Renal And Urology Flashcards
What is acute pyelonephritis ?
When the infection affects the tissue of the kidney. It can lead to scarring in the tissue and consequently a reduction in kidney function.
How does a baby present with a UTI ?
Fever
Lethargy
Irritability
Vomiting
Poor feeding
Urinary frequency
What are the features of a UTI in older infants and children ?
Fever
Abdominal pain - suprapubic pain
Vomiting
Dysuria
Urinary frequency
Incontinence
How is acute pyelonephritis diagnosed ?
A temperature greater than 38 degrees
Loin pain or tenderness
What do nitrites in a urine dip suggest ?
Gram negative bacteria such as E. coli break down nitrates into nitrites.
What does leukocytes in the urine indicate ?
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.
What is the management of a UTI ?
All children under 3 months with a fever should start immediate antibiotics.
Antibiotics for UTI :
- trimethoprim
- nitrofurantoin
- cefalexin
- amoxicillin
What should be done if a child is having recurrent UTI’s ?
USS
DMSA scan
Micturating cystourethrogram
What is vesico-ureteric reflux ?
This is where the urine has a tendency to flow from the bladder back into the ureters.
This predisposes patients to develop upper UTI’s and subsequent renal scarring.
What is the management of vesico-ureteric reflux ?
Avoid constipation
Avoid an excessively full bladder
Prophylactic antibiotics
Surgical input
What is vulvovaginitis ?
It refers to inflammation and irritation of the vulva and vagina.
Commonly affects girls between the ages of 3 and 10.
What causes vulvovaginitis ?
The 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.
What can 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
How does vulvovaginitis present ?
Soreness
Itching
Erythema around the labia
Vaginal discharge
Dysuria
Constipation
What is seen on a urine dip in vulvovaginitis ?
Leukocytes but no nitrites
What is the management of vulvovaginitis ?
Generally no medical treatment is required
Avoid washing with soap and chemicals
Avoid perfumed or antiseptic products
Good toilet hygiene
Keep the area dry
Emollients
What is 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.
What are some signs of nephrotic syndrome ?
Frothy urine
Generalised oedema
Pallor
What is the classic triad of nephrotic syndrome ?
Low serum albumin
High urine protein content
Oedema
What are some other features of nephrotic syndrome not in the classic triad ?
Deranged lipid profile - high levels of cholesterol, triglycerides and low density lipoproteins
High blood pressure
Hyper-coagulability
What are some causes of nephrotic syndrome ?
Minimal change disease
Focal segmental glomerulosclerosis
Membranoproliferative glomerulonephritis
Diabetes
Infection - HIV, hepatitis
What is minimal change disease ?
Most common cause of nephrotic syndrome in children.
Urinalysis shows small molecular weight proteins and hyaline casts.
What is the management of minimal change disease ?
Corticosteroids - prednisolone
What is the management of nephrotic syndrome ?
High dose steroids - prednisolone are given for 4 weeks and then weaned off for over 8 weeks
Low salt diet
Diuretics
Albumin infusion - if severe
Antibiotic prophylaxis
What are some complications of nephrotic syndrome ?
Hypovolaemia
Thrombosis
Infection
Acute or chronic renal failure
Relapse
What is nephritis and what does it cause ?
Inflammation within the nephrons of the kidneys
- Reduction in kidney function
- haematuria
- proteinuria
What are the 2 most common causes of nephritis in children ?
Post-streptococcal Glomerulonephritis
IgA nephropathy - Berger’s disease
What is post-streptococcal glomerulonephritis ?
Occurs 1-3 weeks after a beta-haemolytic streptococcus infection such as tonsillitis.
Immune complexes made up of streptococcal antigens, antibodies and complement proteins get lodged in the Glomeruli of the kidney and cause inflammation.
What is the management of post streptococcus Glomerulonephritis ?
Supportive however if there are complications give :
Antihypertensives
Diuretics
What is IgA nephropathy ?
Also known as Berger’s disease.
This condition is related to Henoch-Schonlein Purpura which is an IgA vasculitis.
IgA deposits in the nephrons of the kidney causes inflammation.
What does IgA nephropathy show on biopsy ?
IgA deposits
Glomerular mesangial proliferation
What is the management of IgA nephropathy ?
Supportive treatment of renal failure
Immunosuppressant medications such as steroids and cyclophophosphamide
What is haemolytic uraemic syndrome ?
Involves thrombosis in small blood vessels throughout the body, usually triggered by shiga toxins from either Ecoli 0157 or shigella.
Often follows gastroenteritis
What is the classic triad of haemolytic uraemic syndrome ?
Microangiopathic haemolytic anaemia
Acute kidney injury
Thrombocytopenia
How does shigella or Ecoli cause the classic triad of haemolytic uraemic syndrome ?
The formation of blood clots consumes platelets leading to thrombocytopenia.
The blood flow through the kidney is affected by thrombi and damaged red blood cells leading to AKI.
The thrombi partially obstruct the small blood vessels and churn the red blood cells as they pass through causing them to rupture.
How does haemolytic uraemic syndrome present ?
Diarrhoea
Fever
Abdominal pain
Lethargy
Pallor
Oliguria
Haematuria
Hypertension
Jaundice
Bruising
What is the management of haemolytic uraemic syndrome ?
Hospital admission as medical emergency
Iv fluids - hypovolaemia
Blood transfusions - severe anaemia
Haemodialysis - severe renal failure
Self limiting
What investigations should be performed if suspecting haemolytic uraemic syndrome ?
Stool culture to establish the causative organism
What is enuresis ?
The term to describe involuntary urination
What is bed wetting called ?
Nocturnal enuresis
What is primary nocturnal enuresis ?
Where the child has never managed to be consistently dry at night.
What are some causes of primary nocturnal enuresis ?
Variation on normal development
Overactive bladder
Fluid intake
Failure to wake
Psychological distress
What are some secondary causes of nocturnal enuresis ?
Chronic constipation
UTI
Learning disability
Cerebral palsy
Type 1 diabetes
Maltreatment
What is the management of primary nocturnal enuresis ?
Reassure parents of children under 5 years old that it is likely to resolve without treatment
Lifestyle changes - reduce fluid intake in evening, pass urine before bed,
Encouragement and positive reinforcement
Enuresis alarms
What indicates secondary nocturnal enuresis rather than primary ?
A child begins wetting the bed when they have previously been dry for at least 6 months
What is diurnal enuresis ?
Daytime incontinence. This occurs when the person has become dry at night but still has episodes of urinary incontinence during the day.
What are some causes of diurnal enuresis ?
Recurrent UTI
Psychosocial problems
Constipation
What is an enuresis alarm ?
A device that makes a noise at the first sign of bed wetting, waking the child and stopping them from urinating.
What are the pharmacological treatment options for nocturnal enuresis ?
Desmopressin
Oxybutinin
Imipramine
When does autosomal recessive Polycystic kidney disease present ?
In neonates and is usually picked up on an antenatal USS
What is autosomal recessive Polycystic kidney disease as result of ?
A mutation in the Polycystic kidney and hepatic disease 1 gene on chromosome 6. This gene codes for the fibrocystin / polyductin protein complex which is responsible for the creation of tubules and the maintenance of healthy epithelial tissue in the kidneys
What does the underlying pathology of autosomal recessive Polycystic kidney disease cause ?
Cystic enlargement of the renal collecting ducts
Oligohydraminos, pulmonary hypoplasia and potter syndrome
Congenital liver fibrosis
What is oligohydraminos ?
A lack of amniotic fluid caused by reduced urine production by the foetus.
What is potter syndrome ?
Characterised by dysmorhpic features such as underdeveloped ear cartilage, low set ears, a flat nasal bridge and abnormalities of the skeleton.
What can autosomal recessive Polycystic kidney disease cause throughout life ?
Liver failure due to liver fibrosis
Portal hypertension leading to oesophageal varices
Progressive renal failure
Hypertension due to renal failure
Chronic lung disease
What is multicystic dysplastic kidney ?
One of the baby’s kidneys is made up of many cysts while the other kidney is normal. ( rare cases it can be bilateral ).
How is multicystic dysplastic kidney diagnosed ?
Antenatal USS
What can having a single kidney put you at risk of ?
UTI
Hypertension
Chronic kidney disease in later life
What is the management of multicystic dysplastic kidney ?
No treatment
Follow up with regular USS
Prophylactic antibiotics
What is Wilm’s tumour ?
A specific type of tumour affecting the kidney in children typically under 5 years old.
How does Wilm’s tumour present ?
Mass in the abdomen
Abdominal pain
Haematuria
Lethargy
Fever
Hypertension
Weight loss
How is the diagnosis of Wilm’s tumour made ?
Initial investigations - USS
CT or MRI can be used to stage the tumour
Biopsy for histology
What is the management of Wilm’s tumour ?
Treatment involves surgical excision - nephrectomy
Adjuvant treatment - chemotherapy or radiotherapy
What is a posterior urethral valve ?
Where there is tissue at the proximal end of the urethra ( closest to the bladder ) that causes obstruction of urine output. This causes a back pressure into the bladder, ureters and up to the kidneys causing hydronephrosis.
How does posterior urethral valve present ( mild ) ?
Can be asymptomatic
Difficulty urinating
Weak urinary system
Chronic urinary retention
Palpable bladder
Recurrent UTI
Impaired kidney function
How does more severe posterior urethral valve present ?
Bilateral hydronephrosis
Oligohydraminos
Pulmonary hypoplasia - respiratory failure
How can posterior urethral valve present on an antenatal scan ?
Oligohydraminos
Hydronephrosis
What investigations should be performed when suspecting posterior urethral valve ?
Abdominal USS
Micturating cystourethrogram
Cystoscopy
What is the management of posterior urethral valve ?
Mild cases - monitoring
Temporary urinary catheter can be inserted to bypass the valve
Definitive management - ablation or removal of the extra urethral tissue
What is the route of the testes when they descend ?
The testes develop in the abdomen and then gradually migrate down through the inguinal canal and into the scrotum. They have normally reached the scrotum prior to birth.
What do undescended testes increase the risk of ?
Testicular torsion
Infertility
Testicular cancer
What is the risk factors for undescended testes ?
Family history of undescended testes
Low birth weight
Small for gestational age
Prematurity
Maternal smoking during pregnancy
What is the management of undescended testes ?
Watching and waiting in newborns.
Orchidoplexy - carried out between 6-12 months
What is retractile testicles ?
It is normal in boys that have not reached puberty for the testes to move out of the scrotum and into the inguinal canal when its cold or the cremasteric reflex is activated.
What is hypospadias ?
Affects males where the urethral meatus ( the opening of the urethra ) is abnormally displaced to the ventral side ( underside ) of the penis towards the scrotum.
Congenital condition
What is epispadias ?
Where the meatus is displaced to the dorsal side ( top ) of the penis.
What is the management of hypospadias ?
Referral to the paediatric specialist urologist
Mild cases - no treatment
Surgery - 3 to 4 months to correct the position of the meatus
What are the complications of hypospadias ?
Difficulty directing urination
Cosmetic and psychological concerns
Sexual dysfunction
What is a hydrocoele ?
A collection of fluid within the tunica vaginalis that surrounds the testes.
What is the tunica vaginalis ?
A sealed pouch of membrane that surrounds the testes
What is a simple hydrocoele ?
Common in newborn males
They occur when fluid is trapped in the tunica vaginalis. Usually this fluid gets absorbed over time.
What is a communicating hydrocoele ?
Occurs 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 hydrocoele.
What is found on examination in a patient with a hydrocoele ?
Soft, smooth, non tender swelling around one of the testes.
Simple remain one size
Key features - transilluminate with light
What are some differentials for a scrotal swelling in a neonate ?
Hydrocoele
Partially descended testes
Inguinal hernia
Testicular torsion
Haematoma
Tumour ( rare )
What investigations are performed when suspecting a hydrocoele ?
USS
What is the management of a hydrocoele ?
Simple hydrocoele - resolve within 2 years
Communicating hydrocoele - surgical operation to remove or ligate the connection between the peritoneal cavity and the hydrocoele
