3 - pediatric voiding dysfunction

Question 1

not medical prob incontinence

Answer 1

1. pri mono-sx noct enuresis
2. behavioral d/o or developmental delay

Question 2

nl time for toilet trainingn time

Answer 2

3-3.5 yrs

Question 3

def primary incontenence

Answer 3

never continent or continent > 6 mo

Question 4

def secondary incontenence

Answer 4

previously achieved continence - nuropathic or severe dysfunciton ultil proven otherwise
r/o traumatic events, abuse, dm, renal d/o

Question 5

dysfunctional voiding def

Answer 5

active habitual contraction of urethral sphincter during voiding
observed by uroflow

Question 6

hinnman syndrome

Answer 6

non-neurogenic neurogenic bladder
severe dysfxn voididng- bladd changes like neurogenic bladder
silent upper tract changes
assd w emotional trauma

Question 7

post void leakage cause

Answer 7

vaginal reflux
urine trapped behind labia
small vol leaks 0-5 mins after standing to void
only aware they feel wet
can be radiographically impressive
tx - reposition on toilet, and blot vag

Question 8

SUI differential in kids

Answer 8

covered exstrophy
female epispadias (missed)
sacral agenisis

Question 9

enuresis risoria

Answer 9

giggle incontinence.
total loss of urine w/ intense emotion/ cataplexy.
Imbalance between cholinergic and monaminergic system
tx - methylphenidate (ritaline).
also have diurnal inctontenence - w/ and w/o laughter. Tx w/ std urge tx +/- anticholinergics

Question 10

why does leakage in ureteral ectopia decrease overnight in girls

Answer 10

urine pools in vagina

Question 11

ddx for u retention in peds

Answer 11

1. constipation
2. UTI
3. bladder base tumor - RMS
4. neurologic disease

Question 12

myelomeningocele

Answer 12

5% void normally.
incomplete lesion –> cant predict voiding.
dynamics of bladder and sphincter can change over time

Question 13

caudal regression

Answer 13

can have either UMN or LMN disease.
bladder neck incompetence.
external sphincter fixed (upper tract problems).
renal anomalies

Question 14

conservative vs proactive medical mgmt of ngb

Answer 14

conservative - UT us –> intervene w CIC/meds if UT changes.
proactive - CMG risk dictates medical mgmt + renal us

Question 15

concerning CMG findings for ut damage

Answer 15

> 40 cm h20 dlpp.
poor compliance.
neurogenic DO w/ DSD.

Question 16

surgical mgmt options for ngb

Answer 16

1. cutaneous vesicostomy (poor uds w max medical tx in infant or noncompliant parent).
2. definitive surgical (UT deterioration refractory to medical mgmt, desire for continence).

Question 17

urinary reconstruction for NGB

Answer 17

1. enterocystoplasty 2. continent catheterizable channel 3. bladder outlet procedure, 4. +/- antireflux procedure (not done as often). +/- MACE

Question 18

long term complications of enterocystoplasty

Answer 18

1. mucous, 2. acidosis, 3. B12 deficiency obvious others

Question 19

metabolic problem with urinary stasis

Answer 19

myperchloremic metabolic acidosis is worsened. Aggravated by renal insuff, possible bone demineralization

Question 20

% risk of malig w augment

Answer 20

5%. No diff btw cic and enterocystoplasty, and cic alone.

Question 21

highest risk of malignancy with augment

Answer 21

Highest risk in transplant, on immunosupression, and cic

Question 22

dx of rethethering of SC

Answer 22

clinical dx. Not seen on imaging. 1. _ functional status (gait, strength). 2. _ continence/voiding (tough to notice if already wet). 3. new back/leg pain. 4. increased/febrile UTI 5. _ routine upper tract imaging

Question 23

spinal dysraphism and imaging

Answer 23

all appear radiographically tethered. Looking for interval increase of syringomyelia or mass. And see if shunt has malfunctioned

Question 24

suspect retethering for urologist

Answer 24

1. verify CIC/ voididng/ meds 2. tx + urine culture, 3. bowel tuneup 4. cmg?

Question 25

suspect rethethering - uds signs

Answer 25

1. any _ from prior, 2. _ contractility, inc voiding pressure, 3. _ compliance, 4. _ DLPP (outlet _)

Question 26

rethethering prognosis

Answer 26

some improvement, but return to baseline unlikely. Goal - 1. halt deterioration, manageable bladder. Amnt of improvement depends on duratino of change

Question 27

circumcision and peds UTI

Answer 27

uncircumcised 10x more likely

Question 28

host factors and peds UTI

Answer 28

1. age/ gender, 2. periurethral colonization, 3. prepuce, 4. genetics/ bact adherence factors, 5. immune status, 6. anatomic anomaly, 7. pathologic flora

Question 29

2011 aap uti guidelines - 1st febrile uti

Answer 29

2 mo- 2 yr - 1. cath specimen, 2. us @ acute phase, 3. vcug not required

Question 30

VUR general stuff

Answer 30

VUR is only improtant in the setting of UTI - “bad” kidneys have more at stake. Hi grade VUR is exception

Question 31

AUA VCUG 2010 guidelines

Answer 31

1. general eval - ht, wt, bp, ua for protein/bacteria, 2. verify renal function - DMSA optional but rec for high grade, 3. followup us/cystogram @ 12-24 mo

Question 32

AUA VCUG 2010 guidelines - prophylaxis

Answer 32

1. < 1yoa, 2. prenatlly detected gr 3-5 3. bladder and bowel dysfunction.

Question 33

AUA VCUG 2010 guidelines - intervention

Answer 33

breakthrough febrile uti

Question 34

fecal elimination disorders - why does this happen

Answer 34

common neural network

Question 35

fecal elimination disorders - acute effect on bladder

Answer 35

irritating to bladder

Question 36

fecal elimination disorders - chronic effect on bladder

Answer 36

inefficient emptying, impaired sensation

Question 37

fecal elimination disorders - UTI

Answer 37

inefficient emptying, colonization