Urology

Question 1

Toilet training

Answer 1

Need spinal cord myelination first in order to control bowel and bladder function, this does not occur until 12-18months. Child not ready until 1.2-2 years, wait until 2 years to 2.5 years to make it easier

Question 2

Enuresis

Answer 2

involuntary voiding of urine > 6 years

Question 3

Primary enuresis

Answer 3

Never achieved dryness for 3 months.

Question 4

Secondary enuresis

Answer 4

Dry for 3-6 months then resume wetness

Question 5

Reasons for secondary enuresis

Answer 5

Can be UTI, psychological, family issues, depression, ADHD, can do watch and wait to see if they retrain themselves can do bladder training, wet bladder alarm pads. Upper airway issues like inflammed tonsils can alter sleep cycle, once tonsils come out stop wetting the bed. Can also be from genentics, sleep disorders, small bladders, urine overproduction, develop delays, sickle cell

Question 6

Diurnal

Answer 6

wetting occurs only in day time

Question 7

Nocturnal

Answer 7

wetting at night time

Question 8

Organic causes of bed wetting

Answer 8

Neurlogical delay, UTI, structural disorder, chronic renal failure, polyuria like in DM, chronic constipation

Question 9

Non organic bed wetting

Answer 9

Sleep arousal problem, sleep disorders from enlarged tonsils, sleep apnea, psychological stress, family hx, innappropriate toilet training

Question 10

Treating bed wetting

Answer 10

Organic – tx underlying cause, nonorganic will outgrow by late childhood. Can do a mat trial with alarms, timed voiding, bladder exercises, elimination diets, behavioral therapy, meds like DDAVP desmopressin

Question 11

UTI

Answer 11

E. Coli #1 cause. Girls more common than boys once > 1 year. Uncircumcised > circumcised. Can lead to renal scarring, ESRD, HTN (kidneys not working properly? –> HTN)

Question 12

Conditions which predispose infants and children to UTIs

Answer 12

Urinary tract obstructions, voiding dysfunction resulting in urinary stasis, anatomic differences d/t small urethra, individual susceptibility to infection, urinary retention while toilet training, bacterial colonization in prepuce of uncircumsized males, infrequent voiding, sexually active adolescent girls

Question 13

s/s UTI children

Answer 13

abdominal or suprapubic pain, frequency, urgency, dysuria, new or increased incidence of enuresis, fever, malodorous urine, hematuria

Question 14

Infants UTI s/s

Answer 14

nonspecific fever or hypothermia, irritable, crying when voiding - dysuria, change in urine odor or color, poor weight gain, feeding difficulties

Question 15

Pyelonephritis

Answer 15

Infection travels to kidneys, UTI s/s plus high fever, flank pain, n/v, sick looking.

Question 16

Dx Pyelonephritis

Answer 16

UA – macro, micro, 24 hr. C&S. Collect w clean catch, suprapubic tap, straight cath. Blood or nitrites in urine, UA showing bacteriuria, pyuria, colony count 100,00 at least 50,000 colony forming units. Elevated WBC, ESR, CRP

Question 17

Clinical guidelines

Answer 17

2011. ages 2 months to 24 months. Need infection dx from both UA and UC needing at least 50,000 colony forming units per mL. Oral parenteral treatment. Renal and bladder US recommended, routine voiding cystourethrography VCUG no longer recommended after the first UTI

Question 18

Probabilities of UTI

Answer 18

Infants 3 months girls risk ~10%, uncirc boys 3-6mo is 5-10%, greater than 2% by 1 year, circ boys

Question 19

uti mgmt

Answer 19

7-14 day course abx, IV if

Question 20

Abx for UTI

Answer 20

Amoxil 45 mg/kg divided BID
Augmentin 25-45 mg/kg BID
Suprax 8mg/kg daily. Available 100mg/5ml.
Bactrim TMP 40/Sulfa 200/5ml. TMP 8-10mg/kg BID sulfa always 40

Question 21

Goals of imaging

Answer 21

After 1st UTI to identify significant urinary abnormalities, prevent recurrent UTI and further renal damange

Question 22

Prevent uti

Answer 22

Toilet training, proper wiping, avoid tight clothing, cotton underwear, avoid holding in urine, avoid bubble baths

Question 23

Testing recommendations

Answer 23

consider pyelo if FWS and 5%. If 38, 3mo - 2 years and FWS > 39. Girls w fever > 2 days. Uncirc boys

Question 24

Imaging recc

Answer 24

US in complicated or recurrent UTI, consider after first UTI in high risk or very young infants, Consider VCUG, If US shows high grade VUR obstruction and need surgical correction, no abx to prevent UTI

Question 25

Hypospadius

Answer 25

congenital. Urethral opening below the normal placement of the glans penis on the ventral surface, may also have a short chordee the fibrous band of the penis causing it to curve downward

Question 26

Epispadius

Answer 26

dorsal placement of the urethral opening

Question 27

Mgmt epi and hyospadius

Answer 27

Outpt surgery to lengthen urethra - meatojmy, position the meatus at the tip and release the chordee. Performed between 1 and 1.5 years

Question 28

Phimosis/Paraphimosis

Answer 28

Phimosis - inability of the foreskin to be retracted. Normal in children up to 6 months. Non physiological if it causes ballooning of foreskin. Paraphimosis - tourniquet to penis – medical emergency to relieve pressure

Question 29

Counseling

Answer 29

Do not forcibly retract foreskin, only clean what is seen, pathologic phimosis that does not resolve naturally or causes other complications like retention, ballooning, paraphimosis, painful erections, balanposthitis - recurent penile infections of the foreskin, or UTI need urology referrals

Question 30

Cryptorchidism

Answer 30

common developmental abnormality, untreated with bilateral will lead to azospermia 89% of the time, lifetime neoplasia 3% 4x higher than average risk, undescended testicle can wait 1 year if does not fall increases risk for testicular cancer

Question 31

Hydrocele

Answer 31

Collection of serious fluid that results from a defect or irritation in the scrotum. Simple is fluid in the tunica vaginalis from delayed closure. Painless enlarged scrotum, may enlarge when baby cries if communicating. Transillumination shines brightly through, will also show hernias. Tx inguinal incisions with high ligation of the patent processus vaginalis and excision of distal sac

Question 32

Acute scrotum

Answer 32

Suspect if traumatic hemorrhage into hydocele or testes, testicular torsion, ischemic testicle. Need US imaging w dopple for blood flow

Question 33

Testicular torsion

Answer 33

True surgical emergency! Irreversible ischemic injury may begin as soon as 4 hours after the occlussion of the cord. Intravaginal torsion results from lack of normal fixation of the testes and epididymus to the fascial coverings that surround the cords causing a bell clapper deformity

Question 34

Testicular torsion most common in

Answer 34

Prepubertal males

Question 35

s/s Testicular torsion

Answer 35

pain, n/v, poor appetite, on exam shows swelling, tenderness, high riding, transverse orientation, loss of cremasteric reflex, may have a blue dot on scrotum

Question 36

Dx TT

Answer 36

Doppler US. Scrotal exploration. Detorte the affected testis and pex the other side while waiting for the testis to pink up. If still alive pex it, if not do orchiectomy.

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Question 37

Hernia

Answer 37

Profusion of the tissue through a defect in fascial and or muscle layers which normally contain it

Question 38

Why do hernias occur

Answer 38

This is a congenital developmental defect, from either failure of fascial opening to close or failure of process to obliterate itself. Can be aquired weakness from deterioration or thinning of fascia w age, loss of tissue from injury, infection, poor wound healing

Question 39

AGN

Answer 39

Sudden inflammation of the glomeruli of the kidney resulting in acute renal failure, peak age is 5-10 years, boys more common than girls, capillary walls of kidney become permeable and allow protein to pass in the urine. Usually 7-10 days after step infection as an immune response to strep, acute post streptococcal glomerulonephritis

Question 40

History/s&s of AGN

Answer 40

Steptococcal skin infection or pharyngeal infection within the past 2-3 weeks. Classically a latent period of 7-10 days elapses between the infection and the onset of symptoms if 14 consider other causes. Abrupt onset of gross hematuria, reduced urine output w diuresis in 5-7 days, lethargy, anorexia, n/v, abdominal pain, chills, fever, backache, review meds taken for a fever in the past weeks. proteinuria, edema/swelling of eyelids

Question 41

s/s AGN

Answer 41

URI preceding symptoms. Suddent hematuria – smokey or tea colored urine, proteinuria +1-+4, edema worse in the morning of eyelids and ankles, oliguria impending renal failure. HTN d/t decreased GFR can lead to pulmonary edema – listen for crackles. Fever, malaise, abd pain, HA, vomiting

Question 42

dx AGN

Answer 42

Presenting ss, UA showing proteinuria 1-4, 24 hr urine 1gm NA, Hematuria. Increased BUN/Cr, serum c3 c4 low early in the disease returns to normal in 6-8 weeks, electrolyte imbalance from poor filtration, high serum K, low serum bicarb. Titer antistreptolysis — indicates presence of antibodies to strep bacteria which will be elevated

Question 43

Mgmt of AGN

Answer 43

No specific tx, supportive. Manage s/s – adequate rest is the main tx. Monitor renal dysfunction, antihypertensive therapy including limiting Na and water or by diuretics and antihypertensive meds. Excellent prognosis. Daily weights, accurate i&o until fully resolves in 2 months, diuresis signals the beginning of resolution

Question 44

Complications of AGN

Answer 44

nephrotic syndrome, htn, aki, volume overload, pulmonary edema, chronic glomerulonephritis, CKI