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Peads > Urology > Flashcards

Urology Flashcards

1
Q

What is the difference between primary and secondary enuresis?

A

Primary - the child has never been dry
Secondary
- the child has previously been dry and is now not continent
-look for cause (cant find-REFER)

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2
Q

When would be expect the child to become continent of urine?

A

3-5 years

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3
Q

What are some likely causes of enuresis?

A

PRIMARY
Behaviour (lack of attention to full bladder)
Anatomy problems
-Ectopic urethra causing dribbling (child always damp)
-Detrusor instability
-Bladder neck weakness
-Neuropathic bladder (irregular, thick walls - associated with spina bifida),
○Distension at presentation
○Abnormal perineal sensation
○Reduced anal tone and sensory loss

SECONDARY

  • Behavioural (abuse, bereavement)
  • UTI
  • Diabetes
  • Constipation
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4
Q

How should we investigate a child with enuresis?

A

Rule out organic causes

  • URINE DIP and CULTURE (nitrites and leucocytes for infection. glucose for diabetes)
  • KUB USS (kidney, ureters, bladder) to look for structural abnormalities
  • Early morning sample-diabetes
  • Urodynamic studies
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5
Q

Define nocturnal enuresis.

How common is it?

A

NOCTURNAL ENEURESIS

  • Child >5 years
  • Involuntary bed wetting at least twice a week
  • Not due to congenital or acquired defects
  • 6% of 5 year olds and 3% 10 year olds
  • more common males
  • more common if family member also had (genetic component of sphincter control)
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6
Q

How should enuresis be managed?

A

Counselling really important - tell parents there is no quick fix and might take time.
1. BEHAVIOUR -star chart to reinforce behaviours
○ Encourage toilet before bed
○ Cut liquids after 6pm
○ Remove nappies or aids
○ Increase daytime liquid
○ Avoid caffeine and fizzy drinks
Star Chart to reinforce
-Sit down with child and make personalised star chart
-Make sure it is as seen as a REWARD not PUNISHMENT
-Decide together what the reward is and how many stars
-ACIC
ACHEIVABLE/CLEAR/IMMEDIATE/CONSISTANT

  1. ENURESIS ALARM (7+)
    ○ From 7 years above, however can use if younger and motivated (a guide)
    ○ Conditioning technique
    ○ Need frequent follow up
    ○ Few months before see progress (70% within 2 months)
    ○Don’t use in parents that are quite annoyed
  2. MEDICATIONS
    -Desmopressin can be used for short term relief e.g. sleep overs or holidays/sleepover
    -Other drugs, specialist only:
    ○ Imipramine can also be used (antidepressent)
    ○ Oxybutynin (anti cholinergic)

END PEICES

  • self help groups
  • school nurse
  • ERIC website
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7
Q

How does the occurrence of UTIs change over a child’s life and what problems might UTIs in childhood expose you to?

A
  • UTIs are more common as the child gets older (UTI in <6m should warrant investigation with USS within 6 weeks)
  • UTIs can spread to upper tract and cause pyelonephritis and scarring of the kidneys
  • This can expose to HTN and Chronic kidney Disease for the rest of their life
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8
Q

Who should have their urine tested for infection?

How is this done?

A
  • ALL children with unexplained fever get urine dipped and culture
  • Best is CLEAN CATCH SAMPLE after nappy removed
  • Alternatively a urine bag can be attached over genitilia and perineum after washing
  • Catheter if URGENT (take it out after)
  • Suprapubic aspiration might be done as last resort
  • Older children-mid stream sample
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9
Q

How would an infant with a urine infection present?

A 
NON-SPECIFIC signs of infection 
Fever 
Vomiting 
Lethargy or irritability 
Poor feeding/FTT
Jaundice (UTI can cause jaundice in neonate)
Septicaemia 
Offensive urine 
Febrile convulsions (6months+)
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10
Q

How will older children present with a UTI?

Atypical UTI?

A 
More classical symptoms 
Dysuria and frequency 
Lower abdo pain 
Frequency 
Fever (with or without rigours/convulsions)
Lethargy, anorexia 
Haematuria 
Offensive, cloudy urine 
Enuresis (secondary)

Atypical UTI

  • seriously ill
  • poor urine flow
  • failure to respond to AB within 48 hours
  • mass in abdo
  • raised creatinine
  • Non E coli organisms
  • Septeceamia
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11
Q

If nitrites and leucocytes are both positive on dip what does this suggest?

A

Both positive-Suggests infection

  • start antibiotic treatment
  • still send for culture if child is aged <3 years or risk of serious illness or pyelonephritis/previous UTI/
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12
Q

If nitrites are positive and leucocytes are negative what does this suggest?

A

Both negative-UTI is unlikely

  • do not start antibiotic treatment
  • send for culture if risk of serious illness or pyelonephritis/previous UTI/
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13
Q

If the leucocytes are positive and the nitrites are negative on dip what does this suggest?

A

Infection still possible

  • SEND FOR MICROSCOPY AND CULTURE
  • under 3 years old, start AB then reassess with results
  • 3 years+ start AB if good evidence of UTI (leucocytes can be raised with any infection)
  • urine might not have been in bladder for long enough to have nitrites (this is why early morning samples are best
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14
Q

If the leucocytes are negative and the nitrites are positive on dip what does this suggest?

A

leuk -, nitrites positive

  • Treat as UTI
  • start antibiotics
  • send for culture to confirm diagnosis and reassess
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15
Q

What are the most common organisms causing UTI in childhood?

A
  • In nearly all it is the bowel flora (E.coli and klebsiella proteus)
  • In the newborn the most common method of spread is haematogenous
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16
Q

How do we manage UTIs (<3 months vs >3 months)

A

<3 months

  • send urine sample microscopy and culture
  • URGENT PEADS REFERRAL for IV antibiotics

> 3 months
LOWER UTI
-3 DAY COURSE trimethoprim or nitrofurantoin (1st line) then reassess after culture results

UPPER UTI (pyelonephritis)

  • 7 to 10 DAY COURSE of Cefalexin, or co-amoxiclav
  • if already on prophylaxis, give a different AB

If younger than 6 months, refer to leads for USS (kidneys, bladder, ureters) within 6 weeks

ADVICE (hydration, constipation, regular toilet breaks-don’t rush), SAFETY NET, FOLLOW UP

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17
Q

When should we consider further structural investigations in a child with a UTI?

A

Structural investigations

  • If younger than 6 months, within 6 weeks
  • 2 or more episodes of UUTI or pyelonephritis
  • 3 or more episodes LUTI
  • 1 UUTI and 1 LUTI
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18
Q

Why should you avoid tetracyclines in children?

A

Teeth discolouration

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19
Q

What common structural abnormality can cause UTI problems in children?

A
  • vesicoureteric reflux - ureters join bladder at different angle meaning they’re easier to have reflux of urine back into
  • ive prophylatic antibiotics
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20
Q

What scans are possible of the urinary tract?

What ages get what scans?

A

MCUG - micturating cystourethrohram (seeing whilst your weeing - look fo reflux)
OR
Dimercaptosuccinic acid (DSMA) - contract dye given to see if both kidneys taking up dye equally

<6 months. Typical=USS. Atypical= USS MCUG and DSMA
6m-3years. Typical=none. Atypical=USS and DSMA
3 years+ Typical=none. Atypical=USS (DSMA if recurrent)

21
Q

What does a finding proteinuria mean in a child and how should it be investigated further?

A

It is not necessarily concerning

  • proteinuria 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)
22
Q

What are some causes of proteinuria in children?

A
  • Orthostatic is a common cause-when they are stood up during the day (follow this up by measuring P-Cr ratio multiple times throughout day). Prognosis is good
  • GLOMERULUS PROBLEMS (glomerulonephritis, minimal change disease, abnormal basement membrane)
  • Increased glomerular filtration pressure
  • HTN
  • Renal mass
  • Tubular protein
  • NEPHROTIC SYNDROME
23
Q

What are the features of nephrotic syndrome?

A

NAPHROTIC SYNDROME
Na+ decreased
ALBUMIN DECREASED <30g/L
PROTEINURIA(>3.5g/day)
Hyperlipideama (liver compensating for protein loss)
Renal vein thrombosis
Orbital ODEMA (lack of albumin in blood-leak out of fluid)
Thromboembolism
Infection (immunoglobins excreted)
Coagulability (due to loss of antithrombin in urine)

(looks like anaphylaxis, but will be passing lots of FROTHY urine)

24
Q

What causes nephrotic syndrome?

A
  • Cause is largely unknown

- Seems to be associated with Henoch-Schonlein Puura and other vasculitis conditions such as SLE, malaria and allergens

25
Q

How will nephrotic syndrome present?

A

Nephrotic sydrome presents with global oedema:

  • Peri-orbital oedema (particularly on waking due to gravity)
  • Scrotal, vulval, leg or ankle oedema
  • Ascites
  • Breathlessness (pulmonary oedema)
26
Q

How do we manage nephrotic syndrome?

A
  • Vast majority (85-90%) will resolve with HIGH DOSE PREDNISILONE then reduced (corticosteroid).
  • urine will become protein free in 11 days median
  • If not responding consider renal biopsy to identify cause
  • weigh regularly to monitor fluids
27
Q

What are some complications of nephrotic syndrome?

A

HYPOVOLAEMIA
○ Because of the high degree of oedema the intravascular compartment can become depleted
○Dizzyness/ fainting/abdo pain
○ High packed cell volume and low urine Na are signs of this
○GIVE IV ALBUMIN

THROMBOSIS - children into hyper coagulable state due to raised haemtocrit, increased clotting factors and loss of antithrombin

INFECTION - immunoglobulins out in urine
○pneumococcal and influenza vaccination
○chicken pox and shingles treated with acyclovir

HYPERCHOLESTEROLAEMIA -liver compensates for reduction in protein

28
Q

How should nephrotic syndrome be managed long term?

A

Parents can test for relapses by dipping the urine at home

29
Q

What is the most common cause of acute renal failure in children?

A 
HUS (heamolytic ureamic syndrome) 
TRIAD 
-acute renal failure 
-micro-angiopathic heamolytic anaemia 
-thrombocytopenia (low platelets)
30
Q

When does HUS occur in children?

A

Toxins from contaminated food and water

-E.coli 0157 infection or less commonly by shigella

31
Q

How does the gastro-enteritis lead to HUS?

A

-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
-Clots obstruct the flow of blood to kidney
○Mechanically churn up RBSc forming schistocytes (haemolytic anaemia)
-These microangiopathic changes can also occur in brain, pancreas and heart

32
Q

How will HUS present?

A

HUS

  • Detection of proteinuria following gastroenteritis with bloody diarrhoea
  • Anaemia
  • Low platelets
  • Will also have HTN (kidney cells detect low blood flow)
  • Abdo pain, siezures, fever, lethargy
33
Q

Management of HUS?

A

Management of HUS

  • Supportive
  • Early therapy is very important
  • Dialysis can form part of the treatment regime
  • Blood transfusions and plasma exchange
  • Treat high blood pressure

INFORM PUBLIC HEALTH IF CAUSED BY E.Coli 0157

34
Q

If a child has haematuria of dark or brown urine what should you be suspecting?

A

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
35
Q

If the blood is bright red the source is probably lower down, what is the most likely cause?

A

UTI

ALSO: Stones, tumours, sickle cell, coagulopathy, Renal vein thrombosis and calciuria

36
Q

What are the causes of Heamaturia? (split into glomerular and non glomerular)

A

GLOMERULAR causes of heamaturia
○ Acute glomerulonephritis (there is proteinuria)
○ Chronic glomerulonephritis (there is proteinuria)
○ IgA nephropathy
○ Familial nephritis e.g. Alport syndrome
○ Thin basement membrane disease

NON GLOMERULAR causes of heamaturia 
	○ Infection (bacterial, viral, TB, schistosomiasis)
	○ Trauma 
	○ Stones or hypercalciuria 
	○ Tumours 
	○ Sickle cell 
	○ Bleeding disorders 
	○ Renal vein thrombosis
37
Q

How should haematuria be investigated ?

A 
Heamaturia 
URINE DIPSTICK 
-If positive send for microscopy 
BLOODS: 
-FBC
-UsEs, Albumin, 
-CRP 
-Clotting 
-Sickle cell

IMAGING
-USS of kidneys and bladder

BIOPSY 
-consider if: 
○ If there is macroscopic haematuria 
○ Renal function is abnormal 
○ Complement levels are persistently abnormal
38
Q

What is hypospadia and which are most common?

A

-when the urethral opening is in the wrong place after improper embryonic urethral tubulisation

-Most common on the ventral aspect somewhere
Can be DOARSALY HOODED - skin of foreskin hasn’t fused properly on the ventral side
OR
CHORDEE - this is when there is ventral curvature of the penis. Most prominent during erection (only in severe hypospadia)

39
Q

How do we treat hypospadias and when is this most appropriate?

A
  • 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
  • May also involve circumsision
40
Q

What is the most common cause of glomerulonephritis in children?

A

Post-infectious (streptococcal infection most common but can be many causes)

41
Q

What are some non-infectious causes of glomerulonephritis?

A

Membrano-proliferative glomerulonephritis
IgA nephropathy (Bergers disease)
SLE
Good-pasture syndrome - basement membrane disease
Vasculitis (Henloch Shernline purpura)
Sub-Acute bacterial endocarditis

42
Q

What are the features of glomerulonephritis?

A

Glomerulonephritis

  • Haematuria (red cell casts)
  • Ologuria (reduced urine output <300ml/day)
  • Oedema (fluid overload, diuretics can help
  • Mild HTN (+/-proteinuria)
43
Q

How should a child with suspected glomerulonephritis be investigated?

A

GLOMERULONEPHRITIS

-Urine dip + microscopy
-throat swab (look for strep throat)
BLOODS: FBC, U+Es, albumin, CRP, immunoglobulins/antibodies

IMAGING

  • urgent renal USS
  • CXR if fluid overload suspected
44
Q

How should glomerulonephritis be managed?

A

Treat life-threatening symptoms first

  • Hyperkalceamia
  • 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

45
Q

Whats the prognosis like for glomerulonephritis?

A

Glomerulonephritis

  • 95% with post-streptococcal GN make a full recovery
  • Microscopic haematuria may persist for 1-2y
  • They can be discharged once there creatinine, bicarbonate and BP are all normal
  • If systemic vasculitis or +ve ANA then refer to nephrology
46
Q

What is vulvovaginitis?

What is the management?

A

Vulvovaginitis is the inflammation/irritation of vulva/vagina

Management
EDUCTAION
- bath everyday in plain water (avoid soaps)
-wear loose fitting cotton underwear
-pat dry
-dont scrub area
-SWABS- to identify an infective cause (inc. threadworm)

FOLLOW UP
-come back in 2 weeks if not worked (if copious and purulent discharge- might need exploration under GA to rule out foreign body)

  • bare in mind SEXUAL ABUSE
  • oestrogen creams can be used in labial adhesions
47
Q

explain different management of enuresis for the following ages

a) <5 years
b) 5-7 years

A

NOCTERNAL ENURESIS
<5 years
-reassure
-check organic cause (e.g. UTI/diabetes)

5-7

  • if less than twice a week- just reassure them
  • behaviour and star chart
  • alarm if motivated
  • drugs for short term (desmopressin)
48
Q

How do you use enuresis alarm?

A

○ Clip the sensor onto their pants and pull PJs over the top.
○ The alarm goes off if the child wets themselves - hopefully they’re shocked enough to stop themselves weeing, get up, go to the toilet and have a wee.
○ These can take weeks to months to start working
○ Trains their mind

Peads (29 decks)

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