Paediatric GU Flashcards
What symptoms would children with a UTI present with?
Dysuria
Frequency
Loin pain
What symptoms would infants with a UTI present with?
Poor feed
Lethargy
Irritability
D&V
How would you diagnose a UTI?
History - distinguish if Upper or Lower UTI
Urine dip - leukocyte esterase and nitrate
If +ve urine dip - send for culture and microscopy
What general management measures would you suggest to prevent UTI’s?
Correct wiping technique Prevent constipation Avoid bubble baths Adequate fluid intake Regular toileting
If a child is <3 months, what do you do if you suspect a UTI?
Immediately refer to paediatric specialist?
How would you manage cystitis in a child over 3 months?
3 days trimethoprim
How would you manage pyelonephritis in a child over 3 months?
7-10 days ciprofloxacin
Consider referral
What investigation must be ordered if a child with a UTI has a fever >38 degrees?
Urinalysis
Who is at risk of recurrent UTI’s?
Poor flow Renal abnormality High BP Vesicoureteral reflux Constipation Sexual abuse
What counts as recurrent UTI’s?
> =2 Upper UTI
1 Upper UTI + 1 Lower UTI
= 3 Lower UTI
How are recurrent UTI’s managed?
USS of urinary tract
Specialist referral
Can consider prophylactic Abx
What is vesicoureteric reflux (VUR)?
Retrograde flow of urine back from bladder to upper tract
What causes vesicoureteric reflux?
Ureters enter bladder perpendicularly leading to inadequate vesicoureteric junction
What can happen if vesicoureteric reflux is compounded by recurrent UTI’s?
Progressive renal scarring which can cause renal failure
How can vesicoureteric reflux be diagnosed?
Routine antenatal scans
Micturating cystourethrogram
Indirect cystogram
When is a micturating cystourethrogram carried out and how does it work?
Children <2yo - catheter insertion needed
Radiocontrast detect reflux on voiding
When is an indirect cystogram carried out and how does it work?
> 2yo children
Give MAG3 injection and void in front of special camera that detects it
What is a key risk factor for vesicoureteric reflux?
Strong family history
How is vesicoureteric reflux graded?
1 - flow back up to ureters
2 - flow back up to kidney
3 - mild dilation of ureter and renal pelvis
4 - dilation of ureter, renal pelvis and calyces
5 - severe dilation of ureter, pelvis and calyces
How is vesicoureteric reflux managed?
Can be self resolving around 2yo - prophylactic Abx to prevent UTI’s
STING procedure - make valve
Open surgery to reimplant ureters
What happens in testicular torsion?
Mobile mesentery within tunica vaginalis leads to twisting of the spermatic cord –> testicular torsion and necrosis
How does testicular torsion present?
Acute severe scrotal pain Referred pain to abdomen N&V Swelling and redness of scrotum Testis retract up Lifting testis increase pain
How would you investigate testicular torsion?
Can do Doppler USS to show arterial flow
Don’t delay surgery to investigate!
When is testicular torsion most common?
12 yo
What is the management for testicular torsion?
Immediate surgical exploration with fixation of both testis
Why do you fix both testis in testicular torsion?
Bell clapper deformity (which causes it) is often bilateral
What complications are associated with testicular torsion?
Sub-fertility in 40% of patients
What happens in congenital torsion?
Cord twists outside tunica vaginalis resulting in an infarcted testis which presents as a hard painless scrotal mass
What differentials do you consider for testicular torsion?
Epididymo-orchitis - associated with UTI
Trauma - swelling more gradual
Hydrocoele - painless
Incarcerated hernia - examine inguinal canal
What is typical bed wetting?
Large volume of urine in first few hours of the night
What is enuresis?
Bed wetting in girls >5yo and boys >6yo
What is primary enuresis?
Child never achieve bladder control
What is secondary enuresis?
Child wetting after 6 months established control
What are the risk factors for enuresis?
Boys Constipated Family history Obese Stressed Developmentally delayed
How is enuresis assessed?
Have they ever had bladder control?
Bed wetting history - what time, how much, do they wake?
Day time symptoms - frequency, urgency, stream
How much fluid are they drinking
When is further investigation required for enuresis?
? Organic cause to bedwetting
What investigations are requested for enuresis?
Urinalysis - recent onset, UTI, diabetic symptoms, unwell
Referral - severe daytime symptoms, UTI, co-morbidities, no response to treatment
Safeguarding - urinating on purpose, punished for bedwetting? persistent
What is the normal process in children’s urination control?
Children learn to recognise full bladder and overcome autonomic pattern of voiding
Achieve during day before night
Dry by 3-4 yo
What advice should you give to parents if their child is suffering from enuresis?
Reassure
Fluid intake advice - normal intake, no caffeine
Toilet regularly - 4-7x per day
Reward for using toilet before bed
What can be trialled in children with enuresis?
Enuresis alarm
Desmopressin - short term (sleepover) or in conjunction with alarm
Both for 1 month
What is first line management for children >7 with enuresis?
Desmopressin
What should be done if the child with enuresis isn’t responding to treatment?
Refer to specialist
They may try drugs such as anticholinergics or tricyclics
How does an enuresis alarm work?
Alarm have sensor which attach to child’s underwear and goes off on moisture detection so child wakes and finishes voiding in toilet
How common is undescended testes in children?
Around 3% of infants but more common if preterm
How does undescended testes normally present?
Normally unilateral
25% bilateral
What complications are undescended testes associated with?
Infertility
Torsion
Testicular cancer
Psychological issues
If testes are palpable but undescended, what does this mean?
Testes sitting at external inguinal ring so should be brought into scrotum with orchidopexy
If testes are impalpable and undescended, what does this mean?
Testes could be within the inguinal canal or intra-abdominal
Need to laparoscopy to investigate and then orchidopexy
What should be done if the testes remain undescended by 3 months?
Refer
What should be done if testes remain undescended by 6 months?
Child seen by surgeon
What should be done if testes remain undescended after 1 year?
Surgery performed
How can haematuria be categorised?
Macroscopic
Microscopic - asymptomatic/symptomatic
What examination would you do if a child has haematuria?
Abdominal exam - palpate for masses
What investigations would you request for haematuria?
Urine dip BP FBC - clotting, eGFR, PCR Cytology - examine urine Renal tract USS Cystoscopy
What do the letters stand for in the VITAMIN O model for differential diagnoses?
Vascular Infection Trauma Autoimmune Metabolic Inherited Neoplastic Other
Using the VITAMIN O model, list some causes for haematuria
V - sickle cell, coagulation, disorder I - UTI T - catheter, prolonged severe exercise A - HSP, glomerulonephritis M - Calcium calculi I - Polycystic kidneys N - Wilm's tumour O - child abuse, fabricated induced illness, beetroot, menstruation
If a child has haematuria, what must be done?
Refer to specialist!
