Renal/urology Flashcards
What makes up the urinary tract?
urethra, bladder, ureters and kidneys
Whatis acute pyelonephritis?
Infection of the kidney
What is cystitis?
Inflammation of the bladder
What is the characteristic feature of a UTI?
Fever
What should always be excluded in any child presenting with a temperature?
UTI
How do babies present with UTI?
Fever Lethargy Irritability Vomiting Poor feeding Urinary frequency
How do older infants and children present with UTI?
Fever Abdominal (suprapubic) pain) Vomiting Dysuria Urinary frequency Incontinence
What is the ideal urine sample?
Clean catch
How does a clean catch sample usually have to be taken in younger children/ babies?
Parent sits with them without nappy and urine pot held ready to catch sample
What things are looked for on a urine sample that would indicate infection?
Nitrites
Leukocyte esterase
What does the presence of nitrites in the urine indicate and why?
Gram negative bacteria break down nitrates (normal waste product in urine) into nitrites, so suggests presence of bacteria
What does the presence of leukocytes in urine suggest?
Rise in WBC in the urine indicate infection or inflammation
What is leukocyte esterase?
A product of leukocytes that gives an indication about the number of leukocytes in the urine
What is the best indication of infection in a urine sample?
Nitrites
What urine sample results would trigger treatment of UTI?
Leukocytes + Nitrites
Just nitrites
(Not just leukocytes unless there is clinical evidence of UTI)
What should happen to the urine sample if nitrites or leukocytes are present?
Should be sent to microbiology lab for culture and sensitivities
How should all children under 3 months with a fever be managed?
Start immediate IV antibiotics (Ceftriaxone) and have full septic screen (+ LP)
How are children over 3 months with UTI managed?
Oral antibiotics (Any features of sepsis/ pyelonephritis= inpatient treatment with IV antibiotics)
What are the usual antibiotics of choice in children with UTI’s?
Trimethoprim
Nitrofurantoin
Cefalexin
Amoxicillin
What should be investigated for with recurrent UTI’s?
Underlying cause and any renal damage
When should children presenting with a UTI recieve an USS?
All under 6 months with first UTI
Those with recurrent UTI’s
Those with atypical UTI’s
What scan should be used 4-6 months after illness to assess for damage from atypical/ recurrent UTI’s?
DMSA
What is a DMSA scan?
Dimercaptosuccinic acid scan- injecting a radioactive material and using a gamma camera to assess how well the material is taken up in the kidneys.
What does a DMSA scan look for?
Scarring in the kidneys as a result of previous infection
What is VUR?
Vesico-ureteric reflux
What is vesico-ureteric reflux?
Where urine has a tendency to flow from the bladder back into the ureters
What predisposes patients to developing upper UTI’s?
VUR
How is VUR diagnosed?
Using a micturating cystourethrogram
How is vesico-ureteric reflux managed?
Avoid constipation
Avoid excessively full bladder
Prophylactic antibiotics
Surgical input
What should be used to investigate atypical/ recurrent UTIs in children under 6 months?
Micturating cystourethrogram (MCUG)
What does MCUG involve?
Catheterising the child, injecting contrast into the bladder and taking series of Xrays to determine whether contrast is refluxing into ureters
When is MCUG used?
To investigate atypical/ recurrent UTI in children under 6 months
In family history of VUR
When there is dilation of ureter on USS
When there is poor urinary flow
What is vulvovaginitis?
Inflammation and irritation of the vulva and vagina
What age range is usually affected by vulvovaginitis?
3-10 year old girls
What causes the irritation in vulvovaginitis?
Sensitive and thin skin and mucosa around the vulva and vagina
What factors exacerbate vulvovaginitis?
Wet nappies Use of chemicals/ soaps Tight clothing Poor toilet hygeine Constipation Threadworms Pressure on area (e.g. horseriding) Heavy chlorinated pools
When does vulvovaginitis usually improve and why?
Much less common after puberty as oestrogen helps keeps skin and vaginal mucosa healthy
How does vulvovaginitis present?
Soreness Itching Erythema Vaginal discharge Dysuria Constipation
What may a urine dipstick show with vulvovaginitis?
Leukocytes (but no nitrites)
How is vulvovaginitis managed?
No medical treatment needed: Avoid soap/ chemicals Good toilet hygiene (front to back) Keep area dry Emolients Loose clothing
What will patients with vulvovaginitis usually have been treated for prior to diagnosis?
UTI and thrush
What is nephrotic syndrome?
When the basement membrane in the glomerulus becomes highly permeable to protein, allowing protein to leak into the urine
In what age range is nephrotic syndrome most common?
2-5
What is the classic triad seen in nephrotic syndrome?
Low serum albumin
High proteinuria
Oedema
What is the usual urine dipstick result in nephrotic syndrome?
> 3+ protein
How does nephrotic syndrome present?
Frothy urine
Generalised oedema
Pallor
What are three other characteristic features of nephrotic syndrome?
Deranged lipid profile
High blood pressure
Hyper-coaguability
What is the deranged lipid profile usually seen in nephrotic syndrome?
High levels of cholesterol, triglycerides & LDL’s
What is the most common cause of nephrotic syndrome in children?
Minimal change disease
What are the secondary causes of nephrotic syndrome?
Intrinsic kidney disease (focal segmental glomerulosclerosis, membranoproliferative glomerulonephritis)
Systemic illness
What systemic illnesses may cause secondary nephrotic syndrome?
Henoch schonlein purpura (HSP)
Diabetes
Infection
What systemic illnesses may cause secondary nephrotic syndrome?
Henoch schonlein purpura (HSP)
Diabetes
Infection
How is minimal change disease diagnosed?
Renal biopsy rules out any abnormalities
Urinalysis shows small molecular weight proteins and hyaline casts
How is the treatment of change disease treatment?
High dose corticosteroids
What is the prognosis of minimal change disease?
Good- most make a full recovery but it may reoccur
What is the general management of nephrotic syndrome?
High dose steroids
Low salt diet
Diuretics
How long are steroids given for in nephrotic syndrome?
high dose given for 4 weeks then gradually weaned over next 8 weeks
What percentage of children with nephrotic syndrome will respond to steroids?
80% are steroid sensitive
What percent of steroid sensitive patients will relapse and need further steroids?
80%
What is given to steroid resistant children with minimal change disease?
ACE inhibitors
Immunosuppressants
What are the main complications of nephrotic syndrome?
Hypovolaemia Thrombosis Infection Acute/ chronic renal failure Relapse
Why do you get hypovolaemia in nephrotic syndrome?
Fluid leaks from the intravascular space into the interstitial space causing oedema and low BP
Why do you get thrombosis in nephrotic syndrome?
Because proteins that normally prevent clotting are lost in the kidneys, and the liver responds to the low albumin by producing pro-thrombotic protiens
Why are you more prone to infection in nephrotic syndrome?
The kidneys leak immunoglobulins, weakening the capacity of the immune system. This is exacerbated by steroid treatment
What is nephritis?
Inflammation of the nephrons of the kidneys
What does nephritis cause?
Reduction in kidney function
Haematuria
Proteinuria
Do you get more proteinuria in nephtrotic syndrome or nephritic syndrome?
Nephrotic syndrome
What are the two most common causes of nephritis in children?
Post-strep glomerulonephritis
IgA nephropathy
How long after streptococcus infection does glomerulonephritis usually occur?
1-3 weeks
Why does streptococcus infection cause nephritis?
Immune complexes get stuck in the glomeruli of the kidney and cause inflammation, which eventually leads to acute kidney injury
What are the immune complexes made of?
Streptococcal antigens
Antibodies
Complement proteins
What is the most common streptococcus infection that leads to glomerulonephritis?
Tonsillitis caused by streptococcus pyogenes
How is post-strep glomerulonephritis managed?
Supportive
may need antihypertensives/ diuretics if they develop complications
What is IgA nephropathy also known as?
Berger’s disease
What is Berger’s disease related to?
HSP (IgA vasculitis)
How does IgA nephropathy cause nephritis?
IgA deposits in the nephrons of the kidney cause inflammation
What will renal biopsy show with IgA nephropathy?
IgA deposits and glomerular mesangial proliferation
How is IgA nephropathy managed?
Supportive treatment of renal failure
Immunosuppressants to slow progression
What is haemolytic uraemic syndrome?
Thrombosis within small blood vessels throughout the body
What usually triggers haemolytic uraemic syndrome?
Shiga toxin (bacterial toxin)
What is the classic triad seen in haemolytic uraemic syndrome?
Haemolytic anaemia
Acute kidney injury
Thrombocytopenia
What is uremia?
‘Urine in the blood’- when the waste products usually excreted by the kidney build up in the blood
What bacteria produces the shiga toxin?
E.coli 0157
Shigella
What increases the risk of developing HUS?
The use of antibiotics and anti-motility medications to treat gastroenteritis caused by e.coli/ shigella
How long after a bout of gastroenteritis do symptoms of HUS usually begin?
Around 5 days later
What are the signs/ symptoms of HUS?
Reduced urine output Haematuria/ dark brown urine Abdominal pain Lethargy Irritability Confusion Oedema Hypertension Bruising
How is HUS managed?
MEDICAL EMERGENCY
Self- limiting so supportive management
Urgent referral to paediatric renal specialist
What is the mortality of HUS?
10%
What is enuresis?
Involuntary urination
What is the medical term for bed wetting?
Nocturnal enuresis
What is diurnal enuresis?
Inability to control bladder function during the day
By what age should most children have control of daytime urination?
2
By what age should most children have control of nighttime urination?
3-4 years
What is primary nocturnal enuresis?
Where the child has never managed to stay consistently dry at night
What is the most common cause of primary nocturnal enuresis?
Variation on normal development
What is common in a history of primary nocturnal enuresis?
A family history of delayed dry nights
What are other causes of primary nocturnal enuresis?
Overactive bladder
Fluid intake prior to bedtime
Failure to wake (deep sleep/ underdeveloped bladder signals)
Psychological distress
What are the secondary causes of nocturnal enuresis?
Chronic constipation
UTI
Learning disability
Cerebral palsy
What is the initial step in management of primary nocturnal enuresis?
Establish underlying cause- keep 2 week diary of toileting, fluid intake and bedwetting episodes
What is the management of primary nocturnal enuresis?
Reassure parents- likely to resolve with no treatment
Lifestyle changes
Encrouagement and positive reinforcement
Treat underlying causes/ exacerbating factors
Pharmacological treatment
What lifestyle changes are recommended in the management of primary nocturnal enuresis?
Reduce fluid intake in evening
Pass urine before bed
Easy access to toilet
Avoid fizzy drinks, juice and caffeine
What is secondary nocturnal enuresis?
Where the child begins wetting the bed when they have been dry for at least 6 months
What are the causes of secondary nocturnal enuresis?
UTI Constipation T1 diabetes Psychosocial problems Maltreatment
What are the two types of diurnal enuresis?
Urge incontinence
Stress incontinence
What are other causes of diurnal enuresis?
Recurrent UTIs
Psychosocial problems
Constipation
What can be used to help with bed wetting?
An enuresis alarm-device that makes a noise at the first sign of bed wetting to wake the child and stop them from urinating
What pharmacological treatment can be used for nocturnal enuresis?
Desmopressin
Oxybutinin
Imapramine
How does desmopressin help in the treatment of nocturnal enuresis?
Analogue of ADH, so reduces the volume of urine produces by the kidneys at night if taken at bedtime
How does oxybutinin help in the treatment of nocturnal enuresis?
Anticholinergic that reduces the contractility of the bladder
What are the two types of polycystic kidney disease?
Autosomal recessive polycystic kidney disease (ARPKD) and Autosomal dominant polycystic kidney disease (ADPKD)
Which type of polycystic kidney disease presents in children?
Autosomal recessive polycystic kidney disease (ARPKD)
When does ADPKD present?
In adulthood
When does ARPKD present?
In neonates/ on antenatal USS
What mutation causes ARPKD?
Mutation in the polycystic kidney and hepatic disease 1 (PKHD1) gene on chromosome 6
What does the PKHD1 gene code for and why does this cause PKD?
Codes for fibrocystin/ polyductin protein complex, which is responsible for the creation of tubules and the maintenance of healthy epithelial tissue in the kidneys, liver and pancreas
What does ARPKD cause?
Cystic enlargement of renal collecting ducts Oligohydramnios Pulmonary hypoplasia Potter syndrome Congenital liver fibrosis
How does ARPKD usually present in the antenatal period?
With oligohydramnios and polycystic kidneys seen on antenatal scans
What is oligohydramnios?
Lack of amniotic fluid caused by reduced urine production by the fetus
What does a lack of amniotic fluid lead to?
Potter syndrome
Pulmonary hypoplasia
What is Potter syndrome?
Syndrome characterised by dysmorphic features
What is pulmonary hypoplasia?
Underdeveloped fetal lungs
What does pulmonary hypoplasia lead to shortly after birth?
Respiratory failure
Why do neonates with PKD often get respiratory failure shortly after birth?
Pulmonary hypoplasia
Large cystic kidneys may take up so much space in abdomen it becomes hard to breathe adequately
What ongoing problems due patients with PKD have throughout life?
Liver failure due to liver fibrosis
Portal hypertension–> oesophageal varices
Progressive renal failure–> Hypertension
Chronic lung disease
What is the prognosis of ARPKD?
Poor- most develop end stage renal failure before reaching adulthood
1/3 die in neonatal period
1/3 survive to adulthood
What is MCDK?
Multicystic dysplastic kidney
What is multicystic dysplastic kidney?
Where one of the baby’s kidneys is made up of many cysts while the other kidney is normal
How is MCDK diagnosed?
On antenatal USS
Does MCDK need intervention?
No- the cystic kidney will usually atrophy and disappear and the single healthy kidney is sufficient
What can having a single kidney put you at risk of?
UTI
Hypertension
CKD
What is Wilm’s tumour?
Specific type of tumour affecting the kidney
What age range is affected by Wilm’s tumour?
Children under 5
In what patients should a Wilms tumour be considered?
Child under 5 presenting with mass in the abdomen
How may Wilms tumour present?
Mass in abdomen Abdominal pain Haematuria Lethargy Fever Hypertension Weight loss
How is a Wilms tumour diagnosed?
USS abdomen
CT/ MRI for staging
Biopsy= definitive diagnosis
How are Wilms tumours treated?
Surgical excision of tumour and affected kidney (nephrectomy)
What may also be given with nephrectomy to treat Wilms tumour?
Adjuvant treatment (chemo or radiotherapy)
What is the prognosis of Wilms tumour?
Early stage tumoour have up to 90% cure rate
Metastatic disease has poorer prognosis
What is a posterior urethral valve?
Congenital disorder where obstructive membranes develop in the proximal end of the urethra, causing obstruction of urine output
What patients are affected by posterior urethral valve?
Newborn boys
What does a posterior urethral valve cause?
Back pressure into the bladder, ureters and kidneys, causing hydronephrosis
What is hydronephrosis?
Swelling of kidneys due to a build up of urine in them
What does posterior urethral valve increase the risk of?
UTI’s
How does a posterior urethral valve present?
(May be asymptomatic) Difficulty urinating Weak urinary stream Chronic urinary retention Palpable bladder Recurrent UTI's Impaired kidney function
What may severe cases of posterior urethral valve in a fetus cause?
Bilateral hydronephrosis and oligohydramnios, leading to pulmonary hypoplasia
How may posterior urethral valve be diagnosed antenatally?
On USS scans as oligohydramnios and hydronephrosis
How might posterior urethral valve be diagnosed after birth?
Abdominal USS
Micturating cystourethrogram
Cystoscopy
What would USS show in posterior urethral valve?
Enlarged, thickened bladder and bilateral hydronephrosis
How can posterior urethral valve be managed?
Temporary urinary catheter while waiting for definitive management
Ablation of extra tissue during cystoscopy
Where do the testes develop in the fetus?
In the abdomen
How do the testes descend into the scrotum?
Migrate through the inguinal canal
By when have the testes usually reached the scrotum?
Prior to birth
What percentages of boys have testes still in the abdomen at birth?
5%
What are undescended testes?
When the testes have not migrated into the scrotum
What are undescended testes also known as?
Cryptochidism
What may undescended testes cause in older children/ after puberty?
Testicular torsion
Infertility
Testicular cancer
What are the risk factors for undescended testes?
Family history Low birth weight Small for GA Prematurity Maternal smoking in pregnancy
How are undescended testes managed?
Watch an wait
After how long will most testes spontaneously descend on their own?
Within first 3-6 months
What should happen if testes are not descended by 6 months?
Should be seen by paediatric urologist
What is orchidopexy?
Surgical correction of undescended testes
When should orchidopexy be carried out?
Between 6-12 months
What are retractile testicles?
When the testes move out of the scrotum into the inguinal canal
Under what circumstances may the testes retract?
In boys who haven’t reached puberty when its:
Cold
Cremasteric reflex
What is hypospadias?
Congenital condition affecting males where the urethral opening is not located at the tip of the penis
Where does the urethral meatus tend to be in hypospadias?
Ventral (underside) of penis, towards scrotum. Can be towards the bottom of the glans (head), halfway down or at the base of the shaft
What is epispadias?
Where the meatus is displaced to the dorsal side (top) of the penis
What is chordee?
Where the head of the penis is bent downwards
When is hypospadias usually diagnosed?
On examination of the newborn
How is hypospadias managed?
Referall to paediatric urologist:
Mild= no treatment
moderate= surgery after 3-4 months to correct position of opening and straighten penis
What are the complications of hypospadias?
Difficulty directing urination
Cosmetic/ psychological concerns
Sexual dysfunction
What is a hydrocele?
A collection of fluid within the tunica vaginalis surrounding the testes
What is the tunica vaginalis?
The pouch of serous membrane that covers the testes
What is the tunica vaginalis originally part of during development?
Peritoneal membrane
What is a simple hydrocele?
When the fluid is trapped in the tunica vaginalis
What usually happens to the fluid in a simple hydrocele?
It gets reabsorbed over time
What is a communicating hydrocele?
When the tunica vaginalis around the testicle is connected with the peritoneal cavity via a pathway (processus vaginalis), allowing fluid to travel from the peritoneal cavity into the hydrocele
What will be found on examination with a hydrocele?
Soft, smooth, non-tender swelling around one of the testes.
Transilluminate with light
What is the difference between simple and communicating hydroceles in terms of their presentation?
Communicating hydroceles will fluctuate in size depending on the volume of fluid from the peritoneal cavity
What are the differential diagnoses for a scrotal/ inguinal swelling in a neonate?
Hydrocele Partially descended testes Inguinal hernia Testicular torsion Haematoma Tumour
How is the diagnosis of a hydrocele confirmed?
USS
What is the management of a simple hydrocele?
Routine follow up with no treatment- will usually resolve within 2 years
What is the management of communicating hydroceles?
Treat with surgery to remove/ ligate the connection (processus vaginalis)
