Paediatrics Renal and Urology Flashcards
1
Q
What is a urinary tract infection?
A
Infection anywhere in urethra, bladder, ureters and kidneys
2
Q
What is acute pyelonephritis?
A
Infection affects the tissue of the kidney leading to scarring and reduction in function
3
Q
What is cystitis?
A
Inflammation of the bladder can be the result of a bladder infection
4
Q
What are the symptoms of a UTI in babies?
A
Fever (especially in young children)
Lethargy
Irritability
Vomiting
Poor feeding
Urinary frequency
5
Q
What are the signs and symptoms in older children?
A
Fever
Abdo pain (suprapubic)
Vomiting
Dysuria (painful urination)
Urinary frequency
Incontinence
6
Q
How is a diagnosis of acute pyelonephritis made?
A
Temp greater than 38 degrees
Loin pain / tenderness
7
Q
How to take a urine sample from an infant?
A
Needs to be clean catch - parent sat with infant without nappy and waiting to watch the sample
8
Q
What may show on a urine dipstick for UTI?
A
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)
9
Q
What to do if nitrites / leukocytes are positive on dipstick?
A
Urine sent to microbiology lab for cultures and sensitivities
10
Q
What is the management for UTI in children under 3 months?
A
IV abx (e.g. ceftriaxone)
Full septic screen (blood cultures, bloods, lactate)
Lumbar puncture should be considered
11
Q
What is the management of UTI in children over 3 months?
A
Oral abx if they are otherwise well (if septic or pyelonephritis then inpatient treatment with IV abx)
12
Q
What are typical abx choices in UTI in children?
A
Trimethoprim
Nitrofurantoin
Cefalexin
Amoxicillin
13
Q
When should abdominal ultrasound scans be used to investigate UTIs?
A
- 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
14
Q
When should a DMSA (Dimercaptosuccinic Acid) be used for UTI?
How is it performed?
A
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)
15
Q
What is vesico-ureteric reflux (VUR)?
A
Urine flow from bladder into the ureters predisposing patients to developing upper urinary tract infections
16
Q
How is vesico-ureteric reflux diagnosed?
A
Micturating cystourethrogram (MCUG)
17
Q
What is the management of vesico-ureteric reflux?
A
- Avoid constipation
- Avoid an excessively full bladder
- Prophylactic abx
- Surgical input from paediatric urology
18
Q
What is a micturating cystourethrogram (MCUG) used for?
A
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
19
Q
How is an MCUG performed?
A
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
20
Q
What is vulvovaginitis?
A
Inflammation and irritation of the vulva and vagina commonly affects girls between 3 and 10 years (due to thin skin and mucosa)
21
Q
What can exacerbate vulvovaginitis?
A
Wet nappies
Use of soaps
Tight clothing
Poor toilet hygiene
Constipation
Threadworms
Pressure e.g. horse riding
Heavily chlorinated pools
22
Q
Why does vulvovaginitis improve after puberty?
A
Oestrogen helps keep the skin and vaginal mucosa healthy
23
Q
How does vulvuvaginitis present?
A
Soreness
Itching
Erythema around the labia
Vaginal discharge
Dysuria
Constipation
24
Q
What will a urine dipstick usually show for vulvovaginitis?
A
Leukocytes but no nitrites often causing a misdiagnosis as a urinary tract infection
25
Do girls develop thrush before puberty?
Not really
26
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
27
What is **nephrotic syndrome**?
**Basement membrane** in the **glomerulus** becomes highly permeable to **protein**
28
When is nephrotic syndrome most common?
Between ages of 2 and 5
29
How does **nephrotic syndrome** present?
**Frothy urine**
**Generalised oedema**
**Pallor**
30
What is the **classic triad** of **nephrotic syndrome**?
- Low serum albumin
- High urine protein (3+ on urine dipstick)
- Oedema
31
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)
32
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
33
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
34
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**
35
How is **minimal change disease** managed?
**Corticosteroids** (i.e. prednisolone)
36
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
37
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
38
What is given to **steroid resistant children**?
**ACE inhibitors**
**Immunosuppressants** e.g. cyclosporine, tacrolimus or rituximab
39
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**
40
What is nephritis?
**Inflammation** within the **nephrons** of the kidney
41
What does nephritis cause?
Reduction in kidney function
**Haematuria:** invisible / visible amounts of blood in urine
**Proteinuria** (less than in nephrotic)
42
What are the two main **causes of nephritis in children**?
**Post-streptococcal glomerulonephritis**
**IgA nephropathy** (Berger's disease)
43
When does post-streptococcal glomerulonephritis occur?
1-3 weeks after a **B-haemolytic streptococcus** infection such as **tonsillitis** caused by **Streptococcus pyogenes**
44
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**
45
What may be found on bloods for **post-strep glomerulonephritis**?
**Anti-streptolysin antibody titres**
46
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**
47
What happens in IgA nephropathy?
IgA **deposits** in the **nephrons** of the kidney **- renal biopsy** will show "**IgA deposits** and **glomerular mesangial proliferation**"
48
What is **IgA nephropathy** also known as? What is it related to?
**Berger's disease** related to **Henoch-Schonlein Purpura** (an IgA vasculitis)
49
Who does IgA nephropathy present in?
Teenagers or young adults
50
What is the **management of IgA nephropathy**?
**Supportive** of renal failure and **immunosuppressant medications** e.g. steroids / cyclophosphamide to slow progression of disease
51
What is **haemolytic uraemic syndrome**?
Thrombosis in **small blood vessels** triggered by a **bacterial toxin** called **shiga toxin**
52
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
53
What is the most common cause of **haemolytic uraemic syndrome**?
Toxin produced by **e.coli 0157** bacteria called **shiga toxin** (shigella also produces this)
54
What increases the risk of developing HUS?
Use of antibiotics and anti-motility medications such as **loperamide** to treat **gastroenteritis** caused by these pathogens
55
How long after onset of diarrhoea do symptoms of HUS present?
5 days
56
What are the **signs and symptoms** of HUS?
- **Reduced urine output**
- **Haematuria / dark brown urine**
- **Abdo pain**
- **Lethargy and irritability**
- **Confusion**
- **Oedema**
- **Hypertension**
- **Bruising**
57
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**
58
What is **enuresis**? What is bed wetting called? What is inability to control bladder function in the day called?
Involuntary urination
## Footnote
**Nocturnal enuresis**
**Diurnal enuresis**
59
When do children get control of urination?
Daytime = 2 years
Nighttime = 3-4 years
60
What is **primary nocturnal enuresis**?
Child has **never managed to be consistently dry at night**
61
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**
62
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**
63
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
64
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
65
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
66
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)
67
What is the **management of secondary nocturnal enuresis**?
Treating the underlying cause
68
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)
69
What are some **other causes** of **diurnal enuresis**?
Recurrent **UTI**s
**Psychosocial** problems
**Constipation**
70
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**
71
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**
72
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)
73
When does ARPKD present?
In neonates and usually picked up on **antenatal ultrasound scans**
74
Where is the mutation on ARPKD?
75
What does **ARPKD** cause?
**Cystic enlargement** of the **renal collecting ducts**
**Oligohydraminos**, **pulmonary hypoplasia** and **Potter syndrome**
**Congenital liver fibrosis**
76
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
77
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**
78
How are patients with ARPKD managed?
**Renal dialysis** within first few days of life
## Footnote
**End stage renal failure before reaching adulthood**
79
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**
80
What is the prognosis of ARPKD?
Poor - 1/3 die in neonatal period, 1/3 survive into adulthood
81
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)
82
How is MCDK diagnosed?
On **antenatal ultrasound scans**
83
What happens to the cystic kidney in MCDK?
Cystic kidney will **atrophy and disappear before 5 years of age**
84
What is the risk with having a single kidney?
Risk of:
**UTI**
**Hypertension**
**Chronic kidney disease** later in life
85
What is the managment of MCDK?
No treatment
**Followup renal ultrasound** scans to **monitor** the abnormal kidney
**Prophylactic abx** used occasionally to prevent UTIs
86
What is a **Wilms tumour**?
Tumour affecting the kidney in children, typically **under the age of 5 years**
87
How does a Wilms tumour present?
**Mass** in abdomen
Abdo **pain**
**Haematuria**
**Lethargy**
**Fever**
**Hypertension**
**Weight loss**
88
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**
89
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
90
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
91
What is a **posterior urethral valve**?
**Tissue** at **proximal** end of the **urethra** obstructs urine output (occurs in **newborn boys**)
92
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)
93
How do **posterior urethral valves** present?
**Difficulty urinating**
**Weak urinary stream**
Chronic **urinary retention**
**Palpable bladder**
Recurrent **urinary tract infections**
94
How may **posterior urethral valves** present **before birth**?
**Bilateral hydronephrosis**
**Oligohydraminos** (leading to pulmonary hypoplasia)
95
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**
96
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 **cy****toscopy**
97
What structure do the **testes** migrate down through?
**Inguinal canal** and into **scrotum** (normally reached here prior to birth - 5% don't)
98
What are undescended testes also known as?
**Cyrptorchidism**
99
What are the **risk associated with undescended testes**?
Testicular **torsion**
**Infertility**
Testicular **cancer**
100
What are the risk factors of **undescended testes**?
**FH** of undescended testes
**Low birth weight**
**Small for gestational age**
**Prematurity**
**Maternal smoking during pregnancy**
101
What is the **management of undescended testes**?
Younger than 6 months = watching and waiting
Older than 6 months = **orchidopexy** (surgical correction of undescended testes)
102
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**
103
What is **hypospadias**?
Condition where **urethral meatus** (opening of the urethra) is displaced posteriorly on the penis - possible further towards the **glans**
104
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**)
105
What condition is associated with **hypospadias**?
**Chordee** - head of the penis bends downwards
106
When is hypospadias diagnosed?
On **examination** of the newborn
107
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)
108
What are some **complications** of **hypospadias**?
**Difficulty directing urination**
**Cosmetic / psychological** concerns
**Sexual dysfunction**
109
What is a **hydrocoele**?
Collection of fluid within the **tunica vaginalis** which surrounds the testes
110
What is the **tunica vaginalis** originally a part of?
**Peritoneal membrane**
111
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**
112
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
113
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**
114
What are the differentials for a scrotal swelling in a neonate?
**Hydrocele**
Partially **descended testes**
**Inguinal hernia**
Testicular **torsion**
**Haematoma**
**Tumours** (rare)
115
How is a hydrocele diagnosed?
**Ultrasound** (helps to exclude other causes)
116
How is a **simple hydrocele managed?**
**Resolves in 2 years** without any negative effects - parents can be reassured and followed up routinely
117
How are **communicating hydroceles** managed?
**Surgical operation** to remove / ligate the connection (the **processus vaginalis**)
118
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
