GU Flashcards
MC organisms involved in UTIs?
e coli
kelbsiella
proteus
enterococcus
RF for UTIs?
constipation VUR (vesicoureteral reflux) urinary tract obstruction neurogenic bladder poor perineal hygiene structural abnormalities catheterization sexual activity
S/s of UTI in new borns/infants?
nonspecific signs: fever, hypothermia, jaundice, poor feeding, irritability, vomiting, FTT, & sepsis
+/- strong, foul-smelling or cloudy urine
s/s of UTIs in pre-school children?
abd &/or flank pain, vomiting, fever, frequency, dysuria, urgency, or enuresis
CVA tenderness is unusual in young children
s/s of UTI in school aged children?
classic s/sx of cystitis: frequency, dysuria, & urgency
possibly pylonephritits: fever, vomiting, flank pain CVA ttp(+/-)
Dx of UTI?
screening UA
- pyuria
- Nitrite* (can be - in young children)
GOLD standard: urine culture of properly collected specimen
Tx for UTI
<3mo, septic, dehydrate:
ADMIT to hospital for IV abx
Older infants/children: empiric therapy
- Amoxicillin, TMP-SMX, 1st gen cephalosporin
- 7-10days
What is vesicoureteral reflux (VUR)
Reflux of urine from bladder into the ureter/upper urinary tract
1% of newborns
increases up to 15%
Epidemiology of VUR?
White > Black
F > M
MC <2yrs
strong fam hx
What is primary VUR?
incompetent or inadequate closure of the ureterovesical junction (UVJ)
Due to a congenitally short intravesicular ureter
MC form of reflux
What is secondary VUR?
BLOCKAGE
Due to an abnormally high voiding pressure in bladder which results in failure of the closure of UVJ during bladder contraction
Functional bladder obstruction (neurogenic bladder)
Anatomic dysfunction - Posterior urethral valves
s/s of VUR?
Prenatal: hydronephrosis on prenatal u/s
Postnatal: febrile UTI
Work up for prenatal VUR?
Prenatal hydronephrosis (on prenatal u/s):
unilateral: repeat ultrasound at 1wk of age
bilateral: repeat ultrasound + VCUG
work up for post natal VUR?
UTI: renal & bladder u/s
Febrile UTI: Voiding Cystourethrogram (VCUG)
Grading for VCUG reflux?
Grade 1 (reflex into ureter w/ no dilation) –>
Grade 4 (reflux w/ dilation of ureter & blunting of reflux calyces)
Tx for grade 1 and 2 VUR?
Monitor for spontaneous resolution (by age 5, 80% spontaneously resolve)
Consider prophylactic antibiotics
Tx for grade III to V VUR?
regardless of age antibiotic prophylaxis:
TMP-SMX (2mg/kg) or nitrofurantoin (1-2mg/kg)
DC when VUR resolves (spontaneously or surgically)
at risk for complications if left untreated
What is posterior urethral valves?
Obstructing membranous folds within the lumen of the posterior urethra
obstructs normal flow of urine
MC etiology of UT obstruction in newborn male
Dx of PUV?
Prenatal US:
Bilateral hydronephrosis, distended and thickened bladder
+/- oligohydramnios
Post natal:
Failure to thrive, distended abdomen, poor urinary stream
Older boys: straining to urinate, UTIs, daytime & nocturnal enuresis
Dx- VCUG- dilated & elongated posterior urethra during the voiding phase
PUV tx?
prenatal: experimental surg
post natal: correct electrolyte abn, foley cath, surg correction
FU post PUV tx?
Bladder dysfunction may require clean intermittent catheterization
Monitor for renal failure- significant risk despite early intervention: Renal transplant
Monitor for UTIs
What is considered daytime freq?
voiding >8x/day
What is enuresis?
Repeated urination into clothing (day & nighttime) by a child > than 5y/o
diurnal enuresis = wetting while awake
Primary v. secondary nocturnal enuresis?
Primary = occurring in children who have NEVER been consistently dry though the night
Secondary = resumption of wetting after at least 6mo of dryness
s/s of enuresis?
child > 5yr (developmentally & chronologically)
at least 2x per week for 3 months
RF for nocturnal enuresis?
often associated w/ underlying constipation
runs in families
sleep apnea
psychological
dx of nocturnal enuresis?
H&P: r/o anatomical abn, constipation
UA +/- culture
Tx of nocturnal enuresis?
pt ed
limit liquids before sleep
awaken the child at night to bathroom
Bedwetting alarms
meds if others fail
What meds can be used for nocturnal enuresis?
Desmopressin Acetate (DDAVP)- synthetic analogue of the antidiuretic hormone (ADH) vasopressin -can be Rx for short term periods
Imipramine- high risk ADEs
What is considered daytime urinary incontinence?
Wetting accident at least once every 2 weeks
Incidence decreases w/ age
when continence NOT achieved by 6yrs of age, need to consider underlying cause
RF for daytime urinary incontinence?
females
hx of nocturnal enuresis
UTI
encopresis (soiling in underwear)
What are some disease assoc. with daytime urinary incontinence?
OAB -urinary urgency is hallmark
Voiding postponement & under active bladder
Dysfunctional voiding
Dx work up for daytime urinary incontinence?
Voiding diary VCUG US MRI spine Abd xray Referral to: urology, nephrology, neurosurgery
Tx of daytime urinary incontinence?
tx underlying path: (i.e. cystitis, DI, DM, seizures, neurogenic bladder, anatomical abn., constipation, psych)
Behavioral therapy
Anticholinergics – oxybutynin
TCAs do not appear to work
What is exstrophy of the bladder?
Complex congenital anomaly involving the musculoskeletal system & the urinary, reproductive, and intestinal tracts
Open, inside-out bladder - the inner surface is exposed
rare! But MC in M >F, white infants, 1st born
S/s of exstrophy of the bladder?
Open bladder plate & exposed urethra
low set umbilicus
diastasis of the symphysis pubis - outward malrotation of pelvic bones (at risk of hip dysplasia)
anteriorly displaced anus
inguinal hernias
genital defects
Dx of exstropy of the bladder?
prenatal US- confirmed w/ MRI (sometimes)
if missed previously, diagnosed at birth
Tx of exstrophy of the bladder?
Prenatal ed
and counseling of parents
Induced vaginal delivery or planned C-section and surgery within 72 hours of delivery
Surgical repair after stabilization
What is hypospadias?
Congenital anomaly of male urethra
Results in abn ventral placement of the urethral opening
The urethral folds fail to completely or partially close
Hypospadias can be assoc. with?
chordee (ventral curvature of penis)
10% have cryptorchidism
increased risk of inguinal hernia
Do not circumcise at birth!
Dx of hypospadias?
New born PE:
-abdnormal foreskin (dorsal hooded)
Abdnormal penile curvature
the “presence” of 2 urrethral openings
Tx of hypospadias?
Isolated hypospadias:
Repair before 18months
Hypospadias with cryptorchidism: At Increased risk for disorders of sex development (DSD) - additional workup:
- Pelvic U/S
- Karyotype
- serum electrolytes
What is cryptorchidism?
a hidden testis - testis not w/in the scrotum & does not descend spontaneously by 4mo of age
MC congenital abnormality of the GU tract
may be assoc. with various genetic anomalies
pts with Cryptorchidism are at risk for…
At risk for infertility & testicular malignancy (5-10x greater risk)
Dx of cryptorchidism?
Clinical- newborn exam
cause of most cases is unclear
2-6mo of age: measure LH, FSH,inhibin B, & testosterone (can help determine whether or not testes are present)
HCG stimulation test
Tx of cryptorchidism?
Surg if descent has not occurred by 6-12mo of age
Palpable – orchiopexy
Non-palpable – exploratory surgery
What is a testicular torsion?
Twisting of testes on the spermatic cord
Inadequate fixation of testis to tunica vaginalis
venous compression, edema or the testicle & cord, ischemia of the testicle
What is the MC abnormality assoc. with testicular torsion?
“bell clapper” deformity
-testis lies horizontally
testicle lacks normal attachment to tunica vaginalis
2 peak incidences of testicular torsion?
Neonatal period (less likely)
Puberty (65% btwn 12-18yrs)
s/s of testicular torsion?
Abrupt onset of severe testicular or scrotal pain
N/V
PE in pt with testicular torsion?
scrotum may be swollen and edematous
Affected testes is usually tender, swollen, slightly elevated
Doppler US/nuclear scan of the scrotum:
Decreased perfusion
Absent cremasteric reflex
negative prehn sign
Tx of testicular torsion?
Immediate consult w/ an urologist
Surgical detorsion and fixation (orchiopexy) of both testes if viable
Orchiectomy if testicle nonviable
Time frame for testicular torsion?
Detorsion within 4 to 6 hours-100% viability
Detorsion after 12 hours 20 percent viability
Detorsion after 24 hours 0 percent viability
Manual detorsion of testicular torsion?
If the child presents before scrotal swelling develops:
Appropriate sedation and analgesia
Rotate outward toward the thigh- “open the book”
Will relieve pain
What is a hydrocele?
Collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis.
May be communicating or non-communicating
generally present as a cystic scrotal mass
Epidemiology of a hydrocele?
Common in newborns
May be a sign of
concerning etiology in older children
Resolve spontaneously, by the 1st birthday
What is a communicating hydrocele?
develop as a result of failure of the processus vaginalis to close during development
fluid = peritoneal fluid
What is a non-communicating hydrocele?
no connection to the peritoneum
fluid comes from the mesothelial lining of the tunica vaginalis
Dx of hydrocele?
Transillumination of the scrotum that demonstrates a cystic fluid collection
Doppler U/S
Tx of Hydrocele?
Surgical repair
-if beyond 1 yr of age
What is a varicocele?
Collection of dilated and tortuous veins surrounding the spermatic cord
MC on the left side
s/s of varicocele?
May be asxs
Dull ache or fullness of the scrotum upon standing
Palpable texture of a “bag of worms”
Tx of varicocele?
If varicocele persists in supine position, or is right sided, need to r/o processes that cause IVC obstruction
-doppler US
conservatively w/ observation
Repaired through surg ligation or testicular vein embolization
