Paeds - Renal + urology Flashcards
UTI presentation
Fever may be only presentation
Babies very non-specific:
- Fever
- Lethargy
- Irritability
- Vomiting
- Poor feeding
- abdo pain
Infants/kids may complain of:
- Increased frequency
- Dysuria
- Abdo pain / LOIN tenderness
Typically just check for UTI in kids with fever unless there’s an obvious alternative source
UTI RFx
- Age below one year
-
Female
– more common in boys < 3 months - Caucasian race
- Previous UTI
- Voiding dysfunction
-
Vesicoureteral reflux (VUR)
- Around 33% of infants and children who have a urinary tract infection have VUR. - Sexual abuse
– can cause urinary symptoms but infection is uncommon - Spinal abnormalities
- Constipation
- Immunosuppression
Oft idiopathic but check for all of these on examination
Main UTI causative organisms
KEEPS:
- Klebsiella
- E COLI
- Enterococcus
- Proteus Mirabilis
- Stap SAPROPHYTICUS
UTI DDx
- Vulvovaginitis / vaginal foreign body
- VAGINAL discharge; urine dip normal
- Consider sexual abuse if presistant/recurrent/no medical explanation BUT also Bubble baths - Kawasaki disease (has sterile pyuria but has other features)
- Voiding dysfunction
- Sepsis (but not UTI)
- Threadworms (perianal itching)
- Meningitis
UTI Dx
1st line = URINE DIP (NOT if < 3 months)
- LEUKOCYTE ESTERASE + NITRITES = get MS+C
If temp >38 C OR pyeloneph suspected:
CLEAN CATCH URINE / URINE COLLECTION PAD / Catheter/suprapubic asipration sample for MS + C within 24 HOURS
Imaging:
- USS if atypical (or for recurrent in < 6 months)
- USS in 6 weeks if recurrent > 6 months (for < 6 months, need to check up anyways)
- Dimercaptosuccinic acid (DMSA) 4-6 months following acute infection if RECURRENT (also for ATYPICAL UTI in kids < 3 y/o)
- Micturating cystography (gold standard for reflux but invasive so typically only do for atypical, recurrent or abnormal KUB USS in kids < 6 months; not necessary in older kids)
Features of Atypical UTI
- Poor urine flow
- Abdominal or bladder mass
- Raised creatinine
- Sepsis
- Failure to respond to treatment within 48 hours
- Non-E.Coli organism
Definition of recurrent UTI
- Two or more episodes of upper UTI (pyelonephritis/systemic)
- Three or more episodes of lower UTI (non-systemic)
UTI management
If < 3 months - refer immediately
Lower UTI:
-
Oral antibiotics for 3 days
- Trimethoprim, Nitrofurantoin, a cephalosporin or Amoxicillin
- should improve within 48 hours at least; otherwise need to see child again (safety-net to parents)
Upper UTI:
- Consider referral
- If vom may be unable to tolerate oral Abx
- Esp if v young; inadequate fluid intake
- Can carer identify deterioration?
-
IV CEFUROXIME (or other cephalosporin)
or CIPROFLOXACIN or CO-AMOXICALV for 7-10 days
No ABx if asymp
N/B - Give IV if <3 MONTHS regardless of severity
Pyloneph Dx
- A temperature greater than 38°C
- Loin pain or tenderness
Dx if either or are present
When should USS be done for UTI
- **All children under 6 months with their first UTI should have an abdominal ultrasound within 6 weeks **
- Children with recurrent UTIs should have an abdominal ultrasound within 6 weeks
- Children with atypical UTIs should have an abdominal ultrasound during the illness
Vesicouretric reflux
Urine refluxes from bladder into ureters
Complications of vesicouretric reflux
predisposes to UPPER UTIs + RENAL SCARRING
- Swelling + hydronephrosis over time
- Grades 1 to 5
Vesicouretric reflux Dx
Micturating Cystourethrogram (MCUG)
Catheter -> Inject CONTRAST to bladdder -> X-RAYS
Kids usually given prophylactic Abx for 3 days before
(can also see later stages on USS - during Ix for UTI)
For what reasons may a MCUG be done
- to investigate atypical or recurrent UTIs in children under 6 months
- FHx of vesico-ureteric reflux
- Dilatation of the ureter on ultrasound
- Poor urinary flow
Vesico-uretric reflux Mx
Depends on severity:
- Avoid constipation
- Avoid an excessively full bladder
- Prophylactic antibiotics
- Surgical input from paediatric urology
Enuresis
Normal micturition that occurs at an inappropriate or socially unacceptable time or place
RFx/Causes for nocturnal enuresis
- Autosomal dominant genetic predisposition
- upper airway obstruction/sleep-disordered breathing
- Constipation
- ADHD
- PSYCHOLOGICAL DISORDERS
- Male sex
Causes:
- Increased fluid intake at night
- Caffine/bladder irritants
- Urinary frequency/urgency (typically due to delaying micturation)
Noncturnal enuresis Dx
Clinical - Urinalysis to exclude DDx
Consider USS if refractory to Tx
Nocturnal enuresis Tx
Just reassure if <7 y/o
7 or older:
- Education (bladder training); life style changes + behavioural measures
- Alarm therapy (alarm goes off as soon as sensor gets wet; child gets conditioned to wake up before peeing)
- Desmopressin (immediate action for short-term Tx - warn about water intoxication/hyponatraemia)
- or oxybutinin (antichol) for overactive bladder
- imipramine (tricyclic antidep)
Causes of nepfrotic syndrome in kids
Minimal change disease
- Congenital nephrotic syndromes,
- focal segmental glomerulosclerosis
- mesangiocapillary glomerulonephritis
Trifecta of nephrotic syndrome
oedema, proteinuria and hypoalbuminaemia
- if typical presentation -> can give STEROIDS without needing renal biopsy
Atypical features of nephrotic syndrome in kids
- Age < 1 year or > 12 years
- Hypertension
- Impaired renal function
- Frank haematuria
- Steroid resistant nephrotic syndrome
NEphrology review + RENAL BIOPSY needed
DDx for swollen child
- Nephrotic syndrome
- Heart failure
- Allergic reaction
- Kwashiorkor (malnutrition)
Investigations for initial presntation of nephrotic syndrome
- urine dip
- urinary protein : creatinine ratio
- urea & electrolytes
- full blood count
- serum albumin
- varicella zoster serology
Potential further investigations if atypical:
complement levels, hepatitis serology, Anti-streptolysin O Titre (ASOT) and autoimmune investigations such as ANA, ANCA and anti-dsDNA
Nephrotic syndrome Tx
- HIGH DOSE STEROIDS (can change results of renal biopsy so discuss first if atypical)
- For 4 weeks then wean for next 8 wks
- May need immunomodulatory drugs such as levamisole, cyclophosphamide, ciclosporin or tacrolimus if steroid-resistant
- LOW SALT DIET
- Prphylactic Abx (to compensate for leaking Ig from kidneys)
Complications of nephrotic syndrome in kids
- Fluid imbalance (combination of oedema + intravascular fluid depletion)
- Diuretics or albumin can help but albumin can expand volume so caution
- Infection - from loss of immunoglobulins
- Chickenpox (may require VZV immunoglobulin or IV acyclovir)
-
Thrombosis (as they are in pro-thrombic state)
- Esp from loss of Protein S + Antithrombin + intravascular hypovolemia
- chest pain = PE
- abdo pain = mesenteric ischaemia
Hypospadias
Congenital condition - diagnosed on examination of newborn
Urethral meatus is displaced to ventral side (underside) of penis
- typically just further down galns but can be halfway down or at bottom of shaft
- dorsal hooded foreskin
Epispadias
Urethral meatus on dorsal (top) side of penis
- usually foreskin also abnormally formed to match
Chordee
Head of penis is bent downwards
- associated with hypospadias
Hypospadias pathophys
occurs due to arrest of penile development, leading to hypoplasia of the ventral tissue of the penis
difficulty directing urination + can cause sexual dyfunction if left untreated
Classification of hypospadias
Glandular, coronal, shaft (distal, mid, proximal), scrotal, perineal
DDx of hypospadias
Disorder of sex development - must exclude
- esp if associated with undesended teste(s)
Congenital ADRENAL Hyperplasia - esp in females with ambiguous genetalia
- can lead to salt wasting crisis due to cortisol + aldosterone deficiency with androgen excess
- need to treat with glucocorticoids
When are investigations considered for hypospadia
if disorder of sex development (DSD) suspected
Investigations to consider for DSD
- Detailed history and examination
- Karyotype
- Pelvic ultrasound scan
- Urea and Electrolytes
- Endocrine hormones:
- Testosterone, 17 alpha-hyroxyprogesterone, LH, FSH, ACTH, renin, aldosterone
Hypospadia Tx
Depends but mainstay = URETHROPLASTY (for functional + cosmetic reasons)
- Brings meatus to glans
- Chordee corrected
- Dorsal foreskin either circumsised or reconstructed
Complications of urethroplasty
- Catheter block, displced or kinked
- Pain + bladder spasms - Bleeding + infection
Urethral fistulas or stenosis can occur in longer term
Phimosis
Congenital narrowing of the opening of the foreskin so it can’t be retracted
Physiologically normal in kids as at birth there are adhesions between the foreskin and penis which often persist till a mean age of ~10
Cause of pathalogical phimosis
95% due to Balanitis xerotica obliterans (BXO)
- keratenisation of tip of foreskin causes scarring + the prepuce (foreskin) remains non-retractile
- peak incidence 9-11 y/o
Balanitis xerotica obliterans Px
- Irritation, dysuria, haematuria + local infection of glans
- foreskin looks white + fibrotic; tip is scarred
- meatus can be similarly affected but is difficult to visualise
BXO/pathological phimosis Mx
Circumcision
- send foreskin to pathology to confirm BXO
Complications of circumcision
Bleeding + infection
- IV access + pressure dressing + contact surgeon if significant bleeding
- topical antibiotics
Some swelling + serous discarge normal for ~ 1 wk after
Examples of congeital kidney abnormalities
- Horseshoe kidney
- Duplex kidney (has 2 ureters)
- Solitary kidney
DMSA (Dimercaptosuccinic acid) scan
radioisotope contrast
particularly good for checking scarring + changes between the 2 kidneys (one might be worse than other - the less darkness visible, the more scarring)
- hence why typically used for recurrent UTIs (but only a few months after to allow the scarring to settle)
When is pediatric follow-up required for UTI
- All kids under 3 months
- Any kids who are systemically unwell
- Recurrent UTIs
Causes of oedema (increased INTERSITIAL FLUID)
- Obstruction of lymphatics (e.g. elephantiasis from roundworm; congenital)
- Obstruction of venous drainage (e.g. DVT)
- Lower oncotic pressure
- Salt + water retention (HF; CKD)
Steroid sensitive vs steroid resistant Nephrotic syndrome
Steroid sensitive:
- Normal BP
- NO HAEMATURIA
- Norm Renal function
- Minimal histological changes
- <10% progress into adulthood
- Responds to steroids
Steroid resistant:
- RAISED BP
- HAEMATURIA
- Renal function can be impaired (not always)
- Basement membrane abnromal / FSGS deposition on histology
- 50% end stage renal failure by 10 years (POOR PROGNOSIS)
- RESISTANT to STEROIDS
Sign on blood test for post-strep glomerularnephritis
Low C3 which raises back to normal after ~ 3 months
Main Sx of Post-strep glomerularnephritis
- Haematuria
- Oedema
- HYPERTENSION
Presentation of Henoch-Schonlein Purpura
IgA deposition affects SKIN, JOINTS, KIDNEYS + GI tract so
- Purpuric rash
- Joint pain
- Haematuria, oedema
- Leaking from GI tract
