Urology Flashcards
What is the difference between primary and secondary enuresis?
Primary - the child has never been dry
Secondary - the child has previously been dry and is now not continent
When would be expect the child to become continent of urine?
3-5 years
What are some likely causes of enuresis?
Lack of attention to bladder stimulation - behavioural Detrusor instability Bladder neck weakness Neuropathic bladder (irregular, thick walls - associated with spina bifida), Distension at presentation, abnormal perineal sensation, anal tone and sensory loss UTI Diabetes Constipation Ectopic urethra causing dribbling
How should we investigate a child with enuresis?
Urine dip (UTI, nitrites, leucocytes, glucose, ketones)
Assess concentrating ability - osmolality on early morning sample
USS of the renal tract
What % of 5 and 10 year olds are not dry by night and who is it more common in?
6% 5yos and 3% 10yos not dry by night. This problem is twice as common in boys and esp those who have a first degree relative who struggled with enuresis (always ask)
What are some common causes of secondary enuresis?
Diabetes
Emotional upset (abuse, bereavement)
UTI
What are some organic causes of enuresis?
UTI
Constipatio + fecal impaction - can press on bladder and limit its capacity
How should enuresis be managed?
Counselling really important - tell parents there is no quick fix and might take time.
- ADVICE - plenty of fluids during day but then none 90mins before bed. Encourage to sit on loo just before bed (no caffeine, energy drinks)
- Start charts
- Enuresis alarm - explain how to use
- Desmopressin can be used for short term relief e.g. sleep overs or holidays
How does the occurrence of UTIs change over a child’s life and what problems might UTIs in childhood expose you to?
More common as the child gets older (any UTI in <6m should warrant investigation)
UTIs can spread to upper tract and cause pyelonephritis and scarring of the kidneys - this can expose to HTN and CKD later in life
Who should have their urine tested for infection? How is this done
ALL children with unexplained fever
Can be done with a dip but this can be hard - in young children you can attach a bag within their nappy to collect urine and then dip this
How would an infant with a urine infection present?
NON-SPECIFIC Fever Vomiting Lethargy or irritability Poor feeding/FTT Jaundice (UTI can cause jaundice in neonate) Septicaemia Offensive urine Febrile convulsions
How will older children present with a UTI?
More classical symptoms Dysuria Lower abdo pain Frequency Fever Lethargy, anorexia Haematuria Offensive, cloudy urine Enuresis
If nitrites and leucocytes are both positive on dip what does this suggest?
Confirms infection
If nitrites are positive and leucocytes are negative what does this suggest?
Could possibly be infection - send for microscopy
If the leucocytes are positive and the nitrites are negative on dip what does this suggest?
Infection still possible - urine might not have been in bladder for long enough to have nitrites (this is why early morning samples are best
Send for microscopy
What are the most common organisms causing UTI in childhood?
In nearly all it is the bowel flora (E.coli and klebsiella proteus)
In the newborn the most common method of spread is haematogenous
How should children <3m old be managed if they have a UTI?
Refer to paediatrics for urinalysis, abx, and KUBUSS within 6 weeks
How should a child older than 3m with UTI be managed?
3 day courses trimethoprim, nitrofurantoin or amoxicillin
7-10 day course if pyelonephritis
Encourage good fluid intake and safety net
When should we consider further structural investigations in a child with a UTI?
A child with 2 or more episodes of UUTI or pyelonephritis
3 or more episodes LUTI
1 UUTI and 1 LUTI
Why should you avoid tetracyclines in children?
Teeth discolouration
What common structural abnormality can cause UTI problems in children?
vesicoureteric reflux - ureters join bladder at different angle meaning they’re easier to have reflux of urine back into
What scans are possible of the urinary tract?
MCUG - micturating cystourethrohram (video while someone is seeing - look fo reflux)
OR
Dimercaptosuccinic acid (DSMA) - contract dye given to see if both kidneys taking up dye equally
What does a finding proteinuria mean in a child and how should it be investigated further?
It is not necessarily concerning - it can occur in a child with a febrile illness or one who is doing a lot of exercise.
Should investigate with an early morning sample and assessing the protein-creatinine ratio (this should not exceed 20)
What are some causes of proteinuria?
Orthostatic - stood up during the day (follow this up by measuring P-Cr ratio multiple times throughout day)
GLOMERULUS - glomerulonephritis, minimal change disease, abnormal basement membrane)
Increased glomerular filtration pressure
HTN
Renal mass
Tubular protein
NEPHROTIC SYNDROME
What are some features of nephrotic syndrome?
Proteinuria, hypoalbuminaemia and oedema
What causes nephrotic syndrome?
Cause is largely unknown
Seems to be associated with Henoch-Schonlein Puura and other vasculitis conditions such as SLE, malaria and allergens
How will nephrotic syndrome present?
Peri-orbital anaemia (particularly on waking due to gravity) Scrotal, vulval, leg or ankle oedema Ascites Breathlessness Abdominal distension
How do we manage nephrotic syndrome?
Vast majority (85-90%) will resolve with CORTICOSTEROIDS (60mg pred, reduced to 40mg after 4 weeks)
- urine will become protein free in 11 days median
If not responding consider renal biopsy to identify cause
What are some complications of nephrotic syndrome?
HYPOVOLAEMIA - because of the oedema the intra-cellular compartment can become depleted and children can feel dizzy and faint and have abdominal pain. High packed red cell volume. Treat with IV albumin
THROMBOSIS - children into hyper coagulable state due to raised haemtocrit, increased clotting factors and loss of antithrombin
INFECTION - increased risk
HYPERCHOLESTEROLAEMIA - levels of cholesterol seem to inversely correlate with albumin
How should nephrotic syndrome be managed long term?
Parents can test for relapses by dipping the urine at home
What is the most common cause of acute renal failure in children?
HUS
Microangiopathic haemolytic anaemia, thrombocytopenia and acute renal failure
When does HUS occur in children?
Following E.coli 0157 infection or less commonly by shigella
How does the gastro-enteritis lead to HUS?
Toxins from bacteria in gut enter intestinal mucosa and blood stream
They collect in kidney and encourage thrombogenesis - multiple microscopic clots form in small vessels of kidney damaging the tissue
Obstruction within vessels leads to kidney failure and mechanical heamolysis of RBCs
This microangiopathic changes can also occur in bran, pancreas and heart
1 in 20 chance after E.coli 0157
How will HUS present?
Detection of proteinuria following gastroenteritis with bloody diarrhoea
Will also be HTN
Anaemia
Low platelets
How do we treat HUS?
Transfusion might be necessary
treat HTN
Plasma exchange
***if there is a confirmed E.Coli 0157 infection need to inform public health
If a child has haematuria of dark or brown urine what should you be suspecting?
Bleeding source high up in tract - GLOMERULAR
E.g. glomerulonephritis, IgA nephropathy, Familial nephropathy (Alpert’s syndrome), thin basement membrane
- the damage to the glomerulus will often mean there is proteinuria as well
If the blood is bright red the source is probably lower down, what is the most likely cause?
UTI
ALSO: Stones, tumours, sickle cell, coagulopathy, Renal vein thrombosis and calciuria
What are some causes of acute nephritis?
Post-infectious (streptococcus) Vasculitis (HSP) SLE IgA nephropathy Good-pasture syndrome - basement membrane disease
How should haematuria be investigated ?
Microscopy
BLOODS: FBC, Plt, clotting, Sickle cell, U&E, LFT, CRP
Consider an USS of kidney and bladder
Consider biopsy if consistently abnormal or there are other abnormalities such as with renal function or compliment levels
What is hypospadia and which are most common?
when the urethral opening is in the wrong place after improper embryonic urethral tubulisation
Most common on the ventral aspect somewhere
Can be HOODED - skin of foreskin hasn’t fused properly
OR
CHORDEE - this is when there is ventral curvature of the penis most prominent during erection (only in severe hypospadia)
How do we treat hypospadias and when is this most appropriate?
Surgery usually done before 2 years of age
Aims are to produce normal urethral opening so boys can micturate in standing position, they can have a straight erection and a normal looking penis
What is the most common cause of glomerulonephritis in children?
Post-infectious (streptococcal infection most common but can be many causes)
What are some non-infectious causes of glomerulonephritis?
Membrano-proliferative glomerulonephritis
IgA nephropathy
SLE
Sub-Acute bacterial endocarditis
What are the features of glomerulonephritis?
Haematuria, ologuria, oedema, HTN (+/-proteinuria)
How should a child with suspected glomerulonephritis be investigated?
Urine dip + microscopy throat swab BLOODS: FBC, U&E, FLT, CRP, clotting, albumin, complement (expect low C3 and C4), Albumin, ASOT/DNAaseB, autoantibody screen RENA USS CXR
How should glomerulonephritis be managed?
Treat life-threatening symptoms (hyperkalaemia) HTN (use CCB NOT ACE-i) Acidosis Seizures Hypocalcaemia
THEN MONITOR FLUID BALANCE CAREFULLY
- take weights regularly have a salt restricted diet and consider furosemide
When should you consider referring the child to a nephrologist?
If they have life-threatening complications Evidence of systemic vasculitis (rash) Normal C3 Proteinuria persisting at 6 weeks \+ve ANA persisting low C3 at 3 months
