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Peds Patho > Urology > Flashcards

Urology Flashcards

kick ASS

1
Q

what are the provider’s 2 main jobs in relation to urology?

A

1) take care of the bladder to protect the kidneys

2) help assure social confidence

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2
Q

what are the bladder’s 2 main jobs?

A

1) store urine

2) empty urine

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3
Q

the shape of the bladder is like… ?

A

an inflated balloon

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4
Q

what works together to successfully store & empty urine & feces?

A

12-14 different reflex arcs

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5
Q

how do the bladders & bowel function–neurological control?

A

through a delicate interplay between the:
1) sympathetic nervous system
2) parasympathetic nervous system
(voluntary & involuntary neural control of both urine & feces)

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6
Q

what muscles control bladder/bowel function?

A

teamwork of many diff muscles, including:

  • -detrusor
  • -internal sphincter
  • -external sphincter (pelvic floor or “bowl”)
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7
Q

what tests can determine if you are performing kegel exercises effectively?

A

biofeedback

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8
Q

what do kegel exercises do?

A

help you to control your internal & external sphincter

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9
Q

what is impt to include in a urology history?

A
  • -voiding pattern: frequency, urgency, dysuria, retention, wetting damp or soaked)
    • -> St. Vincent’s curtsey (pee-pee dance)
  • -stool character & bowel pattern, “corn test”
  • -drinking & voiding diary
  • -hx of sexual activity or abuse
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10
Q

hallmark of a neurogenic bladder?

A

drips of urine coming out

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11
Q

what amount of time should be recorded in a drinking & voiding diary?

A

48 hrs worth is ideal

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12
Q

what should be included in a voiding diary?

A
  • -color, odor, frequency, & volume of urine

- -ECA

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13
Q

what is ECA?

A

expected capacity for age:

age + 1 or 2 in ounces, for kids 2 and older

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14
Q

what does dark urine indicate?

A

not drinking enough

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15
Q

w/UTI, what do you treat first?

A

treat constipation 1st

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16
Q

w/spinal bifida occulta, what urinary problem can occur?

A

can have a neurogenic bladder

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17
Q

what should you pay attention to on physical exam that may point to urinary issues?

A
  • -low-set ears
  • -BP
  • -growth
  • -edema, pallor, dehydration
  • -costovertebral tenderness
  • -external genitalia abnormalities
  • -sacrum (dimple?) or neurological abnormality
  • -reflexes (v. impt!)
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18
Q

what 6 lab tests would you do w/a urinary issue?

A

1) UA (urinalysis), non-sterile
2) enhanced UA, Neubauer hemocytomer to obtain WBC/mm3 count from uncentrifuged urine
3) Urine culture & sensitivities, C&S
4) Serum BUN
5) Creatinine w/creatinine clearance
6) Serum electrolytes & acid base status

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19
Q

what is impt to remember for urine culture & sensitivities test? (c&s)

A

must be midstream clean catch or catheterized urine

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20
Q

what does serum BUN measure?

A

urea concentration in serum

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21
Q

what is the purpose of creatinine w/creatinine clearance test?

A

estimates glomerular filtration rate

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22
Q

what is serum electrolytes & acid base status test used for?

A

to check for renal tubular abnormalities

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23
Q

some docs check what for all kids on DDAVP?

A

Na balance

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24
Q

definition of nocturia

A

the complaint that the individual has to wake at night one or more times for voiding

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25
Q

DDAVP

A

Desmopressin

  • -reduced urine production
  • -used in tx of D.I., bedwetting, nocturia
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26
Q

how should boys prepare for urine specimen collection?

A
  • -wipe meatus w/ 3 different wipes
    • -> tip/center to shaft
  • -then mid-stream
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27
Q

how should girls prepare for urine specimen collection?

A
  • -wipe meatus w/ 3 different wipes
    • -> front to back
  • -then mid-stream
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28
Q

how can we avoid mixed flora culture results in girls?

A

have them take bath or shower before

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29
Q

w/urine specimen collection, what should we always order?

A

always order UA & C&S

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30
Q

if possible, what should you do before starting antibiotics?

A

wait for c&s results

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31
Q

what should creatinine levels be in infants?

A

it is normal for creatinine in infants to be low!

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32
Q

what is an enhanced urinalysis doing?

A

counting the # of white cells

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33
Q

constipated kids are at high risk for… ?

A

UTIs

if are holding back poop–are also holding back urine!

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34
Q

5 types of diagnostic tests we can do w/urinary dysfunction?

A

1) Ultrasonography
2) voiding cystourethrogram (VCUG)
3) IVP (intra venous pyelogram)
4) nuclear imaging scans
5) MRUogram

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35
Q

what does ultrasonography do?

A

non-invasive structural information
(look for: hydronephrosis, kidney size, scarring, cysts, healthy kidney parenchyma, thickened bladder wall, pre & post-void syndromes)

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36
Q

if high-grade ultrasound was done in utero, do we need to do ultrasonography later for urinary dysfunction?

A

not needed

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37
Q

what is the first line test for evaluation of renal system?

A

ultrasonography

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38
Q

what is the only way to diagnose or r/o reflux?

A

by doing a VCUG (voiding cystourethrogram)

a very difficult test

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39
Q

what does an IVP show?

A

the structure & function of renal systems

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40
Q

what is a benefit to doing nuclear imaging scans?

A

involves less radiation than IVP

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41
Q

what is the purpose of a MRUrogram?

A

studies anatomy & function without radiation

–done w/ and w/out contrast; long study, motion artifact

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42
Q

4 types of “minor” urinary dysfunctions?

A

1) extraordinary daytime urinary frequency syndrome
2) giggle incontinence
3) stress incontinence
4) post void dribbling

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43
Q

as PNPs, should we order an IVP?

A

never order this! let specialist do it

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44
Q

extraordinary daytime urinary frequency syndrome is characterized by:

A
  • -voiding every 10-20 min.

- -no incontinence, no dysuria

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45
Q

extraordinary daytime urinary frequency syndrome affects what age group?

A

3-8 yrs old: generally young school-aged kids

often occurs @ stressful times: going to kindergarten, being bullied at school…

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46
Q

what do we do to treat extraordinary daytime urinary frequency syndrome?

A

–give time
(once they get rid of stress: goes away! us. self-limiting disease)
–flow/EMG may help teach child

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47
Q

what is giggle incontinence?

A

embarrassing wetting (not just leaking) assoc. w/giggling & laughter

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48
Q

tx’s for giggle incontinence?

A
  • -anticholinergics
  • -ritalin
  • -biofeedback to strengthen outlet
  • -kegels! (cheaper. to contract & expand pelvic floor)
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49
Q

stress incontinence

A

incontinence w/running, jumping, & high impact landing

–weakness in outlet

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50
Q

stress incontinence often occurs in:

A

athletes or obese patients

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51
Q

how can stress incontinence be treated?

A
  • -void prior to activity

- -Biofeedback/kegels to strengthen outlet

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52
Q

post void dribbling

A

urine accumulation in lower vagina

–urine trickles out as she stands

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53
Q

post void dribbling mainly occurs in:

A

mostly in obese girls (v. common problem!)

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54
Q

what causes post void dribbling?

A

poor posture during micturition

may help to straddle toilet/sit backwards or lean forward to exaggerate bladder angle

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55
Q

what causes post void dribbling in boys?

A

it is due to the external sphincter location at the proximal urethra

56
Q

micturition

A

= urination = voiding = uresis

–the release of urine from the urinary bladder through the urethra to the urinary meatus outside of the body

57
Q

what should you remember w/post-void dribbling?

A

don’t try to squeeze out the residual–not good!

58
Q

4 types of more severe voiding dysfunctions:

A

1) Dysfunctional voiding
2) Overactive bladder
3) Infrequent voiding
4) Bladder neck dysfunction

59
Q

what is worrisome about the more severe voiding dysfunctions?

A

–there are potential consequences for kidney function

60
Q

VCUG indications

A

1) any child under 2 1/2 w/2 febrile UTIs
2) children over 2 1/2 w/2 febrile UTIs or recurrent non-febrile UTIs
3) children w/primary VUR (follow in 1-2 yr intervals)
4) children who have received Deflux injection: re-checked 3 mos after procedure
5) younger siblings of kids w/primary VUR are checked for “sibling reflux”
6) any child w/neonatal hydronephrosis
7) any child w/multicystic kidney
8) any boy w/a suspicion of outlet obstruction
9) most boys any age w/1 UTI

61
Q

Deflux

A
  • -gel implant injected around the ureter opening
  • -creates a valve function and stops urine from flowing back up the ureter (prevents reflux)
  • -used for tx of VUR (vesicoureteral reflux)
    • -> has really changed how kids are managed
62
Q

VUR

A

vesicoureteral reflux

63
Q

“sibling reflux” w/VUR occurs how often?

A

20-30% occurrence rate

64
Q

do older siblings of kids w/primary VUR get a VCUG?

A

no–they just get a sonogram

65
Q

6 types of Urodynamic testing:

A

1) Simple flow (pressure of urine flow)
2) Flow/EMG
3) Urodynamic study
4) Video urodynamic study
5) Needle EMG urodynamic study
6) Neurostimulation testing

66
Q

how many school-age children experience daytime wetting?

A

5-10%

67
Q

do all bladder problems lead to wetting?

A

no!

68
Q

dysfunctional voiding & detrusor over-activity is often accompanied by…

A

recurrent UTI and/or constipation

69
Q

how many 5 yr olds wet the bed? is this considered a medical issue?

A

15% of all 5 yr olds wet the bed.

  • -d/t congenital small bladder & being a heavy sleeper
    • is not considered a medical issue until child turns 7
70
Q

should you work up a kid w/bedwetting if they’re under 7?

A

no! before age 7 should not be medically worked up

71
Q

wet-stop alarm

A

device attached to underwear; as start to pee, alarm goes off
(but may not work in v. heavy sleepers)

72
Q

nocturnal enuresis

A

nighttime bedwetting

73
Q

what should you do w/nocturnal enuresis?

A
  • -make sure pt doesn’t have a 24-hr problem: do voiding/drinking diary)
    • -> do not want to miss a neurogenic bladder!
  • -if capacity is normal, & there is normal frequency during the day w/out urgency or hesitancy–then pt. has high chance of success w/bedwetting alarm
  • -make sure parent/coach knows how to set up the program
74
Q

normal capacity

A

age +2 in ounces

75
Q

why should you do a voiding/drinking diary w/nocturnal enuresis?

A

to make sure pt doesn’t have a 24-hr problem:

do not want to miss a neurogenic bladder!

76
Q

meds for nocturnal enuresis

A
  • -DDAVP (desmopressin acetate), 0.2mg tabs

- -anticholinergics

77
Q

cause of nonneuropathic bladder?

A

detrusor instability

  • -from over or under activity
  • -assoc. w/possible imbalance of autonomic nervous system
78
Q

nonneuropathic bladder can lead to…

A

functional problems of storing & emptying

BUT can be improved or resolved w/healthy bladder behaviors & modifications

79
Q

w/a neurogenic bladder, you must have:

A

chronic catheterizations

80
Q

UTIs can cause what dangerous condition?

A

sepsis

81
Q

neuropathic bladder

A

assoc. w/spina bifida & other dysraphisms; transverse myelitis, spinal cord trauma, tethered cord, CP
- -leads to hypo or hyper or a-reflexia & likely detrusor-sphincter dyssynergy

82
Q

tx for neuropathic bladder:

A

help bladder store urine w/anticholinergics

–empty w/cathing

83
Q

3 types of voiding dysfunctions:

A

1) Nocturnal enuresis (primary, secondary)
2) Diurnal enuresis (daytime)
3) 24-hr wetting

84
Q

5 types of 24-hr wetting:

A

1: dysfunctional voiding formerly known as detrusor/sphincter dyssynergy
2: idiopathic detrusor over activity (detrusor instability)
3: idiopathic detrusor under activity (infrequent voiding)
4: bladder neck dysfunctions (primary, secondary)
also: dysfunctional elimination syndrome (wetting w/encopresis)

85
Q

encopresis

A

soiling (involuntary stool passing)

86
Q

parts of EMG:

A
  • -flow
  • -volume
  • -muscle activity
87
Q

type 1: dysfunctional voiding

A
  • -sphincter closes during voiding intermittently
  • -poor, intermittent flow; bladder instability
  • -residuals d/t increasing outlet resistance
  • -pelvic floor overactivity
88
Q

tx for classic dysfunctional voiding:

A
  • -timed voiding
  • -biofeedback to learn to relax
    • > 80% of pts benefit from anticholinergics
89
Q

EMG of dysfunctional voider:

A
  • -PVR (post-void residual) > 10% of voided volume
  • -staccato stream
  • -pelvic floor contraction creating a dip in flow
  • -early termination of flow
90
Q

Type 2: idiopathic detrusor over activity

overactive bladder

A
  • -0 second or negative EMG lag time
  • -explosive curves
  • -urge at low volumes
  • -wetting
  • -frequency
  • -bladder wall thickening on sono
91
Q

tx for idiopathic detrusor over activity

A
  • -timed voiding “cup story”
  • -anticholinergics
  • -“strengthen” pelvic floor w/biofeedback to prevent leaks
  • -monitor for constipation
92
Q

patho of idiopathic detrusor over activity

A

–detrusor is contracting more than it should, at low bladder volumes
(much below ECA)
–bladder wall thickening

93
Q

ECA

A

expected capacity for age

= age + 2 in ounces

94
Q

meds for overactive bladder:

A

Oxybutynin (Ditropan) (anticholinergic)
**liquid: titrate over 6-8 weeks to 0.2 mg/kg/dose BID-QID
–> give on empty stomach, 1 hr ac or 2 hr pc
Ditropan 5mg TID food okay, can be crushed
Ditropan XL 5, 10, 15 mg may have less ade’s, can’t be chewed or crushed, absorbed in colon

95
Q

Type 3: idiopathic detrusor under activity: patho?

A
  • -infrequent voiding; kid really holds urine back!
  • -large bladder capacity
  • -UTIs
  • -PVC could be > 10%
96
Q

worst-case scenario w/detrusor under activity (type 3)?

A

Hinman’s Syndrome:
non-neurologic neurogenic bladder
–can damage kidneys

97
Q

tx for detrusor under activity (type 3)?

A
  • -timed voiding & fluids to get bladder to cycle more normally
  • -regular hydration
  • -intermittent cath if severe
98
Q

type 4: primary bladder neck dysfunction

A

“shy bladder”

  • -prolonged EMG lag time, > 6 sec
  • -depressed flow
  • -high PVRs
  • -frequency, urgency w/hesitancy
  • -QMax shift to right
  • -small or large capacity
    • +/- wetting
99
Q

patho of type 4: primary bladder neck dysfunction

A
  • *bladder neck doesn’t funnel properly during voiding –> functional obstruction
  • -see prominent bladder neck on sonogram
100
Q

ype 4: secondary bladder neck dysfunction

A

d/t detrusor over activity or anatomic prob.

–hx of PUV (posterior urethral valves)

101
Q

can you use biofeedback w/bladder neck dysfunction?

A

no! no role for biofeedback…bladder neck is not under voluntary control!

102
Q

tx: bladder neck dysfunction

A

Alpha Blockers!!
–> Tamsulosin HCl (Flomax) 0.4mg capsules: open & give partially
–> older teens/adults: alfuzosin (Uroxatral) 10mg
–once/day after dinner
–> ADE: hypotension, stuffy nose, h/a
RELAXATION techniqes!! & education.

103
Q

KUB

A

flat plate of abdomen

104
Q

Bristol Stool chart

A

1-7:

1: little pebbles, 7: diarrhea

105
Q

most common abdom. mass?

A

stool! LLQ

106
Q

encopresis

A

stool holding: colon fills w/poop; stretches…requires more poop next time for you to get the urge to go
–> leakage, liquid stool

107
Q

when to do enemas?

A

in pts over 6 yrs:
on L side, or knees w/bottom up
–glycerin enemas in babies

108
Q

tx constipation

A
  • -scheduled BMs 1/2 hr after meal
  • -Miralax in juice or water
  • warm liquid first thing in am
  • -ground flax seed
  • -exlax or milk of magnesia
109
Q

dysfunctional elimination syndrome

A
  • -wetness & UTIs
  • -urgency, frequency, infrequency, constipation
  • start by tx’ing the CONSTIPATION*
  • -polyethylene glycol (Miralax), fiber
110
Q

UTI guidelines: dx

A
  • -abnormal u/a + positive culture
  • -positive culture = >50000 colonyforming units/mL
  • -assess likelihood of UTI
111
Q

UTI risk factors: infant girls

A 
race: white
age 39 degrees C
fever >2 days
absence of another source of infection
      ** w/1 risk factor: <2% risk
112
Q

UTI risk factors: infant boys

A

race: nonblack
temp: >39degrees C
fever > 24 hrs
absence of another source of infection
** circumcised + 2 risk factors: <2% risk
** uncircumcised: 0% risk

113
Q

if UTI progressed to pyelonephritis, you’d see:

A
  • -high fever

- -vomiting

114
Q

S&S UTIs

A
  • -new onset enuresis (nocturnal +/- diurnal)
  • -+/- fever
  • -dysuria
  • -urgency, frequency
  • -hematuria
  • -flank pain
115
Q

if you suspect UTI:

A

ALWAYS get u/a AND urine culture

116
Q

patho of UTI

A
  • -distal urethra always colonized
  • -proximal urethra, bladder, ureters, kidneys, usually sterile
  • -normal voiding regularly flushes out any microbes
  • -turbulent flow can propel microbes higher into system/cause tears in uroepithelial lining (fosters attach. of microbes)
  • -adhering microbes causes inflam. response in ureter: fosters upward migration
117
Q

w/UTIs caused by proteus/pseudomonas:

A

you prob have some type of anatomical prob: dysfunctional voiding

118
Q

does infection from UTI cause renal damage?

A

no: the reflux of urine or lack of proper draining of kidneys (hydronephrosis) causes renal damage, not the infection

119
Q

imagine for febrile infants w/UTI?

A
  • -should undergo renal & bladder ultrasonography (RBUS) w/in 2 days
    • -> if RBUS is normal, don’t do VCUG after 1st febrile UTI
120
Q

UTI antibiotics

A
  • -Bactrim suspension 40/200/5 mg: 5ml/10kg BID for 7-10 days
  • -Primsol suspension 10mg/kg
  • -Keflex 50-75 mg/kg/24hr divided by q6hr
  • *if no s/s: treat w/hydration, frequent voids
121
Q

must you tx w/meds for kid w/neurogenic bladder?

A

colonization does not REQUIRE tx in kid w/neurogenic bladder:
requires hydration & frequent voiding

122
Q

Vesicoureteral reflux (VUR)

A

Grade 1-5, depend. on how high up it goes

  • -need 2 fill/voiding cycles on VCUG to rule it out
  • -sibling reflux, 20-30%
123
Q

VUR primary/secondary

A

prim: from birth
second: from voiding dysfunction

124
Q

VUR tx

A

antibiotic prophylaxis

Deflux +/or re-implant surgery

125
Q

VUR grades 3-5:

A

has gone up into kidneys

126
Q

posterior urethral valves (PUVs)

A
  • -cause bladder obstruction in males
  • -1 in 8000 to 1 in25000 live births
  • -range in severity: incompatible w/life to v. little sx
  • -“tissue flaps” in posterior urethra require surg.
127
Q

PUVs can cause:

A

renal unsufficiency in 10-15% of kids undergoing renal transplantation

128
Q

how many kids w/PUVs progress to end-stage renal disease?

A

1/3

129
Q

patho of PUVs:

A

–dur. early embryogenesis, caudal end of Wolffian duct is absorbed into the primitive cloaca @ site of future verumontanum in posterior urethra

130
Q

patho, type 1 PUV

A

obstruction resulting from abnormal insertion & absorption of most distal aspects of Wolffian ducts during bladder develop.
(in healthy males, remnants of this process are the posterior urethral folds: plicae colliculi)

131
Q

type 3 PUVs

A

valves are observed as a membrane in the posterior uretha

–believed to originate from incomplete canalization b/t ant & post urethra

132
Q

patho: type 3 PUVs

A

instead of a true valve, a persistent oblique membrane is ruptured by initial catheter placement

  • -s/t rupture, forms a valvelike configuration
  • -bladder dysfunction may –> ongoing & progressive renal deterioration
  • *increased collagen deposition & muscle hypertrophy d/t obstructive process thicken the bladder wall
  • *hypertrophy, hyperplasia of the detrusor muscle; increases in connec. tissue limit bladder compliance during filling
  • *bladder emptying occurs at high pressures –> can be transmitted to ureters, up into renal collecting system
  • *bladder decompensation may develop
133
Q

type 3 PUVs, what happens after bladder decompensation?

A

detrusor failure & increased bladder capacity

  • -boys develop larger-than-expected bladder volumes by age 11; possibly d/t overproduction of urine from tubular dysfunction, & inability to concentrate urine
    • -> nephrogenic diabetes insipidus
  • -bladder function may change at puberty –> high-press., chronic retention –> need for lifelong bladder management
134
Q

presentation of type 3 PUVs

A
  • -antenatal dx
  • -work up for UTI
  • -in older child: poor growth, htn, lethargy
  • *Refer all males w/UTI for renal bladder u.s.**
135
Q

outcome: PUVs

A

susceptible to incontinence, infection, progressive renal damage

136
Q

tx for PUVs:

A
  • -Alpha Blockers +/- anticholinergics
  • -double voiding
  • -overnight catheterization

Peds Patho (8 decks)

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