General GU

Question 1

What are the main mechanisms of GU disorders?

Answer 1

Infection, inflammatory response, congenital malformation, or injury.

Question 2

What is included in the upper urinary tract? In the lower urinary tract?

Answer 2

Upper: kidneys and ureters; Lower: bladder, urethra, & meatus

Question 3

At what age are the kidneys adult size and weight?

Answer 3

At what age does kidney function approach adult values?
Size and weight by adolescence
Function between 6 to 12 months old.

Question 4

What specific information should be obtained in the HPI for GU symptoms?

Answer 4

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.

Question 5

What significant family history questions should be asked for urinary problems?

Answer 5

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.

Question 6

What are important points to consider in the physical exam of a patient with the Gu condition?

Answer 6

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.

Question 7

What does specific gravity measure in a UA?

Answer 7

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.

Question 8

What do leukocyte estrase positive and a UA indicate?

Answer 8

White blood cells in the urine and warrants further investigation.

Question 9

What do nitrites measure in a UA?

Answer 9

Nitrites are an indirect measure of bacteria in the urine and are the most specific marker for infection.

Question 10

At what age is there an increased risk of false negative results for leukocyte estrase and nitrate any UA sample?

Answer 10

< 3yo

Question 11

When should a urine culture be done?

Answer 11

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

Question 12

Urine + for blood or protein on a dipstick should be sent for the UA with reflexive microscopy. What are the values on a microscopy?

Answer 12

• 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

Question 13

what other urine testing may be indicated?

Answer 13

• 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.

Question 14

What is dysfunctional voiding?

Answer 14

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.

Question 15

What is the cause of dysfunctional voiding?

Answer 15

Unknown. Believed to be multifactorial and is often accompanied by Constipation. UTI, structural abnormalities, stress, and abuse must also be considered.

Question 16

What history should be elicited For dysfunctional voiding?

Answer 16

• 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

Question 17

What should you look for in a physical exam of dysfunctional voiding?

Answer 17

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.

Question 18

What are diagnostic studies for dysfunctional voiding?

Answer 18

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.

Question 19

what are the differential diagnosis for dysfunctional voiding?

Answer 19

• 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.

Question 20

What is the treatment goal and interventions for dysfunctional voiding?

Answer 20

• 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.

Question 21

What is any enuresis?

Answer 21

Voluntary or involuntary urination at an age when toilet training should be complete.

Question 22

What is secondary and primary enuresis?

Answer 22

• Primary-children who have never established control

* Secondary-children who have been dry for more than 6 to 12 months and then begin wetting.

Question 23

what is the difference between monosymptomatic (MNE) and non-monosymptomatic nocturnal enuresis (NMNE)?

Answer 23

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.

Question 24

how do you diagnose and enuresis?

Answer 24

Minimum of 5yo & 1 episode a month for at least 3 months.
Frequent= > 4/week
Infrequent= <4/month

Question 25

What are the factors associated with enuresis?

Answer 25

• Constipation: it cannot be over emphasized how important it is to determine if Constipation or impaction exists before treating nocturnal enuresis
• Neurologic developmental delay
• Behavioral comorbidities ADHD, OCD
• Functional small bladder capacity: bladder capacity is normal during the day but is functionally reduced at night
• Sleep disorders
• Stress and family disruptions
• Polyurea
• Inappropriate toilet training for parents who are overly demanding or punitive of the child

Question 26

What are the goals of assessment for dysfunctional voiding?

Answer 26

• determine if there are any comorbid or underlying condition that require pediatric urology referral
• Established the best approach to treating this particular child’s condition

Question 27

what questions should we ask to elicit dysfunctional voiding history?

Answer 27

• voiding characteristics
• Fluid intake including timing type and volume
• UTI
• Family history in your enuresis, treatment, and age of resolution, including parents
• Toilet training history
• Effect of enuresis on child and parents
• Manner in which the family deals with enuresis
• Bowel patterns
• Sleep patterns
• General health.

Question 28

what findings warrant referral to a pediatric urologist for dysfunctional voiding?

Answer 28

• weak or interrupted urinary stream
• Need to use abdominal pressure to urinate
• Combined daytime incontinence and nocturnal enuresis

Question 29

What are the diagnostic studies for dysfunctional enuresis?

Answer 29

UA is recommended for all children within new enuresis. culture should be done if clinical symptoms warranted. More sophisticated testing is not usually necessary.

Question 30

What is a differential diagnosis for enuresis?

Answer 30

• benign idiopathic urinary frequency (pollakiuria) a condition of excessive urination, more than 8 to 12 times a day, often as frequent as every 15 to 30 minutes, seen in previously toilet trained children who do not need to avoid at night.

Question 31

What are other causes of enuresis?

Answer 31

• BBD is the most common organic cause
• Diabetes mellitus
• Diabetes insipidus
• Sickle cell disease due to forced fluids leading to increased UOP
• Chronic renal failure secondary to kidneys inability to concentrate urine
• Structure anomalies, such as ectopic ureter (constantly leakage is noted) or vesicular vaginal fistula
• Neurologic abnormalities including neurogenic bladder
• Hypercalciuria
• Obstructive uropathy other than that due to BBD
• Eosinophillic cystitis
• Vaginitis
• sleep apnea
• Pinworms

Question 32

what are the treatment goals for enuresis?

Answer 32

Established normal bladder function and prevent both physical and emotional complications

Question 33

What treatments should be done prior to treating nocturnal enuresis?

Answer 33

Treatment of daytime urinary dysfunction and Constipation

Question 34

What are the outcomes of treatment for enuresis?

Answer 34

• no response: < 50% decrease in enuresis
• Partial response: 50% to 99% reduction
• Complete response: 100% reduction

long term outcomes include:
• relapse: more than one symptom relapse per month
• Continued success: no return of symptoms in six months
• Complete success: no return of symptoms after two years

Question 35

what is the treatment for enuresis?

Answer 35

• urotherapy
• enuresis alarms: more effective in children with decreased maximal voided volumes, should be first line treatment when conditions such as diabetes, kidney disease, or urogenital malformartions have been ruled out
• Drug therapy see table. It usually has a high initial success rate but cannot be maintained.
• Desmopressin has an anti-diuretic effect that is most effective in children with large nocturnal urine production and normal nocturnal bladder capacity. It is available in three forms: nasal spray (not recommended by FDA), oral tablets, or oyophilisate preparation (MELT) (sublingual administration)
• Avoid high fluid intake with the oral medication, if headache nausea or vomiting occur discontinue medication. Other drugs not recommended as first line treatment:
• Anticholinergics, antimuscarinic drugs also used for treatment of overactive bladder) oxybutynin tolterodine and solifenacin, which cause Constipation and complicate the problem.

Question 36

what should you include in education for enuresis?

Answer 36

For 3-5yo, a nonjudgmental attitude of “benign neglect” in the face of accidents is the best approach. For older children within enuresis, aggressive long term interventions are appropriate; wetting is a common phenomenon and parents should be reassured that it rarely indicates disease.