3 - pediatric voiding dysfunction Flashcards
not medical prob incontinence
- pri mono-sx noct enuresis
- behavioral d/o or developmental delay
nl time for toilet trainingn time
3-3.5 yrs
def primary incontenence
never continent or continent > 6 mo
def secondary incontenence
previously achieved continence - nuropathic or severe dysfunciton ultil proven otherwise
r/o traumatic events, abuse, dm, renal d/o
dysfunctional voiding def
active habitual contraction of urethral sphincter during voiding
observed by uroflow
hinnman syndrome
non-neurogenic neurogenic bladder
severe dysfxn voididng- bladd changes like neurogenic bladder
silent upper tract changes
assd w emotional trauma
post void leakage cause
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
SUI differential in kids
covered exstrophy
female epispadias (missed)
sacral agenisis
enuresis risoria
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
why does leakage in ureteral ectopia decrease overnight in girls
urine pools in vagina
ddx for u retention in peds
- constipation
- UTI
- bladder base tumor - RMS
- neurologic disease
myelomeningocele
5% void normally.
incomplete lesion –> cant predict voiding.
dynamics of bladder and sphincter can change over time
caudal regression
can have either UMN or LMN disease.
bladder neck incompetence.
external sphincter fixed (upper tract problems).
renal anomalies
conservative vs proactive medical mgmt of ngb
conservative - UT us –> intervene w CIC/meds if UT changes.
proactive - CMG risk dictates medical mgmt + renal us
concerning CMG findings for ut damage
> 40 cm h20 dlpp.
poor compliance.
neurogenic DO w/ DSD.
surgical mgmt options for ngb
- cutaneous vesicostomy (poor uds w max medical tx in infant or noncompliant parent).
- definitive surgical (UT deterioration refractory to medical mgmt, desire for continence).
urinary reconstruction for NGB
- enterocystoplasty 2. continent catheterizable channel 3. bladder outlet procedure, 4. +/- antireflux procedure (not done as often). +/- MACE
long term complications of enterocystoplasty
- mucous, 2. acidosis, 3. B12 deficiency obvious others
metabolic problem with urinary stasis
myperchloremic metabolic acidosis is worsened. Aggravated by renal insuff, possible bone demineralization
% risk of malig w augment
5%. No diff btw cic and enterocystoplasty, and cic alone.
highest risk of malignancy with augment
Highest risk in transplant, on immunosupression, and cic
dx of rethethering of SC
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
spinal dysraphism and imaging
all appear radiographically tethered. Looking for interval increase of syringomyelia or mass. And see if shunt has malfunctioned
suspect retethering for urologist
- verify CIC/ voididng/ meds 2. tx + urine culture, 3. bowel tuneup 4. cmg?
suspect rethethering - uds signs
- any _ from prior, 2. _ contractility, inc voiding pressure, 3. _ compliance, 4. _ DLPP (outlet _)
rethethering prognosis
some improvement, but return to baseline unlikely. Goal - 1. halt deterioration, manageable bladder. Amnt of improvement depends on duratino of change
circumcision and peds UTI
uncircumcised 10x more likely
host factors and peds UTI
- age/ gender, 2. periurethral colonization, 3. prepuce, 4. genetics/ bact adherence factors, 5. immune status, 6. anatomic anomaly, 7. pathologic flora
2011 aap uti guidelines - 1st febrile uti
2 mo- 2 yr - 1. cath specimen, 2. us @ acute phase, 3. vcug not required
VUR general stuff
VUR is only improtant in the setting of UTI - “bad” kidneys have more at stake. Hi grade VUR is exception
AUA VCUG 2010 guidelines
- 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
AUA VCUG 2010 guidelines - prophylaxis
- < 1yoa, 2. prenatlly detected gr 3-5 3. bladder and bowel dysfunction.
AUA VCUG 2010 guidelines - intervention
breakthrough febrile uti
fecal elimination disorders - why does this happen
common neural network
fecal elimination disorders - acute effect on bladder
irritating to bladder
fecal elimination disorders - chronic effect on bladder
inefficient emptying, impaired sensation
fecal elimination disorders - UTI
inefficient emptying, colonization
