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Peds II Unit I > Peds Urology > Flashcards

Peds Urology Flashcards

1
Q

The inability to retract the foreskin is referred to as…

A

Phimosis

Can be either physiologic or pathologic

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2
Q

Normal state where foreskin adheres to the glans

A

Physiologic phimosis

Adhesions decrease with age naturally

Incidence of fully retractable foreskin highly variable

NO NEED TO TREAT unless pathologic

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3
Q

Non-retractable foreskin due to scarring/fibrosis that occurs secondary to infection or inflammation or early forcible retraction

A

Pathologic phimosis

Treatment typically required

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4
Q

Clinical presentation for pathologic phimosis

A

Secondary non-retractability after having had fully retractable foreskin

Painful erections

Irritation or bleeding

Dysuria and/or urinary retention

Recurrent infections (balanitis, UTI)

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5
Q

Treatment options for pathologic phimosis

A

Stretching exercises (gently pulling foreskin back BID)

Topical corticosteroid

Circumcision (rarely indicated)

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6
Q

How do you take care of an uncircumcised penis?

A

Avoid forcible retraction at any age

Stop retraction if met with any resistance

Foreskin requires no special care other than what is provided to the rest of the body (cleaning with mild soap and water)

Return foreskin to natural position after cleaning

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7
Q

If you don’t return the foreskin to its natural position after cleaning b/c if not, it can lead to …

A

Paraphimosis - and you’ll have to call the PARAmedics

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8
Q

Urologic emergency in which a retracted foreskin cannot be returned to natural position

A

Paraphimosis

Pathophysiology: entrapment —> impaired venous flow —> engorgement —> arterial compromise

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9
Q

Causes of paraphimosis

A

Forcible retraction of partially phimosis skin by caretaker

Infection or inflammation

Genitourinary procedures (iatrogenic)

Sexual activity, penile trauma (less frequent)

Penile piercings

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10
Q

SSx of paraphimosis

A

Sx: Swelling of the penis, penile pain, irritability in a preverbal infant

Exam: Edema/tenderness of the glans, tender swelling of the distal retracted foreskin (constricting band), color change (blue/black) if ischemia is present

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11
Q

How do you treat paraphimosis

A

Pain control

Timely, manual reduction in office or ED

Surgical intervention by urology

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12
Q

Surgical removal of the foreskin

A

Circumcision

Families usually consider religious, family or cultural factors before medical factors in deciding whether or not to circumcise

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13
Q

Overall prevalence of circumcision in the US

A

80% - higher than in other western countries but declining

Highest rates in Midwest, lowest in West

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14
Q

Benefits of circumcision

A

Decreased rate of UTI (4-10x less likely, but male UTIs typically uncommon)

Decreased rate of penile cancer (from studies before HPV vaccine came into use)

Decreased penile inflammation/dermatoses

Decreased rates of SOME STIs (no effect on susceptibility to gonnorhea or chlamydia)

Benefits greater in infants with congenital uropathy

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15
Q

Risks of circumcision

A

Procedure related complications (0.2-2%)

Inadequate skin removal, bleeding, infection, urethral complications

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16
Q

Female partner of an uncircumcised male is at higher risk for…

A

Cervical cancer due to HPV susceptibility

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17
Q

Potential concerns of circumcision that have not been supported by studies

A

That it leads to sexual dissatisfaction and breast feeding failure

That no anesthesia is used (truth: AAP and major guidelines recommend pharmacological analgesia)

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18
Q

Contraindications for circumcision

A

Unstable infant

Congenital penile anomalies (ie hypospadias, chordee) b/c might need the tissue later for surgical repair of such abnormalities

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19
Q

The AAP stance on circumcision

A

The health benefits of newborn male circumcision outweigh the risks, but the benefits are NOT great enough to recommend routine circumcision for all newborn boys

The final decision should still be left to parents to make in the context of their religious, ethical and cultural beliefs

ACOG has also endorsed this stance

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20
Q

Two different types of circumcision

A

Gomco - metal device holds foreskin for cutting

Plastibell - stays in place until it falls off together with foreskin

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21
Q

Congenital anomaly with abnormal dorsal displacement of the urethral opening

A

Epispadias

May occur with bladder extrophy - exposed bladder, onto the lower abdomen (many times found on prenatal ultrasound)

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22
Q

Congenital anomaly that results in the abnormal ventral displacement of the urethral opening

A

Hypospadias

Displacement varies - glans, shaft, scrotum, perineum

Incidence: 0.3-0.7% of live male births - much more common than epispadias

May also involve chordee

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23
Q

What the heck is a chordee?

A

Abnormal penile curvature

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24
Q

Diagnosis of hypospadias and chordee usually occurs…

A

During newborn exam

PE may include:
• Abnormal foreskin
•A second opening, with one a false opening
• Abnormal penile curvature (chordee)

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25
Q

You diagnosed hypospadias and/or chordee. Now what?

A

If FH of hypospadias, do through exam (look for other congenital anomalies)

Check for palpable testes
• If cryptorchidism, consider Disorder of Sexual Development (ambiguous genitalia)

Referral to urology

Treatment
• DO NOT circumcise newborn
•Surgery usually performed ~6 months of age to fix

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26
Q

The most common GU congenital abnormality

A

Cryptorchidism (hidden or absent testis)

A testis that is not within the scrotum and does not spontaneously descend into the scrotum by 4 months of age

2 to 5% of term infants and up to 30% of premature infants

70% resolve spontaneously

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27
Q

Cryptorchidism should be monitored closely, as it my increase risk of …

A

Testicular torsion (10x more common)
Subfertility (risk improves if corrected before 1 year of age)
Testicular cancer

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28
Q

Different classifications of cryptorchidism

A

ABSENT testis - from a genesis or atrophy (possibly torsion in utero)

UNDESCENDED testes: stopped short along normal descent

RETRACTILE testes: overactive cremasteric reflex pulls testis back inside

Other less common possibilities:
ASCENDING testes
ECTOPIC testes

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29
Q

Clinical presentation of cryptorchidism

A

Absent testicle usually unilaterally (10% BL) with flat, underdeveloped scrotum

Further testing recommended if BL

Good physical exam is the key

Most cases descend spontaneously by 3-4 months age. If not, refer.

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30
Q

Most common location for undescended testis is…

A

Suprascrotal

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31
Q

Treatment for cryptorchidism

A

Urology referral

Spontaneous descent is rare after 6 months of age

Surgery recommended as soon after 6 months as possible (ideally before 1 year)

Orchiopexy: Testicle is brought down and attached into the scrotum
Allows for improved testicular growth and fertility potential

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32
Q

Twisting of the spermatic cord due to a poorly anchored testicle

A

Testicular torsion —> Risk of vascular compromise

Incidence: 1 in 4000 males < 25 years

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33
Q

The two peak periods of incidence of testicular torsion

A

Neonatal period (only about 10%)

During puberty (12-18)

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34
Q

Clinical presentation of testicular torsion

A

ABRUPT onset of SEVERE testicular or scrotal pain
Pain usually constant
Nausea and vomiting (90%)

PE:
• Edematous, infuriated, erythematous scrotum
• Affected testis tender, swollen and slightly elevated (high riding)
• Absent cremasteric reflex (stroking inner thigh)
• Negative Prehn’s sign

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35
Q

What is Prehn’s sign

A

Elevation of scrotum —> pain relief

(+) with epididymitis
(-) with testicular torsion

36
Q

Diagnosing testicular torsion

A

History and physical can indicate a high likelihood even without imaging

Doppler ultrasound (shows position of testes and blood flow) is the confirmatory test of choice

37
Q

Treatment for testicular torsion

A

IMMEDIATE consult with urologist

Surgical decoration and fixation (orchiopexy) of both testes (b/c high risk for it happening again)

Prognosis depends on duration and completeness of torsion

38
Q

Differing prognosis of testicular torsion depending on timing

A

Detorsion within 4-6 hours = 100% viable

Detorsion after 12 hours = 20 % viable

Detorsion after 24 hours = 0 % viable

39
Q

The two different types of urinary tract infection

A

Cystitis (just the bladder)

Pyelonephritis (affecting kidneys) —> CVA tenderness

40
Q

Etiology of UTIs

A

Usually from ascending bacteria

~80% from E.coli
Klebsiella, Proteus, Enterococcus, S.aureus possible as well

Viruses or fungi less common

41
Q

Risk factors for UTIs

A 
Female gender
Urinary tract anomalies
Bowel and bladder dysfunction (chronic constipation)
Vesicoureteral Reflux (VUR)
Sexual activity
Bladder catheterization
Hx of previous UTI
Lack of circumcision
42
Q

Clinical presentation of UTIs in younger children

A 
May have non-specific symptoms 
• Fever w/o another clear source (fever may be the only Sx)
• Vomiting
• Irritability
• Poor appetite
43
Q

Clinical presentation of UTIs in older children

A

May have more classic symptoms

Dysuria, frequency, urgency
Abdominal/suprapubic pain
Back/flank pain
New-onset urinary incontinence

44
Q

Physical exam for UTI

A

Vitals: BP, temp, and growth parameters

Abdominal exam for tenderness or mass

Suprapubic and CVA tenderness

Examination of the external genitalia (look for abnormalities or STI)

Search for other sources of fever

45
Q

How exactly do you get a kid to give you a urine sample

A

If potty trained:
Clean-voided specimen

If not potty trained:
Catheterized specimen recommended
Suprapubic aspiration when catheterization not feasible (rare)

Do NOT use a bag collection

46
Q

If clinical suspicion for UTI, you should…

A

Obtain UA and culture

UA:
• Significant bacteriuria with (usually) pyuria
•(+) leukocyte esterase (created upon WBC breakdown)
• (+) nitrite (produced by gram negative rods)

Culture and sensitivities:
• Sensitivities help to direct treatment

47
Q

UTI treatment options

A

Consider PO vs IV (agent of choice should be guided by local resistance pattern)

Duration of treatment in peds: 3-10 days (if no fever, maybe 3-5)

Choice of Abx: begin with empiric therapy and adjust per C&S
• Cephalosporin (cephalexin or cefdinir)
• Amoxicillin
• Augmenting
• Bactrim
(Increasing rates of resistance to the latter three)

48
Q

Do you need to do a follow up UA for UTIs?

A

No f/u UA is recommended when using C&S if you do it when initially diagnosing

49
Q

Other UTI follow up modalities

A

Renal Bladder Ultrasound (RBUS) - Firstline imaging study in patients with UTI if indicated (noninvasive)

Voiding cystourethrogram (VCUG)
Renal scintigraphy

Some controversy related to use of VCUG and RS

50
Q

Who gets a RBUS?

A

Firstline imaging study in pts with complicated UTI
• <2 years with first febrile UTI
• Children of any age with recurrent UTI
• Children with a UTI and FH of renal or urologic disease, poor growth, or HTN
• Children who do not respond to appropriate antibiotic therapy

51
Q

When do we do a voiding cystourethrogram?

A

Invasive (radiation and catheter)

Test of choice to detect vesicoureteral reflux

Children of any age with ≥2 febrile UTIs

Children of any age with 1st febrile UTI and:
• Any anomaly on RBUS or
• Temp > 102.2 and pathogen other than E.coli or
• Poor growth or HTN

52
Q

Retrograde flow of urine from the bladder into teh upper urinary tract, usually due to inadequate closure of ureterovesicular junction (UVJ)

A

Vesicoureteral Reflux (VUR)

Occurs in 1% of newborns and 30-45% of children with a UTI

Impact of VUR and management is controversial

Clinical presentation: Hydronephrosis (prenatal) or post natal febrile UTI

53
Q

How do you diagnosis vesicoureteral reflux

A

VCUG - catheter placed and contrast injected, under fluoroscopy, movement of contrast and anatomy watched while pt voids

VCUG allows us to grade severity I (mild) to V (severe)

54
Q

Possible risks in patients with VUR

A

Recurrent infections

Scarring and damage to kidney

Many cases spontaneously resolve

Must weigh the benefit of VCUG with the radiation risk, cost, and discomfort

55
Q

What’s the deal with the controversy regarding optimal management of VUR?

A

Watchful waiting/surveillance - hard in infants so rare

Low dose prophylactic abx

Surgical correction only if grade 4/5

Monitoring of reflux

Aggressive screening (UA) in febrile/symptomatic pts with repeat testing at 18 months

56
Q

Nuclear medicine scan using radioisotope dimercaptosuccinic acid (DMSA) to detect acute pyelonephritis and renal scarring

A

Renal scintigraphy

Areas of decreased uptake of DMSA indicate scarring or inflammation
DMSA scans expensive, invasive, involve radiation
Role in acute UTI is controversial
Not recommended in routine evaluation of kids with first UTI

57
Q

Indications for referral in kids with UTI

A

Severe VUR (Grade III-V) or obstruction

Renal abnormalities

Impaired kidney function

Elevated BP

Bowel and bladder dysfunction refractory to primary care measures

58
Q

The most common type of renal fusion

A

Horseshoe kidney - fusion of one pole of each kidney, caused by abnormal migration of kidneys (5th-9th week gestation)

Usually asymptomatic but occasionally may have pain, hematuria (from infection or obstruction)

59
Q

Anomalies and syndromes associated with horseshoe kidney

A

VUR, hypospadias, undescended testes

1/3-1/2 of patients have another urological or genital abnormality

May also be associated with other genetic disorders (ie Turner, Downs)

60
Q

A patient with horseshoe kidney has a small increased risk for …

A

Wilms Tumor (most common renal malignancy in kids)

61
Q

Diagnosing horseshoe kidney

A

Ultrasound, VCUG (if UTI), serum creatinine

If CR is normal and no hydronephrosis, no further eval.

If CR elevated or hydronephrosis present, additional renal scans required

Excellent prognosis in post patients without any intervention

If VUR present, consider prophylactic abx

62
Q

Medical term for bed wetting

A

Nocturnal Enuresis

Urinary incontinence during sleep is common in kids ≥ 5

15% of all 5 year olds have some nocturnal enuresis, but 15%/year have spontaneous resolution

63
Q

Etiologic considerations in cases of nocturnal enuresis

A

Genetic tendency (if 1 parent, 50% affected; if 2 parents, 75% affected; if 0 parents, 15% affected)

Bladder maturation

Organic cause

64
Q

First line treatment for enuresis

A

Educational/motivational therapy

Emphasis it is not the fault of the child or the caregiver

Void regularly during day and multiple times just before bed

Attention to timing of fluid intake (increase hydration in am and afternoon)

Motivation - sticker charts, enuresis alarms

65
Q

Most effective long term therapy for nocturnal enuresis?

A

Enuresis alarms - those creepy electronic gadgets that hook up to a maxi pad looking thing and let you know when the kid wets the bed.

66
Q

Second line treatment for nocturnal enuresis if pt ed fails

A

Pharmacotherapy (if greater than 6 months of problems)

DDAVP/Desmopressin (synthetic ADH) - effective short term but high relapse rate

67
Q

Why do AAP guidelines no longer recommend routine screening UA in asymptomatic healthy peds patients?

A

High false positive for proteinuria/hematuria

Costly, exhaustive workup/concerned families

Still occurring in some offices though

68
Q

What to do first if you notice a change in urine color to red or brown…

A

Determine if it is truly blood or something else

69
Q

DDx for hematuria

A 
UTI, kidney stone, malignancy
Mental or perineal irritation
Trauma
Glomerular disease (post-infectious glomerulonephritis, Henoch-Schonlein purpura, HUS, Alpert syndrome)
FH of SLE, sickle cell, early menses

Discoloration that may not be hematuria - beeturia, pyridium use, food dyes

70
Q

Hx questions to ask in cases of hematuria

A

Recent vigorous exercise or trauma?

UTI symptoms?

Flank pain (+/- radiation, fever)

Brown vs red urine (upper vs lower urinary tract)

Hx of recent illness (last 2-3 weeks)

Personal or FH of medical conditions (sickle cell or coagulopathy)

71
Q

Physical exam suggestions for patients with hematuria

A

BP

Evaluate for periorbital or peripheral edema, weight gain

Skin exam for rash (purpura)

Palpable kidneys or CVA tenderness

Visualization of the genitals

Abdominal exam (for discomfort or masses)

72
Q

________% of kids have a + blood on urine dipstick

A

3-4

If microscopic hematuria (> 3 RBCs per HPV), if asymptomatic, repeat UA dip and microscopy in 2-3 weeks —> if resolved, f/u prn

Consider the following:
• Urine Cx if UTI suspected
• Renal/bladder US
• Referral

73
Q

What to do in cases of gross hematuria

A

UA with micrscopy/urine Cx
Serum CR
Serum complement (low level seen in SLE, glomerular etiology)
Consider antistreptolysin Ab (ASO), ANA

Imaging: RBUS/CT without contrast

If persistent - refer

74
Q

What does “Throat, Bloat, Coke” refer to?

A

Post-Infectious Glomerulonephritis

Typically follows (7-14 days) infection with group A ß-hemolytic strep (usually PHARYNGITIS or impetigo)

COLA-colored urine

EMEMA (peri-orbital, peripheral) b/c kidneys aren’t removing waste and fluid efficiently

Will have some degree of renal insufficiency and elevated BP

75
Q

Lab results that confirm post-infectious glomerulonephritis

A

Gross hematuria - dark colored urine (coffee, COLA, tea)
Urine microscopy with RBC too numerous to count (TNTC)
Urine microscopy with RBC casts (pathognomonic for GN)
Increased serum CR
(+) ASO (antistreptolysin Ab) titer
Low complement (C3, C4)

What do we do then? Supportive care (varies based on severity)

76
Q

Another sweet name for Immunoglobulin A Vasculitis

A

Enoch-Schonlein Purpura (HSP)

Immune mediated response (IgA), cause unknown

77
Q

Classic tetrad for Hemochromatosis-Schonlein Purpura/IgA vasculitis

A

Abdominal pain

Typical maculopapular purpura rash (1/4 of the time its the last symptom) - usually on lower extremities

Arthralgias (knees and ankles most common)

Renal involvement - severity varies

78
Q

Ok, you’re a rock star and suspect HSP. What do you do to treat it?

A

Supportive care (whomp whomp)

Symptoms will spontaneously resolve

79
Q

One of the main causes of acute kidney injury in kids, associated with shiga toxin producing E.coli in 90% of cases

A

Hemolytic-Uremic Syndrome (HUS)

80
Q

SSx of HUS

A

Usually prodromal illness with abdominal pain, vomiting, diarrhea (usually bloody) followed by classic triad:
• Hemolytic anemia
•Thrombocytopenia
• Acute kidney injury (hematuria, proteinuria to severe renal failure)

Initial labs: CBC, peripheral smear, renal function, UA

81
Q

Do we treat HUS with abx?

A

Nope

Supportive care (ICU, possibly dialysis) but abx therapy NOT recommended

82
Q

Rare inherited, progressive glomerular disease caused by genetic mutations that affect collagen proteins in kidneys, eyes, ears

A

Alpert Syndrome (Hereditary Nephritis)

Consider if (+) FH of end-stage renal failure

Syndrome includes:
• Glomerular disease (microhematuria initial finding)
• Deafness (sensorineural hearing loss)
• Visual disturbances

83
Q

Foamy urine is indicative of what?

A

Proteinuria (excessive amount of protein in the urine)

84
Q

DDx for Proteinuria

A 
Benign/transient (fever, hypovolemia, exercise)
SLE
DM
Glomerulonephritis
Nephrotic Syndrome
85
Q

Renal disease (intrinsic or post-infectious) causing massive renal protein loss in urine

A

Nephrotic Syndrome

86
Q

Four main characteristics of NephrOtic Syndrome?

A

NephrOtic range prOteinuria

HypOalbuminemia

Edema (usually face - round O-shape) due to Na and H2O retention

Hyperlipidemia (O=donuts?) - body compensates protein loss by increasing the synthesis of albumin, as well as other molecules including LDL and VLDL

87
Q

What do you do to evaluate a patient with proteinuria?

A

BP

UA with microscopy (urine dipstick helpful as a screen)

First AM void UA to check for proteinuria prior to meal/activity

Protein/CR ratio

CMP

Other testing as indicated by H&P

Refer to nephrology

Peds II Unit I (4 decks)

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