosus or

diabetes.
 Idiopathic nephrotic syndrome is the most commonly

occurring type in children and is often termed

minimal change nephrotic syndrome (MCNS).
 MCNS occurs more frequently in males and is most
common in children less than 3 years of age.
 Complications of nephrotic syndrome include anemia,

infection, poor growth, peritonitis, thrombosis, and

renal failure.
 Pathophysiology.
 Increased glomerular permeability results in the

passage of larger plasma proteins through the

glomerular basement membrane, resulting in excess
loss of protein (albumin) in the urine and decreased
protein and albumin in the bloodstream.
 Hypoalbuminemia results in a change in osmotic
pressure, and fluid shifts from the blood stream into
the interstitial tissue (causing edema).
 The kidneys respond by conserving sodium and water

leading to further edema.

 The liver increases production of lipoproteins.
 Hyperlipidemia develops as the excess lipids cannot

be excreted in the urine.

 Children with nephrotic syndrome are at increased risk
for clotting because of the decreased intravascular
volume.
 At risk for the development of serious infection, sepsis

or peritonitis.
 Corticosteroid therapy
 Intravenous albumin
 Diuretics
 Health history: signs and symptoms include; nausea
and vomiting, weight gain, periorbital edema,
weakness or fatigue, irritability.
 Physical examination: edema (periorbital edema,
anasarca, or abdominal ascitis).
 As the disease progresses: more generalized edema,
stretched skin, tight appearance, pallor, skin
breakdown.
 Weight assessment.
 Increased respiratory rate and work of breathing.
 Heart assessment for fluid overload.
Figure 2. Nephrotic edema.
 Urine dipstick will reveal marked proteinuria.
 Hypoalbuminemia
 Elevated cholesterol level.
 Elevated blood urea nitrogen
 HUS is defined by three features: hemolytic anemia,
thrombocytopenia, and acute renal failure.
 In 90% of cases of HUS, diarrhea precedes the onset of

the syndrome. Other causes idiopathic, inherited, drug

related, associated with malignancies.
 A verotoxin-producing strain of E. coli causes the
majority of cases.
 Streptococuss pnemonia, Shigella dysenteriae may
also be the cause.
 Transmission also occurs via human feces.
 Complications include chronic renal failure, seizures
and coma, pancreatitis, intussusception, rectal
prolapse, cardiomyopathy, congestive heart failure
and acute RDS.
 Goals: maintaining fluid balance, correcting
hypertension, correcting acidosis and electrolyte
abnormalities, replenishing red blood cells, and
providing dialysis if needed.