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Paediatric rotation > Paediatric renal and urology > Flashcards

Paediatric renal and urology Flashcards

1
Q

What is cystitis?

A

Inflammation of the bladder and can be a result of a bladder infection

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2
Q

What are the symptoms of UTI in babies?

A

Fever
Lethargy
Irritability
Vomiting
Poor feeding
Urinary frequency

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3
Q

What are the symptoms of UTI in older children?

A

Fever
Abdominal, suprapubic pain
Vomiting
Dysuria
Urinary frequency
Incontinence

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4
Q

When is a diagnosis of pyelonephritis made?

A

A temperature greater than 38 degrees
Loin pain or tenderness

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5
Q

What does the presence of nitrites in urine suggest and why?

A

Bacteria as gram negative bacteria (such as E.coli) break down nitrates, a normal waste product of urine into nitrites

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6
Q

What do leukocytes in the urine suggest?

A

Leukocytes are white blood cells and normally found in urine. A significant rise however can indicate infection. Urine dipstick tests for leukocyte esterase which is a product of leukocytes

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7
Q

Are nitrites or leukocytes a better indication of UTI?

A

Nitrites- if just increased leukocytes then don’t treat for UTI unless there is clinical evidence

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8
Q

What is sent to the lab when testing for UTI?

A

Midstream urine

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9
Q

What is the management for children under 3 months with a fever?

A

Immediate IV abx (e.g. ceftriaxone) and full septic screen, blood cultures and lactate, maybe also a lumbar puncture

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10
Q

What are typical antibiotic choices for management of UTI in children over 3 months?

A

Trimethoprim
Nitrofurantoin
Cefalexin
Amoxicillin

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11
Q

Which children with UTI should have an ultrsound?

A

All children under 6 months with their first UTI
Children with recurrent UTIs within 6 weeks
Children with atypical UTIs

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12
Q

When are Dimercaptosuccinic acid scans used in UTI in children?

A

4-6 months after illness to assess for damage from recurrent or atypical UTIs.

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13
Q

How do DMSA scans work?

A

Involves injecting a radioactive material (DMSA) and using a gamma camera to assess how well material is taken up by the kidneys. Where there are patches of kidney that have not taken up the material, this indicates scarring that may be the result of previous infection

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14
Q

What is vesico-ureteric reflux and what does it predispose people to?

A

Where urine has the tendency to flow from the bladder back into the ureters predisposing to UTIs and subsequent renal scarring

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15
Q

How is vesico-ureteric reflux diagnosed?

A

Micturating cystourethrogram

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16
Q

What is the management of vesico-ureteric reflux?

A

Avoid constipation
Avoid an excessively full bladder
Prophylactic antibiotics
Surgical input from paediatric urology

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17
Q

When should micturating cystourethrogram used?

A

To investigate atypical or recurrent UTIs in children under 6 months. Also used where there is family history of vesico-ureteric reflux, dilation of the ureter on ultrasound or poor urinary flow

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18
Q

What does micturating cystourethrogram involve?

A

Catheterising the child, injecting contrast into the bladder and taking a series of xray films to determine whether the contrast is refluxing. Children are usually given prophylactic antibiotics for 3 days around the time of the investigation

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19
Q

What is vulvovaginitis?

A

Inflammation and irritation of the vulva and vagina

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20
Q

Who does vulvovaginitis affect?

A

Girls aged 3 to 10 years

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21
Q

What can vulvovaginitis be exacerbated by?

A

Wet nappies, Chemicals or soaps, tight clothing that traps moisture or sweat in the area, poor toilet hygiene, constipation, threadworms, pressure on the area e.g. horse riding, heavily chlorinated pools

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22
Q

Why is vulvovaginitis less common after puberty?

A

Oestrogen helps keep the skin and vaginal mucosa healthy and resistant to infection

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23
Q

What does vulvovaginitis present with?

A

Soreness
Itching
Erythema around the labia
Vaginal discharge
Dysuria
Constipation

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24
Q

Why is vulvovaginitis often misdiagnosed as a UTI?

A

Because a urine dipstick may show leukocytes but will not show nitrites

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25
Q

What is the management for vulvovaginitis?

A

Usually no treatment required
Avoid washing area with harsh soaps and perfumes
Keep the area dry
Emollients
Loose cotton clothing

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26
Q

What is nephrotic syndrome?

A

When the basement membrane in the glomerulus becomes highly permeable to protein, allowing proteins to leak from the blood into the urine.

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27
Q

At what ages is nephrotic syndrome most common?

A

2 to 5 years

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28
Q

What does nephrotic syndrome present with?

A

Frothy urine, generalised oedema and pallor

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29
Q

What is the classic triad of features for nephrotic syndrome?

A

Low serum albumin, High urine protein content (>3 + protein on urine dipstick), oedema

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30
Q

Apart from the classic triad, what other three symptoms occur in patients with nephrotic syndrome?

A

Deranged lipid profile with high levels of cholesterol., triglycerides and low density lipoproteins
High BP
Hyper-coagulability with an increased tendency for blood clots

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31
Q

What is the most common cause of nephrotic syndrome in children?

A

Minimal change disease causes over 90% of cases in children under 10

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32
Q

What are the secondary causes of nephrotic syndrome?

A

Intrinsic kidney disease: focal segmental glomerulosclerosis, membranoproliferative glomerulonephritis
Systemic illness: Henoch schonlein purpura, Diabetes, Infection (HIV, hepatitis and malaria)

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33
Q

What is the diagnosis for minimal change disease?

A

Renal biopsy and standard microscopy
Urinanalysis will show small molecular weight proteins and hyaline cysts

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34
Q

What is the management of minimal change disease?

A

Corticosteroids and most children make a full recovery.

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35
Q

What is the management for nephrotic syndrome?

A

Corticosteroids
Low salt diet
Diuretics for oedema
Albumin infusions in severe hypo
Antibiotic prophylaxis if severe

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36
Q

What is the treatment of nephrotic syndrome using corticosteroids?

A

High dose are given for 4 weeks and then gradually weaned over the next 8 weeks

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37
Q

What does steroid sensitive mean?

A

They respond to steroids (80% of children)

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38
Q

What does steroid dependent mean?

A

Patients struggle to wean steroids due to relapses

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39
Q

What is steroid resistant?

A

Patients that do not respond to steroids

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40
Q

What is used for nephrotic syndrome in steroid resistant children?

A

ACE inhibitors and immunosuppressants such as cyclosporine, tacrolimus or rituximab

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41
Q

What are the complications of nephrotic syndrome?

A

Hypovolemia- fluid from intravascular space leaks into interstitial space, causing oedema and low BP
Thrombosis- proteins that prevent blood clotting are lost in the kidneys and liver responds to low albumin by producing pro-thrombotic proteins
Infection- kidneys leak immunoglobulins, exacerbated by immunosuppressant meds such as steroids
Acute or chronic renal failure
Relapse

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42
Q

What is nephritis?

A

Inflammation within the nephrons of the kidneys

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43
Q

What does nephritis cause?

A

Reduction in kidney function
Haematuria: invisible or visible amounts of blood in the urine
Proteinuria: although less than nephrotic syndrome

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44
Q

What are the two most common causes of nephritis in children?

A

Post-streptococcal glomerulonephritis and IgA nephropathy (Berger’s disease)

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45
Q

When does post-streptococcal glomerulonephritis occur?

A

1-3 weeks after a beta-haemolytic streptococcus infection e.g. tonsilitis caused by streptococcus pyogenes.

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46
Q

How does strep infection cause glomerulonephritis?

A

Immune complexes of streptococcal antigens, antibodies and complement proteins get stuck in the glomeruli of the kidney and cause inflammation. Leading to an acute deterioration in renal function causing acute kidney injury.

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47
Q

What could suggest tonsilitis caused by streptococcus clinically?

A

History, throat swab or anti-streptolysin antibody titres on blood test

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48
Q

What is the management of post-streptococcal glomerulonephritis?

A

Usually supportive. May need treatment with anti-HTN medications and diuretics if they develop complications e.g. HTN and oedema

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49
Q

What is IgA nephropathy also known as?

A

Berger’s disease

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50
Q

What is IgA nephropathy related to?

A

Henoch-Schonlein purpura which is an IgA vasculitis

51
Q

How is IgA nephropathy related to Henoch-Schonlein purpura?

A

IgA deposits in the nephrons of the kidney cause inflammation (nephritis).

52
Q

What will be seen in the renal biopsy of IgA nephropathy?

A

IgA deposits and glomerular mesangial proliferation

53
Q

When does IgA nephropathy usually present?

A

teenagers or young adults

54
Q

How is IgA nephropathy treated?

A

Supportive treatment and immunosuppressant medications such as steroids and cyclophosphamide to slow progression

55
Q

What is haemolytic-uraemic syndrome?

A

Occurs when there is thrombosis within the small blood vessels throughout the body.

56
Q

What is HUS usually triggered by?

A

Shiga toxin produced by e.coli 0157 or shigella

57
Q

What is the classic triad of HUS?

A

Haemolytic uraemia
Acute kidney injury: failure to excrete waste products
Thrombocytopenia: low platelets

58
Q

What can increase the risk of developing HUS?

A

antibiotics and anti-motility meds such as loperamide for gastroenteritis caused by pathogens

59
Q

What is the timeline of presentation in HUS?

A

E.coli 0157 caused by brief gastroenteritis, often with bloody diarrhoea. Symptoms of HUS typically start around 5 days after the onset of the diarrhoea

60
Q

What are the signs and symptoms of HUS?

A

Reduced urine output
Haematuria or dark brown urine
Abdominal pain
Lethargy and irritability
Confusion
Oedema
Hypertension
Bruising

61
Q

What is the prognosis of HUS?

A

Medical emergency and has 10% mortality
70-80% make a full recovery

62
Q

What is the management of HUS?

A

Condition is self-limiting
Renal dialysis may be required
Maybe anti-HTN
Maybe blood transfusions
Careful fluid balance maintenance

63
Q

What is enuresis?

A

Involuntary urination

64
Q

What is diurnal enuresis?

A

Inability to control bladder function during the day

65
Q

When do most children have control of urination the day?

A

2 years

66
Q

When do most children have control of urination at night?

A

3-4 years

67
Q

What is primary nocturnal enuresis?

A

Where the child has never managed to be consistently dry at night

68
Q

What is the most common cause of primary nocturnal enuresis?

A

Variation in normal development especially if child is under 5

69
Q

What are other causes of primary nocturnal enuresis?

A

Overactive bladder
Fluid intake prior to bedtime
Failure to wake due to deep sleep and underdeveloped bladder signals
Psychological distress e.g. low self esteem
Secondary causes such as chronic constipation, UTI, learning disability or cerebral palsy

70
Q

What is the management of primary nocturnal enuresis?

A

reassurance
lifestyle changes
pharmacological treatment

71
Q

What are the two types of polycystic kidney disease?

A

autosomal dominant and autosomal recessive

72
Q

Which type of PKD presents in neonates?

A

Autosomal recessive

73
Q

What mutation results in ARPKD and what does this code for?

A

polycystic and hepatic disease 1 genes (PKHD1) on chromosome 6. this codes for the fibrocystin/polyductin protein complex (FPC), which is responsible for the creation fo tubules and the maintenance of healthy epithelial tissue in the kidneys, liver and pancreas

74
Q

What does the underlying pathology cause in ARPKD (3 things)

A

Cystic enlargement of the renal collecting ducts
Oligohydramnios, pulmonary hypoplasia and potter syndrome
Congenital liver fibrosis

74
Q

What is usually seen on antenatal scans in ARPKD?

A

oligohydramnios and polycystic kidneys

74
Q

What is oligohydraminos?

A

lack of amniotic fluid caused by reduced urine production by the fetus

74
Q

what does a lack of amniotic fluid lead to?

A

Potter syndrome which si charcterised by dysmorphic features such as underdeveloped ear cartilage, low set ears, a flat nasal bridge and abnormalities of the skeleton

74
Q

What does oligohydromnias lead to apart from Potter syndrome?

A

Underdeveloped lungs (pulmonary hypoplasia), resulting in respiratory failure shortly after birth. Also large polycystic kidneys take up a lot of space so hard for neonate to breathe

74
Q

What might patients reuqire in teh first few days of life with ARPKD?

A

renal dialysis

75
Q

What is the prognosis of those with ARPKD?

A

most patients develop end stage renal failure before reaching adulthood. Around 1/3 will die in neonatal period. Around 1/3 will survive to adulthood

76
Q

What are the ongoing problems patients with ARPKD experience?

A

Liver failure due to liver fibrosis
Portal HTN leading to oesophageal varices
Progressive renal failure
HTN due to renal failure
Chronic lung disease

77
Q

What is multicystic dysplastic kidney? (MCDK)

A

Where one of the baby’s kidneys is made up of many cysts while the othe rkidney is normal

78
Q

How is MCDK diagnsoed?

A

antenatal ultrasoun scans

79
Q

What treatment is required for MCDK?

A

no treatment, usually the single kidney is sufficient.

80
Q

What is Wilm’s tumour?

A

Tumour affecting the kidney in children, usually under 5 years

81
Q

What is the presentation of a Wilm’s tumour?

A

Abdominal pain
Haematuria
Lethargy
Fever
Hypertension
Weight loss

Under 5 with a mass in the abdomen

82
Q

What is the investigation for a Wilm’s tumour?

A

Ultrasound
A CT or BMI can be used to stage the tumour

83
Q

What is the treatment for Wilm’s tumour?

A

Surgical excision (nephrectomy)
Adjuvant chemotherapy or radiotherapy

84
Q

What is the prognosis of Wilm’s tumour?

A

Early stage has a good chance of cure (up to 90%)

85
Q

What is a posterior urethral valve?

A

Where there is tissue at the proximal end of the urethra that causes obstruction of urine output

86
Q

Who does a posterior urethral valve occur in?

A

newborn boys

87
Q

What does a posterior urethral valve cause?

A

Hydronephrosis- a restriction in the outflow of urine prevents the bladder from fully emptying, leading to a reservoir of urine that increases the risk of UTI

88
Q

What is the presentation of posterior urethral valve

A

Can be asymptomatic
Difficulty urinating
weak urinary system
chronic urinary retention
palpable bladder
recurrent UTI
impaired kidney function

89
Q

What can severe obstruction from posterior urethral valve cause?

A

Bilateral hydronephrosis
oligohydramnios

90
Q

What can be seen on antenatal scans with severe psoterior urethral valve?

A

Oligohydramnios and hydroneohrosis

91
Q

What investigations are there for posterior urethral valve presenting after birth?

A

Abdominal ultrasound- may show enlarged, thickened bladder and bilateral hydronephrosis
Micturating cystourehtrogram (MCIG) shows location of the extra urethral tissue
Cystoscopy can be used to ablate or remove extra tissue

92
Q

How do the testes develop normally?

A

Develop in the abdomen and then migrates down, through the inguinal canal and into the scrotum

93
Q

What are undescended testes?

A

When the testes have not made it out of the abdomen by birth (around 5% of boys)

94
Q

What is undescended testes also known as?

A

Cryptorchidism

95
Q

What is it called when the testes have not descended fully but are palpable in the inguinal canal?

A

Not undescended testes technically

96
Q

What are the RF for undescended testes?

A

Family history of undescended testes
Low birth weight
small for gestational age
prematurity
maternal smoking during pregnancy

97
Q

What do undescended testes in older children or after puberty hold a higher risk of?

A

testicular torsion, infertility and testicular cancer

98
Q

What is the management for undescended testes?

A

most will descend in first 3-6 months. Orchidopexy should be carried out between 6 to 12 months of age

99
Q

What is retractile testicles?

A

normal before puberty for the testes to move out of the scrotum and into the inguinal canal when it is cold or the cremasteric reflex is activated. usually resolves

100
Q

What is hypospadias?

A

affects males, where the urethral meatus is abnormally displaced to the ventral side of the penis, towards the scrotum

101
Q

Where is the urethral meatus in hypospadias?

A

towards the bottom of the glans (90%)
halfway down the shaft or base of the shaft

102
Q

What is epispadias?

A

where the urethral meatus is displaced to the dorsal side (top) of the penis.

103
Q

What is the foreskin like in hypospadias?

A

usually abnormally formed

104
Q

What condition may be associated with hypospadias?

A

chordee, where the head of the penis bends downwards

105
Q

When is hypospadias usually diagnosed?

A

on examination of the newborn

106
Q

What type of condition is hypospadias?

A

congenital

107
Q

What is the management if hypospadias?

A

mild cases may not require treatment
surgery is usually peformed after 3-4 months of age
correct the position of the meatus and straighten the penis

108
Q

What are the complications of hypospadias?

A

difficulty directing urination
cosmetic and pscyhological concerns
sexual dysfunction

109
Q

What is a hydrocele?

A

A collection of fluid within the tunica vaginalis that surrounds the testes.

110
Q

What is the tunica vaginalis?

A

A sealed pouch of membrane that surrounds the testes

111
Q

What is the tunica vaginalis originally part of?

A

peritoneal membrane

112
Q

What is a simple hydrocele and who are they common in?

A

common in newborn males. occur where fluid is trapped in the tunica vaginalis. usually this fluid gets reabsorbed over time

113
Q

what is a communicating hydrocele?

A

where the tunica vaginalis around the testicle is connected with the peritoneal cavity via a pathway called the processus vaginalis. This allows fluid to travel from the peritoneal cavity into the hydrocele, allowing the hydrocele to fluctuate in size

114
Q

What is a hydrocele like on examination?

A

soft, smooth, non-tender swelling in front of and below the testicle. They transilluminate with light with a pen torch

115
Q

What are the differential diagnosis for a scrotal or inguinal swelling in a neonate?

A

Hydrocele
partially descended testes
Inguinal hernia
Testicular torsion
Haematoma
Tumours (rare)

116
Q

What is a useful investigation for a hydrocele to rule out other causes?

A

Ultrasound

117
Q

How long does it take for a simple hydrocele to resolve?

A

within 2 years

118
Q

How is a communicating hydrocele managed?

A

surgical operation to remove or ligate the connection between the peritoneal cavity and the hydrocele (the processus vaginalis)

Paediatric rotation (14 decks)

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