Renal and Urology Flashcards
What is the most common abdominal tumour in children under 5?
Wilm’s tumour is the most common abdominal tumour in children. It is also known as nephroblastoma and is most common in children under 5 with a peak incidence between 3-4 years of age.
Presentation of Wilm’s tumour
It presents with a palpable abdominal mass, distension and haematuria
Wilm’s tumours typically do not cross the midline but in up to 5% of cases they may be bilateral.
What is a urinary tract infection?
The urinary tract includes the urethra, bladder, ureters and kidneys. Urinary tract infections are infections anywhere along this pathway.
What is acute pyelonephritis?
Acute pyelonephritis is when the infection affects the tissue of the kidney. It can lead to scarring in the tissue and consequently a reduction in kidney function.
What is cystitis?
Cystitis means inflammation of the bladder, and can be the result of a bladder infection.
Babies will present with very non-specific symptoms of UTI, such as?
Fever
Lethargy
Irritability
Vomiting
Poor feeding
Urinary frequency
Signs and symptoms of UTI in older infants and children are more specific, and inlcude what?
Fever
Abdominal pain, particularly suprapubic pain
Vomiting
Dysuria (painful urination)
Urinary frequency
Incontinence
When is the diagnosis of acute pyelonephritis made and why is this significant?
The diagnosis of acute pyelonephritis is made if either there is:
- A temperature greater than 38°C
- Loin pain or tenderness
This is a very important point to note, as it affects the way you would investigate the child for recurrent infections.
Urine dipstick - ?UTI
The ideal urine sample is a clean catch sample, avoiding contamination. This can be tricky in younger children and babies, particularly girls. This often involves the parent sat with the infant without a nappy and a urine pot held ready to catch the sample if it occurs. A clean catch sample is important to avoid contamination and unreliable microbiology results.
Nitrites – gram negative bacteria (such as E. coli) break down nitrates, a normal waste product in urine, into nitrites. The presence of nitrites suggest bacteria in the urine.
Leukocytes – leukocytes are white blood cells. There are normally a small number of leukocytes in the urine, however a significant rise can be the result of an infection or another cause of inflammation. A urine dipstick tests for leukocyte esterase, a product of leukocytes that give an indication about the number of leukocytes in the urine.
Nitrites are a better indication of infection than leukocytes. If both are present the patient should be treated as a UTI. If only nitrites are present it is worth treating as a UTI. If only leukocytes are present the patient should not be treated as a UTI unless there is clinical evidence they have one.
If nitrites or leukocytes are present, the urine should be sent to the microbiology lab. If neither are present the patient is unlikely to have a UTI.
Send a midstream urine (MSU) sample to the microbiology lab to be cultured and have sensitivity testing.
Managing UTIs in children?
All children under 3 months with a fever should start immediate IV antibiotics (e.g. ceftriaxone) and have a full septic screen, including blood cultures, bloods and lactate.
A lumbar puncture should also be considered.
Oral antibiotics can be considered in children over 3 months if they are otherwise well. Children with features of sepsis or pyelonephritis will require inpatient treatment with IV antibiotics. Always follow local guidelines. Typical antibiotic choices in urinary tract infections in children are:
Trimethoprim
Nitrofurantoin
Cefalexin
Amoxicillin
Typical antibiotic choices in urinary tract infections in children?
Trimethoprim
Nitrofurantoin
Cefalexin
Amoxicillin
Over what age can oral antibiotics be considered for a child with UTI
3 months
Recurrent UTIs should be investigated for an underlying cause and renal damage. What kind of investigations might be undertaken?
Ultrasound Scans
DMSA (Dimercaptosuccinic Acid) Scan
Micturating Cystourethrogram (MCUG)
Investigating recurrent UTIs in children - when do NICE recommend USS?
All children under 6 months with their first UTI should have an abdominal ultrasound within 6 weeks, or during the illness if there are recurrent UTIs or atypical bacteria
Children with recurrent UTIs should have an abdominal ultrasound within 6 weeks
Children with atypical UTIs should have an
abdominal ultrasound during the illness
Investigating recurrent UTIs in children - what is a DSMA scan when do NICE recommend them?
DMSA scans should be used 4 – 6 months after the illness to assess for damage from recurrent or atypical UTIs.
This involves injecting a radioactive material (DMSA) and using a gamma camera to assess how well the material is taken up by the kidneys.
Where there are patches of kidney that have not taken up the material, this indicates scarring that may be the result of previous infection.
What is vesico-ureteric reflux and how is it diagnosed?
Vesico-ureteric reflux (VUR) is where urine has a tendency to flow from the bladder back into the ureters. This predisposes patients to developing upper urinary tract infections and subsequent renal scarring.
This is diagnosed using a micturating cystourethrogram (MCUG).
Management of vesico-ureteric reflux
Avoid constipation
Avoid an excessively full bladder
Prophylactic antibiotics
Surgical input from paediatric urology
Investigating recurrent UTIs in children - what is an MCUG and when do NICE recommend them?
Micturating cystourethrogram (MCUG) should be used to investigate atypical or recurrent UTIs in children under 6 months.
It is also used where there is a family history of vesico-ureteric reflux, dilatation of the ureter on ultrasound or poor urinary flow.
A MCUG is used to diagnose VUR.
It involves catheterising the child, injecting contrast into the bladder and taking a series of xray films to determine whether the contrast is refluxing into the ureters.
Children are usually given prophylactic antibiotics for 3 days around the time of the investigation.
What is vulvovaginitis?
Vulvovaginitis refers to inflammation and irritation of the vulva and vagina. It is a common condition often affecting girls between the ages of 3 and 10 years.
Which age group are commonly affected by vulvovaginitis and why?
Ages 3-10 years
This irritation is caused by sensitive and thin skin and mucosa around the vulva and vagina in young girls. The vagina is more prone to colonisation and infection with bacteria spread from faeces.
Vulvovaginitis improves and is much less common after puberty, as oestrogen helps keep the skin and vaginal mucosa healthy and resistant to infection.
What may exacerbate vulvovaginitis?
Wet nappies
Use of chemicals or soaps in cleaning the area
Tight clothing that traps moisture or sweat in the area
Poor toilet hygiene
Constipation
Threadworms
Pressure on the area, for example horse riding
Heavily chlorinated pools
How does vulvovaginitis present?
Vulvovaginitis is a common presentation in young girls before puberty. It presents with:
Soreness
Itching
Erythema around the labia
Vaginal discharge
Dysuria (burning or stinging on urination)
Constipation
A urine dipstick may show leukocytes but no nitrites. This will often result in misdiagnosis as a urinary tract infection.
Management of vulvovaginitis
Often patients have already been treated for urinary tract infections and thrush, usually with little improvement in symptoms. It is unusual for girls to develop thrush before puberty.
Generally no medical treatment is required and management focuses on simple measures to improve symptoms:
- Avoid washing with soap and chemicals
- Avoid perfumed or antiseptic products
- Good toilet hygiene, wipe from front to back
- Keeping the area dry
- Emollients, such as sudacrem can sooth the area
- Loose cotton clothing
- Treating constipation and worms where applicable
- Avoiding activities that exacerbate the problem
In severe cases an experienced paediatrician may recommend oestrogen cream to improve symptoms.
What is nephrotic syndrome?
Nephrotic syndrome occurs when the basement membrane in the glomerulus becomes highly permeable to protein, allowing proteins to leak from the blood into the urine. It is most common between the ages of 2 and 5 years. It presents with frothy urine, generalised oedema and pallor.
What is wrong with the basement membrane in the glomerulus in nephrotic syndrome?
Nephrotic syndrome occurs when the basement membrane in the glomerulus becomes highly permeable to protein, allowing proteins to leak from the blood into the urine.
Nephrotic syndrome is the classic triad of what features?
Low serum albumin
High urine protein content (>3+ protein on urine dipstick)
Oedema
Features of nephrotic syndrome?
It presents with frothy urine, generalised oedema and pallor.
Nephrotic syndrome features a classic triad of:
- Low serum albumin
- High urine protein content (>3+ protein on urine dipstick)
- Oedema
There are three other features that occur in patients with nephrotic syndrome:
Deranged lipid profile, with high levels of cholesterol, triglycerides and low density lipoproteins
High blood pressure
Hyper-coagulability, with an increased tendency to form blood clots
Causes of nephrotic syndrome?
The most common cause in children is minimal change disease. In minimal change disease, nephrotic syndrome occurs in isolation, without any clear underlying condition or pathology.
There are a number of secondary causes of nephrotic syndrome, where it occurs due to an underlying condition.
It can be secondary to intrinsic kidney disease:
Focal segmental glomerulosclerosis
Membranoproliferative glomerulonephritis
It can also be secondary to an underlying systemic illness:
Henoch schonlein purpura (HSP)
Diabetes
Infection, such as HIV, hepatitis and malaria
Most common cause of nephrotic syndrome in children?
Minimal change disease
What might nephrotic syndrome occur secondary too?
Intrinsic kidney disease:
- Focal segmental glomerulosclerosis
- Membranoproliferative glomerulonephritis
Underlying systemic illness:
- Henoch schonlein purpura (HSP)
- Diabetes
- Infection, such as HIV, hepatitis and malaria
What is the most likely underlying diagnosis in a 2 – 5 year old child with oedema, proteinuria and low albumin?
Minimal change disease
How is minimal change disease managed?
Management of minimal change disease is with corticosteroids (i.e. prednisolone). The prognosis is good and most children make a full recovery, however it may reoccur.
Minimal change disease is the most common cause of nephrotic syndrome in children. It can occur in otherwise healthy children, without any clear risk factors or reason for developing the condition. It is not clear why it occurs in most cases.
What abnormalities may be seen on investigation?
A renal biopsy and standard microscopy in minimal change disease is usually not able to detect any abnormality.
Urinalysis (analysis of the urine) will show small molecular weight proteins and hyaline casts.
Nephrotic syndrome should be managed by experienced paediatricians with input from renal specialists. General management includes what?
High dose steroids (i.e. prednisolone)
Low salt diet
Diuretics may be used to treat oedema
Albumin infusions may be required in severe hypoalbuminaemia
Antibiotic prophylaxis may be given in severe cases
Steroid management of nephrotic syndrome?
High dose steroids are given for 4 weeks and then gradually weaned over the next 8 weeks:
80% of children will respond to steroids, and are referred to as steroid sensitive
80% of steroid sensitive patients will relapse at some point and need further steroids
Patients that struggle to wean steroids due to relapses are referred to as steroid dependant
Patients that do not respond to steroids are referred to as steroid resistant
What management for nephrotic syndrome may be used in steroid resistant children?
In steroid resistant children, ACE inhibitors and immunosuppressants such as cyclosporine, tacrolimus or rituximab may be used.
Potential complications of nephrotic syndrome?
Hypovolaemia occurs as fluid leaks from the intravascular space into the interstitial space causing oedema and low blood pressure.
Thrombosis can occur because proteins that normally prevent blood clotting are lost in the kidneys, and because the liver responds to the low albumin by producing pro-thrombotic proteins.
Infection occurs as the kidneys leak immunoglobulins, weakening the capacity of the immune system to respond. This is exacerbated by treatment with medications that suppress the immune system, such as steroids.
Acute or chronic renal failure
Relapse
Why might hypovolemia occur as a complication of nephrotic syndrome?
Fluid leaks from the intravascular space into the interstitial space causing oedema and low blood pressure
Why might thrombosis occur as a complication of nephrotic syndrome?
Because proteins that normally prevent blood clotting are lost in the kidneys, and because the liver responds to the low albumin by producing pro-thrombotic proteins.
Why might infection occur as a complication of nephrotic syndrome?
The kidneys leak immunoglobulins, weakening the capacity of the immune system to respond.
This is exacerbated by treatment with medications that suppress the immune system, such as steroids.
What is a hydrocele, and what structures are involed?
A hydrocele is a collection of fluid within the tunica vaginalis that surrounds the testes.
The tunica vaginalis is a sealed pouch of membrane that surrounds the testes.
Originally the tunica vaginalis is part of the peritoneal membrane, but during development of the fetus it becomes separated from the peritoneal membrane and remains in the scrotum, partially covering each testicle.
What are simply hydroceles?
They occurs where fluid is trapped in the tunica vaginalis.
Usually this fluid gets reabsorbed over time and the hydrocele disappears.
What type of hydrocele is common in the newborn male?
Simple hydroceles
What is a communicating hydrocele?
Communicating hydroceles occur where the tunica vaginalis around the testicle is connected with the peritoneal cavity via a pathway called the processus vaginalis.
This allows fluid to travel from the peritoneal cavity into the hydrocele, allowing the hydrocele to fluctuate in size.
What is seen O/E in a hydrocele?
Hydroceles cause a soft, smooth, non-tender swelling around one of the testes.
The swelling will be IN FRONT OF AND BELOW the testicle.
Simple hydroceles remain one size, whereas communicating hydroceles can fluctuate in size depending on the volume of fluid from the peritoneal cavity.
They transilluminate with light. To transilluminate the hydrocele, hold a pen torch flat against the skin and watch as the whole thing lights up like a bulb.
Simple vs communicating hydrocele
Simple hydroceles remain one size, whereas communicating hydroceles can fluctuate in size depending on the volume of fluid from the peritoneal cavity.
Simple hydrocele occurs where fluid is trapped in the tunica vaginalis, communicating hydrocele occurs where the tunica vaginalis around the testicle is connected with the peritoneal cavity via a pathway called the processus vaginalis
What are the key differential diagnoses of a scrotal or inguinal swelling in a neonate?
Hydrocele
Partially descended testes
Inguinal hernia
Testicular torsion
Haematoma
Tumours (rare)
Management of hydrocele
Ultrasound is a useful investigation for confirming the diagnosis and excluding other causes.
Simple hydroceles will usually resolve within 2 years without having any lasting negative effects. Parents can be reassured and followed up routinely. They may require surgery if they are associated with other problems, such as a hernia.
Communicating hydroceles can be treated with a surgical operation to remove or ligate the connection between the peritoneal cavity and the hydrocele (the processus vaginalis).
What is hypospadias?
Hypospadias is a condition affecting males, where the urethral meatus (the opening of the urethra) is abnormally displaced to the ventral side (underside) of the penis, towards the scrotum.
This might be further towards the bottom of the glans (in 90% of cases), halfway down the shaft or even at the base of the shaft.
Epispadias is where the meatus is displaced to the dorsal side (top side) of the penis.
Usually, the foreskin is abnormally formed to match the position of the meatus.
There can also be an associated condition called chordee, where the head of the penis bends downwards.
Hypospadias is a congenital condition affecting babies from birth and is usually diagnosed on the examination of the newborn.
What is epispadias?
Epispadias is where the urethral meatus is displaced to the dorsal side (top side) of the penis.
What associated condition can be present alongside hypospadias?
Chordee, where the head of the penis bends downwards.
How is hypospadias managed?
Hypospadias requires referral to a paediatric specialist urologist for ongoing management. It is important to warn parents not to circumcise the infant until a urologist indicates this is ok.
- Mild cases may not require any treatment
- Surgery is usually performed after 3 – 4 months of age
- Surgery aims to correct the position of the meatus and straighten the penis
Hypospadias complications?
Difficulty directing urination
Cosmetic and psychological concerns
Sexual dysfunction
What would be seen on histology in renal biopsy in IgA nephropathy?
IgA deposits and glomerular mesangial proliferation
What is seen here on this renal biopsy?
IgA deposits and glomerular mesangial proliferation - IgA nephropathy
What is seen here on this renal biopsy?
IgA deposits and glomerular mesangial proliferation - IgA nephropathy
Typical VS atypical presentaton of minimal change disease
