Urology Flashcards
At which grade VUR do you provide Abx prophylaxis against UTI?
Grade 4 and 5
Or urological anomaly
Discuss w/ urology or nephro
T or F: all febrile UTI < 2 should get prophylactic ABX.
False.
All < 2 = U/S
If Grade 4-5 VUR and starting Abx- what do you start? + for how long?
Septra (Trimethoprim/ Sulfamethoxazole)
OR nitrofurantoin
1/4-1/3 of daily total tx dose
Max 3-6 mon.
If abN persist then prophylaxis R/A at that time (as increased risk of resistance w/ time)
6 mon. old w/ gr 2 reflux on one side. What do you? Start Abx? Monthly urine studies? Repeat VCUG x 6 mo?
Repeat VCUG in 6 mo.
Child on prophylaxis (Septra) found to have organism resistant to Septra AND nitrofurantoin. What do you do? Switch Abx prophylaxis, d/c, monthly urine ?
D/C prophylaxis.
w/ consult w/ uro +/- nephro
- Broader Abx breed resistance
When do you do a VCUG in relationship to pt w/ UTI?
< 2
US findings suggest VUR, selective anomaly or obstructive uropathy
or < 2 y.o. but 2nd UTI!
What is VUR?
Vesicoureteral reflux
= retrograde flow of urine from bladder to ureter + kidney
Is paediatric VUR usually congenital or acquired?
Congenital.
1/3 of siblings have VUR too; but no longer screen!
what is primary VUR?
congenital incompetence of valvular mech of vesicoureteral junction
T or F: VUR often resolve or improve w/ growth?
True.
- mean age of resolution= 6y.o.
- higher grade, b/l, older = less likely to resolve
What is the optimal method of dx VUR?
VCUG
= radionuclide cystogram
Should siblings of kids with VUR have U/S or VCUG?
Royal College- we no longer screen for sibling VUR (30% risk).
American: do U/S
- if abnormalities in cortex, size, asymmetry, UTI = VCUG
List primary and secondary aetiologies for VUR?
Primary:
- valve incompetence (AD),
- malformation (ureteral duplication)
- Assoc. w/ UPJ obstruction
Secondary:
1. neuropathic bladder (i.e. myelomeningocele)
How do you treat VUR?
Observation
- timed voiding
- no constipation
- increase fluid
- bladder emptying
- look for UTI
Grade 4-5: prophylactic Abx
Sx option
5 mon. with UTI. 2 indications for prophylaxis. 2 indications for urology referral.
Prophylaxis and Referral=
- Grade 4 or 5 VUR
- abN kidney or urinary tract structure on US
- Recurrent UTI in < 2 y.o.
Way to detect renal scarring: IV pyelography, nuclear scan (DMSA), renal excretion scan (MAG-3), VCUG?
Renal nuclear scan (DMSA)
List 5 causes of antenatal hydronephrosis:
- Transient hydronephrosis
- Ureteropelvic junction obstruction (UPJ)
- VUR (Vesicoureteral reflux)
- Megaureter
- Multicystic dysplastic kidney (MCDK)
- Posterior Urethral valve (PUV)
Describe Prune Belly Syndrome
Rare
AR; not sex link but M>F
Neo: oligohydraminos, pul hypoplasia
GI: lax lg abdo w/ thin wall where can see loops
GU: kidney dysplasia, VUR, undescended testis
Triad:
Abdo muscle deficient + B/L cryptorchidism + GU anomalies (due to severe urethral obstruction)
Prognosis depend on pul hypoplasia + renal hypoplasia
High risk UTI
1/3= ESRD
Which is consistent with Prune Belly Syndrome:
- PUV
- Progression to ESRD
- Sex linked
- Polyhydraminos
progression to ESRD
- VUR common not PUV
- M dominant but AR NOT sex linked
- oligohydraminos and pul hypoplasia!
What is the triad in prune belly syndrome?
Abdo muscle deficient
+ GU anomalies (due to severe urethral obstruction)
+ B/L cryptorchidism
T or F: most undescended at birth complete descend within first 3-4 months?
True
Name one RF for cryptorchidism
Prematurity
-30% of prem M
When should you do Sx for Cryptorchidism?
< 2y.o.
Ideally < 1; Nelson’s say 9-15 months.
Refer congenital unilateral non palpable or palpable undescended testis:
4-12 months
Refer earlier if undescended testis IF:
- b/l non palpable
- unilateral but hypospadias
- DSD suspicion
Why we repair undescended Testis (complications if untreated):
?1. Poor testicular growth
- Sub fertility (lower sperm count, poorer quality, lower fertility)
- Inguinal Hernia
- Testicular Torsion
- Testicular Trauma
- Testicular CA (increased risk due to inability to examine)
What imaging test confirm testicular torsion?
U/S
Absent cremasteric reflex =
Testicular Torsion
+ higher lie than usual
Blue dot on scrotum=
Torsion of Appendix Testis
List as many things as possible for acute scrotal pain in teenager:
- Testicular Torsion
- Torsion of Appendix Testis
- Epididymitis
- Trauma (rupture testis, hematocele)
- Incarcerated inguinal hernia
- Mumps Orchitis
- Testicular vasculitis
When do you refer kids with inguinal hernias?
Immediately!
- highest risk of incarceration and strangulation in 1st year of life
When do you refer umbilical hernia for Sx?
After >3-4 y.o.
Define nocturnal enuresis
> 2X/week beyond 5 y.o.
Primary vs. secondary (prior continence x 6 mo.)
T or F: there is usually a (+) FHX of enuresis
True
T or F: in primary enuresis you do NOT need to do a U/A:
True
IF hx and P/E reassuring.
What is the most common urologic disorder in kids?
Enuresis
What is the most common cause of enuresis in kids?
Functional
What is the key tx in primary enuresis?
Support + Reassure
- <1% adults; reassure
- no punishing
- q2h void
- avoid caffeine or excessive fluid (<2 oz) pre bed
- void @ bedtime
- stop diaper
What type of tech or drug is most efficacious in primary enuresis?
Alarms
- most efficacious (usually best if > 7-8 y.o.)
Drug options in primary enuresis:
- Desmopressin= synthetic ADH= work for short-term
- Oxybutynin = anticholinergic agent= reduce bladder contraction
- Imipramine HCL= TCA
Most common cause of secondary enuresis in 7 y.o. M:
Constipation
More than DM, UTI, nephrogenic DI, psych
What % of kids over 5 have nocturnal enuresis?
20%
- resolve spontaneously in 15% of kids every year
What % of adults continue to have nocturnal enuresis?
<1%
List aetiologies for urinary incontinence?
- Functional
= dysfunctional void
i.e. voluntary holding, maturational delay, stress - Anatomic
= usually primary enuresis
i.e. small bladder, obstruction at bladder outlet (PUV), ectopic ureter (bypass bladder outlet= dribbling), reflux into vagina (obese, labial fusion) - Neurologic
= disrupted innervation
i.e. myelomeningocele, spinal dysraphism, detrusor instability, CNS trauma, constipation (cause detrusor muscle innervation) - Other
i. e. DM, DI, UTI, DD, Psychogenic polydipsia
What are urinary storage symptoms:
- urge incontinence
- overflow
- urinary f
What are urinary emptying disorder symptoms:
- voiding infrequent
- stream or staccato void
What is the long-term cure rate of enuresis with alarms?
Just under 50%
How do you treat labial adhesions?
No tx if asymptomatic
Symptomatic= topical E cream daily x 6 weeks (AE = breast budding)
Sx rare
What gene causes undifferentiated gonads to become testis?
SRY gene
= Sex-Determining Region on Y chromosome
= Sertoli Cell= make AMH which cause regression of eulerian ducts
= Leydig Cells= T
Note: 5 alpha reductase covert 10% of T to DHT (dihydrotestosterone)
DHT= critical for N + complete male virilization
What are disorders of sex development?
Congenital discrepancy between external genitalia, gonad and chromosomal sex
- Undermasulinized M
> T synthetic defect
> resistance in target tissue - Virilized F
> excess androgen
> ovarian + testicular tissue
Name three findings where you consider DSD?
- B/L non palpable testes
- U/L non palpable gonad + Hypospadias
- Gonads in labioscrotal folds
- Scrotal or Perineal Hypospadias
- Microphallus (< 2.5 length in term)
- Clitromegaly (width > 6 mm or length > 9 mm)
- Posterior labial fusion (anogenital ridge ratio > 0.5)
- Discordant genitalia + sex chromosome
List the 2 most common forms of disorders of sexual development (DSD):
- CAH 46XX
- masculinized F - Mixed gonadal dysgenesis 45X/46XY
Most common form of DSD
46 XX CAH (Congenital adrenal hyperplasia)
Go through broad aetiologies for DSD:
Listed are ones you can remember
- Extra Androgen F=
- Virilizing CAH
- Ovotesticular DSD (extra testicular tissue)
- Maternal androgen - Undervirilized M= lack T or extra E
- Gonadal dysgnesis (Klinefelter)
- Testicular regression (Vanishing testes)
- Defect in T synthesis (Leydig cell hypoplasia)
- Defect in androgen at target tissue= 5 alpha reductase deficiency, androgen insensitivity syndrome
- mother’s ingestion of E - OR Mixed chromosome pattern= mixed gonadal dysgensis = 45 X/ 46 XY
Key P/E findings in DSD:
- dysmorphic features
- midline defect
- hydration, BP
- genitalia: symmetry, measure clitoris or penis
- palpate labioscrotal folds
to R/O gonad, R/O fusion - hypospadias
- anogenital ratio (>0.5 weird)
Investigations for DSD:
- karyotype + FISH for SRY on Y chromosome
- pelvic + abdo US (gonad, mullein structure)
Other: adrenal if suspect CAH (17-OHP, lytes)
Other: gonad function (T, DHT, LH, FSH, +/- AMH)
Managing Mixed Gonadal Dysgenesis DSD:
- Gender assign (multi-D)
- gender concordant Sx
- sex hormone replacement
T or F: In mixed gonadal dysgenesis (45X/ 46XY) gonads with Y chromosome have increased risk of gonadoblastoma.
True
T or F: most hypospadias are part of syndrome
False!
- 90% isolated
T or F: renal imaging is important for non syndromic hypospadias
False!
- no role unless syndrome or DSD thought
T or F: normal virilization of external genitalia occur at 20 weeks?
False!
- occur at 8 weeks
- thus future fetal intervention for this must start before this GA
IV Pyelograms are still used today for stones and obstructions?
False. RARELY ever used.
Prior indication true but risk of IV + Radiation.
T or F: normal US R/O VUR.
False.
- hydronephrosis NYD- need to do VCUG.
Why is VCUG preferred over nuclear cystogram?
VCUG: VUR + PUV
AND allows VUR grading
(-)= VCUG has more radiation
Urodynamic functions look at what?
Bladder f’n w/ voiding
T or F: there are diff radionuclides for diff indications w/ renal scans?
True
DMSA Renal Scan is good for what?
- Function
- Scarring
- Pyelo
MAG-3 Lasix Renal Scan good for what?
- Function
- Obstruction
- Urine Leak
T or F: VCUG gives you information on renal + bladder drainage?
False.
T or F: DMSA Renal Scan give you information on renal drainage?
False.
ONLY:
- Function
- Scar
- Pyelo
Most common fetal anomaly is?
Congenital hydronephrosis
T or F: all hydronephrosis represent obstruction.
False!
- most obstructive lesions can= hydronpehrosis
BUT NOT all hydronephrosis =obstruction
1st line investigation for congenital hydronephrosis?
Renal and Bladder US
What is the diameter of fetal hydronephrosis that require post natal imaging?
7mm (USA 2014 guideline) AP diameter
Note: 2009 Canadian guideline 9mm
When do you plan the postnatal US for fetal hydronephrosis:
after DOL3 (within 1 mo)
UNLESS
- b/l hydro
- solitary kidney
- urethral obstruction
- oligohyraminos
- concern about compliance
When may you do a postnatal US, to follow antenatal hydronephrosis, in hosp pre-d/c instead of waiting > 72hr
- B/L Severe hydro (>15mm)
- Solitary kidney
- Urethral obstruction
- Oligohydraminos
- Concern about compliance to come back
T or F: grade of hydronephrosis correlate with risk of VUR?
False!
BUT grade of SFU hydronephrosis related to obstruction.
- significant obstruction only w/ SFU 3+4
4 most common causes of significant congenital hydronephrosis:
- Ureteropelvic junction obstruction
- VUR
- Ureterovesical junction obstruction
- Posterior Urethral Valves
If see +++ hydronephrosis WITHOUT hydroureter?
UPJO
= Uretero-pelvic junction obstruction
If bilateral ++++ congenital hydronephrosis in male?
PUV
= Posterior urethral valves
- due to bladder obstruction
Most common cause of acquired Hydronephrosis?
UPJO
= Ureteropelvic Junction Obstruction
When to suspect PUV?
Male
Bilateral congenital hydro
Oligohydraminos
Keyhole sign on US
Manage PUV.
ABC Urgent US Bladder decompress Serial Cr Confirm VCUG Consult Nephron (BW, fluid, lytes), + Uro (Sx)
T or F: incidental finding of duplex NOT a concern if no hydronephrosis or hx of UTI?
True.
When is incidental (+) duplex kidney a concern?
Associated w/:
- Hydronephrosis
- UTI
Horseshoe kidney associated w/?
- Turner Syndrome
- Trisomy 18
T or F: Most horseshoe kidney patient asymptomatic.
True
Most common associated complication with horseshoe kidneys?
Hydronephrosis
- usually due to UPJO
Other risk
- UTI
- another anomaly
- renal stone (20%)
- CA (relative risk up but still very rare)
T or F: Horseshoe kidney finding NOT a concern if no hydronephrosis or abdo pain.
True
T or F: Children with suspected cystitis do not require imaging.
True!
if > 2
CPS: cystitis= bacteriuria resulting in local “bladder” symptom (voiding, suprapubic, lower back)
-Note: tx 2-4d ABX for older kids
2 y.o. M with VCUG show b/l grade 3. No PUV. What do you do?
Parental counselling re: signs of recurrence
- No prophylactic Abx (Grade 4-5 only)
- No referral needed
- No need to repeat test; resolution w/ time
- CPS: grade 3 VUR (b/l or uni) with single febrile UTI= Observation
- Behav modifications (timed voiding, no constipation, fluid, empty bladder, look out for signs of UTI)
T or F: VUR does CAUSE UTI
False.
Except if high volume results in inability for bladder to empty.
DOES allow easy access of bacteria in bladder to kidney for pyelo.
T or F: screening for VUR prevent pyelo, renal scar and reflux nephropathy?
False.
- No change via screening
To review here are all the reasons to do a cystogram (VCUG)
- Febrile UTI W/U + abnormal U/S (Dilated collecting system)
- > 1 febrile UTI
- W/U for grade 3-4 congenital hydronpehrosis
- late presenting hydroureteronephrosis
- F/U of VUR if results change tx
- Tx of neurogenic bladder
- suspicion of PUV or urethral stricture in M
- Recurrent cystitis in prepubertal male (R/O PUV)
Most common cause of recurrent cystitis?
1= Bladder + Bowel Dysfunction
Symptoms, no fever.
- Constipation
- In-freq voiding
- Postponing voiding
- Overactive Bladder
- Incomplete Emptying
T or F: if recurrent cystitis symptoms morbid and freq (3 in last 6 mon. or 4 in last year) you can do prophylactic ABX x 3-6 month.
True
Most common cause of daytime incontinence?
Overactive bladder
= inhibited bladder contraction causing urgency
- usually associated w/ constipation, cystitis
- urge, trying to hold via curtsy, very frequent voids
- Tx constipation
- Timed voiding
- Anticholinergic (oxybutinin)
Most common malignant abdo tumour in infant?
- neuroblastoma
2. Wilms
Common ppt of renal stones:
- Colic (flank pain + N/V)
2. Hematuria
Best first test for stone
US
If need more= CT
Best management for stone:
- Analgesic
2. Alpha blocker (Tamsulosin/Flomax) to hasten passage
When do we do something about stones:
- too big
- too much pain
- persistent obstruction
- solitary kidney
- infected kidney
- obstructed kidney
General renal stone prevention tips:
- Lots of fluid
- Avoid extra salt
- normal Ca2+ diet
T or F: calcium restriction good general tip for renal stone prevention.
False
- Normal calcium intake recommended
Teenager with new non-communicating hydrocele:
R/O tumour
R/O infection
R/O trauma
T or F: there is a risk of indirect hernia development with a communicating hydrocele:
True
T or F: You should refer a communicating hydrocele by 1 year.
false.
- allow up to 18 month to fix; then refer
T or F: U/S is the key dx tool for hydrocele:
False.
- Transillumination is your dx.
- US only if can’t feel testis, dont’ know what it is, or wondering if tumour (i.e. teen pt)
Testicular torsion KEYS:
- sudden +++ pain
- tender everywhere
- high riding testis
- transverse lie
- decreased flow in U/S
- Sx within 4-6 h of pain onset
versus. torsion of appendix= gradual, pain to upper pole, blue dot sign, NSAID + rest
T or F: STI transmission and penile CA justify rationale for routine circumcision
False.
If foreskin not retracting as teenager- what do you do?
- Routine daily attempt by child
- Topical steroid x 6 week (weaken skin + release adhesion)
