Paediatric Renal/Urinary Flashcards
Causative organisms of UTI in children
e.coli - 80%
proteus
pseudomonas
predisposing factors to uti in children
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
what is acute pyelonephritis?
what is cystitis?
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
symptoms of uti in children
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
what features show an upper uti in children
temperature over 38
loin pain/tenderness
how would you check urine sample in a child?
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
for uti in kids what do you expect to see?
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.
how would you treat a uti in kids ?
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
what is the vesico-ureteric reflux?
how to diagnose?
how to manage?
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
tell me about the micturating cystourethrogram
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.
what is a dmsa scan - uti
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.
when investigating recurrent utis when do you do ultrasounds ? kids
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
what diff investigations can do you for recurrent utis in kids?
uss
dmsa scan
MCUG
features of lower uti in adults
dysuria
urinary frequency and urgency
cloudy/offensive smelling urine
lower abdo pain
fever: typically low grade in lower uti
malaise
in elderly: acute confusion
if i am to do a urine dipstick in a uti suspected pt (lower), what should i expect to see>
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.
who would you do a urine culture in ? (lower uti ix adults)
women over 65
reccurrent uti - 2 episodes in 6 months or 3 in 12.
pregnant women
men
visible or non-visible haematuria
how would you manage lower uti adults
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.
women gets regular utis after sex what to do ?
give post-coital abx prophylaxis
single dose trimethoprim or nitrofurantoin - 1st line
how would you treat lower uti in men
immediate abx 7 days trimethoprim/nitrofurantoin - 1st line unless prostatitis suspected>
urine culture before abx started.
how would you treat lower uti in catheterised pts? adults
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
how would you treat acute pyelonephritis
hospital admission
broad spectrum cephalosporin or quinolone (non-pregnant women) - 10-14 days
tell me about luts in adult men
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
how would you examine for luts ? adults
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
how would you manage bph sx luts in adults?
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
how would you manage nocturia? luts adults
advise about moderate fluid intake at night
furosemide 40mg in late afternoon poss
desmopressin - poss
how would you manage a predominently overactive bladdder? adults luts
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
what is bph
rf
sx
complications:
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
how would you assess for bph?
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.
how would you manage bph?
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
side effects of alpha-1antagonists
tamsulosin
alfuzosin
dizziness
postural hypotension
dry mouth
depression
side effect of 5 alpha reductase inhibitors
erectile dysfunction
reduced libido
ejaculation problems
gynaecomastia
clinical features of acute pyelonephritis
ix
mx
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
rf for acute pyelonephritis
female
structural urological abnormality
VUR
diabetes
causes of acute pyelonephritis
ecoli - gram negative anaerobic rod shaped
klebsiella pneumonia - g-negative anerobic rod
enterococcus
pseduomonas aeruginosa
staph saprophyticus
candidas albicans - fungal
if treatment of acute pyelonephritis in community what do you give?
cefalexin
coamox - if culture results available
trimethoprim - if culture available
ciprofloxacin - keep tendon damage and lower seizure threshold in mind.
what is chronic pyelonephritis?
recurrent episodes of infection.
scarring of renal parenchyma. = ckd.
can lead to end stage renal failure
do DMSA scan.
if an adult comes in with sepsis.
they need sepsis six
what is it?
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)
what is psa?
reasons for raised psa
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
what would you feel in a bph on dre?
what would a cancerous prostate feel like?
benign prostate : smooth symmetrical and slightly soft with maintained central sulcus.
cancerous prostate?
firm/hard
asymmetrical
craggy
irregular
loss of central sulcus
explain TURP to me
comps of turp
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
days of abx for uti tx in adults
3 days - normal women
5-10 days - immunosuppressed women, abrnormal anatomy or impaired kidney funciton
7 days - men , pregannt, catheter
when do you avoid nitrofurantoin?
when do you avoid trimethoprim?
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.
can uti cause preterm delivery in pregnant woman?
yes
by what age should a child achieve day and night time continence?
3/4 yrs.
what is nocturnal enuresis?
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
how would you manage noctural enuresis?
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
causes of primary nocturnal enuresis?
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
whats the main thing to think about with secondary enuresis?
abuse and safeguarding
What are diurnal enuresis?
types of incontinence
other causes of diurnal enuresis?
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
how does an enuresis alarm?
alarm makes noise first sign of bed wetting.
what medications can you give pharmacologically for nocturnal enuresis?
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.
prerenal causes of aki
major causes : ischaemia or lack of blood flow
eg:
hypovolemia secondary to diarhoea/vomiting
renal artery stenosis
intrinsic cauases of aki
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
post renal causes of aki
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
risk factors of AKI
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
what are kidneys responsible for
fluid balance and maintaining homeostasis.
how can aki be detected
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.
what symptoms will you see in aki?
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
what markets in u+E for aki?
sodium
potassium
urea
creatinine
what ix to do for aki?
urinalysis
imagine - if no cause of deterioration - renal uss within 24 hrs of assessment
criteria of saying yes it is aki
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
what drugs are safe to continue in aki?
paracetamol
warfarin
statins
aspirin - at cardioprotective dose of 75 mg od
clopidogrel
beta blockers
what drugs should be stopped in aki because they might worsen renal function
nsaids - except aspirin at cardiac dose
aminoglycosides
acei
angiotension II receptor antagonists
diuretics
what drugs might need to be stopped in aki as increased toxicity risk but doesnt really worsen aki itself
metformin
lithium
digoxin
What is a vesicoureteric reflux?
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
pathophysiology of VUR
ureters displaced laterally , entering bladder in more perpendicular fasion than at an angle
shorted intramural course of ureter
vesicoureteric junction cant function properly
possible presentations of VUR
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
how would you investigate for vur
micturating cystourethrogram
dmsa scan - renal scarring
grading vur
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
What is haemolytic uraemic syndrome?
what triad is associated with it?
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)
Presentation of Haemolytic Uraemic Syndrome
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
Mx of HUS
Supportive treatment
- Hypovolaemia (IV fluids)
- Hypertension
- Severe anaemia and renal failure (blood transfusion and haemodialysis)
What is Phimosis, what are its causes?
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
Symptoms of Phimosis
Difficulty retracting foreskin
Painful urination
Ballooning of foreskin during urination
Recurrent infections and balanitis
How should Phimosis be ix and tx
urinalysis, swabs, clinical examination.
Treatment
- Expectant if under 2
- Topical steroids
- Circumcision or preputioplasty if severe or recurrent
- Good hygiene!
comps of phimosis
Recurrent Balanitis
Urinary retention
What is Hypospadias
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
What is hypospadias normally characterised by
Ventral urethral meatus
Hooded prepuce
Chordee (head of penis bends down - ventrally)
Urethral meatus may open more proximally (Can be subcoronal, midshaft or penoscrotal)
What is hypospadias sometimes associated with?
Cryptorchidism (undescended testes)
Inguinal hernia
mx of hypospadias
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
What is wilms tumour?
Wilms’ nephroblastoma, one of the most common childhood malignancies (typically presents under 5). Kidney tumour
What is wilms tumour associated with?
Beckwith-Wiedemann syndrome
WAGR syndrome (Wilms, Aniridia, Genitourinary malformations, mental Retardation)
hemihypertrophy
loss of function mutation on WT1 gene on C11
Features of wilms tumour
Child under 5 presenting with abdomen mass.
Painless haematuria
Flank pain
Unilateral
HTN
Lethargy, weight loss
20% metastasise to lung
How should a wilms tumour be ix and mx
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
What is Nephritic syndrome, what how does it presents and what are its most common causes in kids
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
