Urology Flashcards
Toilet training
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
Enuresis
involuntary voiding of urine > 6 years
Primary enuresis
Never achieved dryness for 3 months.
Secondary enuresis
Dry for 3-6 months then resume wetness
Reasons for secondary enuresis
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
Diurnal
wetting occurs only in day time
Nocturnal
wetting at night time
Organic causes of bed wetting
Neurlogical delay, UTI, structural disorder, chronic renal failure, polyuria like in DM, chronic constipation
Non organic bed wetting
Sleep arousal problem, sleep disorders from enlarged tonsils, sleep apnea, psychological stress, family hx, innappropriate toilet training
Treating bed wetting
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
UTI
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)
Conditions which predispose infants and children to UTIs
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
s/s UTI children
abdominal or suprapubic pain, frequency, urgency, dysuria, new or increased incidence of enuresis, fever, malodorous urine, hematuria
Infants UTI s/s
nonspecific fever or hypothermia, irritable, crying when voiding - dysuria, change in urine odor or color, poor weight gain, feeding difficulties
Pyelonephritis
Infection travels to kidneys, UTI s/s plus high fever, flank pain, n/v, sick looking.
Dx Pyelonephritis
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
Clinical guidelines
- 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
Probabilities of UTI
Infants 3 months girls risk ~10%, uncirc boys 3-6mo is 5-10%, greater than 2% by 1 year, circ boys
uti mgmt
7-14 day course abx, IV if
Abx for UTI
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
Goals of imaging
After 1st UTI to identify significant urinary abnormalities, prevent recurrent UTI and further renal damange
Prevent uti
Toilet training, proper wiping, avoid tight clothing, cotton underwear, avoid holding in urine, avoid bubble baths
Testing recommendations
consider pyelo if FWS and 5%. If 38, 3mo - 2 years and FWS > 39. Girls w fever > 2 days. Uncirc boys
Imaging recc
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
Hypospadius
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
Epispadius
dorsal placement of the urethral opening
Mgmt epi and hyospadius
Outpt surgery to lengthen urethra - meatojmy, position the meatus at the tip and release the chordee. Performed between 1 and 1.5 years
Phimosis/Paraphimosis
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
Counseling
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
Cryptorchidism
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
Hydrocele
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
Acute scrotum
Suspect if traumatic hemorrhage into hydocele or testes, testicular torsion, ischemic testicle. Need US imaging w dopple for blood flow
Testicular torsion
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
Testicular torsion most common in
Prepubertal males
s/s Testicular torsion
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
Dx TT
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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Hernia
Profusion of the tissue through a defect in fascial and or muscle layers which normally contain it
Why do hernias occur
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
AGN
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
History/s&s of AGN
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
s/s AGN
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
dx AGN
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
Mgmt of AGN
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
Complications of AGN
nephrotic syndrome, htn, aki, volume overload, pulmonary edema, chronic glomerulonephritis, CKI
