Renal & Urinary Tract Disorders Flashcards
Most common cause of nephrotic syndrome in children
Minimal change disease
Nephrotic syndrome triad
Low serum albumin
High urine protein content(>3+ proteinon urine dipstick = frothy urine)
Oedema (especially peri-orbitally or of testes)
How does proteinuria present as?
frothy urine
Where does oedema present in minimal change disease?
especially peri-orbitally or of testes
Features of minimal change disease
Nephrotic syndrome triad:
Low serum albumin
High urine protein content(>3+ proteinon urine dipstick = frothy urine)
Oedema (especially peri-orbitally or of testes)
Other features:
Deranged lipid profile – due to increased hepatic activity trying to replace albumin
Hypercoagulability – antithrombin 3 is one of the proteins lost
What causes hypercoagulable state in minimal change disease?
Antithrombin III
NOTE: Antithrombin III inactivates F9,10,11. If antithrombin III lost –> no inactivation of factors so hypercoagulable.
What medication potentiates antithrombin III?
Heparin potentiates antithrombin III to inactivate F9,10,11
Diagnostic investigation for nephrotic syndrome
kidney biopsy allows us to differentiate between the different causes of nephrotic syndrome
1st line investigation for nephrotic syndrome
Urine dipstick –> check for proteinuria
Investigative findings on kidney biopsy in minimal change disease
Light microscopy – no signs
Electron microscopy – loss of foot processes on podocytes
Immunofluorescence – no immune deposits
Management of minimal change disease
High dose steroidsare given for 4 weeks and then gradually weaned over the next 8 weeks:
Diuretics may be used to treat oedema
Albumin infusions may be required in severe hypoalbuminaemia
What is henoch schonelin purpura?
IgA vasculitis is an AI disease involving IgA immune complexes.
When does henoch schonlein purpura occur?
occurs after a viral or bacterial upper respiratory tract infection, especially streptococcal infections.
Presentation of henoch schonlein purpura
Purpuric rash – from buttocks downwards stereotypically
Arthralgia (70%) – knees and ankles commonly
Abdominal pain (50%) – N+V, can cause bowel haemorrhage/infarction
Kidney sx (40%) – haematuria, proteinuria
How does rash in henoch schonlein purpura present?
Purpuric rash – from buttocks downwards stereotypically
What is haemolytic uraemic syndrome
A non-AI microangiopathic haemolytic anaemia (MAHA).
What is HUS caused by?
E.coli 0157:H7 which producesshiga toxin
What toxin does E.coli 0157:H7 produce to cause HUS?
shiga toxin
How does HUS cause damage to endothelial cells in the vessels in the kidneys?
fibrin mesh formation that damages RBCs
Presentation of HUS
diarrhoea followed by MAHA and renal impairment (AKI)
Management of HUS
supportive, plasma exchange, eculizumab (a C5 inhibitor monoclonal antibody)
HUS/TTP Triad/Pentad
What is Wilm’s Tumour
A nephroblastoma which typically presents in children.
2nd most common childhood malignancy
Wilm’s Tumour (nephroblastoma)
Presentation of Wilm’s tumour
abdominal mass (unilateral in 95% cases), occasionally haematuria
Unilateral abdominal mass in a child
Wilm’s tumour (nephroblastoma)
Investigations for Wilm’s Tumour
Examination
US doppler - rule out IVC and renal vein involvement
Microscopy – small undifferentiated blue cells, primitive renal tubule formation
What is seen on microscopy in a Wilm’s Tumour?
Microscopy – small undifferentiated blue cells, primitive renal tubule formation
Managemnt of Wilm’s tumour
urgent paeds review within 48h
Small undifferentiated blue cells, primitive renal tubule formation on microscopy
Wilm’s tumour
What is enuresis?
Bedwetting in the absence of congenital or acquired defects of the nervous system or urinary tract.
When do most children achieve day and night dryness?
by 3-4 years old
Types of enuresis
Primary: child never achieved continence (can be with or without daytime symptoms)
Secondary: bedwetting occurs after a child has achieved sustained continence >6months
Primary enuresis
child never achieved continence (can be with or without daytime symptoms)
Secondary enuresis
bedwetting occurs after a child has achieved sustained continence >6months
Table showing possible causes of enuresis
Red flags to ask for in secondary enuresis
ask about psychological/family problems
Investigations for enuresis
clinical diagnosis, urine MC&S to rule out UTI, urine dip to rule out diabetes
Management of enuresis
Primary enuresis + day and night sx → refer to paeds urology
Night sx only → manage in community
Conservative – reduce fluid intake, regular emptying, star charts for actions not outcomes
Enuresis alarm – high success rate and lower relapse than meds
Desmopressin – synthetic ADH replacement, good for short term control or if above fail
How is primary enuresis + day and night sx managed?
refer to paeds urology
How are night Sx of enuresis only managed?
In community
Order of enuresis management
Conservative – reduce fluid intake, regular emptying, star charts for actions not outcomes
Enuresis alarm – high success rate and lower relapse than meds
Desmopressin – synthetic ADH replacement, good for short term control or if above fail
PACES: What is the conservative management of enuresis?
reduce fluid intake, regular emptying, star charts for actions not outcomes
Management of nocturnal enuresis in children <5 years (without daytime symptoms)
Reassure that parents that many children under 5 years wet the bed and this usually resolves without intervention
Ensure easy access to the toilet at night (e.g. potty near bed)
Encourage bladder emptying before bed
Consider a positive reward system
Management of nocturnal enuresis in children >5 years (without daytime symptoms)
If bedwetting is infrequent (< 2 per week) reassure the parents and offer watch-and-wait approach
If long-term treatment is required:
First-Line: Enuresis Alarm with Positive Reward System
Second-Line: Desmopressin
NOTE: fluid should be restricted 1 hour before desmopressin until 8 hours afterwards
It may also be considered when rapid or short-term control is required (e.g. school trips)
TCAs and antimuscarinics may be considered in special cases
What is the vesicoureteral reflex?
abnormal backflow of urine from the bladder into the ureter and kidney.
How does the vesicoureteral reflex increase likelihood of UTI?
abnormal backflow of urine from the bladder into the ureter and kidney –> more likely to retain bacteria
NOTE: found in around 30% of children who present with a UTI
Presentation of vesicoureteral reflex
Antenatal period: hydronephrosis on ultrasound
Recurrent childhood UTI
Reflux nephropathy - chronic pyelonephritis secondary to VUR
What is seen on US in vesicoureteral reflux?
Hydronephrosis
What condition can vesicoureteral reflux cause recurrance?
childhood UTI
What is Reflux nephropathy?
Chronic pyelonephritic secondary to VUR
What does Micturating cystourethrogram (MCUG) do?
assess how the urine flows
What does the DMSA do?
looks for renal scarring, routine referral within 4-6m
When are children referred for DMSA?
Routine referral 4-6m alongside US for UTI if: recurrent UTI sx or <3yo with atypical UTI
Flow charts showing UTI investigation
What does DMSA look for?
hydronephrosis and parenchymal defects
Who is MCUG done in?
children <6 months –> underlying structural disorders of renal tract e.g. reflux nephropathy
What is epididymitis/orchitis?
Infection of epididymis/testis due to STI (chlamydia/gonorrhoea, teens), or bladder (E.coli, younger kids).
What causes Epididymitis/orchitis?
STI (chlamydia/gonorrhoea, teens), or bladder (E.coli, younger kids).
Presentation of epididymitis/orchitis
unilateral testicular pain and swelling, urethral discharge may be present
Investigation of epididymitis/orchitis
MUST EXCLUDE TORSION, urine MC&S, NAAT
What must be excluded if considering a diagnosis of epididymitis/orchitis?
TESTICULAR TORSION
NOTE: USE EXPLORATORY LAPAROTOMY TO EXCLUDE
What is the management of epididymitis/orchitis caused by UTI?
E.coli most likely so treat empirically with a quinolone (e.g. Ofloxacin) for 2 weeks
What is the management of epididymitis/orchitis caused by STI?
if cause unknown IM Cef 500mg + PO Doxy 100mg BD for 10-14days
What is hypospadias?
Congenital defect in which the urethral meatus is not present at the tip of the glans and is instead found along the ventral surface of the penis.
When is hypospadias typically noted?
On neonatal examination
Management of hypospadias
Surgery is NOT mandatory
May be performed on functional or cosmetic grounds (after 3 months)
Ultimate functional aim of surgery is to allow boys to pass urine in a straight line whilst standing and to have a straight erection
IMPORTANT: boys with hypospadias should NOT be circumcised before repair, because the skin is important for the repair
Key point in the management of hypospadias
IMPORTANT: boys with hypospadias should NOT be circumcised before repair, because the skin is important for the repair
What is phimosis? How does it present?
inability to retract foreskin covering glans penis
Non-retractile foreskin +/- ballooning during micturiong and <2yo→ physiological phimosis
PACES: Advice to give if patient has phimosis
Do not attempt to retract the foreskin to clean under it, if it is still fixed.
What is balanitis? WHat typically causes it?
inflammation of glans penis +/- underside of foreskin
Typically caused by bacterial or candidal infection, but can also be dermatological (dermatitis, psoriasis etc)
How does balanitis present?
Swab under foreskin and do an STI screen (esp if high risk)
Management of balanitis
Clean penis with warm lukewarm water regularly; do not use soap,baby wipes as these may irritate the area.
Nappies should be changed frequently
NHS leaflet for balanitis care should be provided
Hydrocortisone considered for severe symptoms, and specific abx/clotrimazole if organism identified
What should be avoided in the management of balanitis? What should be used instead?
do not use soap,baby wipes as these may irritate the area, clean with lukewarm water instead
PACES: Advice for balanitis
NHS leaflet for balanitis care should be provided
What medication may be offered in balanitis?
Hydrocortisone considered for severe symptoms, and specific abx/clotrimazole if organism identified
What is cryptorchidism?
Incomplete descent of one or both testes from abdomen, through the inguinal canal and into the scrotum.
Types of cryptorchidism
True undescended testis—the testislies along the normal path of descent in the abdomen or inguinal region but hasneverbeen present in the scrotum.
Ectopic testis —the testis lies outside of the normal path of descent and outside the scrotum, for example in the femoral region, perineum, penile shaft, oropposite hemiscrotum.
Ascending testis —the testis has previously been present in the scrotum but hasthen moved to a higher position over time.
Absent or atrophic testis— the testisis in the scrotum at birth but later disappears causinga non-palpable testis.
True undescending tesis
the testislies along the normal path of descent in the abdomen or inguinal region but hasneverbeen present in the scrotum.
Ectopic testis
the testis lies outside of the normal path of descent and outside the scrotum, for example in the femoral region, perineum, penile shaft, oropposite hemiscrotum.
Ascending testis
the testis has previously been present in the scrotum but hasthen moved to a higher position over time
Absent or atrophic testis
the testisis in the scrotum at birth but later disappears causinga non-palpable testis
the testislies along the normal path of descent in the abdomen or inguinal region but hasneverbeen present in the scrotum.
True undescended testis
the testis lies outside of the normal path of descent and outside the scrotum, for example in the femoral region, perineum, penile shaft, oropposite hemiscrotum.
Ectopic testis
the testis has previously been present in the scrotum but hasthen moved to a higher position over time
Ascending testis
the testisis in the scrotum at birth but later disappears causinga non-palpable testis
Absent or atrophic testis
Complications of cryoptorchidism
Impaired fertility, increased risk of testicular cancer in the undescended testis, and increased risk of testicular torsion and inguinal hernia.
Biggest complication of cryptorchidism
Infertility
How to differentiate between types of cryptorchidism on investigation?
Hypospadias → disorder of sexual development
Bilateral + ambiguous genitalia → Congenital Adrenal Hyperplasia
Can attempt to manipulate an inguinal testes into scrotum, if it moves back into canal → retractile testis
If unpalpable to unable to manipulate → undescended tests
Contralateral testis is atrophied → testicular absence or atrophy
Management of cryptorchidism
Disorder of sexual development or bilateral at birth → urgent referral to paeds in 24h (ix endocrine and genetics)
Unilateral at birth → review at 6-8w
Bilateral at 6-8w → urgent 2 week referral to paeds urology
Unilateral at 6-8w → reexamine at 4-5 months → still unilateral → urgent referral to paeds urology to be seen by 6m old
Management of cryptorchidism if bilateral at birth or coexisting disorders of sexual development (e.g. hypospadias)
urgent referral to paeds in 24h (ix endocrine and genetics)
Management of cryptorchidism if unilateral at birth
review at 6-8 weeks
Management of bilateral cryptorchidism at 6-8 weeks
urgent 2 week referral to paeds urology
Management of unilateral cryptorchidism at 6-8 weeks
reexamine at 4-5 months → still unilateral → urgent referral to paeds urology to be seen by 6m old
What is testicular torsion? Who is it most common with?
Testicle rotates twisting the spermatic cord that brings blood to the scrotum causing ischaemia. Most common between males ages 12-18
Presentation of testicular torsion
Very tender, hot, swollen SINGLE testis
Cremasteric reflex lost (doesn’t exclude TT if this isn’t seen if TT is top dx)
Elevation of testis doesn’t ease pain (negative Prehn’s sign)
Investigation of testicular torsion
urgent surgical exploration
Management of testicular torsion
BILATERAL fixation (orchidopexy) and possible orchidectomy
Salvage rate 90-100% if <6h
Salvage rate 0-12% if >24h
How do UTIs present in infants?
Poor feeding
Foul-smelling urine
Fever
Irritability
Febrile convulsions
How do UTIs present in children?
Dysuria
Urinary frequency and urgency
Lower abdominal pain
Foul-smelling urine
Enuresis
Investigations for UTIs in children
Bedside
Urine dipstick and MC&S
Bloods
Blood gas if concerns of sepsis
Management of UTIs in infants <3 months
ALL infants < 3 months of agewith suspicion or a UTI or if seriously ill should be referred IMMEDIATELY to hospital
IV antibiotics (e.g. co-amoxiclav) for at least 5-7 days
This should be followed by oral prophylaxis
Management of infants aged >3 months with UTIs and children with acute pyelonephritis/upper UTI
Oral antibiotics
First-Line: Cefalexin, Co-Amoxiclav
If oral cannot be used, give IV antibiotics
First-Line: co-amoxiclav, ceftriaxone, ciprofloxacin, cefuroxime, amikacin or gentamicin
What are first line oral ABs in infants with UTIs?
Cefalexin, Co-Amoxiclav
Features of pyelonephritis
Bacteriuria + fever > 38 degrees
Bacteriuria + loin pain/tenderness
Features of cystitis/lower UTI
Dysuria but NO systemic symptoms
Management of children with cystitis/lower UTI
Oral antibiotics
First-Line: Trimethoprim, Nitrofurantoin
Second-Line: Amoxicillin, Cefalexin
What are first line ABs in children with cystitis/lower UTI?
First-Line: Trimethoprim, Nitrofurantoin
IF FEATURES OF PYELONEPHRITIS –> USE Cefalexin or co-amox
PACES: Advice to give for infants/children with UTIs
Seek medical attention if the child is still unwell after 24-48 hours of antibiotic treatment
Encourage adequate fluid intake
