Renal and Urology Flashcards
What are three causes of UTI in children?
E.Coli
Proteus
Pseudomonas
What are symptoms of a UTI in babies?
- Fever
- Irritability
- Lethargy
- Poor feeding
- Vomiting
- Urinary frequency
How might you diagnose a UTI? What are positive results? What do you do with the results?
Urine dipstick:
Nitrites ++
Leukocytes ++
If either present, send off an MSU for microbiology
When might you consider Pyelonephritis as a differential for a child with ?UTI?
Fever >38C
Loin pain / tenderness
How do you manage a child under 3 months with a ?UTI?
- Immediate paediatric referral
- Immediate IV ABX
- Full sepsis screen, blood cultures, blood, lactate and LP
How do you manage a child over 3 months with a ?UTI?
- Oral ABX for 3 days (Trimethoprim, Nitrofuratoin, Cefalexin, Amoxicillin)
When are Abdominal Ultrasounds indicated regarding UTIs?
- All children under the age of 6 months should have an Abdo US within 6 weeks of their first UTI
- Children with recurrent UTI should have an Abdo US within 6 weeks
- Children with atypical UTI should have an Abdo US during the illness
When is a Micturating Cystogram indicated regarding UTIs?
If you suspect Vesico-Ureteric Reflux (VUR)
UTIs are more common in which gender?
More common in boys until 3 months of age (due to congenital anomalies), and then more common in girls
Vulvovaginitis affects which group of people?
Pre-pubertal girls aged between 3 and 10
In one sentence, explain Vulvovaginitis?
Vulvovaginitis refers to inflammation and irritation of the vulva and vagina, common in girls aged between 3 and 10. It is caused by sensitive and thin skin and mucosa, which is more prone to colonisation with bacteria spread from faeces
Why does Vulvovaginitis improve after puberty?
The protective effects of Oesotrogen help keep skin and mucosa resistant to infection
What are symptoms of Vulvovaginitis?
Soreness, Itching, Erythema around labia, Vaginal discharge, Dysuria, Constipation
Why is Vulvovaginitis misdiagnosed for a UTI?
Have similar symptoms of Dysuria, and on urine dipstick it may also show leukocytes
What are the home remedies for Vulvovaginitis?
- Avoiding washing with soap / chemicals
- Avoid perfumed, antiseptic products
- Good toilet hygiene (wipe front to back)
- Keep the area dry
- Emollients i.e. Sudacreme may help
- Loose cotton clothing
- Treat constipation / worms were applicable
- Avoid activities which may exacerbate the problem i.e. horseriding
In severe cases of Vulvovaginitis, what may be prescribed?
An Oestrogen cream
What is the triad for Nephrotic Syndrome?
What are additional features?
- Peripheral Oedema
- Hypoalbuminaemia (< 25g / L)
- Proteinuria (> 1 g / m2)
Additional features:
- Derranged lipids (Hypercholesterolaemia, hypertriglyceridaemia, high LDLs)
- Hypertension
- Hypercoagulopathy
- Haematuria
- Predisposition to infection
Nephrotic Syndrome is most commonly seen in what age of patients?
Ages 2 - 5 years old
Why are patients in a hypercoagulable state in Nephrotic Syndrome?
Due to loss of anti-thrombin III
Why are patients predisposed to infections in Nephrotic Syndrome
Due to loss of immunoglobulins
What is the most common cause of Nephrotic Syndrome in children, in 80% of cases?
Minimal Change Disease
What might you see on renal biopsy + renal microscopy for Minimal Change Disease?
Minimal changes / No abnormality
What might you see in Urinalysis for Minimal Change Disease?
Small molecular weight proteins and hyaline casts
What might you see in Immunofluorescence for Minimal Change Disease?
Occasional IgM in mesangium
What might you see on Electron Microscopy for Minimal Change Disease?
Effacement of Podocyte foot processes
What is the management for Minimal Change Disease?
- High dose steroids (Prednisolone)
- Low salt diet
- Diuretics
- Albumin infusion (for severe hypoalbuminaemia)
- Antibiotic prophylaxis (for severe immunocompromised patients)
What proportion of patients are treated successfully with Steroids in Minimal Change Disease
- 80% of patients respond to steroids (steroid sensitive)
- 80% of the above 80% will relapse again
- 20% of patients do not respond (steroid resistant)
- Some patients will struggle to wean off steroids (Steroid dependent)
From least severe to most severe, what are the three types of Hypospadias?
Glanular
Mid-shaft
Penoscrotal
From least severe to most severe, what are the three types of epispadias?
Glanular
Penile
Penopubic
What is Hypospadias associated with?
Chordee (downward facing penis)
Inguinal hernia
Cryptochordism
What is Epispadias associated with?
Bladder Extrophy
What are symptoms of Hypo / Epispadias?
Difficulty targeting
Incontinence
Why is Circumcision a contraindication to Hypospadias?
Because the foreskin can be used for Hypospadias reconstruction (can be circumcised later)
What is the management of Hypo / Epispadias?
- Reconstructive surgery in first few months of life
When is Hypo / Epispadias commonly diagnosed?
During the newborn examination
What are the medical benefits of circumcision?
- Reduces the risk of penile cancer
- Reduces the risk of UTIs
- Reduces the risk of STIs i.e. HIV
What are the medical indications for circumcision?
- Phimosis / Paraphimosis
- Recurrent balanitis
- Balanitis Xerotica Obliterans
What are the two most common nephritic syndromes in children?
IgA nephropathy
Post-streptoccocal glomerulonephritis
PSGN is commonly caused by what?
A Group A Beta-haemolytic strep infection, commonly Strep pyogenes
How does PSGN cause nephritis?
Deposition of immune complexes IgG, IgM, C3 in the glomerulus
What are two findings on blood tests in patients with PSGN?
Low C3 levels Raised ASO (antistreptolysin O)
What are the clinical features of Nephritic Syndrome?
Haematuria
Hypertension
Proteinuria (some)
An URTI presents how long before nephritis in PSGN?
1-2 weeks prior
An URTI presents how long before nephritis in IgA nephropathy?
1-2 days prior
What is the management and prognosis of PSGN?
Mainly supportive
80% make a full recovery, however some will have progressively worsening renal function (HTN, oedema) and will need antihypertensives and diuretics
What is IgA nephropathy also known as?
Berger’s disease
What 3 conditions is IgA nephropathy associated with?
Coeliacs disease / Dermatitis Herpetiformis
Henoch-Schonlein Pupura
Alcoholic Cirrhosis
What is seen on histology in patients with IgA nephropathy?
IgA deposits
Glomerular mesangial proliferation
What is the prognosis of IgA nephropathy?
What is good and bad prognostic factors?
25% will develop end stage renal disease
Good: Frank haematuria
Bad: Hypertension, smoking, being male, proteinuria, hyperlipidaemia, ACE Genotype DD
Haemolytic Uraemic Syndrome is a triad of what?
Haemolytic Anaemia
Thrombocytopaenia
Acute Kidney Injury
What is the clinical presentation of HUS?
Brief gastroenteritis, often with bloody diarrhoea, then usually 5 days later:
- Reduced urine output
- Haematuria / dark urine
- Abdo pain
- Lethargy
- Confusion
- Irritability
- Oedema
- Hypertension
- Bruising
Most children get daytime control of urination by what age?
By 2 years
Most children get night-time control of urination by what age?
By 3-4 years
What is the difference between primary and secondary Enuresis?
Primary: Child has never achieved continence
Secondary: Child has had at-least 6 months of being dry
What is the management for Primary Nocturnal Enuresis?
- Bladder diary for 2 weeks
- Reassurance of patients for children under 5
- Encouragement / positive reinforcement
- Enuresis alarms
- Medications:
1. Desmopressin (ADH analogue)
2. Oxybutinin (Anticholinergic)
3. Imipramine (TCA)
Which form of Polycystic Kidney Disease presents in young children / infants?
Autosomal Recessive
Outline the genetics of ARPKD
Mutation of the PKHD1 gene on chromosome 6, responsible for Fibrocystin / Polyductin Protein Complex (FPC). The FPC is responsible for renal tubules and epithelial tissue of kidneys, liver and pancreas
What are the clinical features of ARPKD?
- Cystic enlargement of the renal collecting ducts
- Oligohydramnios
- Pulmonary hypoplasia
- Potter’s sequence
- Congenital liver fibrosis
Outline what Multicystic Dysplastic Kidney is?
Whereby babies have one cystic kidney while the other is normal. The affected kidney atrophies by age 5 and the unaffected kidney is usually enough, however patient is at risk of UTIs, HTN, CKD
What is the epidemiology of Wilm’s Tumour?
One of the most common childhood malignancies, and presents in children under age 5 and has a median age of 3 years old
What 3 syndromes are associated with Wilm’s Tumour?
- WAGR Syndrome
- Beckwith Weiderman Syndrome
- Denys-Drash Syndrome
What mutation is most commonly associated with Wilm’s Tumour?
WT1 on chromosome 11
What is the Presentation of Wilm’s Tumour?
- Large, palpable abdominal mass
- Painless haematuria
- Flank pain
- Lethargy
- Anorexia
- Hypertension (due to renin secretion)
What are the 4 features of WAGR syndrome?
- Wilm’s Tumour
- Aniridia
- Genitourinary Malformation
- Retardation
What are the 4 features of Beckwith Weiderman Syndrome?
- Wilm’s Tumour
- Organomegaly
- Macroglossia
- Hemihypertrophy
What are the 3 features of Denys Drash Syndrome?
- Wilm’s Tumour
- Early Onset Nephrotic Syndrome
- Male Pseudohermaphrodism
What is the referral pathway for children with ?Wilm’s Tumour?
Paediatric review within 48 hours
What is a Posterior Urethral Valve? What is a complication of this? What about in the developing foetus?
A posterior urethral valve refers to tissue at the proximal end of the urethra which obstructs urine output.
The obstruction of urine can cause a back pressure on bladder, ureters, kidney causing hydronephrosis.
In the developing foetus it can cause oligohydramnios and pulmonary hypoplasia.
What is Cryptorchidism?
Cryptorchidism refers to failure of the testes to descend into the scrotum by 3 months of age
What are complications of Cryptorchidism?
Increased risk of testicular torsion
Increased risk of testicular cancer
Increased risk of infertility
What is a differential diagnosis for Cryptorchidism? Outline what it is?
Retractile testes
Usually in prepubescent boys, where the testes retracts out of the scrotum -> inguinal canal when cold or cremasteric reflex is activated.
What is the management for Unilateral Cryptochidism?
Referral from 3 months, usually to be seen by a surgeon by 6 months of age. Orchidopexy by 6-18 months of age
What is the management for Bilateral Cryptochidism?
Refer to senior paediatrician within 24 hours
Briefly outline what a Hydrocele is?
A hydrocele is a collection of fluid within the tunica vaginalis that surrounds the testes
What are the two types of Hydrocele? Outline what they are caused by. Which is more common in newborns?
Communicating type: Connection between the tunica vaginalis and the peritoneal membrane by a processus vaginalis; allowing fluid to travel from the peritoneal cavity to the hydrocele (MORE COMMON)
Non-Communicating type: Caused by excessive fluid production in the tunica vaginalis
What are the presenting features of a Hydrocele?
- Soft, non-tender swelling of the hemi-scrotum (anterior and below the testicle)
- Swelling is confined to the scrotum, can get “above” the mass
- Transillumination with a pen torch
What is the diagnosis / management of a Hydrocele?
Diagnosis: Clinical plus an ultrasound
Management: Surgically repaired if not resolved by 1-2 years
