Paediatric Nephrology / Urology Flashcards
Outline the difference between primary nocturnal enuresis and secondary nocturnal enuresis
Primary nocturnal enuresis - child has never managed to be consistently dry at night
Secondary nocturnal enuresis - child starts wetting the bed, after previously being consistently dry at night for 6 MONTHS
State some reasons for primary nocturnal enuresis
Part of normal development if < 5 years old
Other causes:
- Excessive fluid intake prior to bedtime
- Overactive bladder
- Failure to wake during deep sleep from a full bladder
- Psychological stress
State some reasons for secondary nocturnal enuresis and how it is managed
Secondary to other problems:
- Type 1 diabetes
- Chronic constipation
- UTI
- Psychological stress / abuse or maltreatment
Management:
- Treat the underlying cause!
Outline how primary nocturnal enuresis is managed in the first instance
Important to determine cause of enuresis
- Keep a 2 week bladder diary with: toileting patterns, fluid intake and bedwetting episodes
- Undertake history and examination
Management:
- If under 5 = reassurance
- Lifestyle changes e.g. limit fluid intake before bed, toilet before bed
- Encouragement and positive reinforcement
- Enuresis alarm
- Pharmacological treatment e.g. Desmopressin, Oxybutinin, Imipramine
Outline diurnal enuresis, the 2 types and some causes
Diurnal enuresis is daytime incontinence of urine
2 types:
- Urge incontinence
- Stress incontinence
Causes:
- UTI
- Chronic constipation
- Psychological stress
For the 3 drugs used in the pharmacological treatment of bedwetting, state the class of drug and how it helps
- Desmopressin
- Oxybutinin
Desmopressin = antidiuretic hormone
- Take before bed
- Reduces volume of urine produced by the kidneys
Oxybutinin = anticholingeric
- Reduces contractility of the bladder
- Helpful when cause is an overactive bladder
State what % of boys are born with undescended testes and what future risks this is associated with
5% of boy babies testes won’t be descended out of the abdomen at birth
Associated future risks:
- Infertility
- Testicular cancer
- Testicular torsion
State some risk factors for undescended testes
- Family history of undescended testes
- Prematurity / low birth weight / small for gestational age
- Maternal smoking
Outline how undescended testes are managed
Watch and wait for newborns - in most cases they will descend within 3-6 months (however longer it takes, the less likely it is to happen spontaneously)
If undescended by 6 months, orchidopexy carried out between 6-12 months of age
For epididymo-orchitis, state the most common cause / causative organism for younger paediatric patients, vs older paediatric patients
Younger paediatric patients:
- UTI
- E Coli
- ?Mumps
Older paediatric patients and teens:
- STI
- Gonorrhoea or chlamydia
Hypospadias - state the following:
- Pathophysiology
- Presentation
- Management
Pathophysiology:
- Congenital abnormality where the urethral meatus is positioned posteriorly on the penis
- Mostly at the bottom of the glands, however can be halfway down the shaft or at the base
- Occurs due to arrest of penile development, leading to hypoplasia of the ventral penis tissue
Presentation:
Commonly diagnosed during newborn examination
- Parents may describe abnormal urinary flow
- May have associated chordee
Management:
- Urethroplasty (either single step or 2 step with a foreskin graft)
Briefly state the difference between hypospadias and epispadias
In hypospadias, the urethral meatus displaced posteriorly on the penis
Whereas in epispadias, the urethral meatus displaced anteriorly on the penis
State a differential that must not be missed when hypospadias is suspected
Congenital adrenal hyperplasia
Should be considered in females with ambiguous genitalia
If not detected early, can lead to a hyponatraemic crisis due to cortisol and aldosterone deficiency
State some complications of hypospadias if not treated
- Difficultly controlling urination
- Psychological distress
- Sexual dysfunction
- Cosmetic concerns
State some short-term and long-term complications of urethroplasty for management of hypospadias
Short term:
- Catheter complications e.g. blockage or infection
- Infection
- Bleeding
Longer term:
- Urethral fistula
- Stenosis of meatus or urethra
Hydrocele - state the following:
- Pathophysiology (including 2 main categories)
- Presentation
- Investigations
- Management
Pathophysiology:
- Collection of fluid within the tunica vaginalis
- Either simple (non-communicating) or communicating hydrocele
- Mostly congential
Presentation:
- Swollen/enlarged teste(s), especially after exertion (can get above)
- Soft and smooth
- Minimal associated pain
- Transilluminates
Investigations:
- Often clinical diagnosis with transillumination of testicle
- Ultrasound can be used
Management:
- If simple, reassure that it will resolve within 2 years with follow up
- If communicating/persisting, open / laparoscopic ligation of processus vaginalis
State some differentials for hydrocele in newborns / children
- Testicular torsion
- Partially descended testes
- Epididymo-orchitis
- Inguinal hernia
- Haematoma
- Tumour (rare)
State the difference between simple (non-communicating) and communicating hydroceles in terms of pathophysiology
Simple (non-communicating) hydroceles:
- Due to an imbalance absorbing serous fluid from peritoneal cavity
Communicating hydroceles:
- Persistence of processus vaginalis
- Allows flow of peritoneal fluid from peritoneum to the tunica vaginalis
Inguinal hernia - state the following:
- Pathophysiology
- Presentation (including any red flags)
- Investigations
- Management
Pathophysiology:
- Protrusion of intra-abdominal contents through a defect of the walls of the abdominal cavity, into the inguinal canal
- Indirect hernias are more common due to incomplete closure of processus vaginalis
Presentation:
- Groin swelling / protrusion
- Abdominal discomfort
- Constipation
- Reducible if lying flat / positive cough reflex
Red flag (signs of obstruction or strangulation)
- Vomiting
- Constipation
- Abdominal pain
Investigations:
Largely clinical
- May use ultrasound
- CT scan if features of obstruction or strangulation and uncertainty
Management:
- Surgical herniotomy (repair)
- Emergency surgery may be needed in the case of an irreducible hernia
State whether a direct or indirect hernia is more common in children and explain the pathophysiology
Indirect inguinal hernia are the most common form in children,
- Often due to incomplete closure of the processus vaginalis (after the descent of testes in utero)
- Allows abdominal contents to protrude through the deep inguinal ring into the inguinal canal, and through the superficial inguinal ring into the groin
State some differentials for a scrotal hernia
- Testicular torsion
- Partially descended testes
- Epididymo-orchitis
- Hydrocele
- Haematoma
- Tumour (rare)
State some risk factors for inguinal hernias
- Male
- Family history of inguinal hernias
- Prematurity
State some complications of inguinal hernias
- Strangulation
- Incarceration
- Bowel obstruction
- Recurrence
State how a UTI may present in a young child
- Fever (may be the only sign!)
- Increased urinary frequency
- Irritability
- Lethargy
- Reduced feeding
- Vomiting
State 2 features in children that indicate pyelonephritis and which a diagnosis can be made off
- Fever (>38)
- Loin pain / tenderness
State how children can be managed for UTIs (under 3 months and over 3 months)
If under 3 months and fever:
- Started on IV antibiotics
- Full septic screen (full bloods, blood cultures and lactate)
- Consider lumbar puncture
If over 3 months and fever:
- Consider oral antibiotics if otherwise well
- If features of sepsis or pyelonephritis, start on IV antibiotics
If under 6 months and first UTI, should have ultrasound scan to check for underlying cause
Suggest some antibiotics that could be used to treat paediatric UTIs
- Trimethoprim
- Nitrofurantoin
- Cefalexin
- Amoxicillin
State the referral criteria to renal USS for UTIs (i.e. when to refer for USS)
- < 6 months old
- Atypical UTI e.g. abdominal mass, failure to response to antibiotics, non-E.Coli organism
- Recurrent UTIs (2 or more upper UTIs, 3 or more lower UTIs)
State the test used to diagnose vesico-ureteric reflux (VUR)
Micturating cysto-urethrogram (MCUG)
State some causes of chronic kidney disease in children (inherited and acquired)
Inherited:
- Congenital defects e.g. renal atresia, renal hypoplasia, renal dysplasia
- Inherited conditions e.g. polycystic kidney disease or Alport syndrome
glomerulonephritis
Acquired:
- Trauma / dehydration e.g. sepsis
- Nephrotic syndrome
- Infections e.g. haemolytic uraemic syndrome or post-streptococcal
- Systemic conditions e.g. Lupus
- Chronic obstruction
- Vesico-ureteric reflux
Acute Kidney Injury (AKI) - state the following:
- Pathophysiology
- Presentation
- Investigations
- Management
Pathophysiology:
- Sudden decline in kidney function
Investigations:
- Serum creatinine (> 1.5x reference creatinine or age-specific upper limit)
- Urine output level (<0.5mls/kg/hr for 8 hours)
- FBC
- Ultrasound KUB
- Urinalysis and urine MC&S
Management:
- Resolve underlying cause or any contributing factors
- Omit any nephrotoxic medications
State more common causes of AKI in paediatrics
Reduced renal blood flow secondary to:
- Hypovolaemia e.g. dehydration, diarrhoea, blood loss
- Sepsis
List some causes of true haematuria
Benign:
- Vigourous exercise
- Trauma along urinary tract e.g. catheter
Other:
- UTI
- Renal stones
- Clotting abnormalities
- Glomerulonephritis
- Alport syndrome
- Haemolytic uraemic syndrome
- Tumour e.g. Wilms tumour
- Adenovirus haemorrhagic cystitis
+ myoglobin
+ haemoglobin (not RBCs)
State some conditions/situations that could lead to brown urine (not haematuria)
- Red foods e.g. beetroot
- Medications e.g. Rifampicin, Metronidazole, Nitrofurantoin
- Inborn errors of metabolism
Wilm’s tumour - state the following:
- Pathophysiology
- Most common age
- Presentation (including any red flags)
- Investigations
- Management
Pathophysiology:
- Renal tumour
Most common age:
- Typically affects children under 5 years old
Presentation:
- Abdominal mass
- Abdominal pain
- Haematuria
- B symptoms e.g. fever, weight loss
- Lethargy
- Hypertension
Investigations:
- USS abdomen (KUB)
- Biopsy needed for definitive diagnosis
- CT/MRI can be used for further staging
Management:
- Surgical excision of tumour and affected kidney (nephrectomy)
- Adjuvant treatment (chemotherapy or radiotherapy)
Early disease has a good prognosis 90% cure
