Peds Exam 1 Lecture 6: Renal/GU Flashcards by Tessa Janus

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

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What is typically seen w/Hydrocele with transillumination?

Bilateral Illumination

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What population, sex, age range and side are MC for inguinal hernias?

MC in

premature infants
Boys > girls
< 1 yr
R side

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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

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What is a common PE finding for Incarcerated inguinal hernia?

Testicle appears blue

pressure on spermatic cord–> venous congestion

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Dx test to differentiate hydrocele from inguinal hernia

What is major difference b/t two diseases?

Inguinal Hernia = Painful
Hydrocele = Painless

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What are Tx steps for incarcerated inguinal hernia?

Try to manually reduce

2. Do elective surgical repair

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When should a manual reduction of an incarcerated inguinal hernia NOT be attempted?

child appears ill, signs of peritonitis, obstruction or toxicity

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When should an emergent surgical repair of an incarcerated inguinal hernia be performed?

Child is ill or hernia cant be manually reduced

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Tx for hydrocele w/no mass or reducible mass?

Refer for surgery (not emergent) but do promptly to prevent progression to incarceration

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Dilation of pampiniform plexus

Variocele

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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

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List 3 Grades of Variocele

Present only w/Valsalva
Present w/out Valsalva but not visible
Visibly present (most risk of arrested testicular growth)

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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

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MC d/o of sexual differentiation in boys

Cryptochidism

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Timeframe for testicular descent

7-8 months gestation

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At what age is Cryptochidism likely permanent?

4 months

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4 consequences of Cryptochidism?

Torsion
Testicular malignancy
Indirect hernia
Infertility

“Tommy’s Testicle Is Indiscernible”

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What imaging is recommended for Cryptochidism?

NONE - routine imaging not recommended

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Timeframe for surgery w/Cryptochidism

6 months = earliest

no later than 9-15 months

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What is concerning for ambiguous genitalia?

Bilateral undescended testes

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Definition of micropenis

< 2.5 SD for gestational age

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What is micropenis due to?

Testicular failure during fetal life after morphogenesis is complete

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What two things together are concerning for congenital hypopituitarism?

Hypoglycemia + Micropenis

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What 4 things are part of the evaluation for Micropenis?

1. Karyotype 2. Assess anterior pituitary function 3. Assess testicular function 4. 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

1. Reduction in UTIs, STIs (HIV) 2. Reduction in phimosis/paraphysmosis 3. Prevent penile SCC 4. Easier Hygiene

Before circumcision is done what 3 things should be confirmed?

1. infant at least 12 hrs old (24 preferred) 2. infant voided 3. 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)

1. Hypospadias 2. Chordee w/out Hypospadias 3. Dorsal hood deformity 4. Micropenis 5. Wandering/crooked raphe 6. bilat undescended testes 7. Ambiguous genitalia 8. Bleeding diathesis

Risks a/w Circumcision?

1. 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

1. 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

1. Lack of estrogenization, protective hair & labial fat pad 2. Proximity of vagina to anus 3. Poor hygiene, irritants, contamination

3 main Tx concepts for non-specific | vulvovaginitis

1. Keep area dry/aerated 2. Decrease irritants 3. Sitz bath

How often/ingredient of sitz bath?

2x daily w/ 3 tbsp of baking soda

3 main clinical findings of labial adhesions

1. Fusion of labia minor 2. interference w/voiding 3. Recurrent UTIs

3 Tx options for Labial adhesions

1. Gentle traction (separates labia) --> 3-5 days of estrogen cream 2. Hormonal cream (no traction) for several weeks 3. 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: 1. Higher fever 2. chills 3. N/V 4. 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?

1. Hx of UTI | 2. Hx of congenital GU anomaly

What three factors when combined on UA have a high specificity for UTI?

1. Leuk esterase 2. Nitrites 3. 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?

1. All kids not toilet trained 2. ALL BOYS 3. Toilet trained girls w/recurrent UTIs

When is VCUG recommended in kids not toilet trained?

1. Urinary dilatation or scarring 2. Recurrent febrile UTI 3. Urosepsis 4. UTI d/t organism other than E. coli 5. 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?

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)