Renal/Urological Problems

Question 1

What are the 3 key features of typical nephrotic syndrome?

Answer 1

Oedema
Proteinuria
Hypoalbuminaemia

Question 2

How is typical nephrotic syndrome managed in children?

Answer 2

High dose steroids

- no need for a renal biopsy

Question 3

What is the most common cause of nephrotic syndrome in children?

Answer 3

Minimal change disease

Question 4

Which atypical features would prompt discussion with nephrologist + renal biopsy in children with nephrotic syndrome?

Answer 4

Age < 1 or > 12 years
Hypertension
Impaired renal function
Frank haematuria
Steroid resistant nephrotic syndrome

Question 5

What are the complications of nephrotic syndrome in children?

Answer 5

Dehydration
Infection (prophylactic antibiotics)
Chicken pox –> VZV checked on presentation as very dangerous if child on steroids/immunosuppressants
Thrombosis –> pro-thrombotic state

Question 6

What are the risk factors for UTI in children?

Answer 6

Age < 1 year
Previous UTI
Voiding dysfunction
Vesicoureteric-reflux (VUR) - especially if pyelonephritis
Sexual abuse
Spinal abnormalities 
Constipation --> urinary obstruction
Immunosuppression

Question 7

What are the symptoms of UTI in children?

Answer 7

Age < 5:
- fever, lethargy, irritability
- vomiting + diarrhoea
- neonatal jaundice
- poor feeding + failure to thrive
Age > 5:
- increased frequency
- painful urination
- bed wetting

Temperature > 38 +/- loin pain in pyelonephritis

Question 8

What are the options for collecting a urine sample in young children?

Answer 8

Pads in nappy
‘Clean catch’ when nappy is removed
Suprapubic aspiration or catheter if severely ill or urgent

Question 9

What is the first line imaging to check for abnormal anatomy or obstruction in a child with UTI?

Answer 9

USS

Question 10

What is the gold standard investigation for VUR?

Answer 10

Micturating cystourethrogram (MCUG)

Question 11

What is the gold standard investigation for renal scarring?

Answer 11

DMSA Scintigraphy

Question 12

What are the imaging recommendation for a first time UTI in child age < 6 months?

Answer 12

USS within 6 weeks

Follow up MCUG if USS abnormal

Question 13

What are the imaging recommendation for a first time UTI in child age > 6 months?

Answer 13

No imaging needed

Question 14

What are the atypical UTI features?

Answer 14

Poor urine flow
Abdominal or bladder mass
Raised creatinine
Sepsis
Failure to respond to treatment within 48 hours
Non- E.coli organism

Question 15

What is the definition of recurrent UTIs?

Answer 15

Two or more upper UTIs (pyelonephritis)

Or 3 episode of lower UTI

Question 16

What are the imaging recommendations for a child with atypical or recurrent UTI?

Answer 16

Acute USS
Follow up DMSA for all
Follow up MCUG if < 6 months old

Question 17

When should UTI be treated in children?

Answer 17

If microscopy or dipstick is +ve for infection

OR negative but strong clinical suspicion

Question 18

What are the possible complications of UTI in children?

Answer 18

Renal scarring
Hypertension
Renal insufficiency + failure
Stones

Question 19

What is cryptorchidism?

Answer 19

Failure of testicular descent into the scrotum

Question 20

What are the risk factors for cryptorchidism?

Answer 20

Prematurity
Low birth weight
Other abnormalities of genitalia e.g. hypospadias
First degree relative with cryptorchidism

Question 21

What are the different types of cryptorchidism?

Answer 21

True undescended testis:
- absent from scrotum but lies along line of true descent
Ectopic testis:
- impalpable in normal pathway of descent
Ascending testis:
- previously identified in scrotum but undergoes a secondary ascent

Question 22

What is the role of imaging in cryptorchidism?

Answer 22

None - low sensitivity for locating testis

Question 23

When should a child be urgently referred to senior paediatrician with cryptorchidism?

Answer 23

• disorder of sexual development suspected
• associated ambiguous genitalia or hypospadias
• or bilateral undescended testis

–> may be presentation of congenital adrenal hyperplasia (CAH)

Question 24

How is cryptorchidism managed?

Answer 24

At birth:
- review at 6-8 weeks
At 6-8 weeks:
- if fully descended, no further action
- if unilateral, re-examine at 3 months
At 3 months:
- if testis is retractile, advise annual follow up
- if undescended, refer to paediatric surgery/urology for definitive intervention

Question 25

What is the definitive intervention for cryptorchidism?

Answer 25

If palpable –> open orchidoplexy

If impalpable –> EUA + laparoscopy to identify if testis is absent or intra-abdominal

Question 26

What are the complications of undescended testis?

Answer 26

Impaired fertility, esp if bilateral
Testicular cancer
Torsion

Question 27

What is hypospadias?

Answer 27

Congenital defect causing the urethral meatus to be located at an abnormal site - usually on the underside of the penis rather than at the tip

Question 28

What are the three key features of hypospadias?

Answer 28

Ventral opening of urethral meatus
Ventral curvature of the penis or “Chordee”
Dorsal hooded foreskin

Question 29

What is the management for hypospadias?

Answer 29

Urethroplasty

note circumcision should not be performed as foreskin used in reconstruction

Question 30

What is Balanitis xerotica obliterans (BXO)?

Answer 30

Keratinisation of the tip of the foreskin –> scarring + the prepuce remains non-retractile

Question 31

What is the peak age for BXO?

Answer 31

9-11

Question 32

What are the features of BXO?

Answer 32

Irritation, dysuria, haematuria + local infection

Prepuce appears white, fibrotic + scarred

Question 33

What is the management of BXO?

Answer 33

Circumcision

–> send foreskin for histopathology to confirm diagnosis