Module 17: Genitourinary and Adolescent Health Flashcards
UTI’S
There are different levels of UTI’s- starting from poo in bum and works its way up urinary tract to the bladder and then kidney.
Symptoms of cystitis (bladder infection)
Symptoms of Kidney infection:
What do we do?
How can we tell if its bacterial or Viral or pH?
How do we treat UTI’s in the older child?
Bladder infection
1. dysuria (painful urination)
2. urgency,
3. frequency,
4. suprapubic pain,
5. incontinence,
6. malodorous urine.
* Cystitis does not cause fever and does not result in renal injury.
Kidney infection of Pyelonephritis:
Clinical pyelonephritis is characterized by any or all of the following: abdominal, back, or flank pain, fever, malaise, nausea, vomiting, and, occasionally, diarrhea. Fever may be the only manifestation.
What do we do next?
We must distinguish between a pH issue, subluxation or true infection.
best way to assess this is a Urinalysis or Salivary pH
(pH should not drop below 6.5)
Compare salivary and urinary- if salivary is normal, but urinary is low its a Kidney issue.
How can we tell if its bacterial or Viral or pH?
2 tender kidneys = viral
1 tender kidney = bacterial
A Urinalysis will demonstrate Acidic pH ie <6.5
-leukocytes
-proteinuria
-haematuria (especially once in bladder and kidneys) -blood
How do we treat UTI’s in the older child?
<12 months hospital- high risk of kidney damage infancy UTI. Risk much lower after 12 months
-Adjust the spine
-First line is bicarb soda - 1/4 teaspoon every 1-2 hours in a glass of water (to decreased acidity) - being alkaline will assist in killing infection and makes spread difficult. Within 24-48 hours pH should resolve. - Get them in to retest urinary pH within 1-2 days- if not resolved within 3 days refer for further testing
Unless severe, simple UTIs and cystitis can be treated without AB.
-Arabinoguard, Ultraprobioplex
-cranberry capsules- prevent bacterial adhesion to the walls of bladder and urethra
If suspected viral issue- super mushroom powder.
Assess diet for causes of acidity- grains, dairy, meat, processed foods, soft drinks
Acidity can be cause by sever viral infections, stress or chemical exposures.
-retest UA and salivary pH to ensure resolution.
-Also VIt D!
Proteinuria
If this Is seen we need to determine if it is due to renal disease or due to benign process.
We need to know wether it is transient or constant- repeat tests over 2 weeks.
Transient- can be high temp, exercise, dehydration, stress, heart failure
Persistent proteinuria - Eg Orthostatic proteinuria - gravity helps them leak through membrane, so need to test in morning- if clear then it is, if not probs not.
Fixed proteinuria- seen on urine sample in morning on 3 consecutive days (indicative of renal disease)
yep
Nephrotic Syndrome
https://www.youtube.com/watch?v=ZGPa_4FN9M4
Nephrotic syndrome is a kidney disorder that causes your body to pass too much protein in your urine. Nephrotic syndrome is usually caused by damage to the clusters of small blood vessels in your kidneys that filter waste and excess water from your blood
How does it clinically present?
Whats Ddx?
Treatment?
prognosis?
Clinical manifestation:
Age 2-6 peak time
Usually follows minor UTI, or reaction to insect bites or stings
Mild Oedema around eyes and lower extremities, people think its an allergy but overtime it spreads to everywhere -oedema everywhere.
Ddx?
-hepatic failure
-heart failure
-protein malnutrition
Treatment:
Uncomplicated nephrotic syndrome
4-6 weeks of prednisone (corticosteroids)
low sodium diet bla bla refer GP
Prognosis: unlikely to lead to chronic kidney disease unlikely to be hereditary, etc. If it is steroid resistant - has more complications.
Nephritic Syndrome = blood in urine?
https://www.youtube.com/watch?v=UD47tM3iJO4
Nephritic syndrome is defined by hematuria, variable degrees of proteinuria, usually dysmorphic red blood cells (RBCs), and often RBC casts on microscopic examination of urinary sediment. Often ≥ 1 of the following elements are present: edema, hypertension, elevated serum creatinine, and oliguria.
Nephritic syndrome is characterised by?
What are the causes? Meh clogged filter = HBP
Can be from Post Streptococcal glomerulonephritis
The main features are hypertension and RBC casts. The proteinuria in nephritic syndrome is not usually severe, but may occasionally be significant enough to be in the range found in nephrotic syndrome.
- Haematuria with red blood cell casts
- Proteinuria small amounts of protein are lost in the urine,
but this is usually trivial (<3.5 g/day) - Hypertension
- Uraemia - due to retention of waste products
- Oedema – facial or body
- Tea or cola coloured urine
bla bla bla
Haematuria
The presence of at least 5 RBC per micro litre of urine
Upper Urinary tract causes and Lower Urinary tract causes;
Eg Inflammationm doesn’t have to be infectious
-Trauma
-heavy exercise
-Bladder tumour
ENURESIS
The medical name for not being able to control your pee is enuresis
It is diagnosed after 5 years of age
Affects up to 20% of children at 5 years of age.
Nocturnal (bed wetting) diagnosis isa child has not experienced a period of 30 days or more without wetting
Causes- undiagnosed UTI or other causes can be:
-Diabetes Mellitus
-Diabetes Insipidus
-Chronic renal disease
or organic cause?
A new onset of enuresis in older child is a cause for concern.
Neurological control- meh but weeing is a parasympathetic nerve activity
What ages should bladder control be developed?
What should our examination include?
What are the 3 main Retained primitive reflexes that can be retained in bed wetters?
- Enlargement of the bladder capacity and maturation of the frontal and parietal lobes of the brain occur gradually between the ages of one to two years.
- By the age of three most children have the ability to delay urination.
- The capacity to start and stop the flow of urine usually occurs by four to five years of age.
- The ability to initiate and stop the flow of urine at any degree of bladder fullness usually occurs by five years of age.
Examination:
1. Palpation of kidneys and
2. Palpation of bladder
3. Measuring BP
4. Urinalysis- a Chiro should be doing this with kids with enuresis. What could you see there and what could it indicate
- Glucose in urine- Diabetes mellitus
-abnormal urinary pH can affect bladder function and behaviour (normal 6.5-7)
-infections are associated with blood, leukocytes + protein
3 main primitive reflexes are: Exam Question
1. Galant
2. Perez
3. Cross adductor
Diabetes Insipidus
- Diabetes insipidus, a disorder of vasopressin secretion from the pituitary is associated with polyuria and polydypsia and there is a daily urine output in excess of four liters per day.
> urine 4L p day
What is the impact of mouth breathing?
https://www.youtube.com/watch?v=c6Rao9TWGTU
unusual for paediatric back pain - unless there are obvious signs of pathology, a trial of adjustments may be carried out- No change within 2-3 adjustments warrants further evaluation.
33% post traumatic- occult fracture, spongy
33% developmental scoliosis, kyphosis
18% infection.
CASE
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Write down your findings
- The L2 vertebra shows some loss of height of the anterior vertebral body
- The posterior vertebral line is intact
- A compression deformity of L2 is suspected
- Wouldyouwantfurtherimaging?
- If so, what?
Yes CT
*Serial cuts of L2 are shown here Write down your findings:
* There is a wedge compression deformity of L2 vertebral body with preservation of the disc spaces above and below this level
* There is minimal retropulsion of the L2 body not causing any significant compression of the thecal sac
* The superior end plate and part of the body appear fragmented as seen on image cuts 7, 8 and 9
* There is minimal prevertebral soft tissue prominence
* The bony spinal canal is normal in size and configuration
* No significant posterior bulging or herniation of the disc is present
What would you expect the treatment to be?
- She was hospitalized under the neurosurgery service for observation and discharged home in two days with a brace
- Would you adjust?
Thoraco lumbar fractures
Thoraco-lumbar fractures are a major cause of disability
* Ninety percent of all spinal fractures are in the thoraco- lumbar region
* Fractures at the thoraco-lumbar junction have an incidence of neurologic deficit of up to 40%
Several factors contribute to thoraco-lumbar vulnerability: What are they?
- In the lumbar spine, there are no ribs to provide additional stability as in the thoracic region
- The change in alignment from thoracic kyphosis to lumbar lordosis makes it an area of stress
- Lumbar spinal segments are more mobile than thoracic segments -the coronal orientation of the facets in thoracic region is more stable then the oblique orientation of the lumbar region
Describe the 3 column concept
Lateral View of Lumbo-sacral Vertebrae:
1. The anterior column - anterior longitudinal ligament and the anterior part of the vertebral body
2. The middle column - from the middle portion of the vertebral body to the posterior aspect of the vertebral body and includes the posterior longitudinal ligament
3. The posterior column - all bony and ligamentous structures posterior to the posterior longitudinal ligament and includes the pedicles, facets, spinous processes and all associated ligaments
Stable fractures – involve only anterior column Unstable fractures – involve the middle or all 3 columns
Presentation:
* Thoracolumbar back ache
* 3 months duration
* Footy season started 4 months ago Takes lots of knocks at footy
* Starting to wake him at night
* Can get worse with activity too
* Pain is usually relieved with aspirin
Exam:
* Nil neurological abnormalities
* Localised swelling and point tenderness at L2
* Mild erector spinae spasm on the right thoracolumbar region
Would you image, and what would you ask for?
Osteoid osteoma
- 2:1 male predominance
- 10-25yoa
- Severe pain, worse at night
- Pain dramatically relieve with aspirin – 65%
- Painful & rigid scoliosis
Lesion on concave side of curve Usually lumbar – 60%
* Only 10% occur in spine
Ivory pedicle or neural arch
* CT often required in the spine to see the nidus
What do you see?
Winking owl sign
Loss of A Pedicle
- WinkingOwlSign:
Loss of a pedicle outline
All other pedicles appear normal in size and shape
First consideration MUST be lytic metastatic disease - Congenital Absence of Pedicle:
Loss of a pedicle outline
Contralateral pedicle of the same vertebra will often be enlarged and sclerotic
The present pedicle does this due to increased load
Unilateral Dense Pedicle
* Dense left L5 pedicle (white arrow) and an old right L5 pars fracture (pink arrow)
* Spondylolysis with stress sclerosis on the contralateral side, resulting in a dense pedicle
Other Differentials:
* Benign tumors:
Osteoid osteoma and osteoblastoma may cause a painful rigid scoliosis, with the lesion found on the concave side of the curve. Bone island uncommonly affects the pedicles.
* Malignant tumors:
Blastic metastases most common malignant cause of a unilateral dense pedicle
Other malignant tumors rarely present with a unilateral dense pedicle e.g., lymphoma, multiple myeloma, Ewing sarcoma
* Iatrogenic: Laminectomy - most commonly contralateral to the dense pedicle
* Infection: Rarely affects the pedicle in isolation
* Agenetic or hypoplastic pedicle or facet: The dense pedicle in on the opposite side to the agenetic or hypoplastic pedicle or facet
* Miscellaneous:
Tuberous sclerosis has an affinity for the posterior elements when it occurs in
the spine - multiple sclerotic pedicles
Rarely - Paget disease, fibrous dysplasia, and sarcoidosis, may affect the pedicle in isolation
Adolescent Idiopathic Scoliosis
Whats the definition and curve required?
- Scoliosis is defined as a lateral curvature of the spine, with a Cobb angle of more than 10 degrees.
- Less than 10 degrees - called spinal asymmetry Juvenile Scoliosis:
- Developing between 4-12 years of age
- Similar presentation and progression to adolescent scoliosis
Adolescent Scoliosis:
* Develops during adolescent pubertal growth spurt
* Most research is performed in this age group
The juvenile (detected between the ages of 4 to 10 years) scoliosis may resemble either the infantile or adolescent (detected after 10years of age) scoliosis
As the child develops, right thoracic curves become more common and are the most common lateral curves found in adolescent children (Weinstein 2001)
* Asymmetry at a young age does not always mean the curve will progress into scoliosis
What are the 2 types of Scoliosis?
Postural scoliosis
* Long thoracolumbar curve with no compensatory curves
* Rotation of the vertebrae to the concavity
* Flexible – it disappears when the patient is prone
Functional scoliosis
* Leg length discrepancy
* Single, long thoracolumbar curve, with convexity to side of lower limb
* No compensatory curves
* Rotation of vertebrae to concavity of curve
* Curvature disappears when pelvis is levelled with a heel-lift
What are some of the causes of Scoliosis?
Ie Aitiology
Neurological:
* Abnormalities of visual, vestibular, proprioceptive and postural control
Abnormal symmetries of brain structure and function
In cerebral hemispheres, brainstem, internal capsule and
corpus callosum
Orthopaedic:
* Increased vertebral column length in those with AIS, compared with those without it
Not associated with longer spinal cords
Increase in growth (ie abnormal growth) of the anterior
column of the spine,
the adjacent intervertebral discs are wedged to a lesser degree than the vertebrae, implying that disc wedging occurs secondarily
87
What is the
Syringomyelia
Syringomyelia is the development of a fluid- filled cavity or syrinx within the spinal cord
Can be due to:
* Blockage of CSF circulation
* Or may be communicating with fourth ventricle * Spinal cord injury
* Spinal disraphism
* Intramedullary tumours
* Idiopathic
Rarely occurs in adolescents – more common in 3rd and 4th decade of life
up to page 104
Scheuermann’s Disease
X-ray of Scheuermann’s disease with some of the typical signs:
-narrowed disk space
-wedge shaped vertebral bodies –uneven endplates
-schmorl’s nodes
Spiral-CT sagittal reconstruction of a dorsal spine with extraordinary remnants of Scheuermann’s disease
Most common form of structural hyperkyphosis Anterior wedging of >5 degrees of 3 or more consecutive
More common in boys
Usually present during adolescent growth spurt
Most common complaint – thoracic pain
Radiographic findings –
* Irregularities in vertebral endplates
* Disc space narrowing
* Schmorls nodes
* Apex of curve towards lower thoracic spine, rather than mid thoracic
vertebral bodies at the apex of the deformity
* Measured with standing lateral films
In females it is important to rule out: *Metabolic disease
*Endocrine disease
*Osteoporosis
*Eating disorders
Adolescent Kyphosis
Juvenile kyphosis 13yo girl
Thoracic spine lateral – midthoracic kyphosis with wedged apical vertebra, disc narrowing, end-plate irregularity, and multiple Schmorl nodes
What do we need to rule out>
In females it is important to rule out: *Metabolic disease
*Endocrine disease
*Osteoporosis
*Eating disorders
Case 6:
14yo boy
T/L pain, aches a lot
2 months ago had antibiotics for a bacterial throat infection
Nil radiation
* What are your Differentials?
* Main Physical Examination?
* What Imaging would you want?
X-Rays Demonstrate No Pathology
You start a trial of care
After 4 weeks and 6 adjustments, there has been no big change in the clinical picture
In fact he seems to be having an increased thoracic kyphosis & antalgic positioning
What do you do?
Follow-Up X-ray Findings
* Destruction T11-12 disc, and much of adjacent vertebral bodies
* Excessive sclerotic bone and paravertebral soft tissue swelling
What is your diagnosis?
What are the two key history questions?
Which part of the spine is most commonly affected?
How long doe the bony changes typically take to become apparent?
Chronic Fatigue syndrom:
What is the pathogenesis?
- The individual has had severe chronic fatigue for 6 or more consecutive months that is not due to ongoing exertion or other medical conditions associated with fatigue (these other conditions need to be ruled out by a doctor after diagnostic tests have been conducted)
- The fatigue significantly interferes with daily activities and work
- The individual concurrently has 4 or more of the following 8 symptoms: post-exertion malaise lasting more than 24 hours
unrefreshing sleep
significant impairment of short-term memory or concentration
muscle pain
pain in the joints without swelling or redness headaches of a new type, pattern, or severity tender lymph nodes in the neck or armpit
a sore throat that is frequent or recurring
Pathogenisis:
-Largely unknown
-Multifaceted issues
-Fatigue is a generalised complaint
-A large number have a significantly stressful event and never recover from it.
eg Viral infection- Glandula fever, Influenza
-Emotional trauma/ Stress
-Parasitic infection - gut (commonly after travel)
-After a dose of antibiotics.
Infection vs Dysbiosis
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