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Course: Pediatric Nursing

Topic: Care of Child with Genitourinary Disorder Part III

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Module Goals

Learners will be able to:

Define epispadias, hypospadias, acute renal failure, and chronic renal failure.
Identify signs and symptoms of these disorders in children.
Explain related diagnostic procedures.
Discuss evidence-based management of these disorders in children.
Describe nurse’s role in management of these disorders in children.
Discuss the psychosocial impact of chronic genitourinary disorders on children and their families.

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Urinary System Conditions/Disorders

Epispadias
Hypospadias
Acute Renal failure
Chronic Renal Failure

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Epispadias

Urogenital malformation characterized by failure of urethral tube to tubularize on the dorsal aspect
Exact cause unclear
More common in boys than girls
Male epispadias classified depending on the position of the meatus:

Glandular- found in head of penis
Penile- found along the shaft of penis
Penopubic forms- found near pubic bone

Affected girls have separated pubic bone, also common in boys

Anand & Lotfollahzadeh, 2021

Urology Care Foundation, n.d.a

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Epispadias: Assessment and Diagnostics

History of urinary incontinence, backward flow of urine into kidney, urinary tract infections

Physical assessment in male:

A short-stubby phallus with a dorsally located meatus
Dorsal chordee
Ventrally hooded prepuce

Physical assessment in female:

Bifid clitoris
Patulous urethral opening
Anteriorly placed vaginal opening
Ill-formed or absent mons

Anand & Lotfollahzadeh, 2021

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Epispadias: Assessment and Diagnostics (Continued)

Blood test to check electrolyte levels
Intravenous pyelogram (IVP)
Micturating Cystourethrography (MCUG)
Magnetic Resonance Imaging , computerized tomography and CT scans, depending on the condition
Pelvic X-ray
Ultrasound of the urogenital system

Anand & Lotfollahzadeh, 2021

John Hopkins Medicine, n.d.

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Epispadias: Management

Surgical reconstruction for optimal functioning and cosmetic outcome:

For boys:

Confirm urinary ability
Correct bends in the penis (dorsal bend and chordee)
Correct penis for normal appearance

For girls:

Normal placement of urethra
2 parts of clitoris brought together

Anand & Lotfollahzadeh, 2021

Urology Care Foundation, n.d.a

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Epispadias: Management

Post-surgical management:

Pain relief
Anticholinergic medication for bladder spasms
Immobilization of the lower extremities
Care of the indwelling catheter

Antibiotics to treat or prevent infection

Anand & Lotfollahzadeh, 2021

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Critical Thinking Question

Which of the following nursing interventions would a nurse anticipate while caring for a child diagnosed with epispadias? (Select all that apply)

Assess for urinary tract infection
Assess genital area
Ensure child and parents are counselled by surgical specialist
Parent education on side-effects of prescribed antibiotics
Indwelling catheter care

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Hypospadias

Birth defect in boys where urethral opening is not located at the tip of penis
Problems associated:

Have curved penis (Chordee)
Abnormal spraying of urine
Testicle not fully descended into scrotum

Causes difficulty with sexual intercourse or urinating while standing
Types:

Subcoronal: Opening near the head of penis
Midshaft: Opening along the shaft of penis
Penoscrotal: Opening where penis and scrotum meet

Center for Disease Control and Prevention, 2020

Urology Care Foundation, n.d.b

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Hypospadias: Risk Factors

Hypospadias: Diagnostics

Mothers age over 35 years with elevated BMI
Fertility treatments
Use of certain hormones just before or during pregnancy

Center for Disease Control and Prevention, 2020

Urology Care Foundation, n.d.b

Often diagnosed during physical assessment at birth

Meatus in the wrong place
Foreskin is often not completely formed on its underside
May have abnormal foreskin with the meatus in the normal place or complete foreskin may hide an abnormal meatus

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Hypospadias: Management

Circumcision is avoided because foreskin is required for repair surgery of hypospadias
Surgical operation under general anesthesia

Moving urethral opening to the tip of penis
Straightening penis shaft
Creating urinary channel
Removing excess foreskin or reconstructing foreskin (if required)

Severe chordee many need surgical repair in stages
Catheter may be in situ for 5-12 days to prevent urine contact with surgical site
Pain medications and antibiotics

Children’s Health Queensland Hospital and Health Service, n.d.

Urology Care Foundation, n.d.b

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Nursing Consideration for Management of Epispadias and Hypospadias

Assessment for epispadias and hypospadias at birth
Ensure parents understand disease and treatment management
Provide post-surgical care

Monitor vital signs
Assessment for bleeding at surgical site
Appropriate pain management
Infection prevention
Catheter care if in situ

Children’s Health Queensland Hospital and Health Service, n.d.

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Parent Education (continued)

Child’s care at home relating to:

Urogenital hygiene
Catheter care
Safe medication administration
Signs/symptoms of infection or bleeding
When to seek medical advice

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Critical Thinking Question

Which of the following is appropriate for the nurse to inform the parents of a 1 year old infant with newly diagnosed hypospadias? (Select all that apply)

Have the child circumcised soon to prevent infection
Signs/symptoms of urinary tract infections
Urogenital hygiene
Hypospadias causes problems with sexual intercourse in the future
Surgical intervention is the only definitive treatment

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Renal Failure in Children

Kidneys are unable to remove waste/extra water from blood, or balance body chemicals sufficiently
Types

Acute renal failure (ARF), interchangeably called acute kidney injury (AKI), occurs suddenly (within period of hours or days)

Temporary, may be treated or cured

Chronic renal failure (CRF), or chronic kidney disease (CKD), develops over many years

Permanent condition, cannot be cured

Healthwise Staff, 2020

National Cancer Institute, n.d.

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ARF in Children

Can be treated or cured with immediate management interventions
May lead to death or chronic renal failure if not treated immediately
Causes:

Pre-Renal: hypovolemia, peripheral vasodilatation, impaired cardiac output, renal vessel occlusion, nephrotoxic drugs, hepatorenal syndrome, increased intraabdominal pressure.
Intrinsic Renal: insufficiency, nephrotoxins, renal disease, myo/haemoglobinuria, tumor infiltrate, intratubular obstruction.
Post-Renal: posterior urethral valves, blocked catheter, neurogenic bladder, trauma, calculi.

Acute renal failure in paediatrics- management and investigation, n.d.

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ARF in Children: Assessment

Signs and Symptoms:

Oliguria, urine output: - <300ml/m²/day or 0.5ml/kg/hr
Anuria, Urine output: - <1ml/kg/day

Further assessments:

Daily Weight
Urine Output
Blood Pressure
Hydration Status
Cardiorespiratory exam

Acute renal failure in paediatrics - management and investigation, n.d.)

Clinical Fluid Overload
Edema
Triple rhythm
Hypertension

Neurological exam
Musculoskeletal exam
Bruising/Bleeding
Drug History Investigations

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ARF in Children: Diagnostics

Investigations:

U&E’s, LFTs, CRP
Uric acid
Magnesium
Glucose
Osmolality
FBC ± Blood film
Coagulation Screen
Group and Save

Acute renal failure in paediatrics - management and investigation, n.d.

LDH
FENa
Urinalysis
Urinary Sodium, Osmolality
Microscopy for casts
Culture and sensitivity
Renal Ultrasound

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ARF in Children: Management

Daily weight, urine input/output monitoring
Adequate renal perfusion through:

Fluid management

Correct hypovolemia
Normal intravascular volume: administer fluid that equal insensible loss plus output (renal and extrarenal)
Hypervolemia

Fluid restrictions, minimal drug infusion volumes, diuretics, dialysis, omit insensible loss replacement

Hemodynamic management

Correction of electrolytes: Sodium, potassium, calcium, phosphate

Acute renal failure in paediatrics - management and investigation, n.d.

Hyun Cho, 2020

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ARF in Children: Management (Continued)

Treatment of acid-base disorders
Aggressive nutritional support

Protein 0.6g/kg/day (1.5g if dialysed)
Intralipid - medium chain triglycerides
Folate and Vitamin supplementation

Maintain optimal blood pressure
Avoid Nephrotoxic medications

Where inevitable, dosage and dosing interval needs adjusted and monitored to reduce renal toxicity

Antibiotics for infections
May need Renal Replacement Therapy (RRT): Dialysis or Hemofiltration

Acute renal failure in paediatrics - management and investigation, n.d.

Hyun Cho, 2020

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ARF in Children: Renal Replacement Therapy

Peritoneal Dialysis

Preferred for long-term dialysis, least expensive
Anticoagulant not required, easy peritoneal catheter access
Ultrafiltration with less potential for hemodynamic instability secondary to sudden fluid shifts
Does not provide urgent clearance needed for acute intoxications, tumor lysis syndrome, symptomatic hyperkalemia, or hyperammonemia
Risk for peritonitis, infection, increased dialysate protein loss, compromised nutrition, loss of ultrafiltration production, damage to peritoneal membrane

Bridges, et al., 2012

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ARF in Children: RRT (Continued)

Intermittent Hemodialysis

High blood flow and dialysate flow

Most rapid solute clearance and removal of extracellular fluid volume
Substantial clearance in several hours, allowing freedom from machine for most of the day

Requires skilled personnel in specialized medical center or hemodialysis clinic
Requires reliable vascular access
Rapid removal of urea associated with risk for cerebral edema and potential death

Bridges, et al., 2012

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ARF in Children: RRT (Continued)

Continuous Renal Replacement Therapy

More effective in hemodynamically unstable children
Fluid goals adjusted based on the patient’s status
Provision of nutrition, blood products, and medications without worsening fluid overload
Significant clearance of amino acids leads to additional protein needs
More expensive, and provided in tertiary care with skilled personnel
Requires reliable vascular access, and anticoagulant

Bridges, et al., 2012

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Critical Thinking Question

Which of the following would a nurse find in the assessment of a 17 year old teenager with acute renal failure? (Select all that apply)

Renal output of 0.6 ml/kg /hour
Blood pressure of 148/96 mmHg
Pulmonary rales
Jugular venous distention

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Chronic Renal Failure (CRF) in Children

Causes:

Congenital abnormalities of the kidney and urinary tract
Steroid-resistant nephrotic syndrome, chronic glomerulonephritis (e.g. lupus nephritis, Alport syndrome) and renal ciliopathies,
Thrombotic microangiopathies (especially atypical haemolytic uraemic syndrome), nephrolithiasis/nephrocalcinosis, Wilms tumor, infectious and interstitial diseases

Leads to end-stage renal failure (ESRF) requiring kidney dialysis or kidney transplant

Becherucci, et al., 2016

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CRF in Children: Signs/Symptoms

Signs/symptoms:

Swelling/puffiness around the eyes, feet, ankles
Frequent urination, prolonged bedwetting in older children
Stunted or poor growth
Loss of appetite, chronic nausea
Fatigue
Frequent severe headaches from high blood pressure
Anemia/pallor from decreased red blood cell production

Complications:

Disease of heart and circulation
Cardiac arrest

American Academy of Pediatrics, 2020

InfoKid, n.d.a)

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CRF in Children: Diagnostics

Height, weight to estimate proper growth
Blood pressure
Blood tests for Glomerular Filtration Rate (GFR), creatinine, blood chemical levels, minerals, sugars, fats
Tests for anemia
Urine tests for protein, albumin to creatinine ratio
Parathyroid hormones and other hormones for bone development
Kidney ultrasound/X-rays, CT Scans
Kidney biopsy

National Institute of Diabetes, Digestive, and Kidney Diseases, 2016

American Academy of Pediatrics, 2020

InfoKid, n.d.b

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Stages of CRF

InfoKid, n.d.c

Stage	GFR	Kidney function	Interpretation
1	90 or higher	Normal, but other signs of kidney disease	Normally no symptoms
2	60–89	Mildly reduced	Normally no symptoms
3a	45–59	Moderately reduced	Normally no symptoms
3b	30–44	Moderately reduced	May start to have symptoms of CKD
4	15–29	Severely reduced	Many have more symptoms of CKD Plan treatment options for next stage
5	Less than 15	Cannot support body	ESRF Dialysis and kidney transplantation

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CRF in Children: Management

Delay progression of disease and complications
Management of edema: fluid restriction, diuretics, low sodium diet
Control blood pressure
Diet modification: phosphate restrictions and/or phosphate binders, nutritional supplement- folic acid, iron, injectable erythropoietin
Avoid nephrotoxic medications
Stage 4-5 of CKD:

RRT (Peritoneal Dialysis preferred for long-term dialysis)
Kidney transplant

Conservative and palliative care management for children who reject RRT

Becherucci, et al., 2016; Sanderson & Harshman, 2020

American Academy of Pediatrics, 2020

InfoKid, n.d.c

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Special Nursing Considerations in Management of

ARF and CRF in Children

Assessment focused on clinical signs/symptoms of ARF/CRF
Early referral to the specialist if ARF/CRF suspected
Monitor daily weight, fluid input/output, mental status
Ensure child/parent counselling on diet modifications by nutritionist
Monitor for and immediate management of oliguria, rising serum creatinine, and other complications
Exercise cautions with nephrotoxic drugs in children at risk of AKI/CKD
Assist child/parent in the process of obtaining RRT and/or kidney transplant

Hulse & Davies, 2014

Vaidya, Aeddula, & Doerr, 2021

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Special Nursing Considerations in Management of

ARF and CRF in Children

Child/Parent education:

Disease process, medications
Diet modifications
Signs/Symptoms of complications, when to seek immediate care
Infection prevention

Assist child/parent to gain access to available resources

Emotional and psychosocial support
Financial assistance
Conservative treatments
Palliative care

Hulse & Davies, 2014

Vaidya, Aeddula, & Doerr, 2021

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Psychosocial Impact on Children and Family with CKD

Affected child may experience emotional, behavioral, social, and academic difficulties due to:

Prolonged medication use
Frequent visits to medical professionals
Interruptions in school and everyday activities

Family may experience emotional, marital, social, and financial burden from complexity of care
Siblings may experience sadness, anxiety, stress, or guilt over their good health

Aier, Pais, & Raman, 2022

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Psychosocial Impact on Children and Family with CKD: Nursing Implications

Assess for:

Anxiety, withdrawn behavior, low self-esteem, school refusal, attention deficit, poor scholastic performance, or poor treatment adherence

Provide empathetic and compassionate care
Encourage children and families to share their concerns, emotions

Practice active listening
Be ‘present’ for them

Provide informations about child’s care in timely manner to reduce anxiety

Aier, Pais, & Raman, 2022

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Psychosocial Impact on Children and Family with CKD: Nursing Implications

Arrange child’s follow-up appointments as per parent/guardian’s convenience where possible

Carefully plan child’s follow-up to reduce number of visits

Assist child/family to access mental health specialist and peer-support groups for psychosocial support

Aier, Pais, & Raman, 2022

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Critical Thinking Question

What interventions should a nurse expect in the treatment/ management of a child with stage 3 chronic kidney disease (CKD)? (Select all that apply)

Antibiotics to treat infections
Kidney transplant
Fluid restrictions
Low salt diet
Access to mental health specialist
Mental status examination

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Answer: a, c, d, e, f

Stage 3 CKD do not require kidney transplant or hemodialysis. The management is aimed at treating the underlying cause of CKD to delay the progression of the disease and its complications.

If infection present, antibiotics may be prescribed. Fluid restriction may be necessary to control edema, with dietary modifications like low salt diet.

CKD disease itself as well as the treatment provided can cause cognitive impairment and psychological problems in child. Mental status examination should be performed from the diagnosis of CKD throughout the management of the child.

The burden of the disease and its management may lead to negative financial, emotional, and psychological impact on the child and the family. Thus, the nurse should assist the child and the family to have access to mental health specialist, peer-support groups.

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (con.):

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may effect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

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Cultural Considerations: Examples

Nurse should consider local food habits as well as cultural food preferences while counselling about modified diet for ARF/CRF.

Nurse should respect child’s and parents cultural preferences related to sex of the examiner.

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References:

Acute renal failure in paediatrics (management and investigation (n.d.). NHSGGC Guidelines. NHSGGC Paediatrics for Health Professionals, NHS Greater Glasgow and Clyde. https://www.clinicalguidelines.scot.nhs.uk/nhsggc-guidelines/nhsggc-guidelines/kidney-diseases/acute-renal-failure-in-paediatrics-management-and-investigation/

Aier, A., Pais, P., Raman, V. (2022). Psychological aspects in children and parents of children with chronic kidney disease and their families. Clinical and Experimental Pediatric,65(5), 222–229. https://www.e-cep.org/m/journal/view.php?number=20125555478

American Academy of Pediatrics. (2020). Chronic Kidney Disease in Children. healthychildren.org. https://www.healthychildren.org/English/health-issues/conditions/genitourinary-tract/Pages/Chronic-Kidney-Disease-in-Children.aspx

Anand, S., & Lotfollahzadeh, S. (2021, December 3). Epispadias. StatPearls Publishing. https://www.ncbi.nlm.ni.h.gov/books/NBK563180/

Contact info: info@nursesinternational.org

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References:

Becherucci, F., Roperto, R. M., Materassi, M., & Romagnani, P. (2016). Chronic kidney disease in children. Clinical kidney journal, 9(4), 583–591. https://doi.org/10.1093/ckj/sfw047

Bridges, B. C., Ashkenazi, D. J., Smith, J., & Goldstein, S. L. (2012). Pediatric renal replacement therapy in the intensive care unit. Blood purification, 34(2), 138–148. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5545793/

Centers for Disease Control and Prevention. (2020, October 23). Facts about Hypospadias. https://www.cdc.gov/ncbddd/birthdefects/hypospadias.html

Children’s Health Queensland Hospital and Health Service. (n.d.). Hypospadias. https://www.childrens.health.qld.gov.au/chq/information-for-families/fact-sheets/

Claure-Del Granado, R., Mehta, R.L. Fluid overload in the ICU: evaluation and management. BMC Nephrology, 17(109). https://doi.org/10.1186/s12882-016-0323-6

Contact info: info@nursesinternational.org

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References:

Healthwise Staff. (2020). Acute Kidney Injury in Children: Care Instructions. [Review of article Acute Kidney Injury in Children: Care Instructions by A.Husney, E.Gregory, & K.Romito]. MyHealth.Alberta.ca Network. https://myhealth.alberta.ca/health/AfterCareInformation/pages/conditions.aspx?HwId=ug5310

Hyun Cho, M. (2020). Pediatric Acute Kidney Injury: Focusing on Diagnosis and Management. Child Kidney Disease, 24(1): 19-26. https://www.chikd.org/journal/view.php?id=10.3339/jkspn.2020.24.1.19

Hulse, C., & Davies, A. (2015). Acute kidney injury: prevention and recognition. Nursing Times; 111: 30/31, 12-15. https://www.nursingtimes.net/clinical-archive/critical-care/acute-kidney-injury-prevention-and-recognition-20-07-2015/

InfoKid. (n.d.a). Chronic kidney disease (CKD). https://www.infokid.org.uk/chronic-kidney-disease-ckd

InfoKid. (n.d.b). Chronic kidney disease (CKD). https://www.infokid.org.uk/chronic-kidney-disease-ckd

Contact info: info@nursesinternational.org

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References:

InfoKid. (n.d.c). Chronic kidney disease (CKD) - Stages 3b - 5. https://www.infokid.org.uk/chronic-kidney-disease-ckd-stages-3b-5

John Hopkins Medicine. (n.d.). Epispadias. https://www.hopkinsmedicine.org/health/conditions-and-diseases/epispadias

National Cancer Institute (n.d.). Renal failure. https://www.cancer.gov/publications/dictionaries/cancer-terms/def/renal-failure

National Institute of Diabetes, Digestive, and Kidney Diseases. (2016, October). Chronic Kidney Disease Tests & Diagnosis. https://www.niddk.nih.gov/health-information/kidney-disease/chronic-kidney-disease-ckd/tests-diagnosis

Sanderson, K. R., & Harshman, L. A. (2020). Renal replacement therapies for infants and children in the ICU. Current opinion in pediatrics, 32(3), 360–366. https://doi.org/10.1097/MOP.0000000000000894

Contact info: info@nursesinternational.org

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References:

Urology Care Foundation. (n.d.a). What is Epispadias?. htt ps://www.urologyhealth.org/urology-a-z/e/epispadias

Urology Care Foundation. (n.d.b). What is hypospadias?. https://www.urologyhealth.org/urology-a-z/h/hypospadias

Vaidya, S.R., Aeddula, N.R., & Doerr C. (2021, October 29). Chronic Renal Failure (Nursing). In: StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK568778/

Contact info: info@nursesinternational.org

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