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Urology Flashcards

1
Q

What are some local clinical features of urological problems in children?

A
  • Pain
  • Changes in urine
  • Abnormal voiding
  • Mass
  • Visible abnormalities
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2
Q

What is an inguinal hernia?

A

Herniation into the inguinal canal and potetntially scrotal sac, and is usually caused by a persistently patent processus vaginalis

99% are indirect hernias

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3
Q

What percentage of inguinal hernias are direct?

A

1%

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4
Q

How does an inguinal hernia present?

A
  • Lump in the groin - which may extend into the scrotum
  • Intermittent - visible during straining
  • Pain - if incarcerated - painful lump
    • Intestinal obstruction
    • Strangulation of testes
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5
Q

Who is more likely to develop an inguinal hernia; boys or girls?

A

Boys - 9:1

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6
Q

How would you manage an inguinal hernia?

A
  • < 1 year
    • URGENT referral
    • Repair - no place for observation
  • > 1 year
    • Elective referral and repair
  • Incarcerated
    • Reduce and repair on same admission
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7
Q

What is a hydrocele?

A

Due to a patent processus vaginalis which allows fluid to collect around the tesicle in the tunica vaginalis or within the cord

Same concept as a hernia, but passageway is much narrower

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8
Q

What guides the testes as they migrate down into the scrotum embryologically?

A

Mesenchymal gubernaculum

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9
Q

How would you distinguish a hydrocele from a inguinal hernia?

A
  • Can you get above the swelling?
  • Hydroceles normally tranilluminate
  • Tend to be bluish in colour
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10
Q

How would you manage a hydrocele?

A
  • Conservative - normally closes on it’s own
  • Surgical - if it persists beyond 2 years
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11
Q

What is cryptorchidism?

A

Undescended testis

The abscence of one or both testes from the scrotum

Any testis that cannot be manipulated into the bottom half of the scrotum

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12
Q

What types of cryptorchidism are there?

A
  • Retractile - Can pull down, but retract - strong chremasteric reflex - dartos muscle
  • True cryptorchidism - Properly undescended
  • Ectopic - wrong line of descent
  • Ascending Testis
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13
Q

What are risk factors for developing cryptorchidism?

A

Prematurity

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14
Q

How would you investigate a suspected undescending testis?

A
  • Examination
    • Warm room + Warm hands
    • Testis may be felt in the scrotum/may need to be delivered
    • Palpable testis - may be felt in the groin
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15
Q

What could be the cause of an impalpable testis?

A
  • In the inguinal canal but cannot be identified
  • Intra-abdominal
  • Absent
  • Atrophic
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16
Q

What is the difference between a retractile and undescended testis?

A

Retractile can be manipulated into the scrotum with ease and without tension

Activation of cremaster muscle pulls the testis up

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17
Q

How would you manage an undescended testis?

A

Orchidopexy

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18
Q

Why are orchidopexies performed to treat undescended testicles?

A
  • Cosmetic
  • Reduced tisk of torsion/trauma
  • Fertility
  • Risk of malignancy - greater if bilateral/intra-abdominal
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19
Q

What is an absolute indication for circumcision?

A

Balanitis Xerotica Obliterans

Lichen sclerosis of the penis

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20
Q

What are relative indications for circumcision?

A
  • Balanoprosthitis
  • Religious
  • UTI
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21
Q

What are complications of circumcision?

A
  • Bleeding
  • Meatal stenosis
  • Fistula
  • Cosmetic
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22
Q

What is torsion of the testis?

A

Occurs when the spermatic cord (from which the testicle is suspended) twists, cutting off the testicle’s blood supply

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23
Q

What age range does testicular torsion occur most commonly in?

A

Post pubertal

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24
Q

How does testicular torsion present?

A
  • Severe pain - may be localised to groin or lower abdomen
  • Redness
  • Swelling
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25
Q

What increases the risk of testicular torsion?

A
  • Undescended testis
  • Clapper bell testis - testis lying transversely on its atachement to the spermatic cord
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26
Q

How should you manage testicular torsion?

A

Treated ASAP - oterhwise very high risk of loss of testicle

  • Scrotal exploration
  • Testicular fixation - both testicles
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27
Q

What is the differential diagnosis for an acute scrotum?

A
  • Torsion testis/torsion appendix testis
  • Epididymitis
  • Trauma
  • Haematocele
  • Incarcerated inguinal hernia
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28
Q

What is torsion of appendix testis?

A

The testicular appendage (hydatid of morgany), which is a mullerian (paramesonephric) remnant usually located on the upper pole of the testis. Torsion occurs when this becomes twisted

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29
Q

How does torsion of the appendix testis present?

A
  • Pain - evolves over days
  • Blue dot - seen through scrotal skin
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30
Q

How would you manage torsion of the appendix testis?

A
  • Scrotal exploration
    • Can’t always tell it’s not testicular torsion
    • If blue dot is present + Pain is controlled -> no need for surgery
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31
Q

Which is more common; torsion of the testis or torsion of the appendix testis?

A

Torsion of the appendix testis

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32
Q

What age group does torsion of the appendix testis most commonly affect??

A

Prepubertal boys

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33
Q

How does a UTI present in infants?

A
  • Fever
  • Vomiting
  • Lethargy and irritability
  • Poor feeding/faltering growth
  • Jaundice
  • Septicaemia
  • Offensive urine
  • Febrile seizure (> 6months)
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34
Q

What is the definition of UTI in a child?

A

Clinical signs PLUS

  • Pure growth bacteria > 105
  • Pyuria - pus cells
  • Systemic upset
  • OR mixed growth bacteria, no pyuria, no systemic symptoms
35
Q

Up to what age do UTI’s occur more commonly in boys than girls?

A

Up to 3 months

36
Q

What are the organisms most commonly implicated in urinary tract infections in children?

A
  • E.coli (85%)
  • Klebsiella
  • Proteus
  • Pesudomonas
  • Strep Faecalus
37
Q

What is the most common organism found in boys with UTI?

38
Q

What can UTIs colonised by proteus predispose to?

A

Development of phosphate stones

39
Q

How do children present with UTI’s?

A
  • Dysuria/Frequency/Urgency
  • Abdominal pain/loin tenderness
  • Fever +/- rigors
  • Lethargy and anorexia
  • D + V
  • Offensive, cloudy urine
  • Febrile seizure
  • Recurrence of enuresis
40
Q

What investigations would you do if you suspected a UTI in a child?

A
  • Dipstick and Culture/Microscopy
  • Abdominal US
  • Assess for reflux
41
Q

What threshold on bacterial culture needs to be reached before UTI can be diagnosed?

A

>1x105 CFU/ml - 90% probability

42
Q

What is bacteriuria?

A

The presence of bacteria in urine but not if bacteria’s presence is due to contamination during urine sample collection.

Bacteria often indicate a urinary tract infection, although bacteriuria can also occur in prostatitis.

May be asymptomatic - can cause scarring, increased BP and CKD

43
Q

What is chronic pyelonephritis?

A

Histological/radiological diagnosis with juxtaposition of a cortex scar and dilated calyx.

Can cause hypertension and renal failure

44
Q

If you took a catheter or suprapubic urine sample, what would be diagnostic of UTI?

A

Bacterial growth of a single organism per millilitre

45
Q

On dipstick, if you saw positive leucocytes and nitrites in the context of suspected UTI, how would you interepret?

A

Regard as UTI if clinical symptoms present

46
Q

On dipstick, if you saw leucocyte negative and nitrite positive in a child with suspected UTI, how would you interpret this?

A

Treat as UTI if clinical symptoms

Depends on urine culture

47
Q

On dipstick, if you saw lecuocyte positive and nitrite negative in a child with suspected UTI, how would you interpret this?

A

Start treatment for UTI if clinical symptoms

Diagnosis depends on urine culture

48
Q

On dipstick, if you saw leucocyte and nitrite negative in a child with suspected UTI, how would you interpret these results?

A

UTI unlikely - repeat or send urine for culture if clinical history suggests UTI

49
Q

What is vesicoureteric reflux?

A

Developmental anomaly of the vesicoureteric reflux. The ureters are displaced laterally and enter directly into the bladder rather than at an angle

50
Q

What can cause VUR?

A
  • FH
  • Neuropathic bladder
  • Urethral obstruction
  • UTI - temporary VUR
51
Q

Why is VUR associated ureteric dilatation important?

A
  • Urine returning to bladder from ureters after voiding means bladder does not empty properly
  • Kidneys may become infected - especially if there is intrarenal reflux
  • Bladder voiding pressure is transmitted to the renal papillae which may contribute to renal damage if voiding pressures are high
52
Q

How can UTIs in children cause Kidney complicatons?

A

Bacteria can move into the kidney and lead to scarring. Scarring of the kidney can be associated with high blood pressure and kidney failure.

53
Q

How would you investigate for VUR?

A
  1. Abdominal US
  2. Renal US - renal size/scarring
  3. DMSA scan - function
  4. MAG3 Scan
  5. MCUG Scan - gold standard
54
Q

What is a DMSA Scan?

A

Detects functional defects, such as scars or areas of nonfunctioning renal tissue, but very sensitive.

Need to wait at least 2 months after UTI to avoid diagnosing false scars

55
Q

What is a MAG3 renogram?

A

Dynamic scan, isotope-labelled substance MAG3 excreted from the blood into the urine.

Measures drainage, best performed with high urine flow so furosemide often given

In children old enough to cooperate (>4 years), scan during micturition is done to identify VUR

56
Q

What is a micturating cycstourethrogram (MCUG)?

A

Contrast introduced into the bladder through urethral catheter.

Can visualise bladder and urethral anatomy. Detects VUR and urethral obstruction

REQUIRES CATHETERISATION

57
Q

What is the best way of excluding reflux?

A

MCUG

However, if DMSA is negative, then MCUG is almost always negative

58
Q

What are the different grades of VUR?

A
  • Grade I - incomplete filling of upper urinary tract
  • Grade II - Complete filling +/- slight dilatation
  • Grade III - Ballooned calyces
  • Grade IV - Megaureter
  • Grade V - Megaureter + hydronephrosis
59
Q

How would you empirically treat a child (>1 month - 18 years) with lower UTI or cystitis?

A

Oral Trimethorpim or Cefalexin

3 days

60
Q

How would you empirically treat suspected pyelonephritis in a child less than 6 months old?

A

IV Cefotaxime or Ceftriaxone

61
Q

How would you emprically treat a pyelonephritis in a child > 6 months?

A

Oral/IV Co-amoxiclav +/- Gentamicin, then switch to oral co-amoxiclav

7 days duration

62
Q

What would you use in treating a pyelonephritis in a child > 6months of age who is penicillin allergic?

A

Oral/IV ciprofloxacin

63
Q

How would you empirically treat a catheter related UTI in a child?

A

Remove catheter

Antibiotics only if evidence of systemic infection

64
Q

What would indicate an upper UTI/pyeloneprhitis in a child?

A

Bacteriuria and fever >/= 38oC, or

Bacteriuria + loin pain/tenderness even if fever is <38oC

65
Q

How could you reduce the risk of children getting UTIs?

A
  • High fluid intake -> increased output
  • Regular voiding
  • Complete bladder emptying
  • Prevention of constipation
  • Good perineal hygeine
  • Antibiotic prophylaxis
66
Q

How would you manage a child with VUR?

A
  • Conservative - Voiding advice, constipation, fluids
  • Antibiotic prophylaxis - Trimethoprim (2mg/kg nocte)
  • STING (submucosal Teflon injection) - if it doesn’t resolve on conservative management + Mild/moderate with symptoms
  • Ureteric reimplantation - severe reflux
67
Q

What is PUJ obstruction?

A

Pelvi-ureteric junction (PUJ) obstruction/stenosis, also known as ureteropelvic junction (UPJ) obstruction/stenosis, can be one of the causes of an obstructive uropathy.

Can be congenital or acquired with a congenital PUJ obstruction being one of the commonest causes of antenatal hydronephrosis without VUR

68
Q

How would you manage PUJ obstruction?

A
  • PNUS (Post Natal Ultrasound)/Renography
  • Surgery
69
Q

What can cause antenatal hydronephrosis?

A
  • VUR (Vesico-Ureteric Reflux)
  • VUJ obstruction (Vesico-ureteric Junction Obstruction)
  • Posterior urethral valves
  • Multicystic kidney (MCDK)
  • Duplication anomalies
  • PUJ obstruction (Pelvi-ureteric Junction Obstruction)
70
Q

What is hypospadias?

A

Urethral meatus on the ventral aspect of the penis

Thought to arise from failure of development of the ventral tissues of the penis, in particular uretheral closure

71
Q

What are the three typical features of hypospadias?

A
  • A ventral urethral meatus (variable position)
  • Ventral curvature of the shaft (chordee)
  • Hooded prepuce
72
Q

What is phimosis?

A

Pathologically non-retractile foreskin

73
Q

What is balanoposthitis?

A

Single attack of redness and inflammation of the foreskin, sometimes with purulent discharge

Responds rapidly to warm bath and antibiotics

74
Q

What is pyuria?

A

The presence of pus in the urine, typically from bacterial infection.

Defined as the presence of 6-10 or more neutrophils per high power field of unspun, voided mid-stream urine

75
Q

What is daytime eneuresis?

A

Lack of bladder control during the day in a child old enough to be continent (>3-5 years of age)

76
Q

What can cause daytime enuresis?

A
  • Lack of attention to bladder sensation
  • Detrusor instability
  • Bladder neck weakness
  • Neuropathic bladder
  • UTI
  • Constipation
  • Ectopic ureter
77
Q

How would you investigate daytime enuresis?

A
  • Urine microscopy and culture
  • Ultrasound
  • Urodynamic studies
78
Q

What is secondary (onset) enuresis?

A

Loss of previously gained continence

79
Q

What can cause secondary enuresis?

A
  • Emotional upset
  • UTI
  • Polyuria from diuresis in diabetes or renal concentrating disorder
80
Q

How would you investigate secondary enuresis?

A
  • Urine dipstick - infection, glycosuria, proteinuria
  • Early morning urine osmolality sample
  • Ultrasound of renal tract
81
Q

When should a DMSA scan be performed?

A

4–6 months following the acute infection - should be used to detect renal parenchymal defects.

82
Q

What should be the first line imaging used for checking for VUR in a child with atypical/recurrent UTIs?

A

Abdo ultrasound. This can be followed by DMSA after 3 months

83
Q

Should a child with a first UTI have an abdominal ultrasound as part of their investigaitons?

A
  • No - if child was symptomatic and had response within 48 hrs to treatment
  • Yes - if <6 months, atypical or recurrent infecton
84
Q

What are features of an atypical UTI in a child?

A
  • Seriously ill/septicaemia
  • Poor urine flow
  • Abdominal or bladder mass
  • Raised creatinine
  • Failure to respond to treatment with suitable antibiotics within 48 hours
  • Infection with non-E. coli organisms

Paediatrics (27 decks)

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