renal/urinary system Flashcards
what is enuresis
it is bedwetting when older than 5 yrs old
what are the different types of enuresis
primary enuresis without day time symptoms
primary enuresis with day time symptoms
Secondary enuresis
aetiology of enuresis
inability to arouse + capacity of bladder vs nocturnal urine production
what is the aetiological theory behind enuresis
it is when there is insufficient ADH production at night and so polyuria during the night and the inability of the child to wake up during the night to wee
what is the normal cut off for enuresis
up to 5 yrs old
what is primary enuresis
it is when the child involuntary urinate during the night older the age of 5 and have never achieved continence before
what is secondary enuresis
it is when the child involuntary urinate during the night older the age of 5 and have achieved continence before for > 6 months
what is the general underlying believe of primary enuresis
it is when there is a possible developmental delay in the child but will resovle in time
what is the general underlying believe of secondary enuresis
it is regarded as regression of development and will always require investigation
what can aggravate enuresis
constipation
what is the absolute cut up point of normal enuresis according to NICE
10 yrs old
how common is enuresis in 5 yrs old
8-20%
how common is enuresis in 10 yrs old
1.5 - 10%
how common is enuresis in adult
0.5-2%
RF for enuresis
constipation poor bedtime hygiene caffeine stress daytime incontinence FH sleep apnoea or obstructive sleeping - DM obese children
underlying neuro conditions - spinal bifida or cerebral palsy
underlying developmental conditions
assessment of enuresis
determine which type of enuresis it is
look at enuresis diary
associated symptoms
questions to ask in primary enuresis
FH of bedwetting
male?
daytime LUTS - frequency, urgency, incontinence, poor stream even when straining, pain on urination
if it only occurs in partiuclar situations? eg avoiding toilet in school
lifetime stress - bullying. family bereavement
questions to ask in secondary enuresis
medical conditions
physical health
social problems - eg bullying
environmental - school
examination findings of enuresis
abdo distension - bladder full
palpable feal mass - incontinence
other masses
neuro - leg reflexes
spina bifida occulta - midline lipoma, hairy patch or spinal deformity, legs for neuro signs (neurogenic bladder)
Ix for enuresis
urinalysis not recommended unless recent onst or daytime symptoms
urine MC+S - look for any signs of UTI
renal tract USS - to see pre- and post-micturition residual volume
management of primary enuresis
with/without daytime symptoms
- intervention not usually advised until age 7 - connection of the brain is still developing
- avoid caffeine drink before bed, restricted fluid intake before bed
- good bedtime hygiene
- star chart - do not offer star for not wetting bed because children can not control it
- enuresis alarm
- desmopressin for short term purpose - sleepover
- oxybutynin
when will you refer an enuresis case
severe daytime symptoms - because potential developmental delay
secondary enuresis
suspected neuro probs
what is the management of secondary enuresis
exclude UTI, constipation, emotional/stress related
refer to specialist
definition of UTI
presence of symptoms - dysuria, frequency and loin pain
+
detection of a significant culture of organisms
(any detected in suprapubic aspirate or > 10(5) organism in MSU, clean catch urine or bag urine
what is lower UTI
cystitis
what is upper UTI
pyelonephritis
what can pyelonephritis cause
scar if the kidney –> HTN
epidemiology of UTI
3-7% of girl
1-2% of girls
both before 11 yrs old
50% have congenital abnor of the renal tract
what are the pathogens that cause UTI in children
E.COli - 85%
Kliebsella
proteus
pseudomas
what are the causes/RF for UTI
bowel flora entering the urinary tract
incomplete bladder emptying
- infrequent voiding
- vulvitis
- incomplete micturition
- constipation
- neurogenic bladder
- vesicoureter reflux - developmental anomaly
clinical features of UTI
dysuria frequency loin pain fever +/- rigor haematuria offensive/cloudy urine febrile convulsion enuresis
what are the clinical features of UTI in infancy
same as symptoms of older children
feeding difficulty
FTT
febrile convulsion
prolonged jaundice
what can be a serious cause of UTI that is worth investigation of a social problem
sexual abuse
what should you do as an examination when a child has UTI
plot height and weight on a growth chart
abdo mass
other mass
leg reflex - neurogenic bladder
spin and genitalia examination for any congenital abnor
when would you investigation a UTI
1+ episode < 6 m - congenital abnor
2+ episodes > 6 m - congenital abnor + sexual abuse
when will you not investigate a UTI
when a single episode > 6 m
what investigations would you do for UTI
urinalysis
urine MC+S - MSU, clean catch, bag urine or urine aspirate
USS KUB - abnor structure, always do in acute phase or < 6 m
DMSA scan - to see if there are any scarring in the kidney
MCUG - to see if vesicoureteric reflux present
treatment for UTI
hygiene, regular voiding, prevent constipation
< 3 m - IV ceftriaxone
> 3 m - oral trimethoprim
what Abx should you avoid when treating UTI
tetracycline - stain teeth
How can haematuria present
macroscopic haematuria - causes alarm to child and parents
incidental finding on screening
what are some of the kidney cases of haematuria
kidney
- acute glomerulonephritis (preceded by Strep infection)
- henoch scholenin purpura - to large so cause kidney damage
- SLE - too large so cause kidney damage
- trauma
- bleeding disorder
- alport syndrome - thin membrane so easier to bleed
- tumour - Wilm’s tumour
exercise induce
drugs
polycystic kidney
what are some of the urether cases of haematuria
stoens/hypercalcaemia
congenital abnor
what are some of the Bladder/ureter cases of haematuria
UTI
menstrual blood
which drug can cause red urine
rifampicin
symptoms of haematuria
blood in urine abdo pain rashes abdo mass renal colic pain
what examination would you do for haematuria
BP - for all patient with haematuria - HTn can cause kidney damage
skin rashes - HSP
joint pain
oedema - acute to acute glomerulonephritis - periorbital and ankle
renal mass
Ix for haematuria
urine
- dip - UTI
- microscopy - to detect red cell cast, proteinura suggestign to glmoerular dmage
- MC+S - UTI
Blood
- FBC/CLotting - coagulopathy
- U&E/cretinine/albumin - kindey function
USS KUB - detect any congenital abnor
treatment for haematuria
treat any obvious causes (UTI)
if complex diagnosis eg proteinuria, reduced renal function) –> refer specialist
if not resovle in 6 m - refer specilaist
