GU Flashcards
UTI
asymptomatic bacteriuria, cystitis, and pyelonephritis. 1 is benign, 2 is lower UTI no fever or renal injury, and 3 is severe and involves kidneys and can cause irreversible damage. 3 causes fever, irritability, vomiting, renal tenderness. UTIs most common cause of serious bacterial infections in <2 y in FUO. complicated is UTI with fever, toxicity, dehydration ,or in child <3-6mo. most common cause is E. coli, but other gram - can cause or GBS. reflux into kidneys can cause scarring. biggest risk kidney issues is VUR. risks: structural abnormality, female, poor hygiene, irritation, sexual activity/abuse, pinworms, uncircumcised boys. preemie and low birth weight.
high risk male/female
female: white, <12mo, temp 39 +, fever 2+ days. male: nonblack, temp 39+, fever >24hr. other risks are poor hygiene, tight or nylon underclothing, bubble baths, HTN, bathroom avoidance.
UTI dx
UA/culture esp. prior to abx. clean catch >100,000 colonies or >50,000 in SPA/culture. UA to raise/lower suspicion: foul odor, cloudy, nitrite, leukocytes, alkaline pH, proteinuria, hematuria, pyuria, bacteriuria. if toxic, more labs like CBC/CRP etc. diff: urethritis, vaginitis, viral cystitis, foreign body, sexual abuse, dysfunctional voiding, appendicitis, pelvic abscess, PID.
UTI tx abx
infants 2-24mo: UA/culture. if uncomplicated cystitis, 3-5 days antibiotics; if febrile, 7-14 days. Bactrim: 8-12mg/kg in 2 doses; adolescents, 160mg q12h. amoxicillin <3 mo: 20-30mg/kg/day in 2 divided doses q12; >3mo 25-50mg/kg/day 2 divided doses; adolescents, 250-500mg q8. augmentin is 30mg/kg/day <3mo, 20-45 mg/kg/day >3. cephalexin: 50-100mg/kg/day 4 doses as q6. cefixime: >6mo 16mg/kg/day q12 then 8mg/kg/day for 13 days. nitrofurantoin >1mo: 5-7mg/kg/day divided q6. if severe s/s or <1mo, hospitalization. uncomplicated pyelonephritis: cefixime, cephalexin, augmentin. Adolescents uncomplicated pyelonephritis can do augmentin or ciprofloxacin.
UTI guidelines
first positive urine culture/fever/systemic illness > renal/bladder US. if abnormal > VCUG. f/u culture only 2-3 days after starting treatment if s/s persist or if organism resistance in community. phenazopyridine can be given 6years + for dysuria. <2years first UTI need US; all who have fever/pyelonephritis/or recurrent UTI need US.
VUR
retrograde regurgitation of urine from bladder into ureters and potentially kidney. Grade I doesn’t reach kidney, grade II up to pelvis without dilation, grade III mild-mod dilation of ureter and renal pelvis, grades IV and V definite distention of ureters and pelvis and can have hydronephrosis or reflux. dx with US, VCUG, can do DMSA if concern for renal scarring, BP/creatinine, UA/culture. tx: most outgrow; up to grade III half resolve rs spontaneously. decreased chance resolution: grade IV/V, bilateral, older presentation. abx prophylaxis yes for IV/V and considered at III; same with yearly renal US/VCUG. consider surgery III+. VUR doesn’t scar, but infection does so promptly treat UTIs. give prophylactic meds at night since urinary stasis.
hematuria.
5+ RBC in 3 consecutive spun specimens or 2+ in unseen. brown/tea urine is glomerular origin. blood clots or red/pink = lower tract. assess hx of SLE, CKD, SCD, malignancy. recent illness, trauma sexual activity, edema, rash, pallor, drugs (sulfa, nitrofurantoin, salicylates, phenazopyridine, toxins, foods) can discolor urine. look for malformed ears, edema/ HTN/proteinuria, flank pain.
hematuria red flags
FTT, chronic anemia, complicated enuresis, prolonged unexplained n/v, hypotension, bone disease, poor school performance
hematuria dx studies
dipstick. if >1+ hematuria, microscopic exam. look for proteinuria, if present refer to nephrology and assess nephrotic syndrome. distorted/misshapen RBC suggests glomerular disease. Crystalluria d/t hypercalciuria. urine culture, 24hr collection. renal US if necessary . if systemic s/s, further eval. renal biopsy for recurrent or nephritic syndrome/HTN/renal insufficiency, systemic illness, parental anxiety. refer gross hematuria with unclear cause, symptomatic microscopic hematuria, or persistent asymptomatic since may need renal biopsy. asymptomatic: periodic eval q1-2 years.
proteinuria
detected by dipstick. dx: UA repeated 3x in 1-2 weeks, on first-voided specimen. 1+ significant if specific gravity <1.015, 2+ significant for >1.015. false positives in concentrated or alkaline urine. 75% with abnormal have normal on next testing. look at microscopic RBC/WBC. protein-to-creatinine ratio normal is <0.5 if <2 years and <0.2 if older than 2. 24hr urine collection for creatinine. if protein in urine >4, check CBC, BUN, RFP, creatinine, albumin/total protein, C3/4, cholesterol, LFT, urine culture >refer to nephrology. Diff: can be caused by penicillins or anti-inflammatory agents. eval for orthostatic proteinuria.
cryptorchidism
testis that is undescended. does not live in or can’t be pushed into scrotum. retractile: out but can be brought in. gliding: brought in but returns high once released. ectopic: outside normal path. ascended is fully descended but returned up. trapped is dislocated. any not in scrotum is subject to deterioration. descent usually occurs 7-8months gestation, so more common in preemies and twins. most resolve in 3 months of life, but if after 6months will need surgery. risks: hypospadias, preemie, low birth weight, down, Klinefelter. less developed scrotal rug, absence of testicle, or retractile (common up to 7years). no dx studies needed unless comorbidities suspected. tx: surgery 9-15months old. histologic changes after 6mo that can lead to infertility/malignancy so treat before 2 years. if testicular neoplasm, assess male siblings.
proteinuria management
if protein trace, monthly recheck for 4-6 months; if persistent ,refer. if protein >1+, eval for orthostatic proteinuria. if first morning urine protein 1/2+, do 24hr urine protein or protein/creatinine ratio and UA. if >2+ or hematuria present, eval for nephrotic syndrome.refer if persistent unexplained nonorthostatic proteinuria, hematuria or casts, poly/oliguria, nephrotic levels of protein, elevated BUN/creatinine/BP, systemic complaints.
nephrotic syndrome
d/t excessive excretion of protein in urine d/t alterations in glomerular filtration barrier integrity. classic definition: massive proteinuria 3/4+ with UA, >40 protein:creatinine ratio on first morning void; hypoalbuminemia, edema, hyperlipidemia. causes edema > decreased intravascular volume > decreased renal perfusion and RAAS activation and liver increases synthesis of protein and also hyperlipidemia/lipiduria. chronic disease with remission and relapses. some are steroid responders; best prognostic indicator. can be d/t genetic, immune ,systemic, nephrotoxic, allergic, infectious, malignant, vascular, idiopathic processes. has edema, low urine production, anorexia, pale, listless, diarrhea, vomiting, pain, respiratory issues, effusions, pneumonia.
nephrotic syndrome dx/ tx
UA, quantitative urine protein excretion, karyotype for neonatal/infant; referral with possible biopsy. Diff: congenital renal issues, focal glomerulosclerosis, starvation, liver disease, enteropathy. tx: based clinically; goal control edema and induce remission. consult/refer. prednisone 2mg/kg/day to induce remission; continue for 4=6 weeks post remission. can consider cyclophosphamide and cyclosporine if dependent/resistant. during disease, salt may be restricted. diuretics/albumin replacement in acute phase. daily home proteinuria testing; relapses are persistent proteinuria >2+ for 3 days. hyper coagulable state, can get infections or sepsis.
