RENAL/UROLOGY PAEDS Flashcards
UTI PAEDS presentation
Babies: Fever, lethargy, irritability, vomiting, poor feeding, urinary frequency
Older infants/children: fever, abdo pain, vomiting, dysuria, frequency, incontinence
Urine dipstick: Presence of nitrites
Gram negative bacteria (e.g. E.Coli)
Urine dipstick: Presence of Leukocytes
Significant levels of leukocytes in urine suggest inflammation or infection
Don’t treat for UTI if only leukocytes present - unless clinically indicated
UTI: Antibiotics
All children under 3 months with a fever: start on IV abx (e.g. ceftriaxone), full septic screen, blood cultures, bloods, lactate. Consider LP
Children over 3 months: Oral abx if they are otherwise well (if signs of sepsis —> admission + IV abx)
- Trimethoprim
- Nitrofurantoin
- Cefalexin
- Amoxicillin
Investigations for recurrent UTIs
USS
DMSA (dimercaptosuccinic acid) scan - 4-6 months after illness to assess for damage from recurrent or atypical UTIs
MCUG (micturating cystourethrogram)
Vesicoureteral reflux (VUR)
Urine flows from the bladder back into ureters
Predisposes patient to developing UTIs and subsequent renal scarring
Diagnosed using MICTURATING CYSTOURETHROGRAM
Vulvo vaginitis: Precipitants
Wet nappies CLeaning/soaps use in area Tight clothing that traps moisture in the area Poor toilet hygiene Constipation Threadworms Pressure on area (e.g. horse riding) Heavily chlorinated pools
Why is vulvovaginitis better after puberty?
OEstrogen helps keep skin and vaginal mucosa healthy and resistant to infection
Commonly affects girls aged 3-10 yrs
Vulvovaginitis presentation
Soreness Itching Erythema around labia Vaginal discharge Dysuria Constipation
Vulvovaginitis MANAGEMENT
No medical treatment often required. Simple measures to improve symptoms.
E.g. avoid washing with soap/chemicals, good toilet hygiene, emollients e.g. sudacrem, loose cotton clothing, treat any constipation, avoid activities that exacerbate problem
Oestrogen cream in very severe cases
NEPHROTIC SYNDROME features (triad + 3 others)
- Low serum albumin
- High urine protein conc.
- Oedema
- Deranged lipid profile
- High BP
- Hyper-coagulability
Nephrotic syndrome: what is it?
When the BM in the glomerulus becomes highly permeable to protein.
Frothy urine
Generalised oedema
Pallor
Nephrotic syndrome: cause (primary)
Most common cause in children: MINIMAL CHANGE DISEASE
- accounting for 90% of cases in children U10
Nephrotic syndrome: causes (secondary)
Secondary to intrinsic kidney disease
- focal segmental glomerulosclerosis
- membranoproliferative glomerulonephritis
Secondary to underlying systemic illness
- Henoch-schonlein purpura (HSP)
- Diabetes
- infection (HIV, Hepatitis, malaria)
Minimal change disease: management
Corticosteroids (prednisolone)
Most children make full recovery, it may reoccur
Nephrotic syndrome: Management
High dose steroids - given for 4w then slowly weaned off for 8w
Low salt diet
Diuretics (for oedema)
Albumin infusions may be required if severe hypoalbuminaemia
Antibiotic prophylaxis (in severe cases)
If steroid resistant - ACEi, immunosuppressants (e.g. tacrolimus, cyclosporine, rituximab)
Nephrotic syndrome: complications
Hypovolaemia: fluid goes from intravascular space —> interstitial space (oedema and low BP)
Thrombosis: proteins that normally prevent blood clotting are lost in the kidneys, liver responds to low-albumin by producing pro-thrombotic proteins
Infection: kidneys leak immunoglobulins, exacerbated by treatment with immunosuppressants e.g. steroids
Acute or chronic renal failure
Relapse
Common causes of nephritis in children
Post-streptococcal glomerulonephritis IgA Nephropathy (Berger’s disease)
Post-streptococcal glomerulonephritis: Cause
Occurs 1-3 weeks after beta haemolytic streptococcus infection (e.g. tonsillitis caused by strep pyogenes)
Immune complexes made of streptococcal antigens, antibodies, complement proteins get stuck in glomeruli of the kidneys causing inflammation
Inflammation —> reduction in kidney function —> AKI
Post-streptococcal glomerulonephritis: management
Supportive, 80% make full recovery
Some patients develop a progressive worsening of their renal function
May need treatment with: antihypertensive medication and diuretics if they develop complications
IgA nephropathy: Causes
Condition related to henoch-schonlein purpura (IgA vasculitis)
IgA deposits in the nephrons of kidney causes inflammation
IgA nephropathy: renal biopsy/histology
IgA deposits and glomerular mesangial proliferation
IgA nephropathy: Management
Supportive
Immunosuppressant meds to slow progression of disease (e.g. steroids and cyclophosphamide)
Haemolytic uraemia syndrome: what is it?
Thrombosis within small blood vessels throughout the body
Haemolytic uraemia syndrome: cause
Usually caused by bacterial toxin = SHIGA TOXIN
Produced by the E. Coli 0157 bacteria or shigella
Haemolytic uraemia syndrome: TRIAD
- Haemolytic anaemia
- AKI
- Thrombocytopenia
Haemolytic uraemia syndrome: Risk factors
Use of antibiotics and anti-motility medications (e.g. loperamide) to treat gastroenteritis caused by the causative pathogens increases the risk of developing HUS
Haemolytic uraemia syndrome: Presentation
E. Coli 0157 usually causes gastroenteritis + bloody diarrhoea
Sx of HUS typically start 5 days after the onset of diarrhoea
- reduced urine output, haematuria or dark brown urine, abdo pain, lethargy and irritability, confusion, oedema, HTN, bruising
Haemolytic uraemia syndrome: Management
MEDICAL EMERGENCY (10% mortality) Self limiting, supportive management Renal and paed specialist Renal dialysis may be needed Antihypertensives Careful maintenance of fluids Blood transfusions if required
When should NOCTURAL ENURESIS stop
3-4 years
When should DIURNAL ENURESIS stop
Should be able to control daytime urination by 2 years
Primary noctural enuresis: causes
(Means never managed to be completely dry at night)
Most common = variation in normal development (particularly if child younger than 5) - parents just need reassurance
Other causes:
- Overactive bladder, fluid intake prior to bedtimes, psychological distress, chronic constipation, UTI, learning disability, cerebral palsy
Primary noctural enuresis: Establishing cause
2 week bladder diary (diary of toileting, fluid intake, bed wetting) - identify patterns
Thorough history
Exclude underlying physical / psychological causes
Primary noctural enuresis: Management
- Reassure parents of pt under 5
- lifestyle changes
- encouragement + positive reinforcement
- treat underlying/exacerbating factors (e.g. constipation)
- Enuresis alarms
- Pharmacological treatment
Secondary noctural enuresis: definition
When child starts bed wetting after they have previously been dry for at least 6 months
Secondary noctural enuresis: causes
More indicative of an underlying illness
- UTI
- Constipation
- T1 DM
- New psychological problems
- Maltreatment (consider safeguarding)
Diurnal enuresis: types of incontinence
Urge incontinence
Stress incontinence
Enuresis alarm
Device that makes a noise at the first sign of bet wetting, waking the child up and stopping them from urinating
Needs to be used consistently for a prolonged period (at least 3 months)
Enuresis: Pharmacological treatment
DESMOPRESSIN: reduces volume of urine produced by the kidneys (similar to anti-diuretic hormone). Taken at bedtime to reduce noctural enuresis.
OXYBUTININ: Anticholinergic, reduces contractility of the bladder. Helpful with overactive bladder causing urge incontinence.
IMIPRAMINE: tricyclic antidepressant,
Type of POLYCYSTIC KIDNEY DISEASE that presents in children
There are 2 types of PKD:
1. Autosomal recessive polycystic kidney disease (ARPKD) —> presents in neonates and usually picked up on antenatal ultrasounds
- Autosomal dominant PKD - presents later in life usually adults
PKD: Features
Cystic enlargement of the renal collecting ducts
Oligohydramnios (lack of amniotic fluid - caused by reduced urine production by foetus) —> pulmonary hypoplasia (resp. Failure short after birth) and potters syndrome (dysmorphic features)
Congenial liver fibrosis
ARPKD: Ongoing problems throughout life
Liver failure due to liver fibrosis Portal hypertension —> oesophageal varices Progressive renal failure Hypertension due to renal failure Chronic lung disease
Multicystic dysplastic kidney (MCDK): definition
Where one of babies kidneys made up of lots of cysts, but other kidney is normal
In rare cases it can be bilateral —> death in infancy
Single good kidney to prone to problems (e.g. UTIs, hypertension, CKD later in life)
No treatment required
WILMS TUMOUR: definition
Tumour affecting the kidneys in children
WILMS TUMOUR: Presentation
Consider in a pt. Under 5 yrs presenting with a mass in the abdomen. Signs/Sx: - Abdo pain - haematuria - lethargy - fever - hypertension - weight loss
WILMS TUMOUR: Diagnosis
Ultrasound of abdo
CT/MRI to stage tumour
Biopsy - histology and definitive diagnosis
WILMS TUMOUR: Management
SURGERY: Surgical excision of tumour and nephrectomy of affected kidney
ADJUVANT TREATMENT: chemo/radio therapy
Posterior urethral valve: definition
Where there is tissue at the proximal end of the urethra (closest to the bladder) that causes obstruction to urine outflow
Occurs in newborn boys
Posterior urethral valve: consequences
Obstruction of urine outflow —> hydronephrosis from backward flow pressure
Severe cases can cause obstruction in developing foetus —> bilateral hydronephrosis and oligohydramnios (low amniotic fluid volume)
—> pulmonary hypoplasia + resp. Failure short after birth
Posterior urethral valve: Presentation
Can vary in severity
- difficulty urinating
- weak urinary stream
- chronic urinary retention
- palpable bladder
- recurrent UTIs
- impaired kidney function
Posterior urethral valve: Investigations
Abdo USS Micturating cystourethrogram (MCUG) - shows location of extra urethral tissue and reflux of urine back into the bladder Cystoscopy: to get a view of the tissue/ used to ablate the tissue
Posterior urethral valve: Management
Mild: observed and monitored
A temporary urinary catheter could be inserted to bypass the valve whilst awaiting definitive management
Definitive management: ablation or removal of the extra urethral tissue, usually during cystoscopy
Undescended testis: risk factors
FH do undescended testis Low birth weight Small for gestational age Prematurity Maternal smoking during pregnancy
Undescended testis: Management
Watch and wait in newborns - most cases testis will descend in first 3-6 months
ORCHIDOPEXY (surgical correction of undescended testis) - should be carried out between 6-12 months
Undescended testis: consequences
If undescended in older children or after puberty, higher risk of:
Testicular torsion
Infertility
Testicular cancer
Retractile testicles: explanation
Normal variant - where the testes move out the scrotum into inguinal canal when it is cold or the cremasteric reflex is activated
Occasionally may fully retract and require surgical correction
Hypospadias: definition
Urethral meatus in males abnormally placed posterior on the penis
Usually foreskin is abnormally placed to match the position of the meatus
Congential condition
Hypospadias: Complications
Difficulty directing urine
Cosmetic and psychological concerns
Sexual dysfunction
Hypospadias: Management
Mild cases may not require any treatment
Surgery usually performed at 3-4 months of age
Surgery aims to correct the position of the meatus and straighten the penis
Hydrocele: definition
Collection of fluid within tunica vaginal is surrounding testes
SIMPLE HYDROCELE: common in new board males, usually resolves
COMMUNICATING HYDROCELE: tunica vaginal is around testis connected with peritoneal cavity via PROCESSUS VAGINALIS. - allowing fluid to travel from the peritoneal cavity into the Hydrocele
Hydrocele: examination
Soft, smooth, non-tender swelling around one testes
In front of and below testicle
TRANSILLUMINATE
Differential diagnoses for a scrotal/inguinal swelling in a neonate
Hydrocele Partially descended testes Inguinal hernia Testicular torsion Haematoma Tumours (rare)
Hydrocele: Management
Simple ones: usually resolve within 2 years without having lasting negative affects
Communicating: surgery to ligate the processus vaginalis
