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Chapter 46 Renal/Urinary Tract
Disorders
Review A&P
 Review normal urinalysis & child’s outputpg 1347
 Review diagnostic studies
 Dialysis covered in critical care-procedure
same for children
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Exstrophy of the Bladder
Midline closure defect during first 8 weeks
of embryonic life
 Bladder lies open & exposed on abdomen
 Pic 1354
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Assessment-revealed by fetal sonogram
 Bladder appears bright red & continually
drains urine from open surface
 Epispadius may also be present-males
 Mgt-surgical repair
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Preop-keep exposed bladder covered by a
sterile plastic bowel bag
 Prevent skin from excoriation
 Infants legs may be flexed & brought
together & wrapped to prevent further
separation of the symphysis
 Position on back
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Postop- one or two step procedure
 Position infant on back or in infant seat,
prevent contamination from feces,
indwelling or suprapubic catheter inserted
to allow new bladder to rest. Immediately
postop-urine may be blood tinged but
should clear after couple of hours.
 Antispasmodics, antibiotics & analgesics,
bracing of pubic bones(4-6 weeks)
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Hypospadius
Urethral opening not at end of penis but
on lower aspect
 Pics 1355
 Assess for other defects
 Mgt-don’t circumcise-foreskin may be
needed for surgical repair
 Postop-urinary urethral catheter-may
notice painful bladder spasms as long as
the catheter is in place (3-7 days)
 Analgesics, antispasmodics
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UTI
Assessment-dysuria, frequency, burning &
hematuria
 Low grade fever, abdominal pain &
enuresis
 Pyelonephritis-high fever, abdominal or
flank pain, vomiting & malaise
 Mgt-antibiotics, analgesics, increased
fluids.
 Teaching-1356
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Reflux
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Retrograde flow of urine from bladder to ureters
r/t defective valve
Assess-history of repeated UTI’s, voiding
cystogram
Mgt-double voiding techniques, prophylactic
antibiotics, corrected by cystoscopy
Postop-suprapubic catheter & 2 ureteral stentsobserve closely every hour for first 24 hrs & then
every 4. Note color & amount of drainageinitially bloody but will clear in 24-48h.Analgesics
& antispasmodics, sterile drsg to absorb leaking
urine-no tub baths until suprapubic site closed
completely
Hydronephrosis
Enlargement of the pelvis of the kidney
with urine as a result of back pressure in
the ureter generally caused by obstruction
 Children usually asymptomatic, may have
repeated UTI’s, elevated BP, flank &
abdominal discomfort
 Tx-surgical correction of obstruction

Enuresis
Usually nocturnal
 Children older than 5 need evaluated for
an organic cause
 Assess for-stress, abdominal pain, UTI
 Mgt-Limit stress, limit fluids after dinner
(not if sickle cell ). May be prescribed
DDAVP. May need bladder stretching
exercises
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Kidney Agenesis

Absence of a kidney often has Potter’s
syndrome( misshapen low set ears & stiff,
inflexible lungs from the lack of amniotic
fluid in utero).
Polycystic kidney-”Potter facies”-wide
spaced eyes, epicanthal folds, flattened
nose & small jaw. May be associated with
a cerebral aneurysm. Tx-surgical removal
of kidney or transplantation
 Renal hypoplasia-small, underdeveloped
kidneys-transplantation

Prune Belly Syndrome
Pic 1361
 Severe urinary tract dilation mainly in
boys
 Three symptoms: deficiency of usual
abdominal muscle tone; bilateral
undescended testes; dilated faulty
development of the bladder & upper
urinary tract
 Kidney transplantation
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Acute Glomerulonephritis
Assessment-usually 5-10 yrs of age post
strept infection
 All children who had impetigo, strept
infections should have a urinalysis 2
weeks post infection to evaluate for
glomerulonephritis
 Sudden onset of hematuria & proteinuriaurine appears tea colored, reddish-brown
or smokey
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Abdominal pain, low grade fever, edema, N&V or
headache
Elevated protein, elevated ESR rate, Bun &
creatinine increase, mild anemia due to increased
blood volume
Mgt-course 1-2 weeks-quiet play-return to school
after kidney function is normal. Daily wts, I&O
Diet, antibiotics & diuretics usually not ordered
unless heart failure occurs=Lasix, digoxin, semifowlers, & oxygen
Chronic glomerulonephritis
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May follow acute glomerulonephritis or nephrotic
syndrome
Alport’s syndrome-progressive chronic
glomerulonephritis inherited as an autosomal
dominant disorder
Acute symptoms of edema, hematuria,
hypertension or oliguria.
TX-symptomatic-antihypertensives, bedrest,
diuretics, corticosteroids
Prognosis poor. May need dialysis or
transplantation
Nephrotic Syndrome ( Nephrosis)
Altered glomeruli permeability d/t fusion
of the glomeruli membrane surfaces
causing abnormal loss of protein in urine
 Three forms: congenital: secondary (sickle
cell, SLE; or primary
 Four characteristic symptoms: proteinuria;
edema; low serum albumin;
hyperlipidemia
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Assess-periorbital edema usually most
prominent when they wake up, ascitesclothes don’t fit, skin becomes pale,
stretched & taut
 Table-pg1364
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Mgt-corticosteroids such as prednisonegive every other day. Cytoxin for
immunosupprssion if don’t respond to
corticosteroids
 Foods high in potassium-1365
 Foods high in potassium especially if
receiving diuretics, fluid & sodium may be
restricted during acute phase.
 Keep child in semi fowlers-more
comfortable & reduces periorbital edema

Hemolytic-Uremic Syndrome
Occurs during summer in children 6mon4yrs of age following recent Ecoli infection
 Transient diarrhea, fever, hematuria,
oliguria, edema, petechiae
 Supportive tx to maintain heart & kidney
function ie peritoneal dialysis
 Most recover completely but some have
chronic renal impairment or may die
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Renal Failure
Oliguria-output <1ml/kg/wt/hr
 Azotemia, uremia, hyperkalemia
 Tx-IVF’s, diuretics, daily wts, I&O, dietlow pro, K,& Na & high in CHO
 Peritoneal or Hemodialysis
 Kidney transplantation
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