Renal/Urology/Genitalia Flashcards
What is Potter’s syndrome?
Renal agenesis = oligohydramnios = intrauterine compression
- Facies
- Limb deformities
- Lung hypoplasia
Why is UTI in children important (2)?
- Structural abnormalities in 50%
- Pyelonephritis = scarring = CKD
What is dysuria alone usually due to in boys and girls?
Boys - balanitis
Girls - cystitis, vulvitis
Signs of an atypical UTI
Refractory to abx treatment Abdo/pelvic mass Seriously ill/septicaemia Poor urine flow Raised Cr Non- E.coli organism
Predisposing factors for UTI
Structural abnormality
Incomplete voiding/emptying
Constipation
Vesicoureteric reflux
Is nocturnal enuresis more common in boys or girls?
Boys (2:1)
When is nocturnal enuresis worth investigating?
After 6 years
Organic causes of nocturnal enuresis
- UTI
- Constipation
- DM
- CKD
Contributing factors to nocturnal enuresis
Organic causes (e.g. UTI, constipation, DM)
Genetics
Emotional stress
Lack of parental approval
Management steps of nocturnal enuresis
Explanation (common, most self resolve, not conscious)
Ensure easy access to toilet, bladder emptying before bed
Start chart
Alarms
Desmopressin (ADH)
When are most children dry by day and night?
5 years
When are most children dry by day?
4 years
When is desmopressin appropriate in enuresis?
Short ter control e.g. for school trip or sleepover
Causes of primary daytime enuresis
- Inattention to sensation
- Detrusor overactivity
- Neuropathic bladder
- UTI
- Ectopic ureter (constant dribbling)
Treatment for overactive detrusor
Anticholinergics e.g. oxybutynin
Mx for primary daytime enuresis >5 years
Referral to specialists USS Urine dip (MC&S) USS Spine XR
Causes of secondary enuresis
Emotional upset
UTI
DM
Clinical features of nephrotic syndrome
Periorbital oedema
Scrotal, vulval, leg and ankle oedema
Abdo distension - ascites
Resp distress (pulm effusion/abdo distension)
Nephrotic syndrome triad
Proteinuria
Oedema
Hypoalbuminaemia
Commonest childhood cause of nephrotic syndrome
Minimal change disease
Causes of nephrotic syndrome in children
Glomerular - minimal change disease, glomerulonephritis
Orthostatic proteinuria
HTN
SECONDARY - SLE, HSP
Investigations nephrotic syndrome
Urine dip (+ MC&S) FBC + ESR U&E Complement (SLE) Antistreptolysin O/ DNAse B Abs (HSP) Urinary sodium Malaria (if travel)
Management nephrotc syndrome
Regular urine monitoring
4 weeks PO prednisolone
Wean over next four weeks, or alternate days
(Proteinuria should resolve by 11 days)
Fluid/salt restriction
If it hasn’t resolved after course of pred - consider renal biopsy
- Albumin
- Furosemide
Complications of nephrotic syndrome
Hypovolaemia (abdo pain/faint) - treated with albumin
Thrombosis
Infection (capsulated e.g. pneumococcus)
Hypercholesterolaemia
Commonest cause of haematuria in children
UTI
Two broad categories of haematuria causes
Non-glomerular - UTI, trauma, stones, tumour, hypercalciuria, SCD
Glomerular - acute nephritis, post-streptococcocal, HSP, IgA nephropathy, familial (Alport’s)
Hearing loss and nephritis
Alport’s
Investigations for haematuria
Urine dip (MC&S)
Bloods (FBC, U&E, albumin, ESR)
Special bloods (anti-streptolysin O titre, anti-DNA)
Renal biopsy
Causes of acute nephritis
Post-streptococcal
HSP
IgA nephropathy
Acute nephritis (nephritic syndrome) features
Oedema
HTN
Haematuria/proteinuria
Reduced urine output
Post strep nephritis
Following throat or skin infection
Raised ASO/Anti-DNAse B titres
Low C3 (resolves over 3-4 weeks)
Features of HSP
Fever Characteristic skin rash Arthralgia Glomerulonephritis Periarticular oedema Abdominal pain (colicky)
Features of HSP rash
Trunk sparing. Buttocks, legs, extensor surfaces, ankles
Urticarial –> maculopapular –> purpuric
Palpable
When does HSP typically occur
Winter months
After URTI
(3-10 years)
Demographics of patients at highest risk of HSP
Boys > girls (2:1)
3-10 years
What is HSP?
IgA mediated vasculitis
Management of HSP (by feature)
Arthralgia - ibuprofen/paracetamol
Severe oedema or abdominal pain - oral prednisolone
Proteinuria/deteriorating renal fx - IV corticosteroids
Follow up to check BP and renal fx
Commonest familial nephritis
Alport’s
Commonest vasculitis to involve the kidney
HSP
When is dialysis appropriate?
Severe hyperkalaemia Metabolic acidosis Severe hypo/hypernatraemia Pulmonary oedema HTN
Commonest cause of AKI in children
Pre-renal
Mx pre-renal AKI
Fluid replacement
Circulatory support
Dopamine/adrenaline is very low blood pressure
Furosemide if volume overloaded
Causes of prerenal AKI
Hypovolaemia (gastroenteritis, sepsis, burns, haemorrhage, nephrotic syndrome)
Circulatory failure
Causes of Renal AKI
Vascular - HSP, HUS
Tubular - ATN, ischaemia, toxins
Interstitial - pyelonephritis
Glomerular - glomerulonephritis
Mx of renal AKI
- Treat the underlying cause ***
- Monitor H2O, U&Es
- High calorie, normal protein diet. Reduce catabolism, uraemia nd hyperkalaemia
- Furosemide if vol overload
- IVI if co-existent pre-renal AKI
Causes of post-renal AKI
Obstruction
Mx of post-renal AKI
Urgent r/f to urology for ax of site of obstruction
Nephrostomy
Bladder catheterisation
HUS triad
Uraemia
Haemolytic anaemia
Thrombocytopenia
Primary cause HUS
Gastroenteritis (E.coli H157)
What type of renal failure is HUS?
Acute renal (vascular)
Presentation of HUS
History of bloody diarrhoea (gastroenteritis)
Malaise/lethargy
Bruising
Haematuria
Mx HUS
Refer to haematology/nephrology
Supportive:
- Monitor fluid balance and BP
- IV isotonic crystalloids
- Blood transfusion if anaemic
- 50% will require dialysis
What % of patients with HUS will require dialysis in the acute phase?
50%
What treatments should be avoided in HUS?
Abx, opioids, NSAIDs, anti-diarrhoeals
Features of atypical HUS
No diarrhoeal prodrome
Frequent relapses
–> higher risk of HTN and progressive CKD
Mx for irreversible renal failure caused by HUS
Transplant
Why is long term follow up necessary after resolution of acute HUS?
Persistent proteinuria
HTN
Progressive CKD
How is AKI defined?
Oliguria (<0.5ml/kg/day)
How is CKD defined?
eGFR <15 ml/min
Commonest cause of CKD
Structural abnormalities and malformations
Presentation of CKD
Abnormal AN USS
Anorexia/lethargy FTT Polydipsia, polyuria Real rickets HTN Proteinuria Anaemia
Mx CKD (think different symptoms)
Anorexia/lethargy/FTT - nutrition. Consider NGT/gastrotomy with calorie supplements.
Polydipsia, polyuria
Renal rickets - phosphate restriction, calcium carbonate, activated D3
HTN - ACEi/ARB, CCB, dialysis, transplant
Anaemia - EPO stimulating agent
Hormonal abnormalities - Recombinant GH
Salt imbalances, met acidosos - sodium bicarb, salt supplements, water
What is renal rickets?
Renal osteodystrophy
- Kidney cannot hydroxylate D2 –> D3
- Impaired absorption of Ca/excretion of PO4
= Osteitis fibrosa, osteomalacia leading to secondary hyperparathyroidism
What type of inguinal hernia is more common in children? Why?
Indirect - patent processus vaginalis
Which group of children are most at risk of inguinal hernias?
Prems
Boys
Presentation of inguinal hernia
Intermitten groin swelling (on crying/straining)
Irreducible, firm, tender lump in groin/scrotum
Irritability, vomiting
Mx of reducible hernia
Reduce under opioid analgesia
Surgery 24-48h to allow oedema to go down
Mx of irreducible hernia
Emergency surgery (might be incarcerated)
Common cause of hydrocoele
Patent processus vaginalis
Where does the fluid come from/go to in a hydrocoele?
Peritoneal fluid into tunica vaginalis
Presentation of hydrocoele
Asymptomatic swelling in scrotum (commonly bilateral) Bluish Non-tender Transilluminates Sometimes present after viral/GI illness
Treatment of hydrocoele <2 years
Observe - most resolve spontaneously over 18-24 months
Treatment of hydrocoele 2-11 years
Surgery with open repair.
Laparoscopic exploration
Treatment of hydrocoele 11+ years
Dependent on cause:
- Idiopathic – observe. Surgery if particularly large/uncomfortable
- After varicocelectomy - conservative management
- Parasitic - surgery
When must surgery occur in suspected testicular torsion?
Immediately
Before 6 hours
Testicular torsion surgery
Orchidectomy
Orchidopexy (if undescended)
Contralateral and affected testicle fixed to the posterior wall
When is testicular torsion most common?
Adolescents
Risk factors for testicular torsion
Previous self-limiting episodes
Undescended testes
Presentation epididymoorchitis
Insidious onset unilateral scrotal/groin pain
+/- urinary symptoms
+/- STI symptoms
+/- mumps symptoms
Treatment epididiymoorchitis
Symptomatic relief - bed rest, analgesia, scrotal elevation
Abx if bacteral cause (UTI/STI)
Supportive if viral cause (mumps)
IV abx and fluids if systemically unwell with high-grade fever
Three types of cryptorchidism
Retractile - can manipulate testis into the scortum, but retracts back
Palpable - palpated in groin, but not in scrotum
Impalpable - in inguinal canal/intraabdominal/absent (10%)
What percentage of impalpable testes are completely absent?
10%
Why are undescended testes more common in pre-term infants?
Testes’ descent through the inguinal canal largely occurs during the third trimester
Investigations for undescended testes
USS
Hormonal (check testosterone response to hCG - check to see if there is any testicular tissue)
Laparoscopic exploration
Management of undescended testes in neonate
R/v at 6-8 weeks.
If still not descended, re-exmaine at 3 months.
If retractile –> reassurance +annual review
If still not descended –> orchidopexy
When should infant with undescended testes be referred to paediatrician?
Within first 24 hours if
- possibility of disorder of sexual development
- bilateral
If has not resolved (or at least become retractile) by 3 months
When should orchidopexy be performed?
3 months - 1 year
Why is orchidopexy performed?
Cosmetic
Reduced risk trauma/torsion
Reduced risk malignancy
Fertility
Incidence of hypospasias
1/200 male births
Pathophysiology hypospadias
Urethral tubularisation occurs proximally to distally under the influence of fetal testosterone.
Failure to complete this migration = hypospadia
Three types of hypospadia
Ventral urethral meatus (on underside)
Hooded dorsal foreskin
Chordee (ventral curvature)
What should be investigated in particularly proximal hypospadias?
For other GU anomalies
Management of hypospadia
Surgery is NOT mandatory
May be performend for function or cosmesis after 3 months (ideally before 2 years)
What must not happen in infants with hypospadias
Circumcision - foreskin can be used for reconstruction
What is the aim of hypospadia surgery
Stand and pee in straight line
Straight erection
Medical indications for circumcision
Phimosis (inability to retract foreskin - whitish scarring caused by localised skin disease BXO)
Recurrent balanoposthitis (redness and inflammation of foreskin, purulent discharge)
Recurrent UTI
Paraphimosis
Foreskin trapped in retracted position, proximal to swollen glans
Management of paraphimosis
Topic analgesia - ice packs, compression, osmotic agents
Puncture technique - exudation of oedmatous fluids
Surgical reduction and circumcision
