Paeds GU Flashcards
How would you define a UTI?
+ diagnostic numbers
Growth of bacteria in the urinary tract
10*5 organisms/ml grown on culture of appropriate sample
What are the common organisms that cause UTI in children?
Proteus
E coli
Pseudomonas
Klebsiella
What are predisposing factors for a UTI in children?
Incomplete bladder emptying
- Infrequent emptying, hurried micturition
- Obstruction by rectum due to constipation
Vesicoureteric reflux
Poor hygiene eg wiping back to front
How might a child present with an upper UTI?
Fever, septicaemic illness + meningitis in infancy General malaise Vomiting Loin / abdo pain in an older child Failure to thrive + jaundice in infancy
How might a child present with a lower UTI?
Dysuria Urinary frequency / urgency Incontinence Lower abdo pain Haematuria
How do you diagnose a UTI?
Urine sample
Urinalysis
10*5 organisms/ml grown on culture = diagnostic ting
How would you get a urine sample in a child?
MSU - clean catch
Suprapubic aspirate
Catheter
Bag sample / pad sample if need be
What would you look for in a child’s urine if you suspect a UTI?
Visual inspection - is it cloudy or dark or whatever Protein Nitrites Leucocyte esterase MC&S
What antibiotics would you give to acutely treat an upper UTI?
Ciprofloxacin or co-amoxiclav
What antibiotics would you give to acutely treat a lower UTI?
trimethoprim / nitrofurantoin / cephalosporin / amoxicillin - based on local guidelines + results of culture
As well as antibiotics, how would you manage a child with a UTI?
Pain relief
Fluids
Later - give scans to see if there’s any underlying abnormality
What methods of imaging would you do for a child with a UTI to see if there’s an underlying abnormality?
USS
Micturating cystourethrogram
DMSA (radionuclitide scan)
What would you be looking for on a renal USS in a child with UTI?
Obstruction
What would you be looking for on a micturating cystourethrogram in a child with a UTI?
Retrograde flow of urine from bladder into ureters
What would you be looking for on a DMSA scan in a child with a UTI?
Renal scarring
What are the complications of UTI in childhood?
Renal scarring leading to:
- Hypertension
- Impaired GFR (so CKD in the future ????)
What is a complication of UTI caused by proteus?
Phosphate renal stones - more in boys
What would UTI caused by pseudomonas indicate?
Structural abnormality
What are the atypical organisms that cause UTI?
Anything other than E coli - so pseudomonas, proteus, klebsiella
What are the indications for further investigation in a child with UTI?
Poor flow Bladder mass Raised CK Not responding to abx Atypical organism - not E coli
How would you routinely follow up a child who had a UTI?
Check BP annually
Proteinuria for CKD
Reflux surgery if progression of scarring
Abx prophylaxis - trimethoprim
What are the 3 features of nephrotic syndrome?
Heavy proteinuria 1g/m2/24 hours
Hypoalbuminaemia <25g/L
Oedema
Where would you look for evidence of oedema in a child with nephrotic syndrome?
Peri-orbital on waking = earliest sign Scrotal Leg and ankle Pleural effusion so breathlessness Ascites
What is commonly the earliest sign of nephrotic syndrome?
Periorbital oedema on waking
What are the causes of nephrotic syndrome?
Minimal change disease Focal segmental glomerulosclerosis Membranoproliferative glomerulonephritis Membranous glomerulonephritis Infections - malaria Allergens eg bee stings
What are the types of nephrotic syndrome?
Steroid resistant
Steroid sensitive
What are the features that indicate steroid-sensitive nephrotic syndrome?
Minimal change disease essentially
Normal BP No blood in urine Normal renal function No features to suggest nephritis Responds to steroids (DUH) Histology shows minimal change Normal complement Age 1-10
What are the features that indicate steroid-resistant nephrotic syndrome?
Other diseases not minimal change disease
Elevated BP Haematuria Impaired renal function Features to suggest nephritis Failure to respond to steroids (DUH) Histology shows pathology ie glomerulonephropathy, basement membrane abnormality
What tests would you do to investigate a child with suspected nephrotic syndrome?
Urine dipstick - protein, no nitrites, may be RBCs Urine MC&S FBC ESR U&E Creatinine Albumin C3 + C4 (complement levels) Urinary sodium Hep B / C screen Malaria screen if recent foreign travel
How do you treat nephrotic syndrome?
first line
PREDNISOLOOOOOOONE
60mg/m2 for 4 weeks
Then 40mg/m2 alternate days for 4 weeks
Other than steroids, how would you manage a child with steroid responsive nephrotic syndrome?
Salt and water moderation
Diuretics
Penicillin V
VZV, measles and pneumococcal immunisation
How would you treat steroid resistant nephrotic syndrome?
Refer to nephrology And treat the oedema: - Salt restriction - Diuretics - ACEi - NSAIDs - reduce the proteinuria
What are the complications of nephrotic syndrome?
Hypovolaemia
Thrombosis (because pissing out antithrombin 3)
Infection
Hypercholesterolaemia
Which organism causes post-strep glomerulonephritis?
strep (no shit sherlock)
Group A beta-haemolytic strep (same bitchin thing as rheumatic fever)
CASE
A child presents with swollen testicles, breathlessness, red blood in his urine and a fever.
A week ago he had a sore throat.
What are the differential diagnoses?
Nephrotic syndrome (probs steroid resistant to be picky) Post-strep glomerulonephritis
Which investigations would you perform for a child with suspected post-strep glomerulonephritis?
FBC U&E Immunology Throat / skin swabs for the initial infection Urinalysis
What would you see on urinalysis of a patient with post-strep glomerulonephritis?
Increased protein
Increased protein:creatinine ratio
Haematuria (macroscopic)
RBC casts
How would you manage a child with post-strep glomerulonephritis?
Fluid balance Diuretics Correction of electrolyte imbalance Dialysis (uncommonly needed) Penicillin to treat the strep infection
What is Alport syndrome?
Congenital
Glomerulonephritis
CKD (end-stage)
Hearing loss
What are the symptoms of HSP?
Rash
Arthralgia + periarticular oedema
Colicky abdo pain
Glomerulonephritis
Describe the rash in HSP
Non-blanching
Symmetrical
On buttocks, extensors of arms and legs, ankles
Sparing of the trunk
Palpable
Initially urticarial - then goes to maculopapular and purpuric
What is haemolytic uraemic syndrome?
Triad of:
- Microangiopathic haemolytic anaemia
- Acute renal failure (uraemia)
- Thrombocytopaenia
What is the most common cause of HUS?
E coli O157:H7
From farm animals or uncooked beef
What are the causes of HUS?
E coli O157:H7 Tumours Pregnancy The pill Cyclosporins SLE HIV
How would you investigate a patient with suspected HUS?
FBC - shows the anaemia and the thrombocytopaenia
U&E - shows acute renal failure
Stool culture
How would you manage a patient with HUS?
Supportive:
Fluids
Blood transfusion
Dialysis if required
What is atypical HUS?
Without the bloody diarrhoeal prodrome
Or cerebral involvement
How would you treat atypical HUS?
Plasma exchange
Plasma infusion
What are the causes of proteinuria?
Transient - febrile illness or after exercise
Persistent - nephrotic syndrome basically
What is the definition of daytime enuresis?
Lack of bladder control during the day in a child old enough to be continent of urine
At what age should children be continent of urine?
3-5 years
What are the causes of daytime enuresis?
Lack of attention to bladder sensation (don't respond to a full bladder) Detrusor instability Neuropathic bladder Bladder neck weakness Constipation UTI Ectopic ureter
How would you treat a child with daytime enuresis?
Star charts Bladder training / pelvic floor exercises Enuresis alarm (if lack of attention to bladder sensation) Treat constipation
What is secondary enuresis?
Urinary incontinence in a child who has previously achieved continence
What are the causes of secondary enuresis?
Emotional upset
UTI
Diabetes
Renal concentrating disorders - sickle cell, chronic renal failure
What is nocturnal enuresis?
Bed-wetting
Genetically determined delay in sphincter competence
How would you manage a child with nocturnal enuresis?
Explain that it is normal + stop parents from punishing
Star charts
Enuresis alarm
What pharmacological treatment would you use for nocturnal enuresis?
Desmopressin
