Renal/urology

Question 1

What are the symptoms of a UTI?

Answer 1

Older children- dysuria, frequency, abdominal (especially loin) pain, vomiting

Young babies and neonates- lethargy and irritability

Question 2

How is the diagnosis of acute pyelonephritis made?

Answer 2

A temperature greater than 38 degrees

Loin pain or tenderness

Question 3

What are you looking for on a urine dipstick?

Answer 3

Nitrites (gram negative bacteria convert nitrates into nitrites) 
Leucocyte esterase (shows the amount of leucocytes there are) 

If neither are present then the patient is unlikely to have a UTI

Send a MSU to the lab to be cultures and have sensitivity testing if both are present.

Question 4

What is the management of UTIs?

Answer 4

All children should under 3 months with a fever should start immediate IV Abx (ceftriaxone) and have a full septic screen- blood cultures, bloods and lactate, lumbar puncture.

Typical Abx choices: trimethoprim, nitrofurantoin, cefalexin, amoxicillin

Question 5

How do you investigate recurrent UTIs?

Answer 5

Children under 6 months with their first UTI should have an Abdominal US scan within 6 weeks or during the illness if there are recurrent UTIs or atypical bacteria.

Children with recurrent UTIs should have an abdominal US within 6 weeks
Children with atypical UTIs should have an abdominal US during the illness

Question 6

When do you do a Dimercaptosuccinic acid scan?

Answer 6

These should be used 4-6 months after the illness to assess for damage from recurrent or atypical UTIs.

Question 7

What does the DMSA involve?

Answer 7

Works by injecting isotope into a childs vein which is then absorbed by the kidney, the scan shows function and location and scarring of the kidneys.

Question 8

What is vesico ureteric reflex?

Answer 8

This is where urine has a tendency to flow from the bladder back into the ureters, this predisposes patients to developing Upper UTIs and subsequent renal scarring.

Question 9

How is vesicoureteric reflex diagnosed?

Answer 9

Micturating cystourethrogram

Question 10

What is the management of vesico ureteric reflex?

Answer 10

It depends on the severity 
.avoid constipation
.avoid excessively full bladder
.prophylactic Abx 
.surgical input from paediatric urology

Question 11

When is micturating cystourethrogram used?

Answer 11

Used to investigate atypical or recurrent UTIs in children under 6 months
Used when there is a family history of VUR
Dilatation of ureter on US
Poor urinary flow

Question 12

What does micturating cystourethrogram involve?

Answer 12

It involves catheterising the child and injecting contrast into the bladder and taking a series of xray films to determine whether the contrast is refluxing back into the ureters. Children are usually given Abx for around 3 days around the time of investigation.

Question 13

What is vulvovaginitis and what is it caused by?

Answer 13

Inflammation and irritation of the vulva and vagina, it is a common condition affecting between 3 and 10 year olds.
It can be exarcebated by wet nappies, chlorinated pools, use of soaps, tight clothing, poor toilet hygiene, constipation, threadworms, pressure on the area.

Question 14

Why is vulvovaginitis much less common after puberty?

Answer 14

Oestrogen helps keep the skin and vaginal mucosa healthy and resistant to infection.

Question 15

What would vulvovaginitis present with?

Answer 15

Erythema 
Itchiness 
Discharge 
Dysuria 
Constipation
Urine dipstick may show leucocytes and therefore it may be misdiagnosed as UTI

Question 16

What is the management of vulvovaginitis?

Answer 16

Avoid washing with soaps/chemicals
Avoid perfumed or antiseptic products
Good toiler hygiene
Keep area dry
Emollients such as sudocreme can sooth area
Loose cotton clothing
Treating constipation and worms where applicable
Avoiding activities that exacerbate the problem

Question 17

What is nephrotic syndrome?

Answer 17

This is when the basement membrane in the glomerulus becomes highly permeable to protein, allowing proteins to leak from the blood into the urine. It is most common between 2 and 5 years.

Question 18

How does nephrotic syndrome present?

Answer 18

Classic triad of:
Low serum albumin (hypoalbuminaemia)
High urine protein content (more than 3+ proteins on urine dipstick)
Oedema

Question 19

Why may children with nephrotic syndrome be dehydrated?

Answer 19

This is because the oedema represents all the fluid going into 3rd fluid spaces, so there is less in the intravascular system.

Question 20

Other than the classic triad of nephrotic syndrome, what other important features are there in terms of nephrotic syndrome?

Answer 20

. Hypercoagulability
. High blood pressure
. Deranged lipid profile- high levels of cholesterol, triglycerides, low density lipoproteins

Question 21

What is the most common cause of nephrotic syndrome in children?

Answer 21

Minimal change disease

Causing over 90% of cases in children under ten

Question 22

Other than minimal change disease, what can cause nephrotic syndrome?

Answer 22

It can be secondary to intrinsic kidney disease- focal segmental glomerulosclerosis, membranoproliferative glomerulonephritis

It can also be secondary to an underlying systemic illness:
Diabetes
Infection (HIV, hepatitis, malaria)
Henoch schonlein purpura

Question 23

What is the management of nephrotic syndrome?

Answer 23

Management is with corticosteroids (prednisolone) the prognosis is good and most children make a full recovery.
Low salt diet
Diuretics to treat the oedema
Albumin infusions can be required in severe hypoalbuminaemia
Antibiotic prophylaxis given in severe cases (due to the oedema and ascites)

Question 24

In nephrotic syndrome, how long should steroids be given for?

Answer 24

High dose steroids should be given for 4 weeks and then gradually weaned over the next 8 weeks.

Steroid sensitive= children who respond to steroids (80% of children respond)
Steroid dependent= patients that struggle to wean steroids due to relapses
Steroid resistant= patients that do not respond to steroids

Question 25

Steroid resistant children are children with nephrotic syndrome who do not respond to steroids, what should you give in these cases?

Answer 25

ACE inhibitors and immunosuppresants (cyclosporine, tacrolimus, rituximab).

Question 26

What are the complications of nephrotic syndrome?

Answer 26

Hypovolaemia- occurs as fluid leaks from the intravascular space into the interstitial space causing oedema and low blood pressure. Spontaneous bacterial peritonitis Thrombosis (proteins that normally prevent blood clotting are lost in the kidneys) Infection as kidneys leak immunoglobulins (weakens the capacity of the immune system) Relapses Acute or chronic kidney failure

Question 27

What are the signs of a UTI?

Answer 27

Fever Poor feeding and vomiting (may be the only signs in a neonate) Jaundice (especially in neonates) Sepsis

Question 28

What investigations are done for UTI?

Answer 28

Urine dip, urine for MC&S Bloods (FBC, U and Es, increased CRP) and blood cultures Ultrasound to identify pyelonephritis and structural defects and other imaging (if atypical or recurrent then do during active infection, however if just typical UTI do in 6 weeks)

Question 29

What are the risk factors for UTI?

Answer 29

``` Constipation Female sex Incomplete emptying VUR Structural defect in the urinary tract ```

Question 30

What is the management of UTI?

Answer 30

Antibiotics - initially empirical then guided by MC&S results Antipyretics for fever and analgesia for pain In terms of long term management then those with recurrent UTIS, and those with severe VUR then prophylactic abx can be used Preventative measures include encouraging good hygiene, regular voiding, high oral intake Also treat constipation if present

Question 31

What is reflux nephropathy?

Answer 31

This is renal damage due to the retrograde flow of urine from the bladder to the upper renal tract.

Question 32

What causes reflux nephropathy?

Answer 32

``` Incompetence at the vesicoureteric junction Secondary to obstruction (posterior urethral valve) Neurogenic bladder (fails to void adequately) ```

Question 33

What is the pathophysiology behind reflux nephropathy?

Answer 33

``` . Reflux of urine Leading to . Recurrent upper UTI Leading to . Scarring (neohropathy) Leading to . HTN And eventual . CKD ```

Question 34

What is the diagnostic investigation for reflux nephropathy?

Answer 34

MCUG DMSA is also used to look for scarring

Question 35

How do you manage reflux nephropathy?

Answer 35

Varies depending on the grade of disease If its mild then they can have observation and advice on identifying features of infection If its moderate then antibiotic prophylaxis can be given to prevent further damage to the kidneys due to infection If its severe then surgical repair In 80% of children spontaneous regression is seen

Question 36

What is nephrotic syndrome?

Answer 36

Triad of features which is caused by damage to the basement membrane of the glomerulus, it is not diagnosis in itself instead it is seen as a consequence of other diseases affecting the kidney.

Question 37

What are the primary causes of nephrotic syndrome?

Answer 37

Minimal change disease= most common Primary focal glomerulosclerosis Membranoproliferative glomerulonephritis Idiopathic

Question 38

What are the secondary causes of nephrotic syndrome?

Answer 38

SLE HSP (remember a potential case of this in PAU, boy presenting with blood in stools however he did not have a purpuric rash/other vasculitis) Chronic infections (hepatitis, HIV, malaria) Diabetes

Question 39

What are the consequences of nephrotic syndrome?

Answer 39

Hypercholesterolaemia Hypopvolaemia Thrombosis Risk Infection risk

Question 40

Why is there a thrombosis risk in nephrotic syndrome?

Answer 40

There is a hypercoagulable state due to loss of proteins such as antithrombin via. The kidneys and raised haematocrit from hypovolaemia

Question 41

Why are people with nephrotic syndrome more likely to develop infections?

Answer 41

They are especially at risk to encapsulated organisms, because of urinary loss of complement and immunoglobulins (both are proteins)

Question 42

Why do patients with nephrotic syndrome have hypercholesterolaemia?

Answer 42

Low protein levels triggers the liver to synthesise lipids

Question 43

What are the risk factors for nephrotic syndrome?

Answer 43

Male sex Asian ethnicity Resp tract infections Family history

Question 44

How do you diagnose nephrotic syndrome?

Answer 44

``` You can do a rapid diagnosis which will show the following... Proteinuria >3g/day Hypoproteinaemia (albumin<25g/l) Oedema Hyperlipidaemia ```

Question 45

What would you find on examination of a child with nephrotic syndrome?

Answer 45

Periorbital oedema is an early sign! +/- scrotal oedema, +/- ascites, +/- peripheral Pulmonary oedema or pleural effusion with respiratory distress may be present

Question 46

When would you do a renal biopsy for nephrotic syndrome?

Answer 46

If the patient was steroid resistant or had atypical features.

Question 47

What is the management of nephrotic syndrome?

Answer 47

High dose pred- 60mg/ day for 4 weeks then at a reduced dose for a further 4 weeks If they dont respond to steroids then they have a biopsy (normally they don’t because 80% is minimal change)

Question 48

What is nephritic syndrome?

Answer 48

This is a consequence of glomerulonephritis and is characterised by haematuria, proteinuria, renal failure and hypertension.

Question 49

What are the main causes of nephritic syndrome?

Answer 49

Post streptococcal glomerulonephritis (most common and caused by group A strep) IgA nephropathy Henoch schonlein purpura Glomerular basement membrane disease (alport and goodpasture)

Question 50

What is the classic findings in post streptococcal glomerulonephritis?

Answer 50

. C3 is low but C4 is normal | . ASOT is positive

Question 51

What is henloch schonlein purpura?

Answer 51

IgA/IgG/complement complexes are deposited in organs causing vasculitis and multisystem symptoms Typically a boy aged 3-10 in winter after an URTI (saw in PAU with Jo) Abdo pain, joint pain, rash on legs

Question 52

What are the risk factors for nephritic syndrome?

Answer 52

Male sex Preceding viral illness/URTI Preceding throat infection

Question 53

What are the signs and symptoms of nephritic syndrome?

Answer 53

Symptoms- haematuria, oliguria, feeling non specifically unwell, coca cola urine Signs- hypertension, oedema (peripheral, peri orbital, pulmonary oedema features)

Question 54

What would the differential diagnosis for nephritic syndrome be?

Answer 54

``` Anything that causes blood in urine . UTI Trauma Renal stones Tumours Renal vein thrombosis Bleeding disorders Sickle cell disease TB ```

Question 55

What is the management of nephritic syndrome?

Answer 55

Impaired renal function (electrolytes and renal function need to be closely monitored, if in renal failure then consider ITU and renal filtration/dialysis) Hypertension- ACE-I, CCB Fluid overload- oral fluid and salt intake should be restricted, consider dialysis if severe peripheral or pulmonary oedema Treating the underlying pathology - for PSGN then it is supportive measures only, if IgA nephropathy use ACE-I or steroids if persistent HSP- generally supportive (if renal failure then steroids can be given)

Question 56

What is enuresis?

Answer 56

Involuntary loss of urine, typically nocturnal, beyond developmental age of 5. It can be primary- they have never achieved continence It can be secondary- incontinence in a child that has previously been continent for at least 6 months

Question 57

What are the primary and secondary causes of enuresis?

Answer 57

Primary- bladder sphincter dysfunction, neurogenic bladder, dysfunctional voidkng Reflux nephropathy or posterior urethral valve

Question 58

What questions would you want to ask in a history of enuresis?

Answer 58

Characteristics- is the enuresis in the daytime, nighttime or both Ask about bowel habit Ask about stress/sleeping habits Ask about FH Ask about polyuria, polydipsia and drinking habits and caffeine intake

Question 59

What investigations would you do for enuresis?

Answer 59

Urine dip to exclude infection Blood sugar and ketones to exclude diabetes mellitus Imaging - not for primary but for secondary and diurnal, imaging is with urodynamics +/- spinal imaging if possible

Question 60

What would the differentials for enuresis be?

Answer 60

DM Diabetes insipidus UTI Sleep disorders

Question 61

How do you treat enuresis?

Answer 61

If secondary to organic pathology then treating the organic pathology usually solves it If no organic then can use positive reinforcement techniques Failing the positive reinforcement techniques then enuresis alarms can be affective Evening fluid restriction is helpful If triggered by stress- psychological support Med management RARELY used as recurrence occurs when they stop medications

Question 62

What is hypospodias?

Answer 62

The failure of the urethral folds to close over the urethral groove, so the urethra opens proximal to the meatus

Question 63

What is the management of hypospodias?

Answer 63

Surgical correction at around 2 years Aim to have the urethral opening in the meatus so they can micturate normally Must not be circumcised

Question 64

What is cryptorchidism?

Answer 64

The failure of the testes to follow normal route of descent, they may be absent, intra abdominal or in the inguinal canal.

Question 65

How would you investigate cryptochidism?

Answer 65

USS to identify where they are

Question 66

How do you treat cryptochidism?

Answer 66

Surgical correction (orchidopexy) at 1 year of age (fertility deteriorates the later the corrective surgery is performed Education and surveillance for malignancy Counselling on infertility risk in adulthood

Question 67

What are retractile testes?

Answer 67

Excessive cremasteric reflex causes the testes to retract into the inguinal canal. They will spontaneously descend back into the scrotum in the warm or can be manipulated back, they are normal and common but require follow up until puberty to ensure they do not become ascending (fixed outside the scrotum).