Urology Flashcards
What is phimosis?
Inability to retract the foreskin
Difference between physiologic and pathologic phimosis
Physiologic: normal state where foreskin adheres to the glans, adhesions decrease with age naturally
*no need to treat
Pathologic: non-retractable foreskin due to scarring/fibrosis that occurs secondary to infection of inflammation
What is the main cause of pathologic phimosis?
Early forcible retraction
Presentation of pathologic phimosis
Secondary non-retractability after having had fully retractable foreskin Painful erections Irritation or bleeding Dysuria and/or urinary retention Recurrent infections (balantitis, UTI)
Tx options of pathologic phimosis
Stretching exercises (gently pulling foreskin back qid)
Topical corticosteroid
Circumcision (not often tho)
What pt education is necessary for an uncircumcised penis?
Avoid forcible retraction at any age
Stop retraction if met with any resistance
Clean with mild soap and water (no special care of foreskin)
Return foreskin to natural position after cleaning
What is paraphimosis?
Retracted foreskin in an uncircumcised male that cannot be returned to natural position
EMERGENCY
What happens to the penis in paraphimosis?
Entrapment-impaired venous flow-engorgement-arterial compromise
Causes of paraphimosis
Forcible retraction of partially phimotic skin by caretaker
Infection or inflammation
Genitourinary procedures (iatrogenic)
Sexual activity, penile trauma
Sxs of paraphimosis
Swelling of penis
Penile pain
Irritability in a preverbal infant
What is seen on the physical exam in paraphimosis?
Edema and tenderness of the glans
Tender swelling of the distal retracted foreskin (constricting band)
Color change to blue/black if ischemia present
Treatment of paraphimosis
Pain control
Timely, manual reduction in office or ED
Surgical intervention by urology
Benefits vs risks of circumcision
Benefits: decrease rate of UTI, penile cancer, penile inflammation/dermatoses and some STIs (benefits greater in infants with congenital uropathy)
Risks: procedure related complications (inadequate skin removal, bleeding, infection, urethral complications)
Contraindications for circumcision
Unstable infant, congenital penile anomalies (hypospadias, chordee)
2 types of circumcisions
Gomco or plastibell
What is epispadias?
Congenital anomaly with abnormal dorsal displacement of the urethral opening (on the top)
What might occur with epispadias?
Bladder exstrophy (exposed bladder onto the lower abdomen because the wall didn’t form correctly)
What is hypospadias?
Congenital anomaly that results in the abnormal ventral displacement of the urethral opening (on the bottom)
Displacement can be glans, shaft, scrotum, perineum (may also involve chordee)
What is chordee?
Abnormal penile curvature of the erect penis
If notice cryptorchidism on an infant with hypospadias, what should be considered?
Disorder of Sexual Development
Tx for hypospadias and/or chordee
**circumcision not done in newborn period because the surgeon will need the tissue to repair it first
Surgery is usually performed about 6 mos of age in normal term to fix both probs
What is cryptochidism?
A testis that is not within the scrotum and does not spontaneously descend into the scrotum by 4 mos
What is the most common GU congenital abnormality?
Cryptochidism (up to 30% of premature infants and 70% resolve spontaneously)
What can cryptorchidism increase the risk of?
Testicular torsion, subfertility, testicular cancer
Different types of cryptorchidism
Absent testes: agenesis or atrophy
Undescended testes: stopped short on normal descent
Retractile testes: overactive cremasteric reflex pulls back
Ascending and ectopic testes less common
Presentation of cryptorchidism
Absent testicle unilaterally or bilaterally (10%) with flat underdeveloped scrotum (test more if both)
What is the most common location for undescended testes?
Suprascrotal
When do most cases of cryptorchidism descend spontaneously?
3-4 mos
Treatment of cryptorchidism
Refer to urology
Surgery recommended as soon after 6 mos as possible (try before 1 YO)
Orchiopexy: testicle is brought down and attached into the scrotum (improved testicular growth and fertility potential)
What is testicular torsion?
Twisting of the spermatic cord due to a poorly anchored testicle (emergency because of risk of vascular compromise)
2 peak incidences of testicular torsion
Neonatal period
Puberty (12-18)
Presentation of testicular torsion
Abrupt onset of severe testicular or scrotal pain
Constant pain
N/v
Physical exam of testicular torsion
Edematous, indurated, erythematous scrotum
Affected testis tender, swollen and slightly elevated
Absent cremasteric reflex
Negative Prehns sign
When is Prehn’s sign positive?
Epididimytis (elevate scrotum and there is relief)
What is the test of choice to confirm testicular torsion?
Doppler ultrasound (position of testes and blood flow)
Tx for testicular torsion
Consult with urologist
Surgical detorsion and fixation (orchiopexy) of both
What is the prognosis of testicular torsion?
Depends on duration and completeness of torsion:
Within 4-6 hrs: 100% viable
Detorse after 12 hrs: 20% viable
After 24 hrs: 0%
2 types of UTI
Cystitis (bladder) or pyelonephritis (higher in kidney)
Etiology of UTI
Usually from ascending bacteria (mostly E coli)
Risk factors or UTIs
Female Urinary tract anomalies Bowel and bladder dysfunction (chronic constipation) Vesicoureteral reflux Sexual activity Bladder cath Hx Lack of circumcision
Clinical presentation of UTI in younger children
Non-specific sxs: Fever without clear source Vomiting Irritability Poor appetite
Presentation of UTI in older kids
Classic sxs: Dysuria, frequency, urgency Abdominal, suprapubic pain Back/flank pain New onset incontinence
How do you collect UA in kids?
If potty trained then clean-voided specimen
If not, catheterized specimen recommended (suprapubic aspiration when not feasible)
DO NOT USE BAG COLLECTION
What do you do when clinical suspicion of UTI?
UA (significant bacteriuria with pyuria-+ leukocyte esterase and nitrite) and culture (sensitivities help direct tx)
Duration of tx for UTI in kids
3-10 days
Choices of abx for UTI in kids
Begin with empiric and adjust per C&S Cephalosporin (cephalexin/cefdinir) Amoxicillin Augmentin Bactrim
When do you not need to do a f/u urinalysis?
When using a culture and sensitivity
Diagnostics for UTI follow-up
Renal bladder u/s
Voiding cystourethrogram
Renal scintigraphy
What is the 1st line follow up imaging study in pts with UTI when indicated?
Renal bladder u/s (noninvasive)
When is renal bladder u/s contraindicated?
<2 with first febrile UTI
Any age with recurrent UTI
UTI or FH of renal or urologic disease, poor growth or HTN
Kids not responding to appropriate therapy
What is the test of choice to detect vesicoureteral reflux?
Voiding cystourethrogram
Also used for kids with >2 febrile UTIs or kids with 1st febrile UTI and any anomaly on u/s, temp >102.2 and non ecoli pathogen or poor growth/HTN
What is vesicoureteral reflux?
Retrograde flow of urine from bladder into upper urinary tract, usually due to inadequate closure of ureterovesicular junction
Presentation of vesicoureteral reflux
Hydronephrosis (prenatal u/s) and post natal febrile UTI
How to diagnose vesicoureteral reflux
VCUG (catheter placed and contrast injected- under flouroscopy take real time xrays and watch the movement of contrast and anatomy while the pt voids)
Can then grade the severity
Management of vesicoureteral reflux
Watchful waiting
Low dose prophylactic abx most common
Surgical correction
What is renal scintigraphy?
Nuclear med scan using radioisotope DMSA to detect acute pyelonephritis and renal scarring (areas of decreased uptake indicate scarring and inflammation)
Not recommended in routine eval for first UTI
When should your refer kids with a UTI?
Severe VUR or obstruction (abover grade 3)
Renal abnormalities
Impaired kidney function
Elevated BP
Bowel and bladder dysfunction refractory to primary care measures
What is the most common type of renal fusion?
Horseshoe kidney
What is horseshoe kidney?
Fusion of one pole of each kidney cause by abnormal migration of the kidneys Usually asymptomatic (may have pain or hematuria)
What might be associated with horseshoe kidney?
Almost half have another urologic/gential anomaly (VUR, undescended testes, hypospadias)
Small increased risk for Wilms tumor
What is the most common renal malignancy in kids?
Wilms tumor
Diagnostics for horseshoe kidney
U/s, VCUG if UTI, serum creatinine (if normal and no hydronephrosis then no further eval)
What is nocturnal enuresis?
Urinary incontinence during sleep in kids >5
Tx for nocturnal enuresis
First line is education/motivational therapy (not their fault, void regularly, watch fluid intake, motivation)
Second line is meds >6 (DDAVP/desmopressin-synthetic ADH-short term but relapse rate high)
What is the most effective long term therapy for enuresis?
Enuresis alarms
What is hematuria?
Presence of RBCs in urine
Gross or microscopic
Classification of microscopic hematuria
> 3 RBCs per hpf
If asymptomatic then repeat UA dip and microscopy in 2-3 wks
Labs needed in gross hematuria
UA with microscopy/urine cx Serum creatinine Serum complement Maybe antistreptolysin Ab RBUS/CT without contrast
What is post-infectious glomerulonephritis?
Follows 7-14 days after group s b-hemolytic strep
Presentation of post infectious glomerulonephritis
Acute onset sxs: cola-colored urine, renal insufficiency, elevated BP, edema (peri-orbital or peripheral) Think Throat (sore throat), Bloat, Coke
Labs needed for post infectious glomerulonephritis
Gross hematuria (dark colored urine, urine microscope with RBC too numerous to count)
Increased creatinine
+ ASO (antistreptolysin Ab) titer
Low complement
What is diagnostic of GN on labs?
RBC casts (tubular epithelial cells ) on urine microscopy)
What is IgA vasculitis Henoch Schonlein Purpura (HSP)
Classic tetrad of abdominal pain, typical maculopapular purpuric rash, arthralgias, renal involvement- usually blood in urine)
What is HUS associated with?
Shiga toxin producing E coli mostly
Presentation of HUS
Prodromal illness with abd pain, vomiting, bloody diarrhea followed by a classic triad of hemolytic anemia, thrombocytopenia and acute kidney injury
What initial labs are used in HUS?
CBC, smear, renal function, UA
Tx for HUS
Supportive care- abx not recommended
What is Alport Syndrome (hereditary nephritis)?
Rare inherited, progressive glomerular disease caused by genetic mutation that affect collagen proteins in kidneys, eyes and ears
What does Alport Syndrome include?
Glomerular disease (microhematuria usually seen first)
Deafness (sensorineural hearing loss)
Visual disturbances
How does the urine look in proteinuria?
Foamy
Differential diagnoses of proteinuria
Benign/transient (fever, hypovolemia, exercise) SLE DM Glomerulonephritis Nephrotic syndrome
What is nephrotic syndrome?
Renal disease (intrinsic or post-infectious) causing massive renal protein loss in urine
4 main characteristics of nephrOtic syndrome
NephrOtic range prOteinuria
HypOalbuminemia
Edema usually face (round O shape)
Hyperlipidemia-DONUT (compensate protein loss by increasing synthesis of albumin)
