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Paediatrics > Kidneys + Genitals > Flashcards

Kidneys + Genitals Flashcards

1
Q

How is renal function assessed in children?

A

GFR is not developed until >2 years, but is best measure then
Creatinine is main method but may not be abnormal until renal function has fallen significantly
Urea also useful

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2
Q

What are the ways of imaging the kidneys and urinary tract? When are they used?

A
  • USS: quick and easy. Can be used to visualise stones, dilatation
  • DMSA: static scan of the renal cortex, good for seeing scarring/intrarenal pathology
  • MCUG (micturating cystourethrogram): semi-invasive functional scan of the bladder and urinary tract. Useful for seeing VUR, urethral obstruction
  • Xray (stones), CT KUB
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3
Q

List some congenital renal tract abnormalities. Why are these important?

A
  • Renal agenesis
  • Horseshoe kidney
  • Hydronephrosis
  • Cysts: multicystic dysplastic kidney (many cysts, non-functioning kidney, not attached to ureter), PKD, tuberous sclerosis

May predispose to infection and future kidney disease, may need surgical management. Renal agenesis is incompatible with life and should recommend TOP.

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4
Q

What is Potter sequence?

A

Renal agenesis leads to absent urine production which affects the development of the fetus.

  • Pulmonary hypoplasia
  • Limb deformities
  • Facial abnormalities
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5
Q

What are some causes of hydronephrosis?

A
  • Unilateral: somewhere in the ureter eg. pelvo-ureteric junction or vesico-ureteric junction
  • Bilateral: somewhere in the bladder neck or urethra eg. posterior urethral valves
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6
Q

What is the management of urinary tract abnormalities detected antenatally?

A
  • Renal agenesis: TOP
  • Severe hydronephrosis can cause kidneys to not develop properly -> oligohydramnios, etc. May need antenatal management
  • Bilateral hydronephrosis in boys: urgent USS + MCUG to detect posterior urethral valves and operate early
  • Others: antibiotics prophylaxis and USS at 4-6 weeks
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7
Q

Why are UTIs in childhood important?

A
  • They are very common!!
  • Many children will have anatomical abnormalities that predispose to infection
  • They can cause renal scarring leading to risk of chronic CKD and hypertension
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8
Q

How do UTIs present in children?

A
  • Infants: nonspecific illness. Fever, vomiting, poor feeding, irritability/lethargy, sepsis
  • Older children: enuresis, classic symptoms of abdo pain, dysuria, urgency, frequency, fever, etc
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9
Q

A mother brings her 5 year old daughter to the GP because she has been having some episodes of wetting herself and complaining of pain in her tummy. What would you like to do?

A

History: onset, progression, site of pain, character, severity. Symptoms of dysuria, frequency, blood/smell/cloudy, fever, vomiting, bowels. Eating + drinking. PMH including previous episodes, DHx and allergies. Birth specifically scans, immunisations, development, social.

Examination: general appearance, abdo exam (palpation, ausc), vitals

Investigations: urine dip, MC&S unless negative dipstick. Consider referral to A&E if signs of pyelonephritis for further Ix + Mx

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10
Q

How should you manage a confirmed UTI in children?

A
  • Antibiotics in accordance with trust guidelines, empirical initially then directed by results of MC&S
  • <3 months: admit. IV co-amoxiclav.
  • > 3 months with pyelonephritis: Consider admission if severely unwell. PO trimethoprim 7 days/IV co-amox for 2 days followed by PO
  • Cystitis/lower UTI: PO trimethoprim/nitrofurantoin 3 days
  • Imaging as indicated
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11
Q

Name some factors that predispose to UTIs in children

A
  • Anatomical abnormalities: vesico-ureteric reflux, horseshoe kidneys, etc
  • Immunocompromise
  • Poor hygiene eg. infrequent changing
  • Constipation
  • Neurological problems causing incomplete voiding
  • Indwelling catheter
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12
Q

What is vesico-ureteric reflux? Why is it problematic? How is it diagnosed?

A
  • VUR occurs when there is retrograde passage of urine from bladder into the ureters due to abnormal connection of the ureters to the bladder (not angled)
  • Can predispose to ureteric dilatation, pyelonephritis, renal scarring, etc
  • Dx: seen on USS (dilatation), MCUG
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13
Q

What is an atypical UTI?

A
  • Seriously ill/septicaemic
  • Raised creatinine
  • Atypical organisms
  • Poor response to antibiotics
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14
Q

T/F. It is appropriate to do an MCUG to investigate UTI during the initial management

A

False. Unless there is concern about urethral obstruction, you should wait 3 months after a UTI to do MCUG because of the risk of false +ves due to inflammation

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15
Q

How do you differentiate between pyelonephritis/upper UTI and cystitis/lower UTI?

A

Pyelonephritis should be diagnosed if there is bacteriuria and EITHER temp >38 or loin pain/tenderness

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16
Q

When would you do imaging for UTI?

A
  • Any age with atypical UTI -> USS during infection
  • Recurrent should have USS during infection (<6 mos) or within 6 weeks (>6 mos)
  • <6 months: USS within 6 weeks if normal. DMSA and MCUG if atypical or recurrent
  • 6months-3 years: DMSA if atypical or recurrent.
  • > 3 years: DMSA if recurrent
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17
Q

A 4 year old girl comes to the GP because she has had several episodes of incontinence and is complaining of pain in her tummy. O/E, she is visibly uncomfortable and crying. Abdo exam is normal and she is afebrile. A urine dip is positive for leukocytes and nitrites. What would you like to do next? Does this patient need imaging?

A
  • Send the urine sample for MC&S
  • Explain the diagnosis of lower UTI
  • Conservative management: fluids, pain relief
  • Medical management: antibiotics (trimethoprim 3 days)
  • Safety net: if worsening symptoms, or no improvement in 48 hours, seek medical attention
  • No need for imaging in an uncomplicated UTI >6 months
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18
Q

Define enuresis. What are the causes?

A

Daytime enuresis is lack of bladder control during the day in a child old enough to be continent (3-5 years). Secondary enuresis occurs in children who have previously achieved 6 months of continence.
Causes:
-UTI
-DM
-Developmental conditions
-Behavioural problems
-Detrusor instability
-Neuropathic bladder (eg spina bifida, neuro condition)
-Emotional upset (most common cause of 2˚)

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19
Q

The mother of a 5 year old boy brings him to the GP because he has been wetting the bed. What would you like to know?

A
  • Onset, frequency, progression + when achieved continence
  • Episodes: when in the night, how much
  • Daytime: wetting, urinary symptoms: frequency, dysuria, urgency
  • Bowels (constipation, soiling), weight loss, fever, pain
  • Toileting schedule: how many times, when
  • Fluid intake: how much, what type, when + latest time
  • Changes at home, difficult behaviour, emotional upset
  • PMH (urinary problems), DHx, allergies, immunisations, development
  • FHx if considering DM
  • Social: general Qs
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20
Q

Describe the management of enuresis

A

-Rule out infection, DM, neuro if indicated
-<5 years: reassure normality. Give info.
->5 years: reassure that it may resolve on its own. Conservative: Advise correct fluid intake + toileting patterns. Bed protection, reward system (for behaviour eg fluid intake, toilet before bed NOT dry nights).
1st line: alarm if above not effective. Review in 4 weeks
2nd line/alternative: desmopressin for nighttime wetting only short term improvement. Many will relapse after using.

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21
Q

Explain (to a layperson) what an enuresis alarm is, why it is used, and how to know when it is working.

A
  • A special alarm connected to a pad that senses wetness -> wakes the child up
  • Used to help the child recognise the feeling of needing to go, to get them to get up and use the toilet or to hold the urine, and learn over time to wake up/hold urine
  • May take some weeks to work, and dryness may come quite late. Early signs include smaller wet patches, less frequent wetting, etc
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22
Q

How should desmopressin be used in enuresis?

A
  • Give at bedtime

- Fluid restrict from 1 hour before to 8 hours after taking

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23
Q

When is proteinuria abnormal?

A

When it is persistent, or accompanied by signs of underlying pathology eg oedema

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24
Q

Name some causes of proteinuria

A
  • Physiological after febrile illness or exercise
  • Orthostatic proteinuria
  • Nephrotic syndrome
  • Hypertension
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25
Q

What is nephrotic syndrome? What are the causes?

A 
Nephrotic syndrome is characterised by: proteinuria, oedema, and low albumin
Causes include:
-Idiopathic (primary cause) 
-SLE
-HSP
-Infections
-Allergy
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26
Q

How is nephrotic syndrome diagnosed?

A
  • Clinical diagnosis mainly: oedema (periorbital initially), breathlessness, ascites, proteinuria
  • Bloods: FBC, U+Es, CRP, ESR, LFTs, complement levels, HBV/HCV serology
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27
Q

What are the primary causes of nephrotic syndrome?

A
  • Steroid sensitive nephrotic syndrome/minimal change disease (85% of cases). Especially Asian males, with preceding respiratory infection.
  • Steroid resistant: FSGS, membranoproliferative glomerular nephropathy, membranous nephropathy (associated with HBV or future SLE)
28
Q

Describe the management of nephrotic syndrome

A
  • Fluid restrict, low salt diet
  • Give oral steroids for 4 weeks -> taper if responsive
  • No response in 4-6 weeks -> renal biopsy
29
Q

What are the complications of nephrotic syndrome?

A
  • Hypovolaemia (due to extravascular loss). Give IV NaCl if severe.
  • Thrombosis
  • Infection: flu jab
  • High cholesterol
30
Q

What test should you always do in an oedematous child?

A

Urine dip

31
Q

What should you do if a urine dip is positive for blood?

A

-Microscopy to confirm (MC&S)
-PCR
-USS
-U+Es, renal profile
-FBC
If glomerular: complement levels, ESR, anti-dsDNA, throat swab for Strep, renal biopsy if indicated

32
Q

What are the different types of haematuria? What are some causes of each?

A

Glomerular: red cell casts, brown colour, deformed red cells, often with proteinuria also.
-Causes: glomerulonephritis, IgA nephropathy
Lower urinary tract: pink/red, no proteinuria, unusual in children
-Causes: UTI, stones, cancer, SCA

33
Q

Name some causes of acute nephritis

A
  • Post-infectious (eg Strep)
  • Vasculitis (HSP, SLE, Wegener’s, MPA, PAN)
  • IgA nephropathy
  • Goodpasture syndrome
34
Q

Describe the presentation of acute nephritis

A
  • Hypertension
  • Haematuria, proteinuria
  • Oedema
  • Reduced GFR, decreased urine output
  • Can have rapidly progressive -> AKI
35
Q

Describe the presentation of post-streptococcal or post-infectious nephritis

A

-Nephritic syndrome: haematuria, hypertension, oedema
-Following recent Strep infection/soft tissue infection
-Dx: need evidence of Strep eg. anti-streptolysin O titres, anti-DNAse B titres, throat swab
Also low complement C3 levels

36
Q

What is HSP?

A

Henoch-Schonlein purpura is a vasculitis that usually occurs following an URTI. Develop a symmetrical purpuric rash on extensor surfaces, buttocks, legs as well as systemic features.
Diagnosis is made if there is palpable purpuric rash + at least 1 of: abdominal pain, arthritis/arthralgia, renal involvement (urine dip), IgA on renal biopsy

37
Q

Describe the management of HSP.

A

Depends on the severity

  • Can be managed at home with supportive care. Give pain relief for joint pain/abdo pain (avoid NSAIDs if renal involvement)
  • Antihypertensives if indicated
  • Steroids if severe
  • Monitor for 1 year to check for worsening renal function (initially weekly, fortnightly, monthly etc)
38
Q

What is IgA nephropathy? How is this different to post-strep glomerulonephritis?

A

A type of renal condition caused by deposition of IgA in the kidney. Usually following URTI. Can have macroscopic haematuria and may be recurrent.
The key difference is the timing. Post-strep usually occurs later after the infection. It is due to immune complex deposition.

39
Q

Name some causes of hypertension in children

A
  • Renal: nephritis, PCD, renal failure
  • Cardiac: coarctation
  • Endocrine: Cushings, thyrotoxicosis, phaeo, etc
40
Q

What are the most common type of kidney stones in children?

A

Phosphate stones (associated with Proteus UTI)

41
Q

What investigations should be done in a child with renal stones? How are they managed?

A
  • UTI: urine dip, MC&S
  • Anatomical abnormalities: USS initially
  • Metabolic abnormalities: U+Es, renal and bone profile

Lots of fluids, pain relief, anti-emetics, antibiotics
Medical management to pass: tamsulosin
Surgical if large or ineffective medical Mx

42
Q

List some causes of AKI in children

A
  • Pre-renal: dehydration (sepsis, diarrhoea) mostly
  • Renal: drugs, vasculitis, ischaemia, GN, pyelonephritis
  • Post-renal: obstruction (posterior urethral valves)
43
Q

How do you manage AKI?

A

STOP
Sepsis: septic screen
Toxins: stop any nephrotoxic drugs (NSAIDs, aminoglycosides, etc)
Optomise blood pressure: eg IV fluids or diuretics
Prevent harm: treat reversible causes (eg obstruction) and complications

Monitor fluid balance and electrolytes to treat any abnormalities eg Na bicarb for acidosis

44
Q

When should you consider starting renal replacement therapy?

A

Hyperkalaemia
Pulmonary oedema + overload
Acidosis
End organ complications of uraemia (pericarditis, encephalopathy)

45
Q

What is haemolytic uraemic syndrome? What is it caused by?

A 
Triad of: 
-Haemolytic anaemia (MAHA)
-AKI
-Thrombocytopaenia
Typically caused by infection with E coli O157:H7 or Shigella
46
Q

Describe the management of HUS

A
  • MDT with haem and renal
  • Admit
  • Monitor fluid balance, electrolytes, BP
  • Consider need for RRT
  • Long term followup
47
Q

What is CKD? How is it classified?

A 
Progressive loss of renal function 
1: 120-90
2: 89-60
3A: 59-45
3B: 44-30
4: 29-15
5: 14-0
48
Q

What are the symptoms of CKD?

A

Usually not symptomatic until

49
Q

How is CKD managed?

A

Manage the cause
Manage complications:
-Nutrition: Moderate protein diet, with dietician. Activated Vit D and calcium, limit phosphate. Monitor growth
-Anaemia: EPO and iron
-Hypertension: antihypertensives esp. ACEi/ARB
-Sodium and fluid balance: lots of fluids, salt replacement
-Growth: GH supplements
-RRT
-Transplant at end-stage

50
Q

Describe the development of the scrotum and relevance in hernia formation

A 
Testis migrate from abdomen into the scrotum through the inguinal canal 
Pick up layers of the abdominal wall along the way -> spermatic cord 
Processus vaginalis (peritoneal outpouching) can stay patent, leading to herniation into the scrotum
51
Q

How common are inguinal hernias? What is the cause? How do they present?

A

Inguinal hernias are very common, affecting 5% of male infants (more if premature).
Usually caused by a patent processus vaginalis -> indirect hernia
Groin/scrotal swelling, reducible, usually asymp unless complicated by incarceration -> acute pain, tenderness, vomiting, obstruction

52
Q

What is the management of inguinal hernias?

A
  • If asymp and reducible: non-urgent surgery
  • Non-reducible/incarcerated: urgent surgery
  • To divide the processus vaginalis to prevent re-herniation
53
Q

Describe the process of hydrocoele formation. How are they differentiated from hernias? What is the management?

A
  • Hydrocoeles are usually caused by patent processus vaginalis -> fluid building up
  • Differentiated on examination: can get physically above a hydrocoele, transilluminate.
  • Mx: usually watch and wait as many will close by 2 years. >2 years: surgical repair. If appear at older age, usually non-communicating, watch and wait unless symptomatic.
54
Q

What is a varicocoele? How do they present?

A

Varicocoele is a dilation of the veins in the scrotum, more common on the left side.
Feels like a ‘bag of worms’, visible veins, may have some achy pain.

55
Q

What are the types of undescended testis? How are they diagnosed?

A
  • Undescended testis are testis that are not palpable in the scrotum.
  • They can be either palpable (palpated in the inguinal canal but can’t be moved into the scrotum) or impalpable (eg abdominal, absent)
  • Diagnosed on NIPE exam. If unilateral, allow time to descend, examine at 8 week check. If bilateral: review within 24 hours eg. USS
56
Q

On routine NIPE at 1 day of life, a baby boy is observed to have unilateral undescended testis. Describe the management.

A
  • Reassure parents, re-examine in 6-8 weeks eg. second NIPE at GP
  • If still undescended: reassure parents that most descend by 3 months, re-examine at 3 months
  • If still undescended: refer to paeds urology for surgical management (orchidopexy or laparoscopy) before 6 months of age
57
Q

On routine NIPE at 1 day of life, a baby boy is observed to have bilateral undescended testis. Describe the management.

A

-Urgent referral for endocrine or genetic investigation: karyotype, ?USS

58
Q

Why is orchidopexy performed for undescended testis?

A
  • Cosmetic reasons
  • Fertility preservation
  • Reduce chance of malignancy
  • Decrease risk of torsion
59
Q

Describe the presentation of testicular torsion. What are the differential diagnoses? What is the approach to diagnosis and management?

A
  • Pubertal age boys, acute severe abdo/scrotal pain, vomiting, anorexia, shock. Swollen, red, tender testis
  • DDx: torsion of Hydatid of Morgagni (develops more slowly over days, manageable pain, blue dot on scrotum), incarcerated hernia, epididymo-orchitis

-Manage as a surgical emergency:
A-E, if unclear diagnosis USS can be helpful.
-Clear diagnosis/suspicion: make NBM, IV fluids, analgesia, anti-emetics. Emergency surgical exploration + fixation (of both testes)

60
Q

Describe the presentation of epididymo-orchitis. What are the common organisms?

A
  • Testicular pain, swelling, redness, tenderness
  • +/- vomiting, anorexia, fever
  • In infants/children: mumps, spread from urine eg. E coli
  • In sexually active teens: STIs eg chlamydia, gonorrhoea
61
Q

What is the diagnosis and management of epididymo-orchitis?

A
  • Diagnosis: depends on age + sexual activity. Urine dip + MC&S, NAAT, USS to differentiate from torsion
  • Conservative (especially if mumps): pain relief, rest, fluids
  • Medical: antibiotics depending on likely cause eg. doxycycline, ceftriaxone IM
  • More severe cases: admission, IV fluids, IV antibiotics
62
Q

What is phimosis? When can you diagnose it?

A

Phimosis is a non-retractile foreskin.
Neonates do not have retractile foreskins. 50% will retract by 1 year, and 99% will retract by 16 years
-Meaning should only really diagnose in older children/teens

63
Q

What are some problems with the foreskin in children?

A
  • Phimosis
  • Ammonia dermatitis (nappy rash) due to irritation by urine in infants
  • Bacterial infection eg. balanitis -> lots of redness, purulent discharge
  • Smegma (usually in infants before the prepuce (foreskin) separates from the glans)
  • Balanitis xerotica obliterans (BXO): inflammatory skin condition causing scarring of the glans + foreskin -> phimosis
64
Q

What is paraphimosis? What is the management?

A

When a retracted foreskin cannot be reduced -> oedema of the glans and worsening constriction
Emergency, requires reduction urgently. Manual reduction with topical analgesia, lubrication, ice packs -> surgical reduction and circumcision

65
Q

What is hypospadias? What is the management?

A
  • Failure of correct closure of the ventral tissues -> urethral meatus is not in the normal position
  • Ventral urethral meatus (on the glans or shaft), ventral curvature of the penis, hooded foreskin
  • Management: optional surgery for cosmetic/functional reasons >3 months of age. Important not to circumcise because it may be needed for the repair.
66
Q

What are some causes of vaginal erythema in girls?

A
  • Nappy rash (ammoniacal dermatitis)
  • Candida infection
  • Sexual abuse
  • Other infectious causes

Paediatrics (13 decks)

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