Toddler Urological Problems Flashcards
1
Q
Hematuria Overview (6)
A
- Hematuria is defined as the presence of five or more RBCs per high power (40) field in three consecutive fresh, centrifuged specimens obtained over the span of several weeks.
- Differential diagnosis for hematuria is extensive, most cases are isolated and benign.
- Hematuria is a medical rather than a urologic issue.
* Rarely is extensive imaging needed - Most causes are isolated
* Most of the time it is not a serious entity - Like HTN, the history must be taken over and over again
- Tends to be a medical rather than a surgical issue
2
Q
Mimics of Gross Hematuria (9)
A
Pathologic
1. Pophyrins
- Food dyes-aniline, congo red
- Food- berries, beets
- Urate crystals
* Common to see pink crystals in diaper but mother’s interpret it as red
Drugs
- Phenoazopyridine
- Rifampin
- Metronidazole
- Nitrofurantoin
- Desferoxamine
3
Q
How to figure out if blood is coming from lower tract (6)
A
Urethra bladder ureters:
- Urine red+/- clots
- Dysuria, suprapubic pain
- Minimal proteinuria
- Microscopic analysis
- Normal RBC morphology
- Casts are absents
4
Q
How to figure out of the blood is coming from upper tract (4)
A
Renal parenchyma
- Tea or cola colored urine
- Flank or back pains
- Significant proteinuria
- Microscopic analysis: Dysmorphic RBC and Casts present
5
Q
Lower tract etiologies of hematuria (5)
A
Bladder/ureter
- UTI
- Hemorrhagic cystitis
- Urolithiasis
- Hypercalciuria
- Trauma
6
Q
Upper tract etiologies of hematuria (5 glomerular, 3 non-glomerular)
A
Glomerular:
- Glomerulonephritis: check PSGN
- IgA nephropathy: check proteinuria
- HSP Nephritis: check proteinuria
- Alport syndrome
- Thin basement membrane disease: check blood/RBCs
Non-Glomerular
- Hydronephrosis/cystic disease
- Malposition/ tumors
- SCT/SCD
7
Q
Hematuria Hallmarks and Evaluation (2)
A
- Hallmarks of GLOMERULAR bleeding are discolored urine, RBC casts, and distorted RBC morphology
- Evaluation of RBC morphology is helpful in distinguishing glomerular from extra glomerular sources
8
Q
What lab should you order if you have blood and protein in the urine?
A
C3 (compliment)
*Protein + blood usually requires nephrology referral
9
Q
What lab should you do if you suspect thin based membrane disease with hematuria?
A
check family history
10
Q
What should you do if you suspect infection with hematuria?
A
check culture and then follow-up with ultrasound if positive
11
Q
What should you do if you suspect kidney stones?
A
Get calcium to creatinine ratio
12
Q
What should you do if you suspect lupus nephritis or post-glomerular GM
A
Check compliments; compliments get eaten up
*Will have low C3/C4
13
Q
What will you see with hypocomplimentima and hematuria?
A
C4 normal, C3 low
14
Q
What to suspect with low C3 and low C4? (5)
A
- Post streptococcal GM
- Membrane proliferative GM
- Lupus nephritis
- Shunt nephritis
- Shunt nephritis of chronic antigenemia
15
Q
Diagnostic Evaluation of Glomerulonephritis (7)
A
- Normocomplementemic
- IgA nephropathy
- Henoch Schonlein Purpura
- Pauci-immune vasculitis l Membranous nephropathy
- Focal segmental glomerulosclerosis
- Membranoproliferative glormerulonephritis
- Heredity Nephritis (Alport’s syndrome)
16
Q
What will occur if the cause of hematuria is glomerular? (5)
A
- Color: smoky, tea colored or coke colored
- RBC morphology: dysmorphic
- Clots: absent
- Casts: RBC, WBC
- Proteinurea: >+2
17
Q
What will occur if the cause of hematuria is extra-glomerular? (5)
A
- Color: pink or red
- RBC morphology: normal
- Clots: present
- Casts: absent
- Proteinurea: < +2
18
Q
Types of Hematuria (4)
A
- Gross hematuria
* Symptomatic microscopic - Hematuria
- Asymptomatic microscopic hematuria with proteinuria
- Isolated asymptomatic microscopic hematuria
19
Q
Gross Hematuria Overview (2)
A
- Suspected when urine is discolored, usually red or tea-colored.
- Underlying causes of gross hematuria are identified in 56% of cases
20
Q
Gross Hematuria Causes (23)
A
- Lower tract symptoms (dysuria, urgency, frequency, suprapubic pain)
- Recent illness (pharyngitis, impetigo, viral illness)
- Abdominal pain Concurrent illness
- Extreme exertion, influenza
- Arthralgia
- Diarrhea (bloody)
- Cough, hemoptysis
- Hearing loss
- Nail or patellar abnormalities
- Sickle cell disease
- Drugs (diuretics, cyclophosphamide)
- Birth asphyxia
- Post infectious glomerulonephritis
- HSP, crystaluria/stone
- Rhabdomyolysis
* Excersie a lot → high CK → hematuria - HSP, SLE
- HUS
- Vasculitis
- Alport disease
- Nail patella syndrome
- Glomerulonephritis, papillary necrosis
- Stones, hemorrhagic cystitis
- Renal vein thrombosis
21
Q
Family History and Possible Diagnosis of Hematuria (5)
A
- Hematuria/ Benign familial hematuria, thin basement membrane disease
- Hearing loss or prominent history of renal failure in males/ Alport syndrome
- Cystic kidney disease /Autosomal dominant polycystic kidney disease
- Nail/patellar abnormalities/ Nail patella syndrome
- Sickle cell disease or trait
22
Q
Symptomatic Microscopic Hematuria (5)
A
- Patients who have symptomatic microscopic hematuria
* Require the greatest attention - Elevated proteinuria on a “first” morning urine sample (protein-to-creatinine ratio 0.2), the likelihood of underlying renal disease is higher.
* Worry because they have proteinurea and hematuria - Patient who has malar rash, arthritis, pericardial rub, edema, and hypertension likely has systemic lupus erythematosus.
- Fever, flank pain, nausea, and vomiting suggest upper urinary tract involvement.
- Dysuria, frequency, urgency, and incontinence suggest crystalluria or urinary tract infection
23
Q
Asymptomatic (Isolated) Hematuria Overview (6)
A
- Asymptomatic hematuria rarely are found to have significant renal disease
- Does not warrant an extensive evaluation.
* The child’s disptick showed hematuria but they don’t have HTN or proteinurea - Up to 25% of patients have normalization of their urinalysis findings if followed for 5 years.
- Requires regular monitoring for the development of hypertension and proteinuria.
- Hypercalciuria frequently is associated with asymptomatic hematuria.
- Some affected patients are at risk for developing symptomatic urolithiasis
24
Q
Asymptomatic (Isolated) Family History (2)
A
- Assess for benign familial hematuria, also known as thin basement membrane disorder, in which biopsy specimens are characterized by diffuse thinning of the glomerular basement membrane.
- Multiple family members have a history of hematuria but are free of the long-term complications of progressive renal insufficiency, hearing, or ocular abnormalities seen in those who have Alport’s syndrome. Rarely is gross hematuria seen in this group of patients (10%)
25
Combination of Hematuria and Proteinuria (6)
1. Worrisome
2. Can be due to serious renal disease
3. Serial urinanalysis
* Want them to pee when they first wake up in the morning
4. Must see if proteinuria is orthostatic
* First morning urine protein
* (normal protein-to-creatinine ratio is 0.2)
5. Persistence needs referral to nephrologist
6. Must do protein:creatinine ratio!
26
Evaluation Stages (2)
1. If there is a child with isolated hematuria, you always have to take BP and do dipstick and send urine off to the lab
2. If you take a urine and put it on the counter it will almost always form crystals, and those aren’t problematic crystals
27
Stage I Hematuria Evaluation (6)
1. Blood pressure.
2. Dipstick urinalysis
* Pyuria, proteinuria, heme positivity, and urinary concentrating defect
* Looking for red cells, red cell morphology, crystals, white cells, etc.
3. Urine microscopy
* White blood cells and clumps
* RBC morphology
* Crystals
* Casts.
4. Crystalluria
* Calcium oxalate, calcium phosphate, uric acid, or cystine crystals.
5. Hypercalciuria
* Most common cause of crystalluria
* Urine Calcium/Creatinine ratio
6. Urine culture
* Pyuria, hematuria, bacteriuria, positive nitrites of a urinary tract infection.
28
Stage II Hematuria Evaluation (6)
1. You are considering underlying renal disease, when edema, hypertension, alterations in urine output, or systemic symptoms are present.
2. Serum chemistries (electrolytes, blood urea nitrogen, and creatinine) evaluate for renal insufficiency.
3. Suspicion of acute PIAGN should prompt ordering of ASO, DNASE, and a C3 measurement.
4. Secondary causes of renal disease, such as systemic lupus erythematosus, small vessel vasculitis, hepatitis B, hepatitis C, or human immunodeficiency virus (HIV) disease, warrant checking an antinuclear antibody titer, complement levels (C3,C4), antineutrophil cytoplasmic antibodies (ANCAs), hepatitis serologies, or HIV serology
* Important because found in patients with rheumatological disease
5. Complete blood count is helpful in the setting of petechiae, bruising, fatigue, abdominal masses, or suspicion of chronic disease.
6. Evaluation for sickle cell disease or trait by hemoglobin electrophoresis is indicated if the family is unaware of the patient’s status.
29
What to check with edema, HTN, alterations in urine output, etc
Check if child has/had strep (ASO, DNASE and C3 measurment); Suspicion of acute PIAGN should prompt ordering of ASO, DNASE, and a C3 measurement.
30
What do you check when evaluating for renal insufficiency?
Serum chemistries (electrolytes, blood urea nitrogen, and creatinine)
31
What to check with secondary causes of renal disease, such as systemic lupus erythematosus, small vessel vasculitis, hepatitis B, hepatitis C, or human immunodeficiency virus (HIV) disease,
Check an antinuclear antibody titer, complement levels (C3,C4), antineutrophil cytoplasmic antibodies (ANCAs), hepatitis serologies, or HIV serology
32
What to check with petechiae, bruising, fatigue, abdominal masses, or suspicion of chronic disease.
CBC
33
UTI Overview (4)
1. Cause of Serious bacterial infection (SBI) in children
2. Vesicoureteral reflux can predispose to UTI and both can cause renal scarring
* Bacterial virulence factors and host defense mechanism influence renal damage
3. Coexists with constipation
* Constipation and UTI go hand in hand
* When someone has a full colon, their bladder is not emptying completely or correctly which is a set up for a UTI
* Obliged to treat UTI and the constipation
4. In young children, worry about vesicoureteral reflux since it can cause renal damage
34
UTI Definitions (4)
1. Bacteruria is bacteria in urine without other symptoms—may indicate underlying anatomic abnormality
2. Seen commonly in children with spina bifida
3. Cystitis is infection in the bladder
4. Pyelonephritis is most severe type of UTI involving the renal parenchyma
35
UTI Incidence (4)
1. Up to 7% of girls l 2% of boys have culture proven and symptomatic UTI
2. Recurs in 75% of children with first UTI in infancy
3. Recurs in about 40% of girls and 30% of boys with first UTI after the age of 1 year l
4. Prophylactics are used with children with urological anomalies to prevent recurrent UTI and renal parenchymal damage
* Controversial, RIVUR (vesicoureteral reflux study) didn’t show that much of a difference
36
UTI Manifestations in Infants (9)
1. Fever
2. Malaise
3. Irritability
4. Poor weight gain
5. Vomiting and diarrhea
6. Malodor
7. Dribbling
8. Abdominal pain
9. Difficulty feeding
37
UTI Manifestations in Children (7)
1. Voiding dysfunction
2. Malodor
3. Enuresis
4. Vomiting or diarrhea
5. Malaise
6. Fever and chills
7. Abdominal pain
38
Urinanalysis in Non-toilet trained toddler
1. Nitrates are produced after urine has been in bladder for 4 hours or longer
* Takes at least 4 hours
* If it isn’t an E.Coli producing organism, nitrates may be negative
2. False negative are common
3. Leukocyte esterase detect pyuria but there are other reasons for this
* Ex: poor hygiene is another reason for this
39
UTI Guidelines-Diagnosis
1. If the clinician decides a febrile infant (<2) needs treatment since child is ill or another pressing reason, the urine specimen for urine culture and analysis should be done before antibiotics
2. The specimen needs to be obtained through catheterization or SPA (suprapubic aspiration)
3. Bag specimens are not reliable
4. If a clinician assesses the febrile infant as to be not so ill as to require immediate treatment, the likelihood of UTI needs to assess.
* Don’t need to immediately treat; catheterize and then wait for results
40
UTI Guidelines for febrile infant in a low risk category (two options)
1. First option: Catheterize
2. Second option: obtain urine through most convenient means and do urinalysis
* If the urinalysis suggest a UTI (positive leukocyte esterase test or nitrite test or microscopic analysis for bacteria, WBC), then catheterize
* If no leukocyte or nitrite can monitor
41
Probability of UTI w/ Individual Risk Factor: Female (5)
1. White race
2. Age < 12 month
3. Temperature > 39 degrees or 102.2 degrees
4. Fever > 2 days
5. Absence of another source of infection
Ideal to treat if they meet these criteria
42
Probability of UTI w/ Individual Risk Factor: Male (4)
1. Nonblack race
2. Temperature >39 degrees of 102.2 degrees
3. Fever >24 hours
4. Absence of another source of infection
Ideal to treat if they meet this criteria
43
UTI Guidelines (2)
1. Pyuria and colony count of greater than 50,000 as the new diagnostic criteria:
2. Organisms such as lactobacillus species, Coagulase negative staphylococci and Corynebacterium are not considered clinically relevant in healthy 2-24 months old
44
UTI Management (4)
1. Febrile infants with UTIs should undergo renal and bladder ultrasonography (RBUS)
2. VCUG not performed routinely after first UTI
3. Indicated if RBUS should hydronephrosis, scarring or obstructive uropathy
4. Further evaluation if there is recurrent UTI
* Consider Antimicrobial prophylaxis if recurrent
45
VCUG for UTI
1. Don't do Not with first UTI
2. Put catheter into bladder, fill bladder with contrast dye until child can’t hold it anymore and then they look how far up it goes up into the kidneys and whether it is causing kidney damage
3. Grade I and II not so bad but IV and V are
46
UTI Workup (2)
1st: Ultrasonography
2nd: VCUG
47
Grade I-V VCUG
1. Grade I Vesicoureteral Reflux: urine (shown in blue) refluxes part-way up the ureter
2. Grade II Vesicoureteral Reflux: urine refluxes all the way up the ureter
3. Grade III Vesicoureteral Reflux: urine refluxes all the way up the ureter with dilatation of the ureter and calyces
4. Grade IV Vesicoureteral Reflux: urine refluxes all the way up the ureter with marked dilatation of the ureter and calyces
5. Grade V Vesicoureteral Reflux: massive reflux of urine up the ureter with marked tortuosity and dilatation of the ureter and calyces
48
How long should oral antimicrobials be taken with UTI?
7-14 days as duration of antimicrobial therapy
49
Oral antimicrobial agents for UTI (3)
1. Amoxicillin-clavulanate 20-40 mg/kg/d in 3 divided doses
2. Trimethoprim sulfamethoxazole 6-12 mg/kg trimethoprim and 30-60 mg/kg sulfamethoxazole per day 2 doses
* Not advised for African American patients
3. Cephalosporin—Cefixime, cefpodoxime, cefprozil, cefuroxime axetil, cephalexin
* Cefprozil not recommended
* Cefalexin good
