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Management of Common Pediatric Probs > Pedi GU Conditions > Flashcards

Pedi GU Conditions Flashcards

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1
Q

What is Hypospadius?

A

Urethral opening on ventral surface of penile shaft, foreskin absent ventrally
1/250 newborn males

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2
Q

Complications of Untreated Hypospadius

A
  • Deformity of urinary stream: Ventral deflection or severe splaying
  • Sexual dysfunction due to penile curvature
  • Infertility if meatus is proximal
  • Meatal stenosis (very rare)
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3
Q

Management of hypospadius

A
  • Avoid circumcision -foreskin used for repair
  • Refer to pediatric urologist
  • Educate parents
  • Out-patient surgery ~12 mos

Comfort parents – “not a big deal”

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4
Q

Undescended Testes UDT (Cryptorchidism): when do majority descend and why?

A
  • Majority descend in three months
    • Interaction of hormones and mechanical factors
    • Usually palpable in inguinal canal
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5
Q

UDT: what to do if testes not palpable?

A
  • maybe intra-abdominal, perineum
    • Refer to GU
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6
Q

Consequences of UDT

A
  • Infertility
  • Malignancy: hotter in abdominal area
  • Associated hernias
  • Torsion of undescended testis
  • Possible psychological effects of empty scrotum
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7
Q

DDx for UDT

A
  • Retractile testis– physiologic variation of normal
    • Overactive cremasteric reflex –sends up. E.g., d/t cold
    • Incomplete attachment of testis to scrotum
    • Later diagnosis
  • Inguinal hernia

should be evaluated if retractile and approaching puberty (may get stuck)

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8
Q

PE for UDT

including what to do if can’t find them

A
  • Warm room, warm hands
  • Supine position – better than in parents’ lap
  • Inspect scrotum – e.g., femoral pulses – you may see them though they are retracted later in exam
  • Sweep hand down – occlude inguinal ring
  • Other options:
    • squatting
    • cross-legged
    • standing
    • parents attempt in bath tub and follow-up
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9
Q

Mgmt of UDT

A
  • Spontaneous resolution with age
    • reflex less active
    • testis larger
  • Surgical (orchidopexy) 98% success, OP
    • Move to normal position
    • After 12 mos
  • If nonpalable testis, diagnostic laparoscopy (gu referral):
    • Maybe bring down,
    • Maybe remove if atrophic or abnormal
    • May be completely absent
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10
Q

What is a Hydrocele?

A

Collection of peritoneal fluid in scrotum from different mechanisms

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11
Q

What is a communicating hydrocele?

A
  • Process vaginalis NOT obliterated (should close during fetal dvpt)
  • Little opening – fluid can squeak down through. Be on lookout for hernia as well as time goes on
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12
Q

Communicating hydrocele: Sx, PE, Px

A
  • May increase or decrease during day ask parents
  • Cystic scrotal mass with transillumination
  • Sometimes need Doppler to be sure
  • If congenital, resolve by 1 yr., if not surgery
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13
Q

Noncommunicating hydrocele: what is it?

A
  • No connection to peritoneum
  • Fluid from lining of tunica vaginitis
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14
Q

Noncommunicating hydrocele: presentation and cause

A
  • Does not change – important difference
  • Maybe idiopathic or secondary to other causes
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15
Q

mgmt of hydrocele

A
  • Explain condition to parents
  • Alert to higher risk for hernia
  • If large and tense, needs referral
    • too hard to verify no hernia
    • large hydroceles don’t resolve spontaneously
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16
Q

Inguinal hermia: who gets them and where?

A
  • 10-20/1000 live births; 50% < 12 mos
  • Boys: girls - 4:1
  • 60% on right side
  • 30% on left side
  • 10% bilateral
  • Premature infants -30% higher incidence

Very common in premies – watch for it!

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17
Q

What is an inguinal hernia?

A
  • Persistent patency of process vaginalis → Protrusion of peritoneum into the inguinal canal
  • Usually pv fuse and obliterate entrance to inguinal canal
    • If not, then inguinal anomalies
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18
Q

inguinal hernia - no mass

what is the hx and urgency?

A

history of intermittent bulge (fairly nonurgent)

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19
Q

inguinal hernia - reducible mass

what is the hx and urgency?

A

usually no symptoms, maybe irritability, decreased po, not tender

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20
Q

inguinal hernia - nonreducible mass

what is the hx and urgency?

A

incarceration. Irritable, crying, vomiting, distention, tenderness – abdominal contents stuck in scrotum

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21
Q

inguinal hernia - strangulation

what is the hx and urgency?

A
  • vascular compromise of contents of hernia from edema and vascular obstruction maybe 2 hrs…!! Medical emergency!
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22
Q

MGMT of inguinal hernia

A
  • IF intermittent mass – you’re comfortable it’s only intermittent
    • Refer for repair electively after diagnosis (few weeks)
  • IF
    • Not easily reducible
    • Painful, firm mass
    • Refer immediately for repair
  • Exploration of contralateral side due to high incidence of bilateral hernias-controversial
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23
Q

Hydrocele vs Hernia - how to tell

A
  • May be difficult to distinguish
  • Complete hernia and hydrocele may both transilluminate
  • “Silk sign” -If spermatic cord feels like silk, hernia likely – Difficult in infants; not good evidence for effectiveness
  • mass in inguinal canal – make sure it’s not testicle. If it’s not, you could refer. If intermittent, easily reducible, not an emergency. If constant/irreducible – get it checked!*
  • Incarceration: urologist asap; strangulation: ER*
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24
Q

What is Phimosis?

A
  • Unretractable foreskin in uncircumcised boys
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25
Phimosis: Px
* Normal at birth * Adhesions generally lyse *– age range controversial. Used to say by age of 5 but now much wider*
26
Phimosis: mgmt
_( no E-B guidelines)_ * Gentle cleaning * Very gentle retraction * If persistent (wide age range) Betamethasone .05% cream qd (bid) x 4 (8) weeks - *thins the skin*
27
What is a preputial cyst?
benign – just some smegma under skin
28
Paraphimosis: presentation
* Foreskin retracted beyond corona * Inability to reduce foreskin * Edema * Painful venous stasis ## Footnote *Sometimes if reduntant foreskin. Uncomfortable*
29
Paraphimosis: tx
* Lubricate foreskin and glans * Compress glans and try to push phimotic ring beyond coronal ridge * Sometimes requires emergency surgery
30
Balanitis: definition and cause
Inflammation of glans/foreskin * poor local hygiene irritates area → infection with local skin flora * can be d/t overvigorous care – e.g., over cleaning phimosis*
31
Balanitis: presentation
* inflammation, edema, swelling, localized pain, dysuria, narrowed stream, local cellulitis ## Footnote *can present similarly to paraphimosis. St they come together.*
32
Balanitis: mgmt and complications
* Mgmt: * po antibiotics for gram neg * hygiene * Complications * paraphimosis
33
What is a varicocele and who gets them?
* Painless scrotal mass, usually left side * Very uncommon \<10 yrs. * Consider malignancy or congenital abnormality \<10
34
Varicocele: Hx
* Heavy feeling or dull ache, if large * Can occur with strenuous activity * Maybe pain when standing, resolves reclining
35
Varicocele: PE
* Standing: “Bag of worms” posterior and superior to affected testes. * Collapses while lying; Increases with Valsalva *whether or not disappears, still there*
36
Varicocele: grading
(Dubin, 1970). 1 palpable only during a Valsalva 2 palpable without a Valsalva maneuver. 3 visually detectable.
37
Varicocele: Dx
• Inspection * Palpation or * Color Doppler US * No definite evidence re US as most effective, often done
38
Varicocele: mgmt
* ? Ultrasound for diagnosis * Serial ultrasonography q 6-12 months * Assure equal testicular growth * Refer to surgeon: * If painful * If \>2mm difference if testicular volume * If right sided or bilateral * If testicular growth rate slows * Surgical repair to protect fertility
39
Epididymitis: presentation
* Acute scrotal pain/swelling * Rare before puberty * UA will have pyuria
40
Epididymitis: cause and Rx
* Can be infectious etiology - GC, chlamydia * Rest and antibiotics (Bactrim, Augmentin, doxy) * Usually referred for US evaluation
41
Epididymitis: DDx
Differential - testicular torsion
42
What is the most common cause of testicular pain \> 12 years old?
testicular torsion Uncommon \< 10 yrs.
43
What casuses testicular torsion?
* Inadequate fixation of testis—› excessive mobility = Bell clapper deformity * Often bilateral attachment disorder
44
What happens in testicular torsion?
* Lymphatic drainage and venous outflow occluded → * Arterial blood supply interrupted → ischemic necrosis * Absent blood flow for ~6 hours → lost spermatogenesis
45
Hx in testicular torsion
* Acute pain in 80% * 20% recall minor trauma * 33% history of transient pain (maybe intermittent torsion)
46
Presentation testicular torsion
* Ill, anxious, quiet * Sometimes N/V * Vague abdominal pain * Swelling of scrotum, then erythema & warmth * Testes enlarged, elevated and in “transverse lie” * Exquisite pain in scrotum * Spermatic cord above testis thickened, tender * Cremasteric reflex is absent *– d/t transverse lie* * No inguinal swelling
47
mgmt testicular torsion
**_ER_** * If less than 4-6 hours of symptoms, may try to manually detort the testis by rotating testis inward. * Success = pain relief * \*\*\*Surgical exploration and detortion * Both testes fixed in scrotum - risk of bilateral occurrence
48
Labial Adhesions: what, who, why?
* Labia minora: central line of adherence from area inferior to clitoris to forchette * Often \< 6yrs, usually asymptomatic (~1.5% infant girls) * Etiology: * local inflammation * hypoestrogenic condition of pre-adolescence
49
What happens in extreme cases of labial adhesions?
* Extreme cases → urinary retention and/or infection * 20-40% recurrent UTI if complete labial adhesions
50
Tx for labial adhesions
* Tincture of time * Resolve with hormones of adolescence * Change to acidic urine * GENTLE cleansing and use of Vaseline * ?? Topical estrogen cream qhs x 1 -3 weeks * Surgery RARE
51
Hydronephrosis: what is it / what causes it?
* Dilatation of one or both kidneys caused by obstruction of: * uteropelvic junction * posterior urethral valves * ectopic ureterocele * Ureter ## Footnote *general term*
52
Hydronephrosis: mgmt
* Refer to specialist for imaging and diagnosis * Renal US * Voiding cystourethrogram (VCUG) * Radioisotope studies * CT * May continue to follow child in primary care setting
53
Prevalence of UTIs in infants w/just fever and in older verbal kids?
7%
54
UTIs in newborns vs older kids: who and why?
* More common in boys in first year, especially 0-3 mos * Anatomic abnormalities * Uncircumcised * More common in older girls *- shorter urethra*
55
Etiologies of Pyelonephritis
* Placement of ureters → regurgitation of bladder urine back to ureter → kidney * Mechanical obstruction to drainage of urine (like hydronephrosis) → bacterial access and replication * Toxin produced by bacteria prevents normal peristaltic action of ureter →bladder bacteria ascends the ureter to kidney
56
Cystitis vs pyelonephritis
Pyelo in upper urinary tract + fever + may lead to renal scarring Cystitis in lower UT, not always fever, no renal scarring
57
Urethritis: definition and causes
* Inflammation or infection of the urethra * May be symptomatic or asymptomatic * Some causative agents: * N. gonorrhea, Chlamydia trachomatis * Trichomonas vaginitis, herpes simplex
58
Infants and toddlers w/UTIs: presentation
*very general presentation, keep in DDx* * Fever * Poor growth/feeding * GI symptoms: V/D/pain * Foul smelling urine *– not helpful* * Dribbling * Sepsis (infant) * Hematuria, dysuria *–dysuria hard to determine*
59
Risk Factors for 2-24 mos GIRLS for UTI
* Caucasian * \< 12 mos * Temperature ≥ 39’ ( 102.2) * Temp at least 48 hrs... * No other infection source
60
Risk Factors for 2-24 mos BOYS for UTI
* Circumcision status\*\*\* * Non-black * Temp ≥ 39 (102.2) * Temp for at least 24 hrs... *less time than for girls* * No other infection source
61
Hx: Older Child and Adolescent UTI
* Dysuria, frequency, urgency, enuresis * Acute GI symptoms * Constipation\*\*\* *huge contributor in older kids* * Voiding pattern * Changes in urine -odor, stream, volume * Hygiene * Irritants * Diaper rash * Medications * Sexual activity * Trauma * Sexual abuse * PMH of UTI ## Footnote *Bubble baths – come and go in the evidence*
62
Infant has fever of no visible source - what should you do and why?
* UTI evaluation * Risk of UTI is 7% * higher risk of acute renal injury (higher rate of reflux) * Delay in treatment → kidney damage * If other findings risk decreases UTI risk by 50% *- but does not eliminate*
63
Methods of urine collection for kids
* Adhesive bag over penis/scrotum or perineum * Transurethral Catheterization * Suprapubic Aspiration * Mid stream, clean catch specimen
64
Adhesive bag over penis/scrotum or perineum for urine collection: disadvantages
* Not recommended if considering Ab * Specimen evaluated right after voiding * Negative findings helpful * Positive findings: * Contamination of surrounding skin * Suggestive of UTI * Need to be repeated with catheterized or SPA specimen
65
Transurethral Catheterization for urine collection: how and why?
* *parents hold on lap, legs held up by mom – clearer view* * Sterile, small gauge, straight catheter or small French feeding tube (5 or 8) * Minimal discomfort, minimal risk of contamination if good sterile technique
66
Suprapubic Aspiration for urine collection: why or why not?
* Safe, uncomfortable, seldom done * Phimosis * Complete labial adhesion
67
mid stream clean catch for urine collection: why or why not?
Continent males and females
68
UA: reliable for diagnosis of UTI?
No. May be - and UC may be +
69
UA: what do you consider for dx UTI?
* Physical: Color, clarity, odor * Chemical (on dipstick): Blood, \*leukocytes, \*nitrites * Microscopic: RBC, \>5 WBC, \*bacteria, crystals, casts
70
Next step if UA very suggestive of UTI?
treat pending culture; culture definitive
71
How long can a bagged specimen be kept for UA?
Can be done on bagged specimen if: \< 1 hour @ room temp \< 4 hours refrigerated
72
Nitrites: purpose on UA and when are they (un)helpful?
* Converted from dietary nitrates if Gram – bacteria in urine, takes 4 hrs... * Not sensitive marker in children, esp not infants * Not all urinary pathogens convert dietary to nitrites * But… helpful if positive
73
Leukocyte Esterase: advantages and disadvantages on UA
* OK sensitivity and specificity * Interpret with caution - some false + * Strep infections, Kawasaki, exercise * BUT… unlikely for children with UTI not to have pyuria!
74
What is the gold standard for dx of UTI?
UC Check promptly or refrigerate--- bacteria multiply rapidly at room temp.
75
Current culture guidelines for dx UTI
* Significant bacteriuria * Pyuria (evidence of inflammatory response) * positive leukocyte esterase on dipstick analysis, * ≥5 WBC/hpf with standardized microscopy
76
Criteria for Dx of UTI through suprapubic specimen
* Growth of any organism * Catheter specimen * \>10,000- _50,000_ of a single organism
77
Criteria for Dx of UTI through clean catch
* \>100,000 of a single organism * Low colony count of multiple organisms suggests contamination * History and symptoms and 50-100,000à sometimes treatment
78
Common pathogens in girls: UTI
* E.coli * Klebsiella and proteus * Staphlococcus aureus ( much less common)
79
Common pathogens in boys: UTI
``` After 12 months Klebsiella = E.coli Staphlococcus aureus (much less common) ```
80
Goals of UTI Tx
* Eliminate acute infection * Prevent complications * Reduce likelihood of renal complications
81
Management of UTI in Infants and Young Children: If toxic, dehydrated or \< 2 mos and unable to do po
-\>admit for IV antibiotics If improved in 24-48 hrs..., change to po for 7-14 days
82
Management of UTI in Infants and Young Children: If acutely ill, not toxic
start broad spectrum po wait for sensitivities, need good follow up ability
83
Choice of antibiotic for UTI
* Based on sensitivities * Amoxicillin-lots of resistance (50% to E.coli) * Trimethoprim-sulfamethoxazole (increasing resistance in some communities) * First line -Third generation cephalosporin, [cefixime](http://www.uptodate.com/contents/cefixime-pediatric-drug-information?source=see_link) [cefdinir](http://www.uptodate.com/contents/cefdinir-pediatric-drug-information?source=see_link), [ceftibuten](http://www.uptodate.com/contents/ceftibuten-pediatric-drug-information?source=see_link)) if po
84
Management of UTI in Older Children and Adolescents
* Lower tract disease more common * Antibiotics * Some recommendations for shorter course \< 7 days * Amoxicillin– problems with resistance * Bactrim – some issues with resistance * Cefdinir – good choice * Cipro –not recommended for children
85
F/U imaging in febrile infants after their 1st UTI? Advantages and limitations?
RBUS * Structural not functional information * Renal size – follow growth * Bladder wall thickening * Safe, non-invasive, inexpensive * Limitations * Normal RUS does not exclude VUR *(major reasons for repeat UTIs)* * Not as sensitive as other imaging techniques
86
When to get UTI Follow Up Imaging: Older Children
* Children with any of the following: * Abnormal voiding pattern * Poor physical development * ↑ blood pressure * Evidence of pyelonephritis (fever, flank pain) * Failure to respond to antibiotics
87
What is VCUG and what are the issues with it?
* Contrast media injected into bladder * Mechanics of urination * Stream, urethra, bladder, contractions * Exclude anatomic abnormalities (ie urethral valves * Functional abnormalities * Reflux * Issues * Radiation, discomfort, expense, predictive value, low
88
When to get VCUG
* After second febrile UTI ( 2-24 mos)….Unless: * RBUS showed hydronephrosis, scarring, obstructive uropathy etc suggestive of possible VUR * prophylaxis for UTI may not be necessary and pyelo may not have relationship w/VUR
89
DMSA Renography: advantages and disadvantages
* Gold standard * Renal involvement in acute UTI’s * Assessment of renal scarring * Injection of Tc DMSA 6 weeks after UTI * Negatives * Invasive * Several hours * High radiation to gonads * Unable to differentiate previous scarring from acute defects
90
\>50% of children with UTI\< 1 yr. old have what?
Vesicoureteral Reflux (VUR)
91
What is Vesicoureteral Reflux (VUR)?
* Regurgitation of urine from bladder, up through ureters into kidney * Can lead to pyelonephritis--\> * renal scarring (30% of children with reflux) * loss of future kidney growth * high blood pressure * kidney failure ## Footnote *_but_ – now think pyelo may occur even w/o reflux*
92
Grades of VUR
* **Grade I**: Into non-dilated distal ureter * **Grade II**: Into upper collecting system without dilatation * **Grade III**: Into dilated ureter and/or blunting of calyceal fornices * **Grade IV:** Into grossly dilated ureter * **Grade V**: Massive urinary reflux with ureteral dilatation and effacement of calyceal fornices
93
Course of VUR
Majority of Grades I and II resolves with growth 20-30% rate of resolution every 2 yrs. of growth
94
Controversy over VUR
* Prophylaxis until no further UTI over period of 6-12 months and no reflux demonstrated on annual VCUG * Still controversial (2015) * Prevents UTIs * Does not prevent scarring. *b/c pyelo not d/t VUR* * Managed by urologist
95
What is enuresis? primary vs secondary
* Involuntary urinary incontinence beyond expected age * Diurnal\*: 4 yrs.. for daytime control * Nocturnal: 5 yrs.. for nighttime control Primary: No sustained pattern of dryness (\>6 months) Secondary: Incontinence after period of dryness.
96
New classifications of incontinence since 2009
* Continuous * Ectopic ureter * Damage to external sphincter * Diabetes insipidus * Intermittent * Day or night * Dysfunctional voiding: inappropriate muscle contraction during voiding ## Footnote *We typically stick to Primary or Secondary*
97
Enuresis gender ratio
Boys: girls = 4:1
98
Enuresis: Contributing physiologic factors
* Small bladder * Deep sleeper\* * Neurological ADHD Maturational delay * Hormonal regulation *(ADH)* * Chronic constipation *(can’t hold all overnight, so pee goes first)* * OSA\* *Hormones:* Decreased production of antidiurectic hormone-à decreased urine production and more concentrated urine
99
Enuresis: Contributing psychologic factors
Stress Habit polydypsia
100
Enuresis: Contributing genetic factors
44%- 77% 1 parent→ 45% chance; 2 parents → 77% chance; 0 parents- → 15% chance
101
Enuresis: Contributing organic/structural factors
* Polyuria (DM, DI, SCD) * Incomplete bladder emptying (lower UT obstruction, neurogenic bladder) * Urgency of urination (irritation of bladder mucosa from UTI, calculus). * Labial adhesions *how? Not voiding regularly* * Ectopic ureter
102
Enuresis: Risks of Condition
* Emotional distress to child and family * Low self esteem * Teasing * Sleep loss * Poor school performance * Restricted peer activities
103
Enuresis: DDx
* Structural abnormalities- * Incomplete voiding * Constipation * Encopresis * Neurologic abnormalities * Seizure disorder * Neurogenic bladder * Sleep apnea * Labial adhesions * Vaginal reflux * Abuse
104
Enuresis: Evaluation
* Voiding history * Social history (\*abuse) * Family history: *very genetic* * ROS * Ectopic ureter (constant dribbling, wetness) * Posterior urethral valves (Abnl stream with dribbling, hesitancy) * Spinal tumor (abnormal gait) * Adenoids/ sleep apnea (snoring) *why?* * Constipation/ encopresis * Complete PE: Neuro, GI, GU * UA r/o DM, DI, asymptomatic bacteriuria
105
Enuresis: General Management Principles
* Positive reinforcement * Avoid punishment and criticism *–not deliberate, not opposition.* * Dry night calendar or star chart * Read *Dry All Night* ## Footnote *Stickers can be reinforcing, etc.*
106
Enuresis: msg to send to child / family
Child normal (everyone frustrated)
107
Enuresis: goal and aids
* Goal: Get up to use toilet; NOT stay dry all night *(easy toilet access, parents can get them up)* * Aids (not cures): * Limit nighttime fluids 2 hrs... before bed * Limit dairy products 4 hrs.- **decreases UO from osmotic diuresis** *– increases?* * Limit caffeine products
108
Pharm tx for bedwetting?
DDAVP: vasopressin analog
109
How effective are bedwetting alarms?
* Most effective management * 66-70% cure rates * Most difficult method to apply * Works on conditioning
110
How does DDAVP work?
* Vasopressin analog * Works at level of kidney * Reduces nocturnal urine production * Increases water retention * Increases urine concentration * Provides ADH if not yet producing
111
DDAVP counseling and dosing
Counseling: * Works or doesn’t *- be clear* * Stop during illnesses: fluid/lytes * Intermittent use?? *- kids want to go to a friend’s house* Dosing: * Nasal spray: no longer recommended * Tablets: 0.2mg qhs (max 0.6mg) * ½ hour prior to bed * Effective 1 hr; cleared in 9 hrs.... * Use nightly x 6 mos * Stop x 2 weeks – see if outgrown * May resume
112
Daytime wetting: who and why? most commonly
* Stress, abuse between 2 -5 yrs. = ↑ daytime wetting * Wetting pants in school – 3/20 most stressful life events * More in ADHD kids * More constipation if daytime wetting and difficult temperament
113
Less common causes of daytime wetting
* Giggle incontinence (10-20 yrs. old) * Complete bladder emptying * No associated voiding abnormalities * Vaginal reflux * Urine trapped in introitus-leaks with walking * Overweight and young * Adhesions * Sit backward , thighs apart and empty completely

Management of Common Pediatric Probs (6 decks)

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