Genitourinary Flashcards
Discuss priapism and its aetiology
Engorgement of the dorsal copora cavernosa resulting in penile erection lasting more than 4 hours
Can occur at any age including the neonate, sickle cell disease is responsible for most cases in children - with nearly 50% of all males with SSD have at least one episode of priapism
Other causes include
- malignancy
- immunosuppressive disorders
- medications
- drugs of abuse
- toxins
Contrast low flow and high flow priapism
Low flow is the most common form of priapism and occurs secondary to decreased venous out flow.
Stuttering priapism is recurrent episdoes of ischameic priapism most lasting less than 4 hours
High flow priprism is usually painless and is typically associated with trauma to the cavernosal artery, congential anomaly or fistula resulting in excessive inflow of arterial blood and corporal engorgment. - Oxygenation is maintained and emergent intervention is not typically necessary
Neurogenic priapism is not related to blood flow occlusion
Discuss management of priapisms
Low flow - is a compartment syndrome of the penis and requires emergent treatment. Management include
-hydration
-pain relief
-relief of urinary obstruction
-and treatment of underlying cause
Ring block of the penis should be performed prior to aspiration followed by intracavernous injection of sympathomimetic drugs. Pheylephrine is the preferred agent
Treatment of nonischaemic priapism is observation becuase over 2/3 of cases resolve spontaneously - refractory cases may require cavernosal artery embolization or arterial ligation
Discuss aspiration of the corpus cavernousum in priapism
Ring block
Place an 18 gauge angiocatheter - (smaller for younger children) percutaneously into the lateral aspect of the penile shaft entering the corpus cavernosum. Aspirate blood and evacuate from the cavernosa. Next irrigate with normal saline or in combination with dilute phenylephrine (100-500 mic of pheylephrine per mil of NS
Discuss complications of priapism
Penile firbosis
urinary retention
impotence
Discuss differentiating high flow and low flow priapism
Penile blood appearance
- low flow – venous looking
- high flow – arterial looking
Penile art gas
- Low flow, Pao2 <30mmhg, paco2 >60mmhg, ph <7.25
- high flowm pao2 >90mmhg , paco2 <40mmhg ph 7.4
Doppler
low flow - minimal or absent blood flow
high flow - blood flow normal to high velocity
Discuss phimosis
Constriction of the foreskin that prevents retraction of the prepuce from the glans. Most cases are physiological repreent normal development and do not require intervention.
Those with fully retractable foreskins 4% of newborns 25% of 6 month old 50% of 1 year old 80% of 2 year old 90% of 4 year old boys
Trauma, infection, chemical irritation, poor hygiene congenital abnormality or a complciation of cicumcision may contribute to the development of phimosis
Discuss management of phimosis
Gentle retraction and good hygiene are mainstays of management. Retraction of the prepuce should not be forced as this could lead to future adhesions and strictures.
A 6-8 weeks course of topical corticosteroids applied to the outlet twice daily may expedite the developemnt of retractable foreskin.
Disposition
-patient who are able to urinate and have no evidence of infection or ischaemia can be discharged with OPD urology follow-up
Discuss paraphimosis
Pathalogical condition in which the proximal foreskin is unable to be returned to its anatomic position covering the glans penis resulting in distal venous congestion
Can be caused infection, masturbation, trauma, hair or clothing tourniqutes or failure to reduce the foreskin
It is a urological emergency with potential for arterial compression, penile necrosis, gangrene and/or autoamputation
Discuss management of paraphimosis
Pain should be controlled parenterally and/or with a local dorsal penile nerve block or ring block
Oedema should be reduced –> sprinkle granulated sugar, apply pressure
May spont resolve as oedema resolves, If not manual reduction should be attempted with application of gentle steady pressure on the glans with both thumbs while the shaft is pulled straight
Discuss balanoposthitis
An inflammation that ivovles the glans foreskin, occurs in approximatly 5% of uncircumcised males.
Balanitis invovles the glans penis only.
usually secondary to poor hygeine, infection (bacterail or fungal) contact dermatitis, chemical irritation, or local trauma.
Less common causes include
- drug eruption
- scabies
- STI
- Nummular eczema
Discuss management of balnoposthitis
Emphasis on adequate hygiene with sitz baths to reduce inflammation. Painful micturation can be addressed by having a child urinate while in warm water baths.
Antibiotic ointments should be used for bacterial superinfection and topical corticosteroids may speed recovery.
If candida suspected antifungla should be used
Discuss complications and benifits of cicumcision
Prevents phimosis, paraphimosis, recurrent balanoposthitis and decreases UTIs STI and penile cancer.
most common complciation is minor bleeding
Discuss Entrapment and constrictive injury
Penile rigns, strings, wire and human hair tourniquets can result in penile venous and arterial occlusion. These should be removed and patient ensured that they can pass urine prior to discharge
Zipper entrapment of the foreskin typuically occurs in chidlren between 2 and 6 years of age. LA or sedation may facilitate removal. Cut the median bar of the zipper with mini-hacksaw or metal cutter
Discuss epididymitis
Is inflammation of the epididymis. Infectious causes vary by age. Young children commonly have viral infections. Bacterial epidiymitis in prepubertal boys is associated with structural anomalies of the urinary tract
Gonorrhoea and chlamydia are common causes in adolescents
Discuss clinical features of epididymitis
Presnets with a painful oedemaotus scrotum and tenderness at the epididymis. Urethral discharge may be present particularly when the condition is secondary to STI
Relief of pain with scrotal elevation (Prehns sign) is unreliable and should not be used to make a diagnosis
Discuss IX of epididymitis
Urine sample –>
Swab if puss
US to differentiate from torsion
Discuss management of epididymitis
Scrotal elevation and pain medications. If concerned for STI should be treated presumptively
Ceftriaxone IM and doxyxycline is the preferred treatment. Or azithromycin
In children with non STI epididymitis expectant management wihtout ABs can be undertaken
Discuss orchtiis
Result of bacterial or viral infection of the testes
Paramyxovirus is the most common associated with mumps. Other etiology include e.coli, klebsiella, pseudomonas, staph or strep. EBV, coxsackie, abrovirus, enterovirus, brucella, granulomatous, and filariae
Viral orchitis is mangemed with pain controle, if bacterial possible treat with orals covering gram -ve
Discuss testicular torsion
Most common cause of an acutely painful scrotum
Nearly 100% of testes can be salavaged if de-torted within 4 hours less than 10% if more than 24 hours
Bell clapper deformity(Tunica vaginalais completely covers the testis and attaches higher up on the spermatic cord) increases the risk of torsion
Discuss clinical features of torsion
ACute pain and swelling
elevated testicle
absence of the cremasteric reflex
abnormal (high riding and transverse) epididymal and testicular position may also be noted
Ultrasound is 85-98% sensitivty depending on operator and 100% specific
Both the appendix of the testis and the epididymis can torse but the former is more common
The pathognomic blue dot sign is present in less than 25% of cases
Discuss management of torsion
Should be operative
historically manual detorting has been attempted with analgesia and medial to lateral rotation
up to a 1/3 of patient have torted laterally and the above can worsen the torsion
even with successful detorision compartment syndrome may occyur
Describe idioptathic scrotal oedema
erythema and induration of the scrotum that is typically painless but may be pruritic
Most cases are unilateral and usually occur in prepubertal boys aged 5-11 year sof age.
Nil tenderness to palpation of the teste
Ultrasound will show thickened scrotal wall and icnreased peritesticular blood flow
Can be discharged home with NSAIDS and scortal support
Discuss inguinal herniesa
Both direct and indirect are more common in males with bimodal peaks before 1 year of age and after 40 years
Infants are anatomically at risk for an inguinal hernia secondayr to a short inguinal canal that croses teh abdominal wall perpendicularly
Premature infants are at double the risk
Incarceration are more common in gilrs. and infants often present incarcerated
Discuss UTIs in children
Most common cause of fever in young children
neonatal boys are more susceptible than girls but beyond that females have a much high risk
Vesicuoureteral reflux from the bladder into the ureter is a common cause of recurrent urinary infecitons.
E.coli is the most common pathogen
Enterobacter, proteus, morganella, serratia and salmonella,
UTI in infants yonger than 3 months ar eassociated with baceremia in up to 50% of cases
Discuss the nitrite test
Measures conversion of nitrates to nitrites by gram -ve bacteria, may not be +ve in young children who urinate frequently
Discuss management of UTI in infants younger than 2 months, 2months to 2 years, and older than 2 years
Much high risk of sepsis. Formely reccomended that all infants under 2 months with UTI should have full septic screen and admission for IVABS. Some recent studies have suggested that is may be safe in a subset of patient to be treated in OPD setting
2 months -2 years
Can be treated as an OPD
UTI in this age group are considered to be upper tract disease process 7-14 day courses should be used
Older than 2 years
simple cystitis should have a 3 day course of ABs
List DDX of dysuria in children
INfection -UTI -Vaginitis (gardnerella, trichomonas, or STI) Pinworms -balanitis
Irritation
- Bubble bath, new soups
- foreing body
Trauma
- Sexual or physical abuse
- Strddle injury
- self stimulation or masturation
Other
- labial adhesions ‘
- stones
Discuss DDX of haematuria in children
Extra-renal
- Trauma
- Meatal stenosis or posteiror urethral valves
- exercise
- menstraution or rectal bleeding
- foreign bodies
- cystitis, urethritis, epididymitis
Renal
- Pyelo
- Renal or bladder stones or tumorus
- Post strep or idiopathic GMN
- AIN
- ATN
- Basement membrane glomerula disease
- renal vein or artery thrombosis
- recurrent familial haeaturia
- PCKD
Systemic
- Alport syndrome neprhitis (recessive X-linked disorder that is typically seen in males and is often accompanied by high-frequency sensorineural hearing loss (SNHL), ocular abnormalities including anterior lenticonus, and, over time, progressive renal failure)
- HSP
- SLE
- Haemolytic ureamic syndrome
- EBV (MONO)
- sickle cell disease or other haemoglobinopathies
- Bacterial endocarditis
- bleeding disorders
- drugs
Discuss ix of haematuria
5 RBC or more incidcates haematuria
THe presence of WBC, nitrates or leukocyte esterase indicates infection
RBC casts, large p[roteinuria, HTN or renal insufficency may indicate glomberula pathology
ESR and ANA for SLE
If well and no cause found the child should follow-up with primary care provider for a 24 hours urine collection
Discuss the evaulation of proteinuria in children
Trace to mild proteinuria (1+ to 2+) is a common laboratory finding in young children and can represent many benign conditions such as exercise or dehydration.
If the amount is significnat such as in nephrotic syndrome the resultant hypoalbumineamia may cause
generalised oedema
Disposition
- Children with significant oedema and ascitis, significant HTN or makred renal impariment should be hoispitalized
- otherwise can be managed as OPD with close follow-up
Discuss DDX of proteinuria
Can be glomerula or tubular
Glomerular
- nephrotic syndrome
- glumeruloneprhitits
- posttransplantation rejection
Tubular
- heavy metal poisoning
- UTI
- diabetes
Disucss IX of proteinuria
Mild proteinuria (<=2+ or <100mg/dl) requires no further IX. Evidence of UTI such as WBC or positive luekocyte exterase or nitrate level should be treated
Moderate proteinuria (3+ or >300mg/dl) should have additional investigation
- Serum protein and albumin
- electrolytes
- BUN
- creatinine levels
- urine culture
Random PCR (protein creatine ratio) corrleates well with 24 hours urine collection
- normal is less than 0.2mg/gl
- urine PCR more than 3mg/dl corrleates with nephrotic syndrome
ASO can be used to identify previous strep infections
Discuss Post strep glomerulonephritis
PSGN is the most common glumerulonephritide
Sequalae of streptococcal pharyngitis and less commonly skin infection
PSGN is believed to reuslt from the deposition of circulating immune complexes on the kidney.
Typically occurs in children 3-7 years of age usually with a history of pharyngitis with fever 2 weeks before the onset of nephritis.
Symptoms can be loclaised to the urinary tract manifest as
-haematuria
-f;lank pain
-lethargy
-generalised oedema
Renal failure is found in 2% of cases
Discuss investigation of PSGN
Urinarlysis shows significant haematuria andprotein with RBC cast in 60% of cases
Other finding include pyuria with granular or hylar cast
BUN elevated
hyponatraemia and hyperkalaemia
ASO tirtre and IGG elevation
C3 and C4 decreased
Discuss DDX of PSGN
IGA nephropathy (GIT and respiratory infection) Goodpastures Wegeners granulomatosis Alport HSP HUS
Discuss management of PSGN
Fluid and Na restriction
Diuretics in consult with paeds (thiazides 1st line followed by loop for more signifiacnt disease)
AB not indicated
Antihypertensives if needed (CA or B blocakde)
THose with CCF, uremia or significant HTN should be admitted otherwise can be managed as OPD after talkking to the friendly paeds chaps.
Discuss nephrotic syndrome in children
Characterised b significant proteinuria, hypoproteinemia and oedema. +loss of clotting proteins and immunoglobulins
Primarly commonly occur in children younger than 5 the majority of which are minimal change
Secondary neprhotic syndrome is usually seen in older children from systemic illness such as PSGN or SLE
Discuss clinical features
Onset of oedema may be insidious beginning with periorbital oedema.
Children are not usually ill unless there is pulmonary oedema or ascites
HTN, haematuriaor oliguira can also be present
Nephrotic children are at increased risk of thrmobosis with 2% developing thromboembolic complications
Discuss IX of nephrotic syndrome
Nephrotic range proteinuria is more than 3.5g of proetin or more than 50mg/kg
Complement is reduced in nephrotic syndrome
hyperlipidaemai occurs in neprhotic syndrome for not completley understood reason
Discuss management of nephrotic syndrome
Despirte oedema children with signs of hypovolaemai should be treated with cyrstalloids
Patients with presumptive diagnosis of primary neprhotic syndrome can be treaeted with steroids
If signs of ascites or pulmonary or pleural odema should have loop diuretics and may need fluid and salth restriction
As children with neprhotic syndrome are relatively immunodepressed due to loss of IG any fever should be treated in hosiptal with IVIABs
Discuss DDX of AKI in children
Pre-renal
- Decreased intravascular volume or dehydaration
- -burns
- -third spacing
- sepsis
- Decreased CO
- -Caridiogenic shock
- Decreased renal artery blood flow
Intrarenal
- Glomerula disease
- -PSGN and orthers
- -Pyelo
- Systemic casues
- -HUS
- -HSP
- -SLE
- -Sepsis
- Toxins
- -heavy metals
- -myoglobin or haemoglobin deposits
- -ABs such as aminoglycosides
- -anticonvulsants
- radiocontrast dyes
Post renal
- obstructive lesions
- nephrolithiasis or tumor
- post urehtral valves
- intrabadominal tumor obstructing urinary flow
- infection
- renal vein thrombosis
Discuss HTN in children
Defined as a systolic or diastolic blood pressure higher than 2 standard deviations above the mena for the age
Blood pressure upper limit for age 0-2: 110/65 3-6: 120/70 7-10: 130/75 10-15: 140/80
Discuss DDX of HTN in children
Renal
- Nephritic or nephrotic syndromes
- HSP
- Pyelo
- Obsturctive or reflux
- PCKD
- diabetic nephrtopathy
- trauma
- renal transplant
- tuberous sclerosis
- SLE
Endocrine
- Phae
- Cushings
- congenitial adrenal hyperpalsia
- corticosteroids treatment
- hyperthyroduism
- neuroblastoma
- ovarian tumor
Cardiac
- CCF
- coarctation of the aorta
Vascular
- HUS
- Kawasaki syndrome
- Rneal artery thrmobosis or stenosis
Neurolgoic
- CNS tumor or infection
- CNS trauma or abuse
- Rasied ICP
- Guillian Barre syndrome
Neoplastic
- neuroblastoma
- Wilms tumor
- Phae
- Adrenal carcinoma
Drgus
- Corticosteroids
- cocaine
- sympathomimetics
- OCP
- Phecyclidine
- B blockade or clonidine withdrawlal
Discuss HSP
Is an immunoglobulin A mediated systemic vasculitis involving the small blood vessels of the skin, GIT and joitns
The peak incidence for HSP is between 4-7 years of age
50% of affected children have a history of previous upper respiraotry tract infection and as many as 75% have group A beta haemolytic strep
Disucss clinical features of HSP`
Hallmark is a palpable purpuric or petehcial rash. This is seen in the vast majority of patients and is most prominent on the lower extremities starting at the lateral malleoli
Arthralagia and arthritis are common usually involved knees and ankle joints
Dull peri-umbilical pain resulting from bleeding into the intestinal wall occurs in at least 50% of cases
Self limiting glomerulonephritis will develop in 25-50% of cases manifested by haematuria with or without RBC cast
Discuss IX of HSP
Urine and urinanylysis for RBC and CAST + protein
BUN and creat levels
FBC
Coags
US of the abdomen wif significant abdom signs
Discuss management of HSP`
Most cases resolve spontanesouly and do not require threapy
NSAIDS for pain
corticosteroids reduce time course
Discuss HUS
A microangiopathic haemolytic anaemia is one of the most common causes of AKi in children
HUS is rare after the age of 5 years of age but recurrence is more common in older children and mortality is 30%
Most common cause is Shiga toxin producing e.coli
Transmission is through person to person contact or exposure to contaminated food
HUS can be classified as primary cause by compliment dysregulation and secondary caused by infection
Renal compromise is caused by vascular endothelium injury induced by viral or bacterial agents. RBCs are injured within the narrowed blood vessels resulting in a microangiopathic haemolytic anaemia. Platelets complement and fibrin are deposited in the glomerular lumen resulting in thrombocytopenia, decrease in the GFR and renal failure
Discuss clinical features of HUS
Secondary HUS from STEC present with watery diarrhoea crampy abdominal pain and occasionaly fever. Within days of symptoms increasing abdominal pain with 50-85% of patient developing bloody stool.
up to 10% of patients will experience the triad of sudden onset of haemolytic anaemia, thrombocytopenic and acute renal insufficiency with possible progression to renal failure.
Up to 60% of diarrhoea related HUS cases require dialysis and death or ESRD occur in 12%
Discuss compolciations of HUS
Renal
- AKI
- CKD
GIT
- toxic megacolon,
- ischaemic colitis
- intussusception
- perforation
- delayed colonic stricutre ‘
Systemic
- Anaemia
- Thrombocytopenia
- HTN
Discuss management of HUS
Early peritoneal dialysis and supportive measure current mortality is less than 5%
Fluid resus if dry
electrolyte management (hyper K common)
Do not given antimotility agents
Antibiotics have not be shown to prevent HUS from STEC and may increase the release of verotoxins and worsen sytmpoms
List conditions possibly causing persistant conspitation
1) mec ileus
2) anal anomalise (stenosis, stricter, malposition)
3) spinal anomalise
4) hirschprung’s
5) hypothyroidism
6) metabolic - hypercalcium, hypokalaemia
7) coeliac disease
8) cows milk intolerance
9) lead poisoning
10) intellectual impairment
11) child abiuse
12) CF
13) dietary
14) psychogenic
15) drug releated
Discuss managment of constipation
1) exclude physical treatable cuases with carful history exam and ix
2) empty rectum preferably from the top
3) esatblish a pharmacological bowel rhythm and pattern which may need support for years
4) allow the nelarged rectum to re-restablish it own inherent physiologcial bowel pattern and tone and to regain its normal sensation
5) continue maintenance for some time before considering slowly weaning off pharmaceuticalls
This will involve
- enthusiasm on part of managing clinicians
- non punitve behaviour on part of the parents
- adjunctive behavioural modification interventiojns with achievable golas including motivational praise with star and reward charts
Discuss approach to disimpaction
If consitpation is severe the bowel may need disimpaction before maintenance treatment can be commenced
1) oral OPD faecal disimpaction is the preferred method. Macrogel 3350 sachets are tolerated better if cooled in the fridge. They are administered by esclated dose.
- age 2-5 one sachet on day 1, 2 on day 2and 3, 3 on day 4 and 5 and 4 on day 6 and 7
Rectal disimpaction is avoided when possible
Inpatient disimpaction
-this is usually a planned admission involving the administration of bowel preparation fluid via a NGT.
