Renal and urology Flashcards
What is cystitis?
Inflammation of the bladder
What is pyelonephritis?
Inflammation of the kidneys
How do UTIs present in children?
Fever may be the only symptoms - especially in young children.
Dysuria - painful stinging / burning when urinating
Suprapubic pain or discomfort
Frequency / Urgency
Haematuria
Nocturia / incontinence
Cloudy / foul smelling urine
In babies - irritability, poor feeding
How is a UTI diagnosed?
Ideally clean catch urine sample.
Urine dip looking at
- nitrites (gram negative bacteria bake down nitrates which are normally in the urine into nitrites)
- leukocytes - WBCs
Midstream urine sample for microscopy, culture and sensitivity testing
How are UTIs managed?
Oral antibiotics if otherwise well. If not IV can be considered.
Follow local guidelines but commonly give
- trimethoprim
- nitrofurantoin
- cefalexin
- amoxicillin
What investigations are done for investigating recurrent UTIs in children?
- Ultrasound scans
- DMSA (dimercaotisuccinic acid) scan - inject radioactive material and use a gamma camera to assess how well it is taken up by the kidney. If not this may indicate areas of scarring)
- Micturating cystourethrogram - looking for Vesico-ureteric reflux
What is vesico-ureteric reflux?
When the urine has a tendency to flow from the bladder back up into the ureters
What are complications of vesico-ureteric reflux?
Recurrent upper UTIS / pyelonephritis and subsequent renal scarring.
How is vesico-ureteric reflux managed?
- avoid constipation
- avoid an excessively full bladder
- prophylactic antibiotics
- surgical input from paeds urology
When is a micturating cystouretrogram (MCUG) done?
- investigate atypical or recurrent UTIs in children under 6 months
- family history of vesico-ureteric reflux
- dilation of the ureter on ultrasound
- poor urinary flow
How is a micturating cystourethrogram done?
Catheterising the child, injecting contrast into the bladder and taking a series of xray films.
Prophylactic antibiotics are often given for 3 days around this investigation
What is vulvovaginitis?
inflammation and irritation of the vulva and vagina.
Who is normally affected by vuvlovaginitis?
Girls between the ages 3-10 (pre puberty)
What can cause / exacerbate vulvovaginitis?
Irritation of the sensitive and skin thin
- wet nappies
- use of chemicals and soaps in that area
- tight clothing trapping moisture
- poor toilet hygiene
- constipation
- threadworms
- pressure on that area - e.g. horseriding
- heavily chlorinated pools
Why is vulvovaginitis less common after puberty?
As oestrogen helps keep the skin and vaginal mucosa healthy and resistant to infection
How does vulvovaginitis present?
- soreness
- itching
- erythema around the labia
- vaginal discharge
- dysuria (burning/stinging on urination)
- constipation
What may vuvlovaginitis be misdiagnosed for?
A UTI - as dipstick may show leukocytes but no nitrites
How is vuvovaginitis managed?
- normally symptomatic management (however they are often unnecessarily treated for UTIs or thrush)
- avoid washing with soaps and chemicals
- avoid perfumed/antispeetic products
- good toilet hygiene - wipe from front to back
- keep area dry
- emollients can sooth the area
- loose cotton clothing
- treating constipation and worms where appropriate
How is vuvovaginitis managed?
- normally symptomatic management (however they are often unnecessarily treated for UTIs or thrush)
- avoid washing with soaps and chemicals
- avoid perfumed/antiseptic products
- good toilet hygiene - wipe from front to back
- keep area dry
- emollients can sooth the area
- loose cotton clothing
- treating constipation and worms where appropriate
- if severe a specialist may prescribe oestrogen cream
What is hypospadias?
A congenital condition - Where a males urethral meatus (opening) is on the ventral side (underneath) of the penis towards the scrotum.
There may also be chordee - ventral (downwards) curvature of the penis.
How is hypospadias managed?
- mild may not require treatment
Surgery - usually at 3/4 months old
Urethroplasty - Aims to correct the position of the meatus and straighten the penis.
Circumcision or reconstruction of foreskin may also be done.
What are some complications of hypospadias?
Difficulty directing urine
Cosmetic + psychological concerns
Sexual dysfunction
Post surgery - risk of urethral fistula or urethral stenosis
Describe the normal descent of the testes (embryologically)?
Testes develop in the abdomen
Migrate down, through the inguinal canal into the scrotum (normally have reached here prior to birth)
(should i go into more detail - go over proper embryology)
What is cryptorchidism?
Undescended testes
What are risk factors for cryptorchidism?
Family history of undescended testes
Low birth weight
Small for gestational age
Prematurity
Maternal smoking during pregnancy
What are some complications of cryptorchidism?
At puberty there is a higher risk of
- testicular torsion
- infertility
- testicular cancer
How is cryptorchordism managed?
Watch in first 6 months as often descend themselves.
After 6 months refer to a urologist.
Orchidopexy (surgical correction) should be done between 6 + 12 months of age
What is orchidopexy?
The surgery involved in correcting undescended testes.
What is a hydrocele?
A collection of fluid in the tunica vaginalis that surrounds the testicles.
How will a hydrocele present?
Usually painless
Soft, scrotal swelling
Testicle is palpable within
Irreducible
Transilluminates by shining a torch through the skin
How is a hydrocele managed?
Normally conservative
Surgery (hydrocelectomy) or aspiration + sclerotherapy if large / symptomatic.
In children may do a surgery - ligation of the patent processus vaginalis
What is Wilms tumour?
A specific type of tumour affecting the kidneys in children (particularly <5 years)
How do Wilms tumours present?
- mass in abdomen
- abdominal pain
- haematuria
- lethargy
- fever
- hypertension (headaches)
- weight loss
How is Wilms tumour diagnosed?
- initially ultrasound
- CT or MRI to stage the tumour
- biopsy is required to make a definitive diagnosis
How is Wilms tumour managed?
- surgical excision along with the affected kidney (nephrectomy)
- adjuvant treatment depends on stage, histology and if it has metastised
- can be chemo or radiotherapy
What is the prognosis of Wilms tumour?
Early stage have good chance of cure >90%.
Metastatic = poorer prognosis.
What is haemolytic uraemic syndrome and what triad does it cause?
A condition where there is thromosis within small blood vessels throughout the body.
It causes
- haemolytic anaemia
- AKI (acute kidney injury)
- thrombocytopenia
What causes haemolytic uraemic syndrome?
A bacterial toxin - shiga toxin. This is produced by e.coli or shigella.
The risk is increased when antibiotics or anti motility drugs (loperamide) are used to treat gastroenteritis.
How does haemolytic uraemic syndrome present?
Preceded with gastroenteritis (often w. bloody diarrhoea).
Symptoms of HUS normally after 5 days
- reduced urine output
- haematuria / dark brown urine
- abdominal pain
- lethargy and irritability
- confusion
- oedema
- hypertension
- bruising
How is haemolytic uraemic syndrome managed?
Medical emergency.
Self limiting - so supportive management.
Patients may require
- dialysis
- antihypertensives
- careful maintenance of fluid balance
- blood transfusions
What is enuresis?
Involuntary urination
What is diurnal enuresis?
Inability to control bladder function in the daytime
At which age do children get control of daytime and nighttime urination?
Daytime by 2 years.
Nighttime by 3-4 years
What is primary nocturnal enuresis?
Where the child has never managed to be consistently dry at night.
What can cause primary nocturnal enuresis?
- variation on normal development (<5 years)
- overactive bladder
- fluid intake (prior to bedtime - fizzy drinks, juice or caffeine have diuretic effect)
- psychological distress
- secondary causes - chronic constipation, UTI, learning disability, cerebral palsy.
How is primary nocturnal enuresis managed?
- 2 week diary of toileting, fluid intake and bedwetting episodes.
- reassure parents of children <5
- lifestyle changes
- encouragement and positive reinforcement
- pharmacological management
What is secondary nocturnal enuresis?
when a child begins wetting the bed when they have previously been dry for at least 6 months
What can cause secondary nocturnal enuresis?
- UTI
- constipation
- type 1 diabetes
- psychosocial problems
- maltreatment / abuse
What can cause diurnal enuresis?
- urge incontinence - overactive bladder
- stress incontinence
- psychosocial problems
- recurrent UTIs
- constipation
What pharmacological management can be used for enuresis and how do they work?
- desmopression - vasopressin analogue - reduced volume of urine produced by the kidneys (taken before bed for nocturnal)
- oxybutinin - anticholinergic - reduces contractility of the bladder
- imipramine - tricyclic antidepressant. Mechanism is unknown
What is a proximal urethral valve?
Where there is extra tissue at the proximal end of the urethra (near the bladder) that causes obstruction of urine output. This causes a build up of pressure and hydronephrosis.
How does a proximal urethral valve present?
Can vary in severity
- difficulty urinating
- weak urinary stream
- chronic urinary retention
- palpable bladder
- recurrent UTIs
- impaired kidney function
How can severe proximal urethral valve affect the developing fetus?
Obstruction causing bilateral hydronephrosis and oligohydramnios. This leads to underdeveloped lungs (respiratory hypoplasia) with respiratory failure shortly after birth
How is a proximal urethral valve investigated?
- prenatally may be picked up on antenatal scans (oligohydramnious and hydronephrosis)
- abdominal ultrasound - enlarged thickened bladder and bilateral hydronephrosis
- MCUG - micturating cystourethrogram
- cystoscopy - insert camera into urethra to view extra tissue. Can also then ablate or remove extra tissue
How is a proximal urethral valve managed?
- mild cases may just be observed and monitored
- may insert a temporary urinary catheter
- definitive management - ablation or removal of extra tissue - usually during cystoscopy
When does polycystic kidney disease present?
Autosomal dominant presents in adults.
Autosomal recessive presents in neonates
What does the pathology in autosomal recessive polycystic kidney disease (ARPKD) cause ?
- cystic enlargement of the renal collecting ducts
- oligohydramnios, pulmonary hypoplasia and Potter syndrome
- congenital liver fibrosis = liver failure = portal hypertension
- progressive renal failure = hypertension
- chronic lung disease
What is the prognosis for autosomal recessive polycystic kidney disease (ARPKD)?
Poor prognosis
- 1/3rd die in neonatal period.
- 1/3rd will survive to adulthood
What is multicystic dysplastic kidney?
Where one of the baby’s kidneys has multiple cysts whilst the other is normal. Usually survive on a single kidney and the other one will atropy before 5 years of age.
