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Clin med sem 2 > GU- Peds > Flashcards

GU- Peds Flashcards

1
Q

Dysfunctional Voiding- pathophysiology

A

Daytime voiding abnormailty

contraction of urethral spincter during micturition -> staccator urinary stream

Usually identified via PCP for recurrent UTI/daytime enuresis

Very common

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2
Q

Dysfunctional Voiding- cause

A

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

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3
Q

Dysfunctional Voiding- S/S & PE

A 
Enuresis
Interrupted stream - staccato
Frequency, urgency
Dysuria
Malodorous urine
Postvoid dribbling
Hematuria
Abdominal/pelvis discomfort
Hesitancy

Dysfunctional elimination syndrome
- dysfunctional voiding + constipation/encopresis

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4
Q

Dysfunctional Voiding- labs & imaging

A 
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

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5
Q

Dysfunctional Voiding- treatment

A

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

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6
Q

UTI- pathophysiology

A

Infants

  • Urinary statis - VUR, UPJ/UVJ obstruction, megaureter - >7mm
  • constipation
  • neurogenic bladder
  • diapers

Older children

  • voiding dysfunction
  • constipation
  • upper tract pathology
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7
Q

UTI- epidemiology

A

M>F - <1yr
F>M - rest

Male - 1-3%

  • uncicumcised - w/ in 1st year
  • circum=uncircum

Female - 3-7%
- sexually active

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8
Q

UTI- S/S & PE

A

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
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9
Q

UTI- labs & imaging

A

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
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10
Q

UTI- treatment

A

Abx - based on culture

Address underlying issue

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11
Q

Vesicoureteral Reflux- pathophysiology

A

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

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12
Q

Vesicoureteral Reflux- epidemiology

A

30-35% w/ UTI
- 70% neonates <1
Higher grades w/ inc risk of UTI

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13
Q

Vesicoureteral Reflux- S/S & PE

A

Febrile UTI - found w/ VCUG

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14
Q

Vesicoureteral Reflux- labs & imaging

A

Renal US - recomen
DMSA renal scan - option
MAG 3 renal scan - option

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15
Q

Vesicoureteral Reflux- treatment

A

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
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16
Q

Vesicoureteral Reflux- prognosis

A

F/U

  • annual RUS
  • annual H/W, BP
  • annual UA - proteinuria and bacteriuria
  • UA indicates infection -> C&S
17
Q

Circumcision- pathophysiology

A

Controversial
Almost exclusively cultural decision
Origins - Egypt

Prevelant - in US, less so in Canada and UK

18
Q

Circumcision- epidemiology

A 
Cultural 
UTI prevention 
- esp babies w/ VUR &/or UVJ
Dec transmission rates of HIV
Dec risk of penile cancer
19
Q

Circumcision- S/S & PE

A

UTI Prophylaxis
Recommended for:
- Recurrent UTI
- at risk - PUV, high grade VUT, Neuropathic bladder

Penile Carcinoma

  • exclusively in uncircumcised
  • associated w/ phimosis & genital infections
20
Q

Circumcision- diagnosis

A

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
21
Q

Circumcision- labs & imaging

A

If deferred

  • Refer for eval by urology b/t 2-6w of age
  • If surgery needed or >6w - surgery after 6m - anesthesia
22
Q

Circumcision- treatment

A 
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
23
Q

Hypospadias- pathophysiology

A

1:150-250boyx

DON’T CIRCUMCISE

24
Q

Hypospadias- S/S & PE

A

Constellation of findings

  • Meatus Malposition - along ventral penis
  • chordee- ventral penile curvature
  • Dorsal hooded foreskin - incomplete ventral foreskin
25
Q

Hypospadias- diagnosis

A

Can circumcise if

- hypospadias remains on glans

26
Q

Undescended Testes- pathophysiology

A 
Undescended - true
- palpable
- non palpable
Retractile - can bring it down into scrotum
Ascended - prev descended
27
Q

Undescended Testes- epidemiology

A 
Premature - 45%
low birth weight - 29%
Maternal diabetes
Small
Fhx
28
Q

Undescended Testes- labs & imaging

A

DO NO get imaging for nonpalpable

- US - noncontributory

29
Q

Undescended Testes- treatment

A

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

Clin med sem 2 (30 decks)

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