Peds Exam 1 Lecture 6: Renal/GU Flashcards
Young male patient comes in:
mother says he has been tolerating feeds, is still consolable but she has noticed a painless, somewhat mobile mass around the testicle/scrotum, what is the Dx?
Hydrocele
What is typically seen w/Hydrocele with transillumination?
Bilateral Illumination
What population, sex, age range and side are MC for inguinal hernias?
MC in
- premature infants
- Boys > girls
- < 1 yr
- R side
Young male patient comes in w/a firm, discrete mass that is tender and surrounded by erythema and edema overlying the skin. His mother says he has been vomiting and has not had a BM in awhile, what is the Dx?
Incarcerated Inguinal Hernia
What is a common PE finding for Incarcerated inguinal hernia?
Testicle appears blue
pressure on spermatic cord–> venous congestion
Dx test to differentiate hydrocele from inguinal hernia
What is major difference b/t two diseases?
US
Inguinal Hernia = Painful
Hydrocele = Painless
What are Tx steps for incarcerated inguinal hernia?
- Try to manually reduce
2. Do elective surgical repair
When should a manual reduction of an incarcerated inguinal hernia NOT be attempted?
child appears ill, signs of peritonitis, obstruction or toxicity
When should an emergent surgical repair of an incarcerated inguinal hernia be performed?
Child is ill or hernia cant be manually reduced
Tx for hydrocele w/no mass or reducible mass?
Refer for surgery (not emergent) but do promptly to prevent progression to incarceration
Dilation of pampiniform plexus
Variocele
What dz is MC on L side, uncommon in boys under 10, is a cause of “subfertility”, is typically painless and described as a “bag of worms”
Variocele
note: if on R side need imaging
List 3 Grades of Variocele
- Present only w/Valsalva
- Present w/out Valsalva but not visible
- Visibly present (most risk of arrested testicular growth)
When retractile testes occur in boys > 1 what is it often caused by?
What are boys w/retractile testes at risk for?
Brisk cremasteric reflex
at risk for developing undescended testes
MC d/o of sexual differentiation in boys
Cryptochidism
Timeframe for testicular descent
7-8 months gestation
At what age is Cryptochidism likely permanent?
4 months
4 consequences of Cryptochidism?
- Torsion
- Testicular malignancy
- Indirect hernia
- Infertility
“Tommy’s Testicle Is Indiscernible”
What imaging is recommended for Cryptochidism?
NONE - routine imaging not recommended
Timeframe for surgery w/Cryptochidism
6 months = earliest
no later than 9-15 months
What is concerning for ambiguous genitalia?
Bilateral undescended testes
Definition of micropenis
< 2.5 SD for gestational age
What is micropenis due to?
Testicular failure during fetal life after morphogenesis is complete
What two things together are concerning for congenital hypopituitarism?
Hypoglycemia + Micropenis
What 4 things are part of the evaluation for Micropenis?
- Karyotype
- Assess anterior pituitary function
- Assess testicular function
- MRI –> assess pituitary, hypothalamus, other CNS midline structures
Why is Tx w/androgens controversial for boys w/micropenis?
May limit their growth potential
but good news… most boys w/micropenis have satisfactory sexual function (yay)
4 potential benefits of circumcision
- Reduction in UTIs, STIs (HIV)
- Reduction in phimosis/paraphysmosis
- Prevent penile SCC
- Easier Hygiene
Before circumcision is done what 3 things should be confirmed?
- infant at least 12 hrs old (24 preferred)
- infant voided
- no CIs
Objectives said we need to know the CIs to Circumcision so there’s a lonnggg list on the flip side…learn it, live it, love it
(note most are not absolute CIs)
- Hypospadias
- Chordee w/out Hypospadias
- Dorsal hood deformity
- Micropenis
- Wandering/crooked raphe
- bilat undescended testes
- Ambiguous genitalia
- Bleeding diathesis
Risks a/w Circumcision?
- Pain
2. Penile Injury (fistula, glans injury, excess skin removal, adhesions)
What should NOT be given during circumcision?
Epi
Post Circumcision:
Why should you use petroleum jelly?
What size of blood is okay to see on diaper?
Jelly: prevent adhesion to diaper
Blood < quarter size okay
What congenital defect occurs when the opening of the urethra is on the underside of the penis rather than at the tip?
Hypospasdias
Two clues for Hypospadias
- downward curvature of penis
2. “dorsal hood” - foreskin only on top 1/2 of penis
What is MC degree for Hypospadias and location?
MC = 1st degree
location: meatus = distal
What is the Tx for all 2nd & 3rd degree Hypospadias?
Surgical repair (must correct functional abnormalities)
Why do you consider a VCUG in 3rd degree Hypospadias (proximal)?
some pts have dilated prostatic utricle
Inability to retract prepuce at age when it should be retractable
What is typical age that prepuce becomes retractable?
Phismosis
Age 3 - normally prepuce is retractable
How does physiologic phismosis differ from pathologic phismosis?
Physio - natural in newborns
Pathologic - previously retractable or occurs after puberty
How does phismosis differ from paraphismosis?
Phismosis - prepuce cant be retracted
Paraphismosis
- prepuce can retract but then it cant be extended
- EMERGENCY (could have loss of blood supply to glans)
Preferred position for genital exam (both sexes)
Supine w/hips elevated & frog leg position
3 contributing factors for non-specific vulvovaginitis
- Lack of estrogenization, protective hair & labial fat pad
- Proximity of vagina to anus
- Poor hygiene, irritants, contamination
3 main Tx concepts for non-specific
vulvovaginitis
- Keep area dry/aerated
- Decrease irritants
- Sitz bath
How often/ingredient of sitz bath?
2x daily w/ 3 tbsp of baking soda
3 main clinical findings of labial adhesions
- Fusion of labia minor
- interference w/voiding
- Recurrent UTIs
3 Tx options for Labial adhesions
- Gentle traction (separates labia) –> 3-5 days of estrogen cream
- Hormonal cream (no traction) for several weeks
- Occasionally need surg
When should you consider febrile UTI?
When fever of unknown source
Although most Febrile UTIs resolve on own what complications can result from delaying Tx?
Urosepsis
Abscess Formation
Renal scarring –> HTN & CKD
What signs/Sxs increase the suspicion for pyelonephrititis?
All Sxs assoc w/cystitis plus:
- Higher fever
- chills
- N/V
- Flank pain/tenderness
What age group must you ALWAYS consider UTI in febrile children?
< 24 months
What factors are a/w incr risk of febrile UTI specifically in girls?
White, Fever 2+ days, Age < 12 mo
What factors are a/w incr risk of febrile UTI specifically in boys?
non-black, fever 1+ day, uncircumscribed
What 2 factors of the Hx significantly increase the risk of febrile UTIs?
- Hx of UTI
2. Hx of congenital GU anomaly
What three factors when combined on UA have a high specificity for UTI?
- Leuk esterase
- Nitrites
- WBC
All three negative –> unlikely UTI
Note: if Urine culture negative also unlikely UTI
What are the requirements for UTI Dx?
Positive UA and least 50 cfu of urinary pathogen
Length of Tx for febrile UTI
oral or IV ABX 7-14 days
When should a US be preformed after a febrile UTI to r/o anatomic abnormalities?
- All kids not toilet trained
- ALL BOYS
- Toilet trained girls w/recurrent UTIs
When is VCUG recommended in kids not toilet trained?
- Urinary dilatation or scarring
- Recurrent febrile UTI
- Urosepsis
- UTI d/t organism other than E. coli
- Fam Hx of congenital GU anomalies or reflux
Tx for reflux?
ABX +/- surg
Higher stage –> less likely to resolve on own
Why is VUR important?
- identifies RF for recurrent UTI
- identifies risk for VUR nephropathy (can monitor/tx them)
Why is ABX ppx used in VUR? What ABX used? What does ABX ppx in VUR not effect?
- Used to decrease risk of recurrent febrile UTI
- Bactrim = ABX for ppx
- NO effect on renal scarring nephropathy
Major RF for enuresis?
Fam Hx of nighttime bedwetting
Difference b/t primary and secondary enuresis?
Primary - child hasnt had 6 mo of dry nights
2ndary - child previously had 6 mo of dry nights, most often a/w stress or underlying condition
Sxs of Non-monosymptomatic enuresis?
What can Non-monosymptomatic enuresis suggest?
daytime incontinence or daytime lower urinary tract sxs
could suggest overactive bladder, dysfxtional voiding or something more serious
How old must a child be for nocturnal enuresis?
5
Common comorbidity a/w enuresis?
Constipation
Others: UTI, OSA, overactive bladder, ADHD. DM, DI, Sickle cell anemia
Initial Tx for Enuresis
Behavioral modifications
Most effective Tx for enuresis
Bed Alarm therapy
How old must be to start pharmacotherapy for enuresis? what drug MC used?
Kids must be age 7 or older
MC used = DDAVP (Desmopressin)