Paediatrics Renal and Urology Flashcards
What is a urinary tract infection?
Infection anywhere in urethra, bladder, ureters and kidneys
What is acute pyelonephritis?
Infection affects the tissue of the kidney leading to scarring and reduction in function
What is cystitis?
Inflammation of the bladder can be the result of a bladder infection
What are the symptoms of a UTI in babies?
Fever (especially in young children)
Lethargy
Irritability
Vomiting
Poor feeding
Urinary frequency
What are the signs and symptoms in older children?
Fever
Abdo pain (suprapubic)
Vomiting
Dysuria (painful urination)
Urinary frequency
Incontinence
How is a diagnosis of acute pyelonephritis made?
Temp greater than 38 degrees
Loin pain / tenderness
How to take a urine sample from an infant?
Needs to be clean catch - parent sat with infant without nappy and waiting to watch the sample
What may show on a urine dipstick for UTI?
Nitrites - gram neg bacteria (e.g. E.Coli) break down nitrates into nitrites (better indication of infection than leukocytes)
Leukocytes - white blood cells - urine dipstick tests for leukocyte esterase a product of leukocytes (need clinical evidence of UTI if only these raised)
What to do if nitrites / leukocytes are positive on dipstick?
Urine sent to microbiology lab for cultures and sensitivities
What is the management for UTI in children under 3 months?
IV abx (e.g. ceftriaxone)
Full septic screen (blood cultures, bloods, lactate)
Lumbar puncture should be considered
What is the management of UTI in children over 3 months?
Oral abx if they are otherwise well (if septic or pyelonephritis then inpatient treatment with IV abx)
What are typical abx choices in UTI in children?
Trimethoprim
Nitrofurantoin
Cefalexin
Amoxicillin
When should abdominal ultrasound scans be used to investigate UTIs?
- All children under 6 months with UTI (scanned within 6 weeks or during illness if recurrent / atypical)
- Children with recurrent UTIs have ultrasound within 6 weeks
- Children with atypical UTIs have ultrasound during illness
When should a DMSA (Dimercaptosuccinic Acid) be used for UTI?
How is it performed?
4-6 months after illness to assess for damage from recurrent or atypical UTIs
Injecting radioactive material (DMSA) and using gamma camera to assess how well the material is taken up by the kidneys (if not taken up = scarring)
What is vesico-ureteric reflux (VUR)?
Urine flow from bladder into the ureters predisposing patients to developing upper urinary tract infections
How is vesico-ureteric reflux diagnosed?
Micturating cystourethrogram (MCUG)
What is the management of vesico-ureteric reflux?
- Avoid constipation
- Avoid an excessively full bladder
- Prophylactic abx
- Surgical input from paediatric urology
What is a micturating cystourethrogram (MCUG) used for?
Investigate atypical / recurrent UTIs in children under 6 months for diagnosing vesico-ureteric reflux
Used in FH of VUR
Dilatation of ureter on ultrasound
Poor urinary flow
How is an MCUG performed?
Catheterising child and injecting contrast into the bladder and taking a series of xray films to determine whether the contrast is refluxing
Children are given prophylactic abx for 3 days around time of investigation
What is vulvovaginitis?
Inflammation and irritation of the vulva and vagina commonly affects girls between 3 and 10 years (due to thin skin and mucosa)
What can exacerbate vulvovaginitis?
Wet nappies
Use of soaps
Tight clothing
Poor toilet hygiene
Constipation
Threadworms
Pressure e.g. horse riding
Heavily chlorinated pools
Why does vulvovaginitis improve after puberty?
Oestrogen helps keep the skin and vaginal mucosa healthy
How does vulvuvaginitis present?
Soreness
Itching
Erythema around the labia
Vaginal discharge
Dysuria
Constipation
What will a urine dipstick usually show for vulvovaginitis?
Leukocytes but no nitrites often causing a misdiagnosis as a urinary tract infection
Do girls develop thrush before puberty?
Not really
What is the management of vulvovaginitis?
- Avoid washing with soaps
- Avoid perfumed products
- Good toilet hygiene (wipe from front to back)
- Keep area dry
- Emollients e.g. sudacrem soothes area
- Loose cotton clothing
- Treating constipation / worms where applicable
- Avoid activities which exacerbate problem
What is nephrotic syndrome?
Basement membrane in the glomerulus becomes highly permeable to protein
When is nephrotic syndrome most common?
Between ages of 2 and 5
How does nephrotic syndrome present?
Frothy urine
Generalised oedema
Pallor
What is the classic triad of nephrotic syndrome?
- Low serum albumin
- High urine protein (3+ on urine dipstick)
- Oedema
What three other features may occur in patients with nephrotic syndrome?
- Deranged lipid profile with high levels of cholesterol, triglycerides and low density lipoproteins
- High blood pressure
- Hyper-coagulability (increase in blood clots)
What is the most common cause of nephrotic syndrome in children?
Minimal change disease (over 90% of cases in children under 10) - here nephrotic syndrome occurs in isolation without any clear underlying pathology
What can nephrotic syndrome occur secondary to?
Intrinsic kidney disease
- Focal segmental glomerulosclerosis
- Membranoproliferative glomerulonephritis
Systemic illness
- Henoch schonlein purpura (HSP)
- Diabetes
- Infection e.g. HIV, hepatitis and malaria
How to diagnose minimal change disease?
Renal biopsy and standard microscopy will not usually detect abnormalities
Urinalysis shows small molecular weight proteins and hyaline casts
How is minimal change disease managed?
Corticosteroids (i.e. prednisolone)
What is the general management of nephrotic syndrome?
- High dose steroids (prednisolone)
- Low salt diet
- Diuretics for oedema
- Albumin infusions (for severe hypoalbuminaemia)
- Antibiotic prophylaxis in severe cases
How long are steroid given for minimal change?
What is the typical response?
High dose steroids given for 4 weeks and weaned over next 8
Steroid sensitive children = respond (80% of these will relapse)
Steroid dependant = struggle to wean
Steroid resistant = do not respond to steroids
What is given to steroid resistant children?
ACE inhibitors
Immunosuppressants e.g. cyclosporine, tacrolimus or rituximab
What are some complications of nephrotic syndrome?
Hypovolaemia (as fluid is lost to the interstitial space)
Thrombosis (proteins which normally prevent blood clotting are lost in the kidneys - liver responds to low albumin by producing pro-thrombotic proteins)
Infection (kidneys leak immunoglobulins - exacerbated by steroid use)
Acute / chronic renal failure
Relapse
What is nephritis?
Inflammation within the nephrons of the kidney
What does nephritis cause?
Reduction in kidney function
Haematuria: invisible / visible amounts of blood in urine
Proteinuria (less than in nephrotic)
What are the two main causes of nephritis in children?
Post-streptococcal glomerulonephritis
IgA nephropathy (Berger’s disease)
When does post-streptococcal glomerulonephritis occur?
1-3 weeks after a B-haemolytic streptococcus infection such as tonsillitis caused by Streptococcus pyogenes
Why does inflammation occur in post-strep glomerulonephritis?
Immune complexes made up of streptococcal antigens, antibodies and complement proteins get stuck in the glomeruli causing acute kidney injury
What may be found on bloods for post-strep glomerulonephritis?
Anti-streptolysin antibody titres
What is the management of post-strep glomerulonephritis?
Supportive - 80% of patients make full recovery
May need: antihypertensive medications and diuretics if they develop hypertension and oedema
What happens in IgA nephropathy?
IgA deposits in the nephrons of the kidney - renal biopsy will show “IgA deposits and glomerular mesangial proliferation”
What is IgA nephropathy also known as? What is it related to?
Berger’s disease related to Henoch-Schonlein Purpura (an IgA vasculitis)
Who does IgA nephropathy present in?
Teenagers or young adults
What is the management of IgA nephropathy?
Supportive of renal failure and immunosuppressant medications e.g. steroids / cyclophosphamide to slow progression of disease
What is haemolytic uraemic syndrome?
Thrombosis in small blood vessels triggered by a bacterial toxin called shiga toxin
What is the classic triad in haemolytic uraemic syndrome?
- Haemolytic anaemia: anaemia caused by RBCs being destroyed
- Acute kidney injury: failure of kidney to excrete waste products
- Thrombocytopenia: low platelet count
What is the most common cause of haemolytic uraemic syndrome?
Toxin produced by e.coli 0157 bacteria called shiga toxin (shigella also produces this)
What increases the risk of developing HUS?
Use of antibiotics and anti-motility medications such as loperamide to treat gastroenteritis caused by these pathogens
How long after onset of diarrhoea do symptoms of HUS present?
5 days
What are the signs and symptoms of HUS?
- Reduced urine output
- Haematuria / dark brown urine
- Abdo pain
- Lethargy and irritability
- Confusion
- Oedema
- Hypertension
- Bruising
What is the management of HUS?
Medical emergency with 10% mortality
Supportive (condition is self-limiting)
Urgent referral to paediatric renal unit for renal dialysis
Antihypertensives
Maintenance of fluid balance
Blood transfusions if required
70-80% of patients make a full recovery
What is enuresis? What is bed wetting called? What is inability to control bladder function in the day called?
Involuntary urination
Nocturnal enuresis
Diurnal enuresis
When do children get control of urination?
Daytime = 2 years
Nighttime = 3-4 years
What is primary nocturnal enuresis?
Child has never managed to be consistently dry at night
If the child is younger than 5 what is the cause of primary nocturnal enuresis?
Variation on normal development (often FH on delayed dry nights) - reassurance is important here
What are the other causes of primary nocturnal enuresis?
Overactive bladder (requent smll volume urination prevents development of bladder capacity)
Fluid intake before bedtime (fizzy drinks, juice and caffeine which can have diuretic effect)
Failure to wake during particularly deep sleep and underdeveloped bladder signals
Psychological distress e.g. low self esteem, stress
Secondary causes e.g. chronic constipation, UTI, learning disability or cerebral palsy
How to investigate primary nocturnal enuresis?
Helpful to keep a 2 week diary of toileting, fluid intake and bedwetting episodes - identiry fluid intake before bed
What is the management of primary nocturnal enuresis?
- Reassure patients under 5 that its likely to resolve
- Reduce fluid in evening, pass urine before bed, ensure easy access to a toilet
- Avoid blame / punishment (use positive reinforcement)
- Treat any constipation
- Enuresis alarms
- Pharmacological treatments
What is secondary enuresis?
Child begins wetting the bed when they have been dry for at least 6 months - more indicateive of an underlying illness
What are some causes of secondary nocturnal enuresis?
Urinary tract infection
Constipation
Type 1 diabetes
New psychosocial problems (e.g. stress in family / school life)
Maltretment (think about abuse / safeguarding e.g. deliberate bedwetting / punishment for bedwetting)
What is the management of secondary nocturnal enuresis?
Treating the underlying cause
What are the two types of diurnal enuresis?
- Urge incontinence (overactive bladder which gives little warning before emptying)
- Stress incontinece (leakage of urine during exertion, coughing or laughing)
What are some other causes of diurnal enuresis?
Recurrent UTIs
Psychosocial problems
Constipation
What is an enuresis alarm?
Device which makes a noise at first sign of betwetting, waking the child and stopping them from urinating
Requires lots of commitment and used for at least 3 months
Sometimes its helpful and others it adds to the burden and frustration
What is the pharmacological treatment for nocturnal enuresis?
Desmopressin (analogue of vasopressin - aka ADH to reduce volume of urine produced by kidneys - taken at bedtime
Oxybutinin is an anticholinergic which reduces contractility of the bladder (helps with overactive bladder)
Imipramine is a TCA - not sure how it works but may relax bladder and lighten sleep
What are the two type of polycystic kidney disease? Which presents later in life?
Autosomal recessive polycystic kidney disease (ARPKD)
Autosomal dominant (presents in adults)
When does ARPKD present?
In neonates and usually picked up on antenatal ultrasound scans
Where is the mutation on ARPKD?
What does ARPKD cause?
Cystic enlargement of the renal collecting ducts
Oligohydraminos, pulmonary hypoplasia and Potter syndrome
Congenital liver fibrosis
What is the result of oligohydraminos?
Potter syndrome = dysmorphic features e.g. underdeveloped ear cartilage, low set ears, flat nasal bridge, abnormalities of the skeleton
Pulmonary hypoplasia = respiratory failure shortly after birth
What is the result of the large cystic kidneys?
They take up so much space in the abdomen its hard for neonate to breath adequatley
How are patients with ARPKD managed?
Renal dialysis within first few days of life
End stage renal failure before reaching adulthood
What are the complications of ARPKD?
Liver failure due to fibrosis
Portal hypertension leading to oesophageal varices
Progressive renal failure
Hypertension due to renal failure
Chronic lung disease
What is the prognosis of ARPKD?
Poor - 1/3 die in neonatal period, 1/3 survive into adulthood
What is multicystic dysplastic kidney (MCDK)?
Separate to PKD where one of the kidneys is made up of many cysts and the other is normal (rarely it can be bilateral which causes death in infancy)
How is MCDK diagnosed?
On antenatal ultrasound scans
What happens to the cystic kidney in MCDK?
Cystic kidney will atrophy and disappear before 5 years of age
What is the risk with having a single kidney?
Risk of:
UTI
Hypertension
Chronic kidney disease later in life
What is the managment of MCDK?
No treatment
Followup renal ultrasound scans to monitor the abnormal kidney
Prophylactic abx used occasionally to prevent UTIs
What is a Wilms tumour?
Tumour affecting the kidney in children, typically under the age of 5 years
How does a Wilms tumour present?
Mass in abdomen
Abdo pain
Haematuria
Lethargy
Fever
Hypertension
Weight loss
How is a Wilms tumour diagnosed?
Ultrasound of the abdomen (initially)
CT / MRI to stage the tumour
Biopsy to identify the histology for definitive diagnosis
What is the management of a Wilms tumour?
Surgical excision of the tumour along with the affected kidney (nephrectomy)
Adjuvant treatment refers to treatment which is given after the initial management with surgery:
- Adjuvant chemo
- Adjuvant radio
What is the prognosis of a Wilms tumour?
Early stage tumours with a favourable histology hold a good chance of cure (90%) - if metastasised then poorer prognosis
What is a posterior urethral valve?
Tissue at proximal end of the urethra obstructs urine output (occurs in newborn boys)
What is a result of the obstruction in posterior urethral valve?
Back pressure on the bladder and ureters leading to hydronephrosis (the stagnant urine causes increased UTIs)
How do posterior urethral valves present?
Difficulty urinating
Weak urinary stream
Chronic urinary retention
Palpable bladder
Recurrent urinary tract infections
How may posterior urethral valves present before birth?
Bilateral hydronephrosis
Oligohydraminos (leading to pulmonary hypoplasia)
What are the investigations for posterior urethral valves in younger boys?
Abdo ultrasound (enlarged, thickened bladder and bilateral hydronephrosis)
Micturating cystourethrogram (MCUG) shows location of extra urethral tissue and refluc of urine into bladder
Cytoscopy involves using a camera inserted into the urethra to get a view of the extra tissue - can ablate or remove the extra tissue
What is the management of posterior urethral valves?
Mild = observed and monitored (temporary urinary catheter can be used whilst awaiting definitive management)
Definitive - ablation or removal of extra tissue usually during cytoscopy
What structure do the testes migrate down through?
Inguinal canal and into scrotum (normally reached here prior to birth - 5% don’t)
What are undescended testes also known as?
Cyrptorchidism
What are the risk associated with undescended testes?
Testicular torsion
Infertility
Testicular cancer
What are the risk factors of undescended testes?
FH of undescended testes
Low birth weight
Small for gestational age
Prematurity
Maternal smoking during pregnancy
What is the management of undescended testes?
Younger than 6 months = watching and waiting
Older than 6 months = orchidopexy (surgical correction of undescended testes)
What are retactile testicles?
In boys who have not yet reached puberty it is notmal for the testes to move out of the scrotum and into the inguinal canal when its cold or cremasteric reflex is activated - usually resolves when going through puberty
What is hypospadias?
Condition where urethral meatus (opening of the urethra) is displaced posteriorly on the penis - possible further towards the glans
What is epispadias?
Meatus is displaced anteriorly on the top of the penis (usually foreskin is abnormally formed to match the position of the meatus)
What condition is associated with hypospadias?
Chordee - head of the penis bends downwards
When is hypospadias diagnosed?
On examination of the newborn
What is the management of hypospadias?
Mild = no treatment
Surgery is performed after 3-4 months of age (correct position of meatus and straighten penis)
What are some complications of hypospadias?
Difficulty directing urination
Cosmetic / psychological concerns
Sexual dysfunction
What is a hydrocoele?
Collection of fluid within the tunica vaginalis which surrounds the testes
What is the tunica vaginalis originally a part of?
Peritoneal membrane
What is a simple hydrocoele?
Common in newborn males - fluid is trapped in the tunica vaginalis - this fluid is reabsorbed over time and hydrocoele disappears
What is a communicating hydrocoele?
Tunica vaginalis is connected with the peritoneal cavity via a pathway called the processus vaginalis - allowing fluid to travel from peritoneal cavity into hydrocoele
How does a hydrocoele appear on examination?
Soft, smooth, non-tender swelling around one of the testes - in front of and below the testicle
Simple hydrocoele = one size
Communicating hydrocoele = fluctuate in size
Transilluminate with light
What are the differentials for a scrotal swelling in a neonate?
Hydrocele
Partially descended testes
Inguinal hernia
Testicular torsion
Haematoma
Tumours (rare)
How is a hydrocele diagnosed?
Ultrasound (helps to exclude other causes)
How is a simple hydrocele managed?
Resolves in 2 years without any negative effects - parents can be reassured and followed up routinely
How are communicating hydroceles managed?
Surgical operation to remove / ligate the connection (the processus vaginalis)
What is the fluid replacement regime over 24 hrs for children?
First 10kg = 100 ml / kg
Second 10kg = 50 ml / kg
Subsequent 10kg = 20ml / kg
