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
-look for cause (cant find-REFER)
When would be expect the child to become continent of urine?
3-5 years
What are some likely causes of enuresis?
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
How should we investigate a child with enuresis?
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
Define nocturnal enuresis.
How common is it?
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)
How should enuresis be managed?
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
- 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 - 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
How does the occurrence of UTIs change over a child’s life and what problems might UTIs in childhood expose you to?
- 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
Who should have their urine tested for infection?
How is this done?
- 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
How would an infant with a urine infection present?
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+)
How will older children present with a UTI?
Atypical UTI?
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
If nitrites and leucocytes are both positive on dip what does this suggest?
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/
If nitrites are positive and leucocytes are negative what does this suggest?
Both negative-UTI is unlikely
- do not start antibiotic treatment
- send for culture if risk of serious illness or pyelonephritis/previous UTI/
If the leucocytes are positive and the nitrites are negative on dip what does this suggest?
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
If the leucocytes are negative and the nitrites are positive on dip what does this suggest?
leuk -, nitrites positive
- Treat as UTI
- start antibiotics
- send for culture to confirm diagnosis and reassess
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 do we manage UTIs (<3 months vs >3 months)
<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
When should we consider further structural investigations in a child with a UTI?
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
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
- ive prophylatic antibiotics
What scans are possible of the urinary tract?
What ages get what scans?
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)
What does a finding proteinuria mean in a child and how should it be investigated further?
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)
What are some causes of proteinuria in children?
- 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
What are the features of nephrotic syndrome?
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)
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?
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)
How do we manage nephrotic syndrome?
- 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
What are some complications of nephrotic syndrome?
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
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 (heamolytic ureamic syndrome) TRIAD -acute renal failure -micro-angiopathic heamolytic anaemia -thrombocytopenia (low platelets)
When does HUS occur in children?
Toxins from contaminated food and water
-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
-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
How will HUS present?
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
Management of HUS?
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
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 the causes of Heamaturia? (split into glomerular and non glomerular)
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
How should haematuria be investigated ?
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
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 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)
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
- May also involve circumsision
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 (Bergers disease)
SLE
Good-pasture syndrome - basement membrane disease
Vasculitis (Henloch Shernline purpura)
Sub-Acute bacterial endocarditis
What are the features of glomerulonephritis?
Glomerulonephritis
- Haematuria (red cell casts)
- Ologuria (reduced urine output <300ml/day)
- Oedema (fluid overload, diuretics can help
- Mild HTN (+/-proteinuria)
How should a child with suspected glomerulonephritis be investigated?
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
How should glomerulonephritis be managed?
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
Whats the prognosis like for glomerulonephritis?
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
What is vulvovaginitis?
What is the management?
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
explain different management of enuresis for the following ages
a) <5 years
b) 5-7 years
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)
How do you use enuresis alarm?
○ 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
