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a Paediatrics by themes > Kidney and Urinary Tract Disorders > Flashcards

Kidney and Urinary Tract Disorders Flashcards

1
Q

What are the signs and symptoms of urinary tract infections in children?

A
  • Dysuria
  • Frequency
  • Flank pain
  • Offensive smelling urine
  • Fever / rigors
  • Diarrhoea and Vomiting
  • Lethargy / Irritability
  • Febrile seizures
  • Infants
    • Fever
    • Poor feeding / faltering growth
    • Jaundice
    • Septicaemia
  • Children
    • Abdominal pain / lion tenderness
    • Haematuria
    • Enuresis
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2
Q

What are the appropriate investigations for suspected urinary tract infections in children?

A
  • Urine dip
    • Nitrite stick test – very specific
    • Leucocyte esterase test
  • Urine MC&S = diagnostic
  • Imaging not recommended
    • Unless atypical or recurrent UTIs = USS à DMSA ± MCUG
      • Atypical UTI = USS ± DMSA (<3yo only)
      • Recurrent UTI = USS + DMSA
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3
Q

What is the management of urinary tract infections?

A
  • <3m = Emergency
    • Admit to hospital
    • IV Abx for 5-7 days → oral prophylaxis
    • Urgent USS should be booked (4-6w)
  • >3m Upper UTI
    • Consider hospital admission
    • IV Abx for 7-10 days
    • <6m old when they have 1st UTI = urgent USS should be booked (4-6w)
  • >3m Lower UTI
    • Oral Abx for 3 days
    • Safety net parents → bring child back if they remain unwell after 48 hours (may be atypical)
    • <6m old when they have 1st UTI = urgent USS should be booked (4-6w)
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4
Q

What is the management of recurrent UTIs in children?

A
  • Antibiotic prophylaxis
  • USS - during admission if <6m, urgent if >6m
  • DMSA scan (routine)
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5
Q

What strategies can prevent UTIs?

A
  • High fluid intake to produce high urine output
  • Regular voiding
  • Ensure complete bladder emptying
  • Treatment and/or prevention of constipation
  • Good perineal hygiene
  • Lactobacillus acidophilus probiotic
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6
Q

What is Enuresis?

A

Bed-wetting

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7
Q

What is the management of primary bedwetting without daytime symptoms <5 years old?

A
  • Reassure parents → often resolves by 5yo
  • Educate
    • Easy access to toilet at night
    • Bladder emptying before bed
    • Positive reward system
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8
Q

What is the management of primary bedwetting without daytime symptoms >5 years old?

A
  • Infrequent (<2/week) → offer watch-and-see approach
  • Frequent
    • 1st line = enuresis alarm, positive reward system - encourage child to help change sheets
    • 2nd line = desmopressin (1st line if >7yo or for short-term control (i.e. sleepovers, school trips, etc))
    • 3rd line = combination
  • Referral to enuresis clinic
  • Community paediatrician if bedwetting not responded to 2 courses tx
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9
Q

What counselling should be given to parents with a child with primary bed-wetting without daytime symptoms?

A
  • Bedwetting not the child/parent’s fault - take a neutral attitude to bedwetting so not to embarrass
  • Reason is excess volume that does not wake the child to go to the toilet
    • Reassure that pretty much all children become dry with time as their bladder capacity increases and they learn to wake at the sensation of a full bladder
  • Child should go to the toilet regularly and before bed
  • Avoid caffeine before bed
  • Easy access to toilet
  • Waterproof mattress or bed pads
  • Lifting or waking during the night does not promote long-term dryness
  • Positive reward systems - rewards for going to the toilet before bed
  • Drink the recommended amount of fluid during the day
  • Support groups
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10
Q

What is the management of primary bedwetting with daytime symptoms?

A

Referral to enuresis clinic and community paediatrician

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11
Q

What are the appropriate investigations for troubling enuresis?

A
  • Renal USS
  • Urine diary
  • Dipsticks
  • MCUG
  • Urine MC&S
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12
Q

What is the management of secondary bedwetting with daytime symptoms?

A
  • Primary care management = manage the cause
    • UTI
    • Constipation
  • Secondary care management = manage the cause
    • Diabetes
    • Recurrent UTI
    • Psychological problems
    • Family problems
    • Developmental, attention or learning difficulties
    • Known or suspected physical or neurological problems
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13
Q

Define Secondary Bedwetting.

A

Enuresis that occurs after the child has previously been dry at night for 6 months.

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14
Q

What are the signs and symptoms of osteosarcoma?

A
  • Occurs in end of long bones - 60-75% in the knee
  • Relatively painless
  • Mass/swelling that restricts movement
  • Rapid metastasis to lung
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15
Q

What are the appropriate investigations for suspected osteosarcoma?

A
  • X-Ray - bone destruction and formation
    • Soft tissue calcification = sunburst appearance
    • Elevated periosteum = “Codman’s triangle”
  • Biopsy
  • CT/PET/MRI
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16
Q

What is the management of osteosarcoma?

A
  • Specialised sarcoma team (London) management
  • Surgery + Chemotherapy
    • Limb-sparing surgery ± amputation
  • Post-treatment
    • OT
    • PT
    • Dietician
    • Orthotics/prosthetics
    • Support group - Sarcoma UK
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17
Q

What is the difference between osteosarcoma, Ewing’s sarcoma and chondrosarcoma?

A
  • Osteosarcoma = forms bone
  • Ewing’s sarcoma = forms mesenchymal tissue (neuroectodermal)
  • Chondrosarcoma = forms cartilage (occurs in those >40yo)
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18
Q

What is the prognosis of osteosarcoma?

A

60% 5-year survival

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19
Q

What is Nephrotic syndrome?

A
  • Low albumin
  • Peripheral oedema
  • Proteinuria
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20
Q

What is the most common cause of nephrotic syndrome?

A

Minimal Change Disease - 90%

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21
Q

What are the signs and symptoms of nephrotic syndrome?

A
  • 1st = Peri-orbital oedema - often misdiagnosed as allergy
  • 2nd = Other delayed features of oedema + Features of underlying diagnosis
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22
Q

What are the types of nephrotic syndrome?

A
  • Steroid-sensitive nephrotic syndrome - 80-95%
  • Steroid-resistant nephrotic syndrome
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23
Q

What are the appropriate investigations for suspected nephrotic syndrome?

A
  • Urine
    • Dipstick
    • MC&S
    • Sodium
  • Bloods
    • Urea
    • U&Es
    • FBC
    • ESR
    • Creatinine
    • Albumin
    • Complement levels (C3, C4)
    • Anti-streptolysin O or Anti-DNase B titres - recent streptococcal throat infection
  • HBV, HCV, malaria screen
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24
Q

What is the management of nephrotic syndrome?

A
  • 1st = Oral prednisolone for 4-6 weeks - reduced dose from 4+ weeks
    • Renal histology of steroid-sensitive nephrotic syndrome = normal on light microscopy
    • However, on electron microscopy, fusion of podocytes is seen (minimal change disease)
  • 2nd (steroid-resistant or atypical) = specialised renal biopsy and care
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25
Q

What are the main complications of nephrotic syndrome?

A
  • Risk of thrombosis → loss of AT-III in the urine = hypercoagulable state
  • Risk of infection → loss of immunoglobulin in urine
  • Hypercholesterolaemia → urinary albumin loss → less oncotic pressure → hepatic cholesterol synthesis
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26
Q

What are the causes of childhood acute glomerulonephritis?

A
  • Minimal change disease
  • Focal-segmental glomerulosclerosis
  • Membranous - more common in adults
    • Post-infectious (streptococcus in children)
    • Vasculitis (SLE, ANCA +ve)
    • IgA nephropathy (adults, but includes HSP in children)
    • Mesangiocapillary glomerulonephritis
    • Goodpasture’s
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27
Q

What is Minimal change disease?

A

Change to the glomeruli, usually from an idiopathic cause but can be due to drugs or infection

  • Normal renal function, complement and BP
  • Most common in 2-4 year olds
  • 90% of nephrotic syndrome
  • Usually responds to high dose prednisolone
28
Q

What is Focal segmental glomerulonephritis?

A

Segmental scarring and foot process fusion.

  • Hypertension and impaired renal function
  • Common in older children
  • 50% respond to steroids
29
Q

What is Membranous nephropathy?

A

Widespread thickening, granular deposits of Ig and complement.

  • More common in adults
30
Q

What are the signs and symptoms of acute glomerulonephritits?

A
  • Nephrotic syndrome
    • Low albumin
    • Peripheral oedema
    • Proteinuria
  • Nephritic syndrome
    • Haematuria
    • Hypertension
    • Proteinuria
  • Decreased urine output and volume overload
  • Oedema
  • Hypertension
  • Seizures
31
Q

What are the appropriate investigations for suspected acute glomerulonephritis?

A
  • Urine
    • Dipstick
    • MC&S
    • Sodium
  • Bloods
    • Urea
    • U&Es
    • FBC
    • ESR
    • Creatinine
    • Albumin
    • Complement levels (C3, C4)
    • Anti-streptolysin O or Anti-DNase B titres - recent streptococcal throat infection
  • HBV, HCV, malaria screen
32
Q

What is the management of acute glomerulonephritis?

A
  • Depends on type, severity and complications
    • Minimal change = Nephrotic Syndrome = Corticosteroids
    • Focal-segmental = depends on cause
      • Corticosteroids
      • Immunosuppressive drugs
      • Plasmapheresis
      • ACE inhibitors and ARBs
      • Diuretics
      • Diet change
    • Membranous = Supportive, ACEi and ARBs
  • Correct water and electrolyte balances
  • Treat oedema → diuretics and potassium supplement
  • BP management
  • Dietary advice and/or Lipid lowering therapy
33
Q

What is IgA Vasculitis?

A

Small-vessel vasculitis in which complexes of IgA and C3 are deposited on arterioles, capillaries, and venules.

  • AKA - Henoch-Schonelin Purpura
34
Q

What is the most common cause of vasculitis in children?

A

IgA vasculitis → particularly in boys aged between 3-10yo

35
Q

What are the signs and symptoms of IgA vasculitis?

A
  • Purpuric Rash (100%)
    • Extensor surface of legs, arms, buttocks, ankles - spares trunk
    • Maculopapular
  • Arthralgia and Periarticular oedema (60-80%):
    • Large Joints
    • Joint pain and swelling of knees and ankles
  • Abdominal pain (60%)
    • Colicky abdominal pain
    • Haematemesis, melena, intussusception
  • Glomerulonephritis (20-60% → 97% within 3m of onset)
    • Microscopic or macroscopic haematuria
    • Nephrotic syndrome - rare
  • Recent URTI
  • Winter time
36
Q

What are the appropriate investigations for IgA vasculitis?

A
  • 1st
    • FBC
    • Clotting screen
    • Urine dipstick
    • U&Es
  • Urinalysis
    • RBCs
    • Proteinuria
    • Urea
    • Creatinine
    • 24hr protein → rule out meningococcal sepsis
  • Increased IgA
  • Normal coagulation
  • Follow-up → BP measurements and urine dipstick (haematuria)
37
Q

What is the management of IgA vasculitis?

A
  • Most cases = resolve spontaneously within 4 weeks
  • Symptomatic management:
    • Joint pain → NSAIDs
  • Scrotal involvement or severe oedema or severe abdominal pain = oral prednisolone
  • Renal involvement:
    • IV corticosteroids - nephrotic-range proteinuria and those with declining renal function
    • Renal transplant may be considered in end-stage renal disease
38
Q

What are the complications of IgA vasculitis?

A
  • Testicular pain (rare)
  • Arthritis of knees
  • Intussusception
  • Acute/Chronic renal failure
  • Pancreatitis
39
Q

What are the most common causes of acute renal failure in children in the UK?

A
  • Haemolytic Uraemic Syndrome (HUS)
  • Acute Tubular Necrosis – usually in context of organ failure in ITU or after cardiac surgery
40
Q

Define Haemolytic Uraemic Syndrome.

A

Microangiopathic haemolytic anaemia, thrombocytopenia, and acute kidney injury.

41
Q

What are the signs and symptoms of haemolytic uraemic syndrome?

A
  • Diarrhoea - some times bloody
  • Known E. coli or food poisoning
    • Most common cause = Shiga toxin from haemorrhagic E. coli O157 (infectious diarrhoea)
  • More common <5 years old
  • Requires admission
  • On investigations
    • Schistocytes on blood film
      • Distorted erythrocytes → MAHA → schistocytes
42
Q

What are the signs and symptoms of renal failure in childhood?

A
  • Oliguria or anuria
  • Discoloured urine – brown
  • Oedema – feet, legs, abdo, weight gain
  • Fatigue / Lethargy
  • N&V
43
Q

What are the indicatiosn fo rreferral to urology in childhood renal failure?

A
  • Signs/findings of Post-renal cause
    • Pyonephrosis
    • Obstructed solitary kidney
    • Bilateral upper urinary tract obstruction
    • Complications of AKI caused by urological obstruction
  • Requires assessment of the site of obstruction (i.e. PUV, VUJ obstruction, etc.)
  • Relief can be achieved by nephrostomy or catheterisation
44
Q

What are the appropriate investigations for childhood renal failure?

A
  • Renal USS - might identify obstruction
    • CKD = small kidneys
    • AKI = large, bright kidneys with loss of cortical medullary differentiation
  • Bloods → FBC, U&Es, Urea
45
Q

What is the management of renal failure in a child?

A
  • Diuretics PRN + Fluid restriction → treat fluid overload/oedema whilst awaiting dialysis
    • Unless cause in hypovolaemic → fluid replacement and circulatory support
  • Dialysis – indicated if failure of conservative management, multisystem failure or one of the following:
    • Refractory hyperkalaemia
    • Refractory fluid overload
    • Metabolic acidosis
    • Uraemic symptoms (encephalopathy, nausea, pruritis, malaise, pericarditis)
    • CKD stage 5 (GFR <15mL/min)
46
Q

What are the signs and symptoms of uraemia?

A
  • Encephalopathy
  • Nausea
  • Pruritis
  • Malaise
  • Pericarditis
47
Q

What is Phimosis?

A

Inability to retract foreskin, “tight” foreskin.

  • Physiological at birth
    • 1yo → 50% have a non-retractable foreskin
    • 4yo → 10%
    • 17yo → 1%
      • If persistent to puberty = increase risk of infection and issues with urination and intercourse
48
Q

What is the management of phimosis?

A
  • <2yo = Reassure + Review in 6 months + Personal hygiene promotion
  • >2yo = Circumcision or Topical steroid creams - depending on severity
49
Q

What is balantis xerotica obliterans (BXO)?

A

Pathological phimosis = scarring of foreskin → rare before 5y

  • S/S
    • Haematuria
    • Painful erections
    • Recurrent UTI
    • Weak stream
    • Swelling
    • Redness
    • Tenderness
50
Q

What is Paraphimosis?

A

Foreskin becomes trapped in the retracted position proximal to swollen glans.

  • Restricting blood flow to head of penis → penis turns dark purple → urological emergency
51
Q

What is the management of Paraphimosis?

A
  • 1st line
    • Adequate analgesia
    • Attempt to reduce foreskin - gentle compression with saline soaked swab
  • 2nd line = Emergency referral to urologist
52
Q

What is Hypospadias?

A

Wrongly positioned meatus (ventral in hypospadias; dorsal in epispadias)

  • Features
    • Ventral foramen ± Hooded foreskin
    • Foreskin not fused ventrally ± Chordee
    • End-membrane
53
Q

What is the management of hypospadias?

A
  • Do nothing - surgery is not mandatory
  • Hypospadias repair surgery (after 3 months)
    • No circumcision should be done prior as skin required
54
Q

What is Balanoposthitis?

A

Inflamed/purulent discharge from foreskin - single attacks common

55
Q

What is the management of Balanoposthitis?

A
  • Warm baths
  • Broad spectrum Abx
  • Recurrent = Circumcision
56
Q

What are the risk factors for testicular torsion?

A
  • Undescended testes
  • ‘Clapper bell’ testis - testes free hanging on spermatic cord
  • 11-30yo → 16 is the mean age
    • Must be ruled out in any-aged boy with an acute abdomen
57
Q

Describe torsion of appendix testes.

A
  • Pain evolves over multiple days
  • Surgery often needed as cannot be distinguished from true torsion
  • Blue dot on superior pole of the testes = torsion of appendix testes → no surgery - only simple analgesia
  • More common than testicular torsion
58
Q

What are the signs and symptoms of testicular torsion?

A
  • Redness
  • Oedema
  • N&V
  • Sudden onset pain – localised in testis or in the abdomen
  • One testicle higher than the other
59
Q

What are the appropriate investigations for suspected testicular torsion?

A
  • Doppler USS - cannot delay surgery
  • Lifting testes increases pain
    • Epididymitis = relieves pain (Prehn’s sign)
60
Q

What is the management of testicular torsion?

A
  • Surgical Emergency
    • Exploratory surgery ± Bilateral orchiopexy ± Orchidectomy ± Fixation of contralateral testes
      • <6hrs = 90-100% saved
      • >24hrs = 0-10% saved
  • Supportive care
    • Analgesia
    • Sedation
    • Antiemetics
61
Q

What is a Nephroblastoma (Wilm’s tumour)?

A

Undifferentiated mesodermal tumour of intermediate cell mass – primitive renal tubules and mesenchymal cells

  • Most common intra-abdominal tumour of childhood
  • 2nd most common cancer of childhood - after ALL
    • <5yo (80%) – often 3yo
    • 95% unilateral
    • 1-2% familial /FHx
62
Q

What is associated with nephroblastoma?

A
  • Beckwith-Wiedemann syndrome - specific body parts overgrow, usually present at birth
  • WAGR syndrome - Wilm’s tumour, Aniridia, Genitourinary malformations, Retardation
  • Hemihypertrophy
  • 33% with a loss-of-function mutation in the WT1 gene on chromosome 11
63
Q

What are the signs and symptoms of a nephroblastoma?

A
  • Asymptomatic abdominal mass - most common
  • Painless haematuria
  • Abdominal pain
  • Anorexia
  • Anaemia - from haemorrhage into mass
  • Hypertension
64
Q

What are the appropriate investigations for suspected nephroblastoma?

A
  • USS
  • CT/MRI
    • Staging 1-5
      • 1 = limited to kidney, completely excisable
      • 2 = not limited to kidney, completely excisable
      • 3 = not limited to kidney, not completely excisable
      • 4 = spread beyond abdomen, haematogenous metastasis
      • 5 = bilateral (each tumour graded separately)
  • Avoid biopsy → can worsen the condition
65
Q

What is the management of a nephroblastoma?

A
  • Nephrectomy + chemotherapy ± Radiotherapy prior to surgery (advanced disease)
    • 80% cure rate

a Paediatrics by themes (26 decks)

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