Paeds Pelvis Flashcards
When should orchidopexy be done?
first year of life
What is an orchidopexy?
placement of testis into scrotum
6 month old boy comes into GP with bilateral impalpable testes. What do you do?
MEDICAL EMERGENCY
karyotype and laparoscopy
Sometimes testes are descended and sometimes not. What’s this?
retractile (‘vanishing’)
need warm env, can be manipulated down
Scrotal swelling due to dilated testicular veins. What’s this?
varicocoele
What is a varicocoele?
scrotal swelling due to dilated testicular veins
Hydroceole and inguinal hernia are both due to?
patent processus vaginalis
Who are inguinal hernias particularly common in?
boys + premature babies
Inguinal hernia presents as lump in groin, you can’t get above it. Where can this extend to ?
scrotum, labia
5 yr old boy who was premature presents to GP with reducible inguinal hernia, visible on coughing. What is management?
TAXIS (reduce it)
wait for herniotomy
If inguinal hernia is irreducible, strangulated, or incarcerated, what is the management?
EMERGENCY HERNIOTOMY
4 yr old boy presents to GP with lump in scrotum, which appears a bit blue. He feels well. Management?
Hydrocoele
he’s >2yrs surgery (cut + drain fluid out)
can transilluminate but weird thing to do
Excess fluid around the testis. What’s this?
hydrocoele
4 month old baby boy is brought to GP with mum complaining of lump in scrotum. Is doesn’t seem to be causing him any pain but appears blue. On examination, you can get above it. What is management?
hydrocoele
<2 yrs so expectant - wait for patent processus vaginalis to close
Do inguinal hernias in children tend to be direct or indirect?
indirect
When are varicocoeles common?
puberty
13 yr old boy presents to GP with dull ache in is left testicle, saying it looks like a bag of worms. Why is this condition more common on the left?
varicoele
- testicular vein drains straight into left renal vein with no valves
Give me 4 good reasons for orchidopexy.
cosmetic
reduce risk of:
- torsion
- infertility
- malignancy
Management of varicocoele?
expectant, supportive pants
~~ surgical ligation of gonadal veins
14 yr old has varicocoele which has persisted for a year and is causing lots of discomfort depsite trying supportive underpants. What now?
surgical ligation of gonadal veins
Why are varicocoele more common on left?
left testicular vein drains straight into left renal vein with no valves
What percent of undescended testes are palpable somewhere in the groin?
80%
What percent undescended testes are impalpable?
20%
Why might testes be impalpable?
intra-abdominal or absent
When should orchidopexy for undescended testes be performed?
within first year of life
What is the treatment for undescended testes?
orchidopexy
What is taxis?
reducing hernia
16 yr old presents to A&E with scrotal swelling and sudden onset intense testicular pain on the right. On examination, scrotum is red and swollen. He has been vomiting. What is your course of action.
analgesia+antiemetics
straight to theatre for scrotal exploration and probably bilateral orchidopexy
What is actually twisting in testicular torsion?
spermatic cord twists within tunica vaginalis, compromising blood supply
spermatic cord twists within tunica vaginalis, compromising blood supply. What’s this?
testicular torsion
Testicular torsion is most common in boys aged 12-25. What other age group does it sometimes happen in?
newborns
negative Prehn’s sign is
cremasteric reflex absent
tesicular torsion
blue dot on scrotum makes you think of
torsion of hyatid appendage
Investigation for suspected testicular torsion?
go to theatre for scrotal exploration
In the operating theatre for a 16 yr old boy with testicular torsion. It’s been a few hours and the testis is no longer viable :( What needs to happen?
orchidectomy :(
Even if testicular torsion is untwisted and fixed with bilateral orchidopexy, bad things can happen to the testis later on. Name one.
testicular atrophy
chronic pain
When is a case of testicular torsion confirmed?
in theatre
17yr old boy presents with sudden onset unilateral testicular pain, says he has been feeling feverish over the past few days. On examination there a blue dot on the scrotum. You suspect torsion of Hyatid appendage. Investigations and treatment?
scrotal exploration in theatre
remove infarcted hyatid
What is phimosis?
phimosis = pathologically non retractile foreskin
When is it normal for the foreskin to be non-retractile?
infancy
pathologically non retractile foreskin. What’s this?
phimosis
In a 3 yr old, the preputial opening is red and sore, with purulent discharge. What’s this?
balanoposthitis
if recurrent - circumcision
Posh word for foreskin is?
prepuce
What is the main cause of phimosis (pathologically non-retractile foreksin)?
balanitis xerotica obliterans
What age boys are affected by balanitis xerotica obliterans (causing pathologically non retractile foreskin?)
older boys + young adults
What is the treatment for balanitis xerotica obliterans?
circumcision
Can retract foreskin but can’t return it back (reduce it). What’s this?
paraphimosis
What is paraphimosis?
can retract foreskin but can’t return it back over the glans penis
Give me four indications for circumcision.
recurrent balanoposthitis
balanitis xerotica obliterans
high risk for UTI
intermittent catheterization
What is female equivalent of balanitis xerotia obliterans?
lichen sclerosis !
What condition in childhood might need intermittent catheterization leading to need for circumcision?
spina bifida
If left untreated, paraphimosis can lead to what?
oedema of glans and maybe necrosis
What is the treatment for paraphimosis?
emergency reduction of prepuce
pull the foreskin back up with analgesia. ouch.
congenital defect causing ventral urethral meatus + penile curvature. What’s this?
Hypospadia
What is Hypospadia?
congenital defect causing ventral urethral meatus + penile curvature
Don’t circumcise if you suspect… what
hypospadia. Because you might need to use the prepuce for surgical repair of the hypospadia.
What is chordee?
ventral curvature of the penis
How common is hypospadia?
common. 1 in 200.
If you see a child with hypospadia and undescended testes, what might you suspect?
disorder of sexual development (eg CAH - could be ambiguous genitalia)
What is the mainstay surgical treatment for hypospadia?
urethroplasty
Vulvovaginitis in pre-pubertal girl could be due to…
- thrush
- nappy rash
- vaginal rhabdomyosarcoma if bloody discharge
UTIs in children are most common in boys or girls?
girls
half have strucutral abnormality of urinary tract
Give me three examples of congenital kidney abnormalities, detected on antenatal US.
- renal agenesis
- ADPKD
- horseshoe kidney
(need prophylactic Abx at birth)
Obstruction to urine flow at PUJ causes unilateral or bilateral hydronephrosis?
PUJ obstruction = unilateral hydronephrosis
Obstruction to urine flow at VUJ causes unilateral or bilateral hydronephrosis?
VUJ obstruction = unilateral hydronephrosis
What does PUJ stand for?
pelvic uteric junction
What does VUJ stand for?
vesico uteric junction
Obstruction to urine flow at bladder neck causes unilateral or bilateral hydronephrosis?
bladder neck obstruction = bilateral hydronephrosis
Obstruction to urine flow at posterior urethral valve causes unilateral or bilateral hydronephrosis?
posterior urethral valve obstruction = bilateral hydronephrosis
2 yr old in nappies is brought in with fever, vomiting, poor feeding, and jaundice. You suspect UTI. What investigations ?
“clean catch” urine sample
…
dipstick
culture
Investigation for atypical or recurrent UTIs for <1yr old?
US of kidneys + urinary tract
MCUG + DMSA
what is MCUG?
micturating cystourethrogram (x ray)
what is a DMSA?
dimercaptosuccinic acid (radionucleotide localises the renal cortex to see scarring in imaging)
Investigation for atypical or recurrent UTIs in 1-3yr olds?
US of kidneys + urinary tract
DMSA
Investigation for atypical or recurrent UTIs in >3yrs?
ultrasound of kidneys + urinary tract, if normal no further Ix
which scan detects scars in kidneys
DMSA
which scan detects obstruction / reflux
MCUG
UTI treatment under 3 months
<3 months - refer to paed (admit, IV co-amox)
UTI treatment for LOWER UTI >3months
trimethroprim / nitrofurantoin
UTI treatment for UPPER UTI >3months
co-amox
does potters syndrome cause
oligohydramnios, yes
involuntary discharge of urine by day or night or both, in a child aged 5 years or older, in the absence of congenital or acquired defects of the nervous system or urinary tract’. What’s this?
enuresis
what is enuresis?
involuntary discharge or urine by day or night or both in a child aged 5 yrs or older, in the absence of congenital or acquired defects of the nervous system or urinary tract
management of enuresis?
advise of toileting, fluid intake
star charts e.g. wee before bed
<7yr - enuresis alarm
>7yrs - desmopressin
difference between primary and secondary enuresis?
primary (the child has never achieved continence) secondary (the child has been dry for at least 6 months before)
in secondary enuresis the child has been dry for at least 6 months before. what can be causes
emotional upset
UTI
diabetes !!
in primary enuresis, the child has never achieved continence. what can be causes
detrusor instability
neuropathic bladder
UTI
constipation
first step management of enuresis
advise on tolieting fluid intake
second step managemnet of enuresis
star charts
oral trimethoprim / nitrofuratnoin in treatment for
LOWER UTI in >3month old
oral co-amox treatment for what utis
UPPER UTI in >3 month old
IV co-amox is treatment ofr what utis
any <3month old
2 causes of transient proteinuria
exercise
febrile
4 causes of persistnet proteinuria
orthostatic proteinuria
hypertension
CKD
NEPHROTIC SYNDROME!
leaky glomerulus = ?
nephrotic syndrome
heavy proteinuria, hypoalbuminaemia, oedema is triad for?
nephrotic syndrome
what is triad of nephrotic syndrome?
heavy proteinuria
hypoalbuminaemia
oedema
two types of nephrotic syndrome in kids
steroid sensitive
steroid resistant
where can oedema go in nephrotic syndrome
periorbital
scrotal / vulval
ankle
triad of nephrotic syndrome is proteinuria, hypoabluminaemia, and oedema. what symptoms might there be apart from oedema?
breathlessness (effusion)
infection (sepsis!)
which investigation in nephrotic syndrome tests for post-infectious strep glomeruloneprhitis
throat swab: anti-streptolysin O :)
what protein:creatinine ratio is bad in first morn urine
> 20mg/mmol = nephrotic syndrome
investigations for nephrotic syndrome?
urine dipstick first morn urine protein:creatinine ratio serum albumin FBC, U+Es, ESR etc throat swab!
4 complications of nephrotic syndrome
hypovolaemia
thrombosis
infection
hypercholesterolaemia
hypovolaemia
thrombosis
infection
hypercholesterolaemia
are all complications of what
nephrotic syndrome
90% of nephtoric syndromes are
… steroid sensitive
10% of nephrtoic syndromes are
…. steroid resistant
most steroid sensitive nephrotic syndrome is due to
MINIMAL CHANGE DISEASE
or henoch schonlein purpura
most steroid resistant nephrotic syndrome is due to…..
FOCAL SEGMENTAL GLOMERULONEPHROPATHY
focal segmental glomerulomephrotpathy causes what
steroid resistant nephrotic syndrome
minimal change disease causes what
seroid sensitive nephrotic syndome
what makes you think its steroid sesnitive
aged 1-10yrs
no macroscopic haematuria
normal BP
what makes you think its steroid resistant
high BP
frank haematuria
13 yr old boy presents with oedema, hypoalbuminaeia, and proteinuria. He has frank haematuria and high BP. What’s the likely diagnosis?
steroid resistant nephrotic syndrome
probs focal segmental glomerulonephropathy
3 yr old boy from Indonesia presents with oedema, hypoablimnumaia, and proteinuira. He has microscopic haematuria and his BP is normal. What’s likely diagnosis.
steroid sensitive nehrotic syndrome
probs minimal change disease
If nephrotic syndomre doesnt respond to steroids, you want to do renal biopsy. On histology, what would you see if its minimal change disease?
normal on light microscopy
then dodgy podocytes on electron microscopy
dodgy podocytes on electron microscopy. whats this
minimal change disease
what is treatment for steroid sentivie nephrotic syndrome (clue in name LOL)
oral prednisolone
daily for 4wks, then alternate days for 4wks, then wean
what is treatment for steroid resistant nephrotic syndrome (clue, its just symptomatic at this point)
diuretics, salt restriction, ACE-i
apart from nephrotic syndome, what are some other causes of generalzed oedema in kid?
LOW ALBUMIN: kwashiorkor malnutrition malabsoprtion of protein bad liver nephrotic syndrome
SALT + WATER RETENTION:
kidney failure
heart failure
positive urine dipstick for uti? what would this show
nitrites (good indicator)
leukocytes (just show febrile)
how many colony forming units does urine culture have to have to be pos
> 10 to the power 5 colony forming units
apart from e.coli, two uti culprits
proteus
klebsiella
causes of childhood uti?
incomplete bladder emptying (eg neuropathic bladder) vesicouteric reflux (often familial)
severe vesicouteric reflux causing recurrent utis merits..
surgery
inflamed glomerulus = ?
nephritic syndrome
what is nephritic syndrome
inflamed glomerulus
= less glomerular blood flow = less filtration
what counts as haematuria on microscopy?
> 10 red cells per high power field
serum albumin in nephrotic syndrome is
<25mg/mmol
how long do you prescribe prednisolone for in steroid sensitive nephrotic ysndrome?
daily 4wks, alternate days next 4 wks, wean)
what is prognosis for steroid sensitive nephrotic syndrome?
one third resolve
one third infrequent relapses
one third frequent relapses
3 causes of nephritis
post-infectious
IgA nephropathy
vasculitis
what is the management of acute nephritis? (if its not severe)
fluid + electrolye balance
? diuretics
what is the management of severe acute nephritis?
renal biopsy
imm supp
plasma exchange
suspect post-infectious glomerulonephritis? Ix?
culture (skin/throat)
anti-streptolysin O / ani-DNAase B titres
low C3 levels
sudden reduction in renal function (potentially reversible) usually w oliguria = ?
acute kidney injury
define acute kidney injury
sudden reduction in renal function (potentially reversible) usually with oliguria
define oliguria
when you’re weeing less than 0.5ml / kg/hr
AKI can be pre-renal, renal or post-renal. Which is most common in kids?
pre-renal
what is pre-renal cause of AKI?
hypovolaemia (e.g. gastroenteritis, burns, haemorrhage)
give one RENAL cause of AKI?
glomerulonephritis
haemolytic uraemic syndrome
pyelonephritis
what’s the POST-RENAL cause of AKI?
obstruction of tuuubes
what electrolyte imbalances do you get in renal AKI?
METABOLIC ACIDOSIS
HYPER PHOS
HYPER K
treatment for pre-renal AKI?
fluid replacement + circulatory support
treatment for hyperkalaemia in renal AKI?
glucose + insulin
calcium gluconate
salbutamol
…. dialysis if bad
