General GU Flashcards
What are the main mechanisms of GU disorders?
Infection, inflammatory response, congenital malformation, or injury.
What is included in the upper urinary tract? In the lower urinary tract?
Upper: kidneys and ureters; Lower: bladder, urethra, & meatus
At what age are the kidneys adult size and weight?
At what age does kidney function approach adult values?
Size and weight by adolescence
Function between 6 to 12 months old.
What specific information should be obtained in the HPI for GU symptoms?
Any preceding illness especially streptococcal infection
voiding pattern: stream force and direction, dribbling or discharge
enuresis or incontinence, dysuria, or urinary urgency or hesitancy.
Color, order, frequency, volume of urine.
What significant family history questions should be asked for urinary problems?
Renal disease, deafness, hypertension, structural abnormalities, or syndromes involving the Gu system. Also include a past history of UTI, hematuria, proteinuria, syndromes associated with Gu abnormality.
What are important points to consider in the physical exam of a patient with the Gu condition?
Failure to thrive can be associated with UTI, renal tubular acidosis, and chronic renal failure in infants. Unusual weight gain can be associated with nephrotic syndrome or acute renal failure. Elevated blood pressure often with nephritis and nephrotic syndrome. Unusual facial features associated with syndromes including renal disease. Ear position if low center abnormal, may have concurrent renal involvement.
What does specific gravity measure in a UA?
It is a measure of hydration and renal concentration ability and varies from 1.003 to 1.030. First void sample of 1.010 or more indicates intact renal concentrating ability. Specific gravity is greater than 1.030 is concentrated.
What do leukocyte estrase positive and a UA indicate?
White blood cells in the urine and warrants further investigation.
What do nitrites measure in a UA?
Nitrites are an indirect measure of bacteria in the urine and are the most specific marker for infection.
At what age is there an increased risk of false negative results for leukocyte estrase and nitrate any UA sample?
< 3yo
When should a urine culture be done?
Any urine sample positive for nitrates or Lucas S traits if the child has symptoms of a UTI, the risk criteria for UTI eyes are met, or the child has a high fever without a source. The combination of leukocyte esterase and nitrates is highly predictive of a positive urine culture. Negative leukocyte esterase and nitrates reasonably rule out a UTI; however, a culture is still indicated for bold negative and positive urine dipstick findings call mom especially if the urine was not in the bladder for at least four hours. Next time
Urine + for blood or protein on a dipstick should be sent for the UA with reflexive microscopy. What are the values on a microscopy?
- RBC 2-5 if unspun, 2-10 if spun urine are normal. If elevated, and cells are dysmorphic, the origin of the blood is most likely the kidney.
- WBCS: more than 10 often indicates an infection
- Bacteria: leukocytes in unspun urine are associated with bacterial colony counts greater than 100,000.
- Casts: ARB, hyaline, waxy, epithelial, leukocyte, or fatty casts are seen in various disease states
- Crystals, if amorphus, are not unusual
what other urine testing may be indicated?
- Gram stain
- urine culture and sensitivities
- 24-hour urine determines calcium excretion, the calcium creatinine ratio, and protein quantification
- BUN estimates urea concentration in the blood and measures toxic metabolites that can cause uremic syndrome
- Serum creatinine and creatinine clearance estimate the GFR, a measure of kidney function
- Serum electrolytes and acid base status help detect renal tubular abnormalities
- Ultrasound provides noninvasive structural information
- Dimercaptosuccinic acid (DMSA) scanning is the most sensitive tool for detecting acute pyelonephritis and renal scarring. DMSA is the most appropriate where there’s concern for scarring or when the serum creatinine is elevated.
- Voiding cystourethrogram (VCUG) is the most reliable method for detection of vesicoureteral reflux. Limited indications are for febrile UTI’s after abnormal ultrasound or a DMSA scan when there is a second febrile UTI.
What is dysfunctional voiding?
A problem of bladder emptying. During voiding the child contracts the external urethra in a stick Otto pattern (resulting in intermittent flow, prolonged micturation time, and often, incomplete bladder emptying closed parentheses or a plateau pattern (related to continuous, tonic sphincter contraction that results in dynamic bladder outlet obstruction). Either detrusor overactivity or underactivity may be present. A longstanding pattern of incomplete emptying can lead to over extension of the bladder and subsequent uh under active detrusor function. As a result UTI symptoms of urgency frequency and overflow incontinence can occur.
What is the cause of dysfunctional voiding?
Unknown. Believed to be multifactorial and is often accompanied by Constipation. UTI, structural abnormalities, stress, and abuse must also be considered.
What history should be elicited For dysfunctional voiding?
- infrequent voiding
- Cluster voiding or they void a lot after a period of not voiding during each day (not voiding at school)
- Holding maneuvers
- Sudden daytime incontinence after having been dry
- Urgency
- Frequency
- Inability to stop the voiding stream
- Occasional nocturnal unary sis but usually daytime wedding
- Urine pooling in the vagina during voiding that results in later leakage (vaginal voiding)
- Constipation
- UTI
What should you look for in a physical exam of dysfunctional voiding?
Genital abdominal exam should include labial adhesions and females and needle stenosis in males. Consider the possibility of Constipation and check for abdominal masses indicating retained stool.
What are diagnostic studies for dysfunctional voiding?
Urodynamic diagnostic procedures are not routinely performed. But the following tests may be indicated:
• U A
• UC and sensitivity
• Bladder ultrasound for post void residual
• Renal and bladder ultrasound is structure abnormality suspected
• VCUG ordered by pediatric neurology.
what are the differential diagnosis for dysfunctional voiding?
- UTI
- Structure abnormalities such as abnormal sphincters, ectopic ureter, duplicated urethra, or urethral valves
- Neurogenic bladder
- Non-neurogenic dysfunctional voiding in which child holds urine, which leads to overactivity of the detrusor muscle, high voiding pressure, bladder decompensation, and a predisposition for infection and renal damage. Hinman-Allen syndrome.
- Asymptomatic VUR that does not cause voiding symptoms
- Trauma or abuse
- Urethritis which may be caused by chemicals and soaps or bubble bath.
What is the treatment goal and interventions for dysfunctional voiding?
- treat UTI of present
- Treat Constipation if present. This may eliminate the entire problem but could take months to correct
- First line treatment should involve urotherapy–see table.
- Second line treatment combined urotherapy with pharmacotherapeutics.
- Treat skin breakdown if present, vinegar sitz baths can be very effective.
What is any enuresis?
Voluntary or involuntary urination at an age when toilet training should be complete.
What is secondary and primary enuresis?
- Primary-children who have never established control
* Secondary-children who have been dry for more than 6 to 12 months and then begin wetting.
what is the difference between monosymptomatic (MNE) and non-monosymptomatic nocturnal enuresis (NMNE)?
MNE occurs in the child with normal daytime elimination without concerns and then has nocturnal enuresis.
NMNE occurs in children with nocturnal enuresis and BBD symptoms during the day.
how do you diagnose and enuresis?
Minimum of 5yo & 1 episode a month for at least 3 months.
Frequent= > 4/week
Infrequent= <4/month
