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General Pediatrics > Urology > Flashcards

Urology Flashcards

1
Q

When does differentiation in of the bipotential gonad begin?

A

6 weeks

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2
Q

What is the SRY gene

A

Sex-determining Region on the Y chromosome

-on the short arm Y chromosome causes gonads to become testes

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3
Q

What hormone does the Sertoli cells make and what is it’s effect

A

Antimullerian hormone (AMH)

-Results in ipsilateral regression of mullerian ducts (which would become fallopian tubes, uterus, cervix and upper vaginal in normal F)

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4
Q

What hormone does the Leydig cells make and what is it’s effects

A

Testosterone

-Ipsilateral development of wolfian ducts (which become vas, epididymis, seminal vesicles)

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5
Q

How does development of male external genitalia occur?

A

-at 8 weeks there is virilization of the external genitalia due to Testosterone exposure

  • Enzyme 5 alpha reductase converts 8% of testosterone to dihydrotestosterone (DHT) (the more potent form of T)
  • DHT is critical for normal and complete male virilization
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6
Q

How does the development of female internal and external genitalia occur?

A

XX –> no SRY –> no testes –> no testosterone & No AMH (female by default)

XX –> no SRY –> Ovaries and mullerian duct development

No testosterone –> Female external genitalia

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7
Q

What are the two most common forms of DSD

A
  1. 46 XX CAH
    - masculinized female
    - most common form of DSD
  2. 45X/45 XY Mixed gonadal dysgenesis
    - 2nd most common form of DSD
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8
Q

Describe 46XX CAH

A
  • AR Inborn error of metabolism
  • Deficient glucocorticoid synthesis (+/- mineralocorticoid synthesis) by the adrenal gland
  • 75% virilized salt water, 25% simple virilizers (no salt waste)
  • 95% have 21-hydroxylase deficiency
  • metabolic pathway shunted toward adrenal sex steroid production, proximal to the defect
  • decrease/no cortisol production –> increase ATCH –> ++ increased testosterone
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9
Q

What is the management of 44XX CAH

A

gender assignment: usually female
Surgery: feminizing genitoplasty & vaginoplasty
Medical: Hydrocortisone (to restore cortisol & suppress further virilization), Fludrocortisone if salt waster

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10
Q

Which gonads have increased risk for cancer

A
  • Gonads with Y chromosome have increased risk of gonadoblastoma
  • If male gender selected, need informed discussion regarding orchiopexy vs orchiectomy and androgen replacement
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11
Q

What are the 3 defects that can be seen in hypospadias

A

Hypospadias is an arrest during embryologic penile development

  1. Foreskin is incomplete ventrally
  2. Urethra meatus not at tip of penis
  3. Erections curve downwards

-90% of HS cases are isolated penile defects, but may be part of a syndrome

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12
Q

When should prenatal XX CAH treatment start

A

Should begin before normal virilization of external genitalia occurs (before 8 wks)

  • only the female fetus with defect will benefit from prenatal treatment
  • AR so only 1/4 of preg affected
  • treatment only beneficial for 1/8 of preg
  • only for research
  • treat with dexamethasone
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13
Q

What is an Intravenous Pyelogram

A

IVP

  • no longer really used now
  • used IV contrast taken up by the kidney and excreted during a series of KUB x-rays
  • Indications: to diagnosis stones and obstruction
  • able to define the collecting system anatomy better than US and provides functional information regarding obstruction
  • however it is invasive and needs radiation
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14
Q

What is a Voiding Cystourethrogram

A

VCUG
-injection of contrast into the bladder via a urethral catheter and fluoroscopy during bladder filling and voiding

indications: assess for VUR and PUV
advantages: provides anatomic detail of refluxing collecting system and urethra (Allows for IRS grading)
risks: invasive (catheter) radiation

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15
Q

What is a Nuclear Cystogram

A

NC
-injection of radionuclide into bladder via urethral catheter
Imaging of bladder filling and voiding

Indications: Initial assessment for VUR in F only . Follow-up of VUR in both M & F

advantage: less radiation than VCUG
risks: invasive (cath). radation

does not assess for PUV (should not be 1st line for M with hydronephrosis or UTI )

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16
Q

What is a Renal Scan

A
  • IV injection of radionuclide. Gamma camera imaging of kidney uptake +/- excretion
    indications: multiple: Different radionucleotide for different indications

advantages: provides functional information
risks: invasive (IV +/- cath) radiation. child must be held still

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17
Q

What does a MAG3, radionuceotide + diuretic and DMSA tell you

A

MAG3 = split renal function (always adds up to 100%)

Only diuretic can tell you about obstruction

DMSA - can only tell you about renal scarring

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18
Q

What is a Renal/Bladder US

A

-anatomical assessment using sound waves

indication: anatomical imaging of the urinary tract
advantages: non invasive, no radiation exposure, clarifies cystic vs solid masses
risks: not as sensitive as CT. May miss stones/masses. Normal US does not rule out VUR

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19
Q

What is Urodynamics

A

-various functional studies done to assess bladder function

Voiding calendar: two day home data collection of time and volume of voids. Provides urinary frequency and functional bladder capacity. Helpful to dx overactive bladder (OAB)

Post Void Residual (PVR): US bladder scanner. Assess bladder emptying

Uroflowmetry: Velocity curve of urinary stream. Assess for urethral obstruction

Cystometry (AKA “invasive “ UDS): Assessment of bladder pressures during bladder filling and voiding. Requires urethral and rectal pressure problems and child must lay still while awake

Pelvic floor electromyography (EMG): Assessment of relaxation/contraction of plevic floor muscles during bladder filling and voiding. Assess for N pelvic floor relaxation w/ voiding (synergistic voiding)

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20
Q

What is the definition of unresolved congenital hydronephrosis (CH)

A

2009 Canadian Urological Association Guideline

3rd trimester: CH if >/ 9 mm APD

21
Q

How do you do a postnatal assessment of CH. What is considered to require an urgent US (4)

A

-recommend RBUS for all newborns with a history of unresolved CH

Urgent US (before discharge from hospital):

  • bilat severe CH (> 15 mm APD) or solitary kidney with CH
  • oligohydramnios
  • urethral obstruction
  • concern about patient compliance with postnatal evaluation
Elective US (w/n 30 days)
-all others
22
Q

What can be wrong with doing an U/S too early

A

US done < 48 hours age may underestimate grade of HN/HUN and warrant repeat

23
Q

Which grades of CH is associated with significant obstruction?

A

Significant obstruction only associated with SFU III & IV HN

Severe HN has thinned parenchyma

24
Q

What are the 4 most common causes of significant CH

A
  1. UPJO: uretero-pelvic junction obstruction
    - significant hydronephrosis without hydroureter
  2. High grade VUR (vesico-ureteral reflux)
  3. UVJO (Uretero-vesical junction obstruction)
    - due to UVJ stenosis
  4. PUV (posterior urethral valves)
    - significant bilat HN in males
    - due to bladder outlet obstruction
    - bladder anomalies would likely be noted
25
Q

What is recommended as follow up of CH after postnatal US

A

Further imaging AFTER initial post-natal US:

SFU I & II: Repeat US in 6 months (no VCUG unless UTI)
SFU: III & IV HN/HUN: Appropriate to refer to urology, VCUG (no age restriction) and diuretic renal scan (age 4 - 6 wks to allow for renal maturity)

26
Q

What are the symptoms of acquired hydronephrosis

A 
Often UPJO
Typically presents with symptoms:
-recurrent abdominal pain/flank pain
-recurrent pyelonephritis
-vomiting (+/- pain) after increased fluid intake

Investigations: RBUS. If Hydropresent, confirm obstruction with diuretic renal scan

27
Q

List 7 causes of obstructive Uropathies

A

Obstruction may occur anywhere along the urinary tract and be congenital or acquired

UPJO
UVJO/Ureterocele/Ectopic ureter
Prolapsing ureterocele (obstructs bladder neck)
PUV (obstructs posterior urethra)
Urethral stricture
Severe meatal stenosis
Scarred phimosis
28
Q

What are suspicious signs antenatally of PUV (5)

A
  • male
  • bilateral hydronephrosis
  • distended thick walled bladder
  • Keyhole sign
  • oligohydramnious
29
Q

How do you manage PUV (7)

A
  1. stabilize if resp issues
  2. urgent postnatal RBUS
  3. Bladder decompression
  4. Serial serum creatinine levels
  5. Confirmatory VCUG
  6. Consult with nephro (fluid, acid-base, lyte management)
  7. Consult Urology (surgical management)
30
Q

What are the highlights of the CPS statement on UTIs in infants and children

A

-imaging should only be performed when it is likely to alter management
-RBUS after 1st febrile UTI
-VUCG (or NC in females) is reserved for those w/ abnormal RBUS or if have a 2nd febrile UTI)
-No abx prophylaxis for VUR I-III w/ hx of febrile UTI
-Referral/discussion with Uro/nephro for VUR IV - V or significantly abnormal RUBS findings
-Children w/ recurrent UTIs should be managed individually
-bagged urine maybe be used for UA but not Ucx
-contamination is very common from a male when foreskin cannot be retracted
-cystitis in older children - 2 - 4 day course of oral Abx is usually adequate
children with suspected cystitis do not require imaging

31
Q

What is VUR

A

Vesico-Ureteric Reflex

  • the retrograde flow of urine from bladder to kidneys
  • does not cause UTI (except high volume VUR preventing adequate bladder emptying)
  • does increase ease of access of bacteria in the bladder to the kidney to cause pyelo
32
Q

How has VUR management changed?

A
  • more selective about who we screen/treat for VUR
  • avoid dx asymptomatic VUR: don’t screen siblings with VUR (30% risk), no longer screen for VUR in those with SFU I & II CH (15% risk)
  • don’t txt asymptomatic VUR
  • avoid treating low VUR associated with UTI
33
Q

When is a cystogram warranted? (7)

A
  1. Febrile UTI WU: abnormal RBUS, if > 1 febrile UTI
  2. Work up of SFU III of IV congenital hydro
  3. WU of late presentation of HUN
  4. FU of VUR if results will alter management
  5. Management of neurogenic bladder
  6. Suspicion of PUV or urethral stricture in male (VCUG)
  7. Recurrent cystitis in prepubertal male (rule out PUV w/ VCUG)
34
Q

How do you investigate recurrent cystitis? What are symptoms of bladder and bowel dysfunction (BBD) (5)

A

Focus on behavioural anomalies rather than anatomic ones

Look for bladder and bowel dysfunction

  1. Constipation
  2. Infrequent voiding
  3. Voiding postponement
  4. Overactive bladder (OAB)
  5. Incomplete emptying
35
Q

How do you manage recurrent cystitis

A

Manage bladder and bowel dysfunction

  • diet/meds for constipation
  • timed voiding for infrequent voiding
  • avoidance of urine holding
  • management of overactive bladder if identified

If symptoms morbid and frequent (3 UTI in 6 mo or 4 in last year) consider offering 3-6 mo continuous abx proph

36
Q

Highlights of CPS statement on Prophylatic abx for children with recurrent UTIs

A
  • Managing constipation appropriately may be helpful for decreasing UTI recurrences
  • if CAP used, should be used for no more than 3 - 6 mon then reevaluate
  • choice antimicrobials is TMP/SMX or nitrofurantoin
  • switch antimicrobial if urine cx shows resistant organism, even if suspect contamination
  • if urine isolate shows resistance to both TMP/SMX & nitrofurantoin, consider stopping CAP rather than using broad spectrum antimicrobials for CAP
37
Q

What is the most common cause of Daytime Incontenance. List 8 other causes

A

Most common: Overactive bladder

Other causes:

  1. Infrequent voiding
  2. Voiding postponement
  3. Vaginal voiding
  4. Giggle incontinence
  5. Ectopic ureter
  6. Cystitis
  7. Bladder outlet obstruction
  8. Neuropathic
38
Q

What is overactive bladder? What are signs and symptoms of OAB (7)

A

uninhibited bladder contractions causing urgency or incontinence

OAB signs/symptoms:  
-no neurogenic anomalies
-frequency (> 8 voids/day on voiding calendar)
-Urgency (history)
-urge incontinence (history/voiding calendar) 
-urine holding position 
-small functional bladder capacity
-commonly associated with:
constipation
nocturnal enuresis
recurrent cystitis
39
Q

What are treatments for OAB

A
  • treat constipation
  • observation (if not bothersome)
  • timed voiding (every 1.5 - 2 hrs)
  • treat UTIs

2nd line:
-anticolinergics (AKA antimuscarinics): reduces intensity and frequency of involuntary contractions

40
Q

What is the presentation of renal stones (3)

A
  • renal colic (flank pain +/- nausea & vomiting)
  • incidental on imaging (RBUS or CT)
  • Hematuria
41
Q

What is the treatment for renal colic

A

Conservative txt:
-analgesia & alpha blocker (tamsulosin) to hasten passage of small ureteric stones

Interventional txt:
- for large stones to large to pass, unremitting pain, persistent severe obstruction, solitary kidney or infected kidney

42
Q

How do you prevent stones recurrence?

A

To prevent recurrence:

  • metabolic work up (blood work and 24 hour urine collection)
  • passed stone should be retrieved and sent for chemical analysis

-60% are calcium oxalate

  • when no metabolic anomaly is identified and stone composition either CaOx or unknown:
  • increase fluid intake
  • avoid excess salt intake (urinary Ca excreted w/ urine Na)
  • normal calcium intake (more effective than Ca restriction)
43
Q

What are causes of scrotal swelling (8)

A
  1. Testicular swelling:
    - testicular tumor
    - orchitis
    - testicular torsion
  2. Peri-testicular swelling
    - hydrocele
    - varicocele
    - large epididymal cyst
    - inguinal hernia
    - infectious epididymitis
  3. Scrotal wall edema due to inflammation:
    - testicular torsion
    - torision of the appendix testis
    - Epididymo-orchitis or orchitis
44
Q

What are the 2 different types of Hydrocele

A

Communicating

  • risk is development of indirect hernia
  • allow for 18 mon for resolution before referral

Non-Communicating

  • may be part of continuum of resolution of communication hydrocele
  • may be reactive (infection, trauma, tumor)
  • imbalance of scretion > absorption
  • refer if large/bothersome
45
Q

What is the role of US in Hydrocele (4)

A

Limited role

  • to confirm scrotal testis (> 6 mons of age)
  • to differentiate from inguinal hernia
  • to rule out testis tumor (adolescent age)
  • when associated with scrotal pain NYD
46
Q

What is the DDX of a tender testes?

A
  1. Testicular torsion (this unless proven otherwise)
  2. Torsion of the appendix of the testes or appendix epididymis
  3. Infectious epididymitis/epididymo-orchitis: rare in prepubertial males, if afebrile screen with urine dip
47
Q

When should surgical reduction of testicular torsion occur?

A

Ideally btw 4 - 6 hours of onset

-if suspect don’t do u/s just call surgery

48
Q

What are the CPS Circumcision Highlights?

A
  • the CPS statement does not recommend the routine circumcision of every newborn male
  • Rate of Canadian newborn circumcision 32%
  • Age 6 yrs: 50% of foreskins retract
  • Age 17 yrs: 95% of foreskins retract
  • increased risk of STI transmission and penile cancer does not justify recommendation of routine circumcision
  • Topical steroids recommended for hastening retraction of foreskin and release of adhesions
  • Meatal stenosis (seen following 2 - 10% of newborn circumcision can be prevented by applying petroleum jelly to the glans for up to 6 mons following circumcision

General Pediatrics (19 decks)

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