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Renal/urology Flashcards

1
Q

What makes up the urinary tract?

A

urethra, bladder, ureters and kidneys

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2
Q

Whatis acute pyelonephritis?

A

Infection of the kidney

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3
Q

What is cystitis?

A

Inflammation of the bladder

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4
Q

What is the characteristic feature of a UTI?

A

Fever

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5
Q

What should always be excluded in any child presenting with a temperature?

A

UTI

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6
Q

How do babies present with UTI?

A 
Fever
Lethargy
Irritability 
Vomiting
Poor feeding
Urinary frequency
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7
Q

How do older infants and children present with UTI?

A 
Fever
Abdominal (suprapubic) pain)
Vomiting
Dysuria
Urinary frequency
Incontinence
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8
Q

What is the ideal urine sample?

A

Clean catch

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9
Q

How does a clean catch sample usually have to be taken in younger children/ babies?

A

Parent sits with them without nappy and urine pot held ready to catch sample

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10
Q

What things are looked for on a urine sample that would indicate infection?

A

Nitrites

Leukocyte esterase

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11
Q

What does the presence of nitrites in the urine indicate and why?

A

Gram negative bacteria break down nitrates (normal waste product in urine) into nitrites, so suggests presence of bacteria

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12
Q

What does the presence of leukocytes in urine suggest?

A

Rise in WBC in the urine indicate infection or inflammation

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13
Q

What is leukocyte esterase?

A

A product of leukocytes that gives an indication about the number of leukocytes in the urine

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14
Q

What is the best indication of infection in a urine sample?

A

Nitrites

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15
Q

What urine sample results would trigger treatment of UTI?

A

Leukocytes + Nitrites
Just nitrites
(Not just leukocytes unless there is clinical evidence of UTI)

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16
Q

What should happen to the urine sample if nitrites or leukocytes are present?

A

Should be sent to microbiology lab for culture and sensitivities

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17
Q

How should all children under 3 months with a fever be managed?

A

Start immediate IV antibiotics (Ceftriaxone) and have full septic screen (+ LP)

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18
Q

How are children over 3 months with UTI managed?

A 
Oral antibiotics
(Any features of sepsis/ pyelonephritis= inpatient treatment with IV antibiotics)
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19
Q

What are the usual antibiotics of choice in children with UTI’s?

A

Trimethoprim
Nitrofurantoin
Cefalexin
Amoxicillin

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20
Q

What should be investigated for with recurrent UTI’s?

A

Underlying cause and any renal damage

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21
Q

When should children presenting with a UTI recieve an USS?

A

All under 6 months with first UTI
Those with recurrent UTI’s
Those with atypical UTI’s

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22
Q

What scan should be used 4-6 months after illness to assess for damage from atypical/ recurrent UTI’s?

A

DMSA

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23
Q

What is a DMSA scan?

A

Dimercaptosuccinic acid scan- injecting a radioactive material and using a gamma camera to assess how well the material is taken up in the kidneys.

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24
Q

What does a DMSA scan look for?

A

Scarring in the kidneys as a result of previous infection

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25
Q

What is VUR?

A

Vesico-ureteric reflux

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26
Q

What is vesico-ureteric reflux?

A

Where urine has a tendency to flow from the bladder back into the ureters

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27
Q

What predisposes patients to developing upper UTI’s?

A

VUR

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28
Q

How is VUR diagnosed?

A

Using a micturating cystourethrogram

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29
Q

How is vesico-ureteric reflux managed?

A

Avoid constipation
Avoid excessively full bladder
Prophylactic antibiotics
Surgical input

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30
Q

What should be used to investigate atypical/ recurrent UTIs in children under 6 months?

A

Micturating cystourethrogram (MCUG)

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31
Q

What does MCUG involve?

A

Catheterising the child, injecting contrast into the bladder and taking series of Xrays to determine whether contrast is refluxing into ureters

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32
Q

When is MCUG used?

A

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

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33
Q

What is vulvovaginitis?

A

Inflammation and irritation of the vulva and vagina

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34
Q

What age range is usually affected by vulvovaginitis?

A

3-10 year old girls

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35
Q

What causes the irritation in vulvovaginitis?

A

Sensitive and thin skin and mucosa around the vulva and vagina

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36
Q

What factors exacerbate vulvovaginitis?

A 
Wet nappies
Use of chemicals/ soaps
Tight clothing
Poor toilet hygeine
Constipation
Threadworms
Pressure on area (e.g. horseriding)
Heavy chlorinated pools
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37
Q

When does vulvovaginitis usually improve and why?

A

Much less common after puberty as oestrogen helps keeps skin and vaginal mucosa healthy

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38
Q

How does vulvovaginitis present?

A 
Soreness
Itching
Erythema
Vaginal discharge
Dysuria
Constipation
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39
Q

What may a urine dipstick show with vulvovaginitis?

A

Leukocytes (but no nitrites)

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40
Q

How is vulvovaginitis managed?

A 
No medical treatment needed: 
Avoid soap/ chemicals
Good toilet hygiene (front to back)
Keep area dry
Emolients
Loose clothing
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41
Q

What will patients with vulvovaginitis usually have been treated for prior to diagnosis?

A

UTI and thrush

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42
Q

What is nephrotic syndrome?

A

When the basement membrane in the glomerulus becomes highly permeable to protein, allowing protein to leak into the urine

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43
Q

In what age range is nephrotic syndrome most common?

A

2-5

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44
Q

What is the classic triad seen in nephrotic syndrome?

A

Low serum albumin
High proteinuria
Oedema

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45
Q

What is the usual urine dipstick result in nephrotic syndrome?

A

> 3+ protein

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46
Q

How does nephrotic syndrome present?

A

Frothy urine
Generalised oedema
Pallor

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47
Q

What are three other characteristic features of nephrotic syndrome?

A

Deranged lipid profile
High blood pressure
Hyper-coaguability

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48
Q

What is the deranged lipid profile usually seen in nephrotic syndrome?

A

High levels of cholesterol, triglycerides & LDL’s

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49
Q

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

A

Minimal change disease

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50
Q

What are the secondary causes of nephrotic syndrome?

A

Intrinsic kidney disease (focal segmental glomerulosclerosis, membranoproliferative glomerulonephritis)
Systemic illness

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51
Q

What systemic illnesses may cause secondary nephrotic syndrome?

A

Henoch schonlein purpura (HSP)
Diabetes
Infection

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52
Q

What systemic illnesses may cause secondary nephrotic syndrome?

A

Henoch schonlein purpura (HSP)
Diabetes
Infection

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53
Q

How is minimal change disease diagnosed?

A

Renal biopsy rules out any abnormalities

Urinalysis shows small molecular weight proteins and hyaline casts

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54
Q

How is the treatment of change disease treatment?

A

High dose corticosteroids

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55
Q

What is the prognosis of minimal change disease?

A

Good- most make a full recovery but it may reoccur

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56
Q

What is the general management of nephrotic syndrome?

A

High dose steroids
Low salt diet
Diuretics

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57
Q

How long are steroids given for in nephrotic syndrome?

A

high dose given for 4 weeks then gradually weaned over next 8 weeks

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58
Q

What percentage of children with nephrotic syndrome will respond to steroids?

A

80% are steroid sensitive

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59
Q

What percent of steroid sensitive patients will relapse and need further steroids?

A

80%

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60
Q

What is given to steroid resistant children with minimal change disease?

A

ACE inhibitors

Immunosuppressants

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61
Q

What are the main complications of nephrotic syndrome?

A 
Hypovolaemia
Thrombosis
Infection
Acute/ chronic renal failure
Relapse
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62
Q

Why do you get hypovolaemia in nephrotic syndrome?

A

Fluid leaks from the intravascular space into the interstitial space causing oedema and low BP

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63
Q

Why do you get thrombosis in nephrotic syndrome?

A

Because proteins that normally prevent clotting are lost in the kidneys, and the liver responds to the low albumin by producing pro-thrombotic protiens

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64
Q

Why are you more prone to infection in nephrotic syndrome?

A

The kidneys leak immunoglobulins, weakening the capacity of the immune system. This is exacerbated by steroid treatment

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65
Q

What is nephritis?

A

Inflammation of the nephrons of the kidneys

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66
Q

What does nephritis cause?

A

Reduction in kidney function
Haematuria
Proteinuria

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67
Q

Do you get more proteinuria in nephtrotic syndrome or nephritic syndrome?

A

Nephrotic syndrome

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68
Q

What are the two most common causes of nephritis in children?

A

Post-strep glomerulonephritis

IgA nephropathy

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69
Q

How long after streptococcus infection does glomerulonephritis usually occur?

A

1-3 weeks

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70
Q

Why does streptococcus infection cause nephritis?

A

Immune complexes get stuck in the glomeruli of the kidney and cause inflammation, which eventually leads to acute kidney injury

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71
Q

What are the immune complexes made of?

A

Streptococcal antigens
Antibodies
Complement proteins

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72
Q

What is the most common streptococcus infection that leads to glomerulonephritis?

A

Tonsillitis caused by streptococcus pyogenes

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73
Q

How is post-strep glomerulonephritis managed?

A

Supportive

may need antihypertensives/ diuretics if they develop complications

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74
Q

What is IgA nephropathy also known as?

A

Berger’s disease

75
Q

What is Berger’s disease related to?

A

HSP (IgA vasculitis)

76
Q

How does IgA nephropathy cause nephritis?

A

IgA deposits in the nephrons of the kidney cause inflammation

77
Q

What will renal biopsy show with IgA nephropathy?

A

IgA deposits and glomerular mesangial proliferation

78
Q

How is IgA nephropathy managed?

A

Supportive treatment of renal failure

Immunosuppressants to slow progression

79
Q

What is haemolytic uraemic syndrome?

A

Thrombosis within small blood vessels throughout the body

80
Q

What usually triggers haemolytic uraemic syndrome?

A

Shiga toxin (bacterial toxin)

81
Q

What is the classic triad seen in haemolytic uraemic syndrome?

A

Haemolytic anaemia
Acute kidney injury
Thrombocytopenia

82
Q

What is uremia?

A

‘Urine in the blood’- when the waste products usually excreted by the kidney build up in the blood

83
Q

What bacteria produces the shiga toxin?

A

E.coli 0157

Shigella

84
Q

What increases the risk of developing HUS?

A

The use of antibiotics and anti-motility medications to treat gastroenteritis caused by e.coli/ shigella

85
Q

How long after a bout of gastroenteritis do symptoms of HUS usually begin?

A

Around 5 days later

86
Q

What are the signs/ symptoms of HUS?

A 
Reduced urine output 
Haematuria/ dark brown urine
Abdominal pain
Lethargy 
Irritability 
Confusion
Oedema
Hypertension
Bruising
87
Q

How is HUS managed?

A

MEDICAL EMERGENCY
Self- limiting so supportive management
Urgent referral to paediatric renal specialist

88
Q

What is the mortality of HUS?

A

10%

89
Q

What is enuresis?

A

Involuntary urination

90
Q

What is the medical term for bed wetting?

A

Nocturnal enuresis

91
Q

What is diurnal enuresis?

A

Inability to control bladder function during the day

92
Q

By what age should most children have control of daytime urination?

A

2

93
Q

By what age should most children have control of nighttime urination?

A

3-4 years

94
Q

What is primary nocturnal enuresis?

A

Where the child has never managed to stay consistently dry at night

95
Q

What is the most common cause of primary nocturnal enuresis?

A

Variation on normal development

96
Q

What is common in a history of primary nocturnal enuresis?

A

A family history of delayed dry nights

97
Q

What are other causes of primary nocturnal enuresis?

A

Overactive bladder
Fluid intake prior to bedtime
Failure to wake (deep sleep/ underdeveloped bladder signals)
Psychological distress

98
Q

What are the secondary causes of nocturnal enuresis?

A

Chronic constipation
UTI
Learning disability
Cerebral palsy

99
Q

What is the initial step in management of primary nocturnal enuresis?

A

Establish underlying cause- keep 2 week diary of toileting, fluid intake and bedwetting episodes

100
Q

What is the management of primary nocturnal enuresis?

A

Reassure parents- likely to resolve with no treatment
Lifestyle changes
Encrouagement and positive reinforcement
Treat underlying causes/ exacerbating factors
Pharmacological treatment

101
Q

What lifestyle changes are recommended in the management of primary nocturnal enuresis?

A

Reduce fluid intake in evening
Pass urine before bed
Easy access to toilet
Avoid fizzy drinks, juice and caffeine

102
Q

What is secondary nocturnal enuresis?

A

Where the child begins wetting the bed when they have been dry for at least 6 months

103
Q

What are the causes of secondary nocturnal enuresis?

A 
UTI
Constipation
T1 diabetes
Psychosocial problems
Maltreatment
104
Q

What are the two types of diurnal enuresis?

A

Urge incontinence

Stress incontinence

105
Q

What are other causes of diurnal enuresis?

A

Recurrent UTIs
Psychosocial problems
Constipation

106
Q

What can be used to help with bed wetting?

A

An enuresis alarm-device that makes a noise at the first sign of bed wetting to wake the child and stop them from urinating

107
Q

What pharmacological treatment can be used for nocturnal enuresis?

A

Desmopressin
Oxybutinin
Imapramine

108
Q

How does desmopressin help in the treatment of nocturnal enuresis?

A

Analogue of ADH, so reduces the volume of urine produces by the kidneys at night if taken at bedtime

109
Q

How does oxybutinin help in the treatment of nocturnal enuresis?

A

Anticholinergic that reduces the contractility of the bladder

110
Q

What are the two types of polycystic kidney disease?

A

Autosomal recessive polycystic kidney disease (ARPKD) and Autosomal dominant polycystic kidney disease (ADPKD)

111
Q

Which type of polycystic kidney disease presents in children?

A

Autosomal recessive polycystic kidney disease (ARPKD)

112
Q

When does ADPKD present?

A

In adulthood

113
Q

When does ARPKD present?

A

In neonates/ on antenatal USS

114
Q

What mutation causes ARPKD?

A

Mutation in the polycystic kidney and hepatic disease 1 (PKHD1) gene on chromosome 6

115
Q

What does the PKHD1 gene code for and why does this cause PKD?

A

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

116
Q

What does ARPKD cause?

A 
Cystic enlargement of renal collecting ducts
Oligohydramnios
Pulmonary hypoplasia
Potter syndrome
Congenital liver fibrosis
117
Q

How does ARPKD usually present in the antenatal period?

A

With oligohydramnios and polycystic kidneys seen on antenatal scans

118
Q

What is oligohydramnios?

A

Lack of amniotic fluid caused by reduced urine production by the fetus

119
Q

What does a lack of amniotic fluid lead to?

A

Potter syndrome

Pulmonary hypoplasia

120
Q

What is Potter syndrome?

A

Syndrome characterised by dysmorphic features

121
Q

What is pulmonary hypoplasia?

A

Underdeveloped fetal lungs

122
Q

What does pulmonary hypoplasia lead to shortly after birth?

A

Respiratory failure

123
Q

Why do neonates with PKD often get respiratory failure shortly after birth?

A

Pulmonary hypoplasia

Large cystic kidneys may take up so much space in abdomen it becomes hard to breathe adequately

124
Q

What ongoing problems due patients with PKD have throughout life?

A

Liver failure due to liver fibrosis
Portal hypertension–> oesophageal varices
Progressive renal failure–> Hypertension
Chronic lung disease

125
Q

What is the prognosis of ARPKD?

A

Poor- most develop end stage renal failure before reaching adulthood
1/3 die in neonatal period
1/3 survive to adulthood

126
Q

What is MCDK?

A

Multicystic dysplastic kidney

127
Q

What is multicystic dysplastic kidney?

A

Where one of the baby’s kidneys is made up of many cysts while the other kidney is normal

128
Q

How is MCDK diagnosed?

A

On antenatal USS

129
Q

Does MCDK need intervention?

A

No- the cystic kidney will usually atrophy and disappear and the single healthy kidney is sufficient

130
Q

What can having a single kidney put you at risk of?

A

UTI
Hypertension
CKD

131
Q

What is Wilm’s tumour?

A

Specific type of tumour affecting the kidney

132
Q

What age range is affected by Wilm’s tumour?

A

Children under 5

133
Q

In what patients should a Wilms tumour be considered?

A

Child under 5 presenting with mass in the abdomen

134
Q

How may Wilms tumour present?

A 
Mass in abdomen
Abdominal pain
Haematuria
Lethargy
Fever
Hypertension
Weight loss
135
Q

How is a Wilms tumour diagnosed?

A

USS abdomen
CT/ MRI for staging
Biopsy= definitive diagnosis

136
Q

How are Wilms tumours treated?

A

Surgical excision of tumour and affected kidney (nephrectomy)

137
Q

What may also be given with nephrectomy to treat Wilms tumour?

A

Adjuvant treatment (chemo or radiotherapy)

138
Q

What is the prognosis of Wilms tumour?

A

Early stage tumoour have up to 90% cure rate

Metastatic disease has poorer prognosis

139
Q

What is a posterior urethral valve?

A

Congenital disorder where obstructive membranes develop in the proximal end of the urethra, causing obstruction of urine output

140
Q

What patients are affected by posterior urethral valve?

A

Newborn boys

141
Q

What does a posterior urethral valve cause?

A

Back pressure into the bladder, ureters and kidneys, causing hydronephrosis

142
Q

What is hydronephrosis?

A

Swelling of kidneys due to a build up of urine in them

143
Q

What does posterior urethral valve increase the risk of?

A

UTI’s

144
Q

How does a posterior urethral valve present?

A 
(May be asymptomatic)
Difficulty urinating
Weak urinary stream
Chronic urinary retention
Palpable bladder
Recurrent UTI's
Impaired kidney function
145
Q

What may severe cases of posterior urethral valve in a fetus cause?

A

Bilateral hydronephrosis and oligohydramnios, leading to pulmonary hypoplasia

146
Q

How may posterior urethral valve be diagnosed antenatally?

A

On USS scans as oligohydramnios and hydronephrosis

147
Q

How might posterior urethral valve be diagnosed after birth?

A

Abdominal USS
Micturating cystourethrogram
Cystoscopy

148
Q

What would USS show in posterior urethral valve?

A

Enlarged, thickened bladder and bilateral hydronephrosis

149
Q

How can posterior urethral valve be managed?

A

Temporary urinary catheter while waiting for definitive management
Ablation of extra tissue during cystoscopy

150
Q

Where do the testes develop in the fetus?

A

In the abdomen

151
Q

How do the testes descend into the scrotum?

A

Migrate through the inguinal canal

152
Q

By when have the testes usually reached the scrotum?

A

Prior to birth

153
Q

What percentages of boys have testes still in the abdomen at birth?

A

5%

154
Q

What are undescended testes?

A

When the testes have not migrated into the scrotum

155
Q

What are undescended testes also known as?

A

Cryptochidism

156
Q

What may undescended testes cause in older children/ after puberty?

A

Testicular torsion
Infertility
Testicular cancer

157
Q

What are the risk factors for undescended testes?

A 
Family history
Low birth weight
Small for GA
Prematurity
Maternal smoking in pregnancy
158
Q

How are undescended testes managed?

A

Watch an wait

159
Q

After how long will most testes spontaneously descend on their own?

A

Within first 3-6 months

160
Q

What should happen if testes are not descended by 6 months?

A

Should be seen by paediatric urologist

161
Q

What is orchidopexy?

A

Surgical correction of undescended testes

162
Q

When should orchidopexy be carried out?

A

Between 6-12 months

163
Q

What are retractile testicles?

A

When the testes move out of the scrotum into the inguinal canal

164
Q

Under what circumstances may the testes retract?

A

In boys who haven’t reached puberty when its:
Cold
Cremasteric reflex

165
Q

What is hypospadias?

A

Congenital condition affecting males where the urethral opening is not located at the tip of the penis

166
Q

Where does the urethral meatus tend to be in hypospadias?

A

Ventral (underside) of penis, towards scrotum. Can be towards the bottom of the glans (head), halfway down or at the base of the shaft

167
Q

What is epispadias?

A

Where the meatus is displaced to the dorsal side (top) of the penis

168
Q

What is chordee?

A

Where the head of the penis is bent downwards

169
Q

When is hypospadias usually diagnosed?

A

On examination of the newborn

170
Q

How is hypospadias managed?

A

Referall to paediatric urologist:
Mild= no treatment
moderate= surgery after 3-4 months to correct position of opening and straighten penis

171
Q

What are the complications of hypospadias?

A

Difficulty directing urination
Cosmetic/ psychological concerns
Sexual dysfunction

172
Q

What is a hydrocele?

A

A collection of fluid within the tunica vaginalis surrounding the testes

173
Q

What is the tunica vaginalis?

A

The pouch of serous membrane that covers the testes

174
Q

What is the tunica vaginalis originally part of during development?

A

Peritoneal membrane

175
Q

What is a simple hydrocele?

A

When the fluid is trapped in the tunica vaginalis

176
Q

What usually happens to the fluid in a simple hydrocele?

A

It gets reabsorbed over time

177
Q

What is a communicating hydrocele?

A

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

178
Q

What will be found on examination with a hydrocele?

A

Soft, smooth, non-tender swelling around one of the testes.

Transilluminate with light

179
Q

What is the difference between simple and communicating hydroceles in terms of their presentation?

A

Communicating hydroceles will fluctuate in size depending on the volume of fluid from the peritoneal cavity

180
Q

What are the differential diagnoses for a scrotal/ inguinal swelling in a neonate?

A 
Hydrocele 
Partially descended testes
Inguinal hernia
Testicular torsion
Haematoma
Tumour
181
Q

How is the diagnosis of a hydrocele confirmed?

A

USS

182
Q

What is the management of a simple hydrocele?

A

Routine follow up with no treatment- will usually resolve within 2 years

183
Q

What is the management of communicating hydroceles?

A

Treat with surgery to remove/ ligate the connection (processus vaginalis)

Paeds (18 decks)

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