Paediatric Renal/Urinary

Question 1

Causative organisms of UTI in children

Answer 1

e.coli - 80%
proteus
pseudomonas

Question 2

predisposing factors to uti in children

Answer 2

incomplete bladder emptying:
- infrequent voiding
-hurried micturition
-obstruction by full rectum due to constipation
-neuropathic bladder

vesicoureteric reflux - developmental anomaly seen in 35% of kids with uti

poor hygiene: not wiping front to back in girls

Question 3

what is acute pyelonephritis?

what is cystitis?

Answer 3

pyelo - infection affecting tissue of kidney. can lead to scarring in tissue and reduction in kidney function.

mc caused by ascending infection - ecoli from lower urinary tract. can be due to blood stream spread of infection eg sepsis.

cystitis - inflammation of bladder can be due to bladder infection

Question 4

symptoms of uti in children

Answer 4

fever .

babies - non specific: fever, lethargy,irritable,vomiting,poor feeding , urinary frequency.

older infants/childre: fever, abdo pain (suprapubic) , vomiting, dysuria, urinary frequency, incontinence
older children: dysuria, frequency, haematuria

Question 5

what features show an upper uti in children

Answer 5

temperature over 38

loin pain/tenderness

Question 6

how would you check urine sample in a child?

Answer 6

if any sx/signs suggestive of uti

unexplained fever or higher - test urine after 24 hours at least

collection method:
clean catch
if not urine collection pads

cotton wool balls, gauze and sanitary towels not suitable!!

suprapubic aspiration - only if non invasive method not possible

send msu to microbiology to be cultured and have sensitivity testing

Question 7

for uti in kids what do you expect to see?

Answer 7

nitrites - gram negative bac like eoli break down nitrates into nitrites.

leukocytes - theyre wbc. normally small amount but in infection itll be higher.

nitrites better check than leukocytes. if both there then treat for uti. if only nitrites treat as uti. if only leuko dont treat as uti unless clear evidence.

Question 8

how would you treat a uti in kids ?

Answer 8

all kids under 3 months with fever: iv abx - ceftriaxone.
FULL SEPTIC SCREEN, BLOOD CULTURES, BLOOD AND LACTATE. LP possible.

over 3 months:
oral abx consider. cephalosporin or co-amoxiclav for 7-10 days. (if think upper uti)
if features of sepsis or pyelonephritis, inpatient tx with iv abx.

over 3 months with lower: oral abx 3 days - trimethoprim, cephalo, amox, nitro. bring kid back if still unwell after 24-48 hrs.

typical abx:
trimethoprim
nitrofurantoin
cefalexin
amoxicillin

Question 9

what is the vesico-ureteric reflux?

how to diagnose?

how to manage?

Answer 9

urine flow from black back into the ureters.

get upper utis and renal scarring.

diagnosis: micturating cystourethrogram (MCUG)

mx:
avoid constipation
avoid excessively full bladder
prophylactic abx
surgical input from paeds urology

Question 10

tell me about the micturating cystourethrogram

Answer 10

to investigate atypical or recurrent uti in kids under 6 months.

fhx of VUR, dilatation of ureter on uss or poor urinary flow.

catheterise child
inject contrast into bladder
take xray films to see if contrast refluxes into ureter.

give prophylactic abx for 3 days around this time to child.

Question 11

what is a dmsa scan - uti

Answer 11

dimercaptosuccinic acid scan.

used 4-6 months after illness see damage from recurrent or atypical utis.

inject DMSA using gamma camerra - see how well kidney takes it up.

where patches of kidney not taken up indicates scarring.

Question 12

when investigating recurrent utis when do you do ultrasounds ? kids

Answer 12

all kids under 6 months with 1st uti - abdo uss within 6 weeks, or during ilness if recurrent or atypical

children with recurrent - abdo uss within 6 weeks
children with atypical should have abdo uss during illness

Question 13

what diff investigations can do you for recurrent utis in kids?

Answer 13

uss
dmsa scan
MCUG

Question 14

features of lower uti in adults

Answer 14

dysuria
urinary frequency and urgency
cloudy/offensive smelling urine
lower abdo pain
fever: typically low grade in lower uti
malaise

in elderly: acute confusion

Question 15

if i am to do a urine dipstick in a uti suspected pt (lower), what should i expect to see>

Answer 15

can use to aid diagnosis in women under 65 with no rf for complicated uti

positive for nitrite or leukocyte and rbc - uti likely

negative for nitrite and positive for leukocyte - uti equally likely to be something else too

negative for all - uti not likley

urine dip NOT USED FOR UTI DIAGNOSIS FOR OVER 65 WOMEN, MEN AND CATHETERISED PTS.

Question 16

who would you do a urine culture in ? (lower uti ix adults)

Answer 16

women over 65
reccurrent uti - 2 episodes in 6 months or 3 in 12.

pregnant women
men
visible or non-visible haematuria

Question 17

how would you manage lower uti adults

Answer 17

non pregnant women:
trimethoprim or nitrofurantoin for 3 days.
send urine culture if : over 65 , visible/nonvisible haematuria

pregnant:
symptomatic:
- urine culture
abx for 7 days
1st line: nitrofurantoin (avoid near term)
second line: amox or cefalexin
trimethoprim teratogenic in 1st trimester - avoid during pregnancy

asx bacteriuria in pregnant:
urine culture - routine 1st antenatal visit.
immediate abx nitrofurantoin - avoid near term, amox or cefalexin. 7 days.

treat to avoid risk of acute pyelonephritis.
send further urine culture after tx - prove cured.

Question 18

women gets regular utis after sex what to do ?

Answer 18

give post-coital abx prophylaxis

single dose trimethoprim or nitrofurantoin - 1st line

Question 19

how would you treat lower uti in men

Answer 19

immediate abx 7 days trimethoprim/nitrofurantoin - 1st line unless prostatitis suspected>

urine culture before abx started.

Question 20

how would you treat lower uti in catheterised pts? adults

Answer 20

dont treat asx bacteria in catheterised pts

if sx:
7 days rather than 3
consideer removing or changing catheter asap if been in place more than 7 days

Question 21

how would you treat acute pyelonephritis

Answer 21

hospital admission

broad spectrum cephalosporin or quinolone (non-pregnant women) - 10-14 days

Question 22

tell me about luts in adult men

Answer 22

very common
most men over 50.
usually secondary to bph. can be due to prostate cancer.

voiding - hesitancy, poor stream,straining, incomplete empty, terminal dribble
storage - urgency frequency nocturia, incontinence
post-micturition - post-micturition dribble. sensation of incomplete empty

Question 23

how would you examine for luts ? adults

Answer 23

urinalysis : exclude infection, check for haematuria

dre: size and consistency of prostate

psa

get pt to :
urinary frequency volume chart
IPSS: assess impact on pts life. mild mod, severe

Question 24

how would you manage bph sx luts in adults?

Answer 24

voiding:
pelvic floor muscle training, bladder training, prudent fluid intake

if moderate/severe: alpha blocker - tamsulosin

if prostate englarged and pt high risk of progression: 5-alpha reductase inhibitor

if pt enlarged prostate and moderate/severe sx: alpha + 5-alpha reduc inhib

if mixed of void and storage and not respon to alpha blocker then a antimuscarinic (anticholinergic) can be added

Question 25

how would you manage nocturia? luts adults

Answer 25

advise about moderate fluid intake at night furosemide 40mg in late afternoon poss desmopressin - poss

Question 26

how would you manage a predominently overactive bladdder? adults luts

Answer 26

moderate fluid intake bladder retaraining antimuscarinic if sx persist. oxybutynin - immediate release and so is tolterodine darifenacin - once daily prep mirabegron - if 1st lines fail

Question 27

what is bph rf sx complications:

Answer 27

common in older men rf: age - 50% of 50 yr old will have evidence of it and 30% symptoms 80% of 80 yr old have evidence of it black>white>asian luts symptoms voiding (obstructive) storage (irritative) post micturition dribble complications: uti retention obstructive uropathy

Question 28

how would you assess for bph?

Answer 28

dipstick urine u+e psa: if obstructive sx urinary frequency volume chart - at least 3 days ipss: 20-35 severely sx. 8-19 mod 0-7 mild. - classifies severity of lluts and QoL.

Question 29

how would you manage bph?

Answer 29

alpha-1 antagonists - tamsuloson, alfuzosin - decrease smooth muscle tone of prostate and baldder. - 1st line - if mod to severe voiding sx ipss over 8 5 alpha reductase inhibitors - finasteride block testosterone to dihydrotestosterone conversion - which usually induces bph. give if englarged prostate . reduces prostate vol and slows disease progression. sx may not improve for 6 months. can decrease psa by upto 50% combine above 2. if mixture of storage and voiding after tx with alpha blocker alone add antimuscaranic like tolterodine or darifenacin. surgery: transurethral resection of prostate (TURP) OTHERS: transurethral electrovaporisation of prostate (TEVAP/TUVP) holmium laser enucleation of prostate (HoLEP) open prostatectomy - via abdo or perineal incision

Question 30

side effects of alpha-1antagonists tamsulosin alfuzosin

Answer 30

dizziness postural hypotension dry mouth depression

Question 31

side effect of 5 alpha reductase inhibitors

Answer 31

erectile dysfunction reduced libido ejaculation problems gynaecomastia

Question 32

clinical features of acute pyelonephritis ix mx

Answer 32

fevers rigors, loin pain n+v sx of cystitis: dysuria,urinary frequency haematuria loss of apetite renal angle tenderness on exam ix: MSU before starting abx - causatie organism. urine dip: nitrites,leukocytes,blood. bloods: wbc and raised crp. uss or ct. mx: hospital admissio abx : broad spect cephalosporin or quinolone (nonpregnant women) for 7-10 days

Question 33

rf for acute pyelonephritis

Answer 33

female structural urological abnormality VUR diabetes

Question 34

causes of acute pyelonephritis

Answer 34

ecoli - gram negative anaerobic rod shaped klebsiella pneumonia - g-negative anerobic rod enterococcus pseduomonas aeruginosa staph saprophyticus candidas albicans - fungal

Question 36

if treatment of acute pyelonephritis in community what do you give?

Answer 36

cefalexin coamox - if culture results available trimethoprim - if culture available ciprofloxacin - keep tendon damage and lower seizure threshold in mind.

Question 37

what is chronic pyelonephritis?

Answer 37

recurrent episodes of infection. scarring of renal parenchyma. = ckd. can lead to end stage renal failure do DMSA scan.

Question 38

if an adult comes in with sepsis. they need sepsis six what is it?

Answer 38

3 tests: blood lactate level, blood cultures and urine output 3 tx: - iv fluids -empirical broad spect iv abx - ox to maintain ox sats of 94-98% (88-92 in copd)

Question 39

what is psa? reasons for raised psa

Answer 39

prostate specific antigen unreliable high false positives and false negatives. common causes of raised psa: prostate cancer bph prostatitis uti vigourous exercise - cycling recent ejaculation/prostate stimulation

Question 40

what would you feel in a bph on dre? what would a cancerous prostate feel like?

Answer 40

benign prostate : smooth symmetrical and slightly soft with maintained central sulcus. cancerous prostate? firm/hard asymmetrical craggy irregular loss of central sulcus

Question 41

explain TURP to me comps of turp

Answer 41

remove part of prostate from inside urethra. resectoscope inserted into urethra and prostate tissue is removed using diathermy loop. so you can expansive space for urine to flow through improving sx. COMPS: - bleeding and infection and ED, incontinence - retrograde ejaculation - semen goes backwards and not produced from urethra - urethral strictures -failure to resolve sx

Question 42

days of abx for uti tx in adults

Answer 42

3 days - normal women 5-10 days - immunosuppressed women, abrnormal anatomy or impaired kidney funciton 7 days - men , pregannt, catheter

Question 43

when do you avoid nitrofurantoin? when do you avoid trimethoprim?

Answer 43

nitrofurantoin - 3rd trimester - risk of neonatal haemolysis trimeth - 1st trimestrer. folate antagnoist. neede din early pregnancy. can cause congenital malformations - neural tube defects like spina bifida.

Question 44

can uti cause preterm delivery in pregnant woman?

Answer 44

yes

Question 45

by what age should a child achieve day and night time continence?

Answer 45

3/4 yrs.

Question 46

what is nocturnal enuresis?

Answer 46

involuntary discharge of urine by day or night or both. in a child aged 5 yrs or older. can be primary - child never achieved continence can be secondary - child been dry for at least 6 months before

Question 47

how would you manage noctural enuresis?

Answer 47

look for underlying causes/triggerS: -constipation -dm -uti if recent onset general: - fluid intake -toilet patterns: encourage to empty bladder during day and before sleep - lifting and walking reward systems - star charts enuresis alarm - 1st line. sensor pads that sense wetness. high success rate. desmopressin: short term control - ie sleepovers - or if enuresis alarm inefffective/not acceptable to family

Question 48

causes of primary nocturnal enuresis?

Answer 48

overactive bladder - frequent small volume urination prevents development of bladder capacity. fluid intake - prior to bedtime, fizzy drinks ,juice and caffeine which diuretic effect failure to wake - particularly deep sleep and underdeveloped bladder signals psychological distress - ie low self esteem, too much pressure or stress at home/school secondary causes : chronic constipation, UTI, learning disability or cerebral palsy, T1DM

Question 49

whats the main thing to think about with secondary enuresis?

Answer 49

abuse and safeguarding

Question 50

What are diurnal enuresis? types of incontinence other causes of diurnal enuresis?

Answer 50

daytime incontinence. person dry at night but episodes of urinary incontinence during the day. more in girls. incontinence comes in 2 types: urge - overactive bladder little warning before empty stress - leakage of urine during physical exertion, coughing or laughing. other causes: recurrent utis psychosocial problems constipation

Question 51

how does an enuresis alarm?

Answer 51

alarm makes noise first sign of bed wetting.

Question 52

what medications can you give pharmacologically for nocturnal enuresis?

Answer 52

Desmopressin - analogue of vasopressin - reduces vol of urine produced by kidneys. take at bedtime. oxybutinin - anticholinergic - reduces contractility of the bladder. - help with overactive bladder causing urge incontinence. imipramine - TCA.

Question 53

prerenal causes of aki

Answer 53

major causes : ischaemia or lack of blood flow eg: hypovolemia secondary to diarhoea/vomiting renal artery stenosis

Question 54

intrinsic cauases of aki

Answer 54

damage to glomeruli, renal tubules, intersitium of kidneys. due to toxins or immune-mediated glomerulonephritis eg: glomerulonephritis ATN- acute tubular necrosis acute intersitial nephritis (AIN) rhabdomyolysis tumour lysis syndrome

Question 55

post renal causes of aki

Answer 55

after kidneys. obstruction to urine coming from urine cause back up affect normal renal function. eg: kidney stone in ureter or bladder bph - bilateral hydronephrosis secondary to acute urinary retention caused by bph external compression of ureter

Question 56

risk factors of AKI

Answer 56

ckd hf,liver disease,dm hx of aki nephrotoxic drugs: nsaids,aminoglycosides,acei, ARBs and diuretics within past week over 65 iodinated contrast agents within last week oliguria( urine output less than 0.5 ml/kg/hour) - neuro/cognitive impairement or disability - limited acess to fluids because reliance on carer

Question 57

what are kidneys responsible for

Answer 57

fluid balance and maintaining homeostasis.

Question 58

how can aki be detected

Answer 58

reduced urine output. oliguria - less than 0.5 ml/kg/hr fluid overload rise inm molecules that kidney normally excretes - maintains balance of. like potassium urea and creatinine.

Question 59

what symptoms will you see in aki?

Answer 59

some none some reduced urine output pulmonary and peripheral oedema arrhythmias - 2nd to potassium and acid-base balance changes features of uraemia - eg pericarditis or encephalopathy

Question 60

what markets in u+E for aki?

Answer 60

sodium potassium urea creatinine

Question 61

what ix to do for aki?

Answer 61

urinalysis imagine - if no cause of deterioration - renal uss within 24 hrs of assessment

Question 62

criteria of saying yes it is aki

Answer 62

RIFLE , AKIN KDIGO rise in serum creatinine of 26 micromol/litre or more within 48 hrs 50% or greater rise in serum creatinine known/presumed in last 7 days fall in urihne output to less than 0.5 ml/kg/hr for more than 6 hours in adults

Question 63

what drugs are safe to continue in aki?

Answer 63

paracetamol warfarin statins aspirin - at cardioprotective dose of 75 mg od clopidogrel beta blockers

Question 64

what drugs should be stopped in aki because they might worsen renal function

Answer 64

nsaids - except aspirin at cardiac dose aminoglycosides acei angiotension II receptor antagonists diuretics

Question 65

what drugs might need to be stopped in aki as increased toxicity risk but doesnt really worsen aki itself

Answer 65

metformin lithium digoxin

Question 66

What is a vesicoureteric reflux?

Answer 66

abnormal backflow of urine from bladder into ureter and kidney. common urinary tract abnormality in kids predisposes to uti 35% get renal scarring. ix for vur in kids after uti

Question 67

pathophysiology of VUR

Answer 67

ureters displaced laterally , entering bladder in more perpendicular fasion than at an angle shorted intramural course of ureter vesicoureteric junction cant function properly

Question 68

possible presentations of VUR

Answer 68

antenatal period: hydronephrosis on ultrasound reccurrent childhood uti reflux nephropathy: - chronic pyelonephritis secondary to vur commonest cause of chronic pyelonephritis renal scar might produce increased quanities of renin causing htn

Question 69

how would you investigate for vur

Answer 69

micturating cystourethrogram dmsa scan - renal scarring

Question 70

grading vur

Answer 70

1 - reflux into ureter, no dilatation 2 - reflux into renal pelvic on micturition, no dilatation 3 - mild/moderate dilatation of ureter, renal pelvis and calyces 4 - dilation of renal pelvis and calyces with moderate ureteral tortuosity 5 - gross dilatation of ureter, pelvis and calyses with ureteral tortuosity

Question 71

What is haemolytic uraemic syndrome? what triad is associated with it?

Answer 71

Thrombosis in the small vessels around the body, usually triggered by Shiga toxins, either from E coli 0157 or Shigella. Abx used to treat these also increase risk Usually follows a gastroenteritis bout and has the classic triad: - Microangiopathic haemolytic anaemia (destruction of RBC due to thromboses in small vessels causing shearing) - AKI - Thrombocytopenia (low platelets)

Question 72

Presentation of Haemolytic Uraemic Syndrome

Answer 72

Diarrhoea is first symptom, turns bloody in 3 days. One week after onset, HUS symptoms start - Fever - Abdo pain - Lethargy and pallor - Bruising - Haematuria - Jaundice - Confusion - Reduced urine output

Question 73

Mx of HUS

Answer 73

Supportive treatment - Hypovolaemia (IV fluids) - Hypertension - Severe anaemia and renal failure (blood transfusion and haemodialysis)

Question 74

What is Phimosis, what are its causes?

Answer 74

The inability for the foreskin to be retracted over the glans. Can be physiological or pathological (caused by scarring or inflammation) Physiological: Normal, 90% resolve by age 3. Pathological: Much less common, but caused by infection, scarring, trauma (forceful retraction), chronic inflammation/infections. Fibrosis of the preputial ring prevents retraction. Recurrent infection/inflammation may arise from poor hygiene

Question 75

Symptoms of Phimosis

Answer 75

Difficulty retracting foreskin Painful urination Ballooning of foreskin during urination Recurrent infections and balanitis

Question 76

How should Phimosis be ix and tx

Answer 76

urinalysis, swabs, clinical examination. Treatment - Expectant if under 2 - Topical steroids - Circumcision or preputioplasty if severe or recurrent - Good hygiene!

Question 77

comps of phimosis

Answer 77

Recurrent Balanitis Urinary retention

Question 78

What is Hypospadias

Answer 78

A condition where the Urethral meatus (opening) is placed on ventral (under) side of the penis, towards scrotum. Also epispadias, where the meatus is displaced to dorsal (top) side of the penis Significant risk factor: Family history

Question 79

What is hypospadias normally characterised by

Answer 79

Ventral urethral meatus Hooded prepuce Chordee (head of penis bends down - ventrally) Urethral meatus may open more proximally (Can be subcoronal, midshaft or penoscrotal)

Question 80

What is hypospadias sometimes associated with?

Answer 80

Cryptorchidism (undescended testes) Inguinal hernia

Question 81

mx of hypospadias

Answer 81

May not need treatment if very distal. Surgery normally after 4 months (usually 12 months of age). Essential child NOT circumcised before surgery, as foreskin can be used in procedure. Surgery aims to correct meatus position and straighten peni

Question 82

What is wilms tumour?

Answer 82

Wilms’ nephroblastoma, one of the most common childhood malignancies (typically presents under 5). Kidney tumour

Question 83

What is wilms tumour associated with?

Answer 83

Beckwith-Wiedemann syndrome WAGR syndrome (Wilms, Aniridia, Genitourinary malformations, mental Retardation) hemihypertrophy loss of function mutation on WT1 gene on C11

Question 84

Features of wilms tumour

Answer 84

Child under 5 presenting with abdomen mass. Painless haematuria Flank pain Unilateral HTN Lethargy, weight loss 20% metastasise to lung

Question 85

How should a wilms tumour be ix and mx

Answer 85

Unexplained enlarged abdo mass = arrange paediatric review within 48 hours USS to visualise kidneys, CT/MRI for staging, biopsy for definitive diagnosis Managed with nephrectomy of affected kidney Chemo and radio may be needed Prognosis good - 80% cure

Question 86

What is Nephritic syndrome, what how does it presents and what are its most common causes in kids

Answer 86

Inflammation of nephrons of kidneys. Presents with: - Haematuria - Oliguria (low urine) - Hypertension (Na+ retention) - Oedema Slight proteinuria BUT <3.5g of protein in 24hrs (Anymore = nephrotic syndrome) Most common causes of nephritis in kids are post-strep glomerulonephritis and IgA nephropathy