GU- Peds Flashcards
Dysfunctional Voiding- pathophysiology
Daytime voiding abnormailty
contraction of urethral spincter during micturition -> staccator urinary stream
Usually identified via PCP for recurrent UTI/daytime enuresis
Very common
Dysfunctional Voiding- cause
Learned behaviors
- holdings - response to potty training, environmental
Infection - UTI
Detrusor over-activity
- heightened pelvec floor tone 2nd to urge incontinence
Neurologic
- brain/spinal pathology effecting bowel/bladder/pelvic floor
Dysfunctional Voiding- S/S & PE
Enuresis Interrupted stream - staccato Frequency, urgency Dysuria Malodorous urine Postvoid dribbling Hematuria Abdominal/pelvis discomfort Hesitancy
Dysfunctional elimination syndrome
- dysfunctional voiding + constipation/encopresis
Dysfunctional Voiding- labs & imaging
KUB - stool burden, lumbosacral spine Additional imaging not usually required - RUS - + UTI - VCUG - + febrile UTI - MRI - tethered cor/neuro pathology
Uroflow
- voiding into specialized collection device
- measure voided volume, avg flow, voiding time, pressure flow
- voided volume - at least 50% of child’s functional bladder cap
- estimated bladder cap - age+2 x 30
Bladder Scan
- u/s for post void residual
- after uroflow
- heightened tone of urethral spincter -> post void residual -> inc UTI/incontinence
- <10% of voided volume
UA - low levels of blood and leukocytes
Urine culture
Dysfunctional Voiding- treatment
Bowel/Bladder program
- Timed voiding - 2-3hr
- Double voiding
- Good H2O intake
- Avoid bladder irritants - citrus, chocolate, caffeine, carbonation, artificial dyes
- avoid constipation - diet, bowel cleanout, miralax, refer to GI
Alpha blockers
Doxazosin - Cardura
- indications - inc PVR, staccato stream, spinning top urethra on VCUG
- SE - hypotension, dizziness, HA, palpitations
- low dose - 0.5mg before bed
Tamsulosin - Flomax
- >7yo
Anticholinergics - Oxybutyin - Ditropan
- irritavie voiding symptoms - urgency, frequency, enuresis
- relax bladder tone, improve storage
- SE - dry mouth, constipation, blurred vision, urinary retention, abdominal pain, confusion
- CONTRA - w/ inc PVR
- better tolerated w/ extended-release version
Biofeedback - taught to contract/relax pelvic floor muscles
UTI- pathophysiology
Infants
- Urinary statis - VUR, UPJ/UVJ obstruction, megaureter - >7mm
- constipation
- neurogenic bladder
- diapers
Older children
- voiding dysfunction
- constipation
- upper tract pathology
UTI- epidemiology
M>F - <1yr
F>M - rest
Male - 1-3%
- uncicumcised - w/ in 1st year
- circum=uncircum
Female - 3-7%
- sexually active
UTI- S/S & PE
Infants - nonspecific
Irriatative voiding - dysuria, enuresis, frequency, urgency, hematura, hesitancy
Febrile?
Fecal mass?
Febrile UTI - more worrisome
- fever = more likely renal involved
- Pyelonephritis
- Infants - nonspecific pres, fever, more susceptible to parencymal scaring
UTI- labs & imaging
UA/UCx - first line
- suprapubic aspirate - gold
- cath>midstream
- bag - only good if neg
UA microscopic
- required if evaling hemature >3RBC
Urine culture - diagnosis of UTI
UA dipstick - manys ways to have false +/-
RBUS- all w/ UTI KUB - all w/ UTI >4yr or constipation VCUG - voiding cystouretrogram - +/- febrile UTI - recurrent febrile UTI - 1st UTI in circumcised M - atypical bacteria - very rare w/o hx of febrile UTI and nl RBUS
UTI- treatment
Abx - based on culture
Address underlying issue
Vesicoureteral Reflux- pathophysiology
Reflux of urine from bladder -> ureters +/- kidneys
2nd to thin tunnel through bladder at ureteral orifice
- not thick enough to compress ureter when the bladder fills up to prevent back flow of urine
Can be a nl finding
UTI - pathway for infected urine to get to kidney
Vesicoureteral Reflux- epidemiology
30-35% w/ UTI
- 70% neonates <1
Higher grades w/ inc risk of UTI
Vesicoureteral Reflux- S/S & PE
Febrile UTI - found w/ VCUG
Vesicoureteral Reflux- labs & imaging
Renal US - recomen
DMSA renal scan - option
MAG 3 renal scan - option
Vesicoureteral Reflux- treatment
Observation - spontaneous resolution
- pt w/ low grade reflux
Observation, abx proph, spontaneous resolution
Abx prophylax, teat voiding dysfunction - reassess
Surgery - deflux, ureteral reimplantation
<1yr Recomm - abx prophy - grad III-V - pabx - Grades 1-11 - observation Option - grade 1-2- pabx - circumcision >1yo Recomm - Treat bladder/bowel dysfunction (BBD) - pabx - higher grade, + BBD, recurrent febrile UTIs, renal cortical abnormalities Option - pabx - low grade, - BBD, recurrent febrile UTIs, renal cortical abnormalities - observation - surgical intervention Surgery Endoscopic - deflux injection - 80% succ Ureteral reimplantation - 97% succ Consider: - breakthrough UTI, UTI pos pabx, Fm pref - AVOID- if <1yo
Vesicoureteral Reflux- prognosis
F/U
- annual RUS
- annual H/W, BP
- annual UA - proteinuria and bacteriuria
- UA indicates infection -> C&S
Circumcision- pathophysiology
Controversial
Almost exclusively cultural decision
Origins - Egypt
Prevelant - in US, less so in Canada and UK
Circumcision- epidemiology
Cultural UTI prevention - esp babies w/ VUR &/or UVJ Dec transmission rates of HIV Dec risk of penile cancer
Circumcision- S/S & PE
UTI Prophylaxis
Recommended for:
- Recurrent UTI
- at risk - PUV, high grade VUT, Neuropathic bladder
Penile Carcinoma
- exclusively in uncircumcised
- associated w/ phimosis & genital infections
Circumcision- diagnosis
Contraindications
- no vit K at birth
- Fmhx of bleeding
- anatomic anomalies - hypospadias, chordee, penile torsion(>45deg), penoscrotal webbing, micropenis, buried penis or large suprpubic fat pad, significant edema, small size
Circumcision- labs & imaging
If deferred
- Refer for eval by urology b/t 2-6w of age
- If surgery needed or >6w - surgery after 6m - anesthesia
Circumcision- treatment
If you start the circumcise -> finish it Gamco Clamp Adv - added precision possible w/ regard to amount of foreskin removed - nothing attached to baby on discharge - fewer follow up calls after discharge Dis - inc bleeding risk - preferred if incomplete foreskin
Pastibell Adv - dec bleeding - quicker procedure Dis - less precision - can tend to leave more foreskin - family discharge w/ bell attached - more f/u - Bell may not fall off - may require removal - bell herniation
Post proc
- Gomco - keep in clinic 1 hr
- Plastibell - go hoe immediately after procedure
- no bathing w/ in 24hr
- abx ointment or Vaseline to cut skin edges liberally w/ every diaper change for 7-10d
- push remaining foreskin down once a day to avoid reformation
- Tylenol as needed
Hypospadias- pathophysiology
1:150-250boyx
DON’T CIRCUMCISE
Hypospadias- S/S & PE
Constellation of findings
- Meatus Malposition - along ventral penis
- chordee- ventral penile curvature
- Dorsal hooded foreskin - incomplete ventral foreskin
Hypospadias- diagnosis
Can circumcise if
- hypospadias remains on glans
Undescended Testes- pathophysiology
Undescended - true - palpable - non palpable Retractile - can bring it down into scrotum Ascended - prev descended
Undescended Testes- epidemiology
Premature - 45% low birth weight - 29% Maternal diabetes Small Fhx
Undescended Testes- labs & imaging
DO NO get imaging for nonpalpable
- US - noncontributory
Undescended Testes- treatment
Congenital - 35-43% spontaneously descend
Refer to specialist if not descended by 6m of age
Orchiopexy w/in 1yr
- improve cosmesis/esteem
- Fertility
- Malignancy - improved w/ surgery
