Flashcards in Paeds 2 - GU/Neuro/Endocrine/Haem etc Deck (309)
what are 5 clinical features a urinary tract anomaly might present with?
recurrent abdo pain
failure to thrive
how are urinary tract anomalies usually diagnosed?
antenatal USS - good as allows early treatment to avoid progressive renal damage
list some of the key urinary tract anomalies
- renal agenesis
- kidney dysplasia (MCDK)
- PKD (polycystic kidney disease - both autosomal recessive and dominant)
- tuberous sclerosis
- pelvic/horseshoe kidney
- duplex kidney
- bladder extrophy
- absent musculature syndrome
- obstructions - e.g. congenital hydronephrosis
what is renal agenesis and what does it result in?
absence of both kidneys --> Potter syndrome, in which oligohydramnios (due to lack of foetal urine) is associated with lung hypoplasia and postural deformities)
what is MCDK?
multicystic dysplastic kidney - failure of the union of the ureteric bud with the nephrogenic mesenchyme - kidney is non-functioning, with large fluid filled cysts, no renal tissue and no connection to bladder.
Potters syndrome if bilateral.
if unilateral - they're fine, got a spare!
what are the main cystic kidney anomalies and how do they affect a patient?
autosomal recessive and autosomal dominant polycystic kidney disease
some/normal kidney function maintained (but always affects both kidneys).
hypertension and haematuria in kids, renal failure in adults.
what is pelvic/horseshoe kidney?
abnormal caudal migration, so lower poles of each kidney are fused in midline.
abnormal position means increased risk of infection/obstruction.
what is a duplex system (urinary tract anomaly)?
premature division of ureteric bud - varies in the extent, might have a bifid renal pelvis, might have complete division with two separate ureters (from one kidney).
lower pole ureter often refluxes, upper pole ureter often ectopic (draining into urethra or vagina).
where are the main sites for obstructive lesions of the urinary tract (in babies)?
pelviureteric (PU) junction
vesicoureteric (VU) junction
if an obstructive lesion of the urinary tract isn't picked up antenatally, how might it present?
palpable bladder or kidney
what causes congenital hydronephrosis?
a pelviureteric obstruction - by a narrow lumen or compression by fibrous band or blood vessel, can vary from partial --> almost complete obstruction
mild obstruction can resolve spontaneously but if severe need surgery with conservation of renal tissue where possible
what causes vesicoureteric obstruction?
stenosis, kinking or dilatation of lower part of ureter.
may be unilateral or bilateral.
there's a combo of hydroureter and hydronephrosis.
what is primary vesicoureteric reflux and what causes it?
reflux of urine from bladder into ureter (or if severe, all the way back to kidneys).
due to developmental anomaly of vesicoureteric junction where ureters enter directly into bladder instead of at an angle, and the bit of ureter in bladder is abnormally short.
during voiding, urine goes back up the ureter - risk of infection, hits kidneys with bacteria and high pressure.
what are the clinical features of vesicoureteric reflux?
associated w/ other GU anomalies, may be secondary to bladder pathology.
- get lots of UTIs
- when they get UTI, it's severe ± pyelonephritis
- reflux nephropathy = destruction of renal tissue because of infection and back pressure - can get hypertension and renal failure
how is vesicoureteric reflux diagnosed?
MCUG - micturating cystourethrogram
how is vesicoureteric reflux managed?
if mild - resolves spontaneously, but prophylactic trimethoprim until child is infection-free, normal bladder control and >5 years.
if severe or prophylaxis fails = surgery.
what is phimosis and how is it treated?
adhesion of foreskin to glans penis after age 3 years.
mild = daily stretching routine (retraction)
some say topical corticosteroids may help.
circumcision if not.
what is a hypospadia and how is it treated?
abnormal position of external urethral meatus on the ventral penis - causes difficulty urinating while standing / cosmetic.
surgery, use foreskin for repair preschool.
what pathogens typically cause UTIs in children?
mostly E. coli (from bowel flora).
also - Proteus, Klebsiella, Pseudomona and Enterococcus
what is the most common predisposing factor to UTI in children?
urinary stasis (lack of flow) due to:
- vesicoureteric reflux
- obstructive uropathy (ureterocele, urethral valves)
- neuropathic bladder (spina bifida)
- habitual infrequent voiding
up to 50% of kids with UTI will have underlying structural anomaly!
how does UTI present in neonates/very young infants?
might see jaundice.
septicaemia develops quickly - leading to shock and hypotension.
how does UTI present in infants?
fever (but can have without), diarrhoea, vomiting, lethargy/irritability, failure to thrive/poor feeding, jaundice, sepsis etc
may see febrile convulsions if over 6 months old.
how does UTI present in a young child (1-5yrs)?
dysuria and frequency, nocturnal enuresis, fever, malaise, abdo pain. may see febrile convulsions.
DDx - balanitis / vulvovaginitis
how does UTI present in a child (>5yrs)?
classic cystitis features - frequency, dysuria, fever, enuresis
or pyelonephritis features - fever and loin pain. if <6y may see febrile convulsions.
NB - asymptomatic bacteruria common in school-age girls, don't bother treating.
how should urine samples be collected from kids?
need a CLEAN CATCH - can use catheter/suprapubic aspiration if seriously ill.
bag sometimes used - not useful really as usually contaminated.
MSU can be used for older kids.
for young kids/infants basically parents have to sit around with nappy off and try and catch in a cup!
how should you investigate a child with suspected UTI?
send off urine sample for MC+S
controversial to follow up investigate for cause of UTI - moving towards only kids with recurrent/atypical UTI - for them do:
renal and urinary tract USS
MCUG (micturating cystourethrogram) - for vesicoureteric reflux
DMSA (static radioisotope scan) - looks for renal scarring
how would you manage a child under three months with a UTI?
needs hospital admission and IV abx e.g. ampicillin plus gentomycin/cefuroxime
how would you manage a child systemically unwell with a UTI, with signs of pyelonephritis and high fever (38+)?
IV abx e.g. ampicillin plus gentomycin/cefuroxime for 7-10 days
(might be able to give orally/switch to oral)
how would you manage a child with a UTI, no signs of pyelonephritis, not seriously unwell?
oral abx for 3 days - trimethoprim can be used