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Peds Blueprint: Urology/Renal

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What is Glomerulonephritis (GN)?
AKA Nephritic syndrome. Damage to the renal glomeruli due to inflammatory proteins in the glomerular membranes as the result of an immunologic response. 60% of cases are in children 2-12. Prognosis is excellent in children, worse in adults. Can be focal (affects <50%) or diffuse (affects >50%)
What are causes of GN in children?
Benign hematuria
Honoch-Schonlein purpura
IgA nephropathy
Hereditary nephritis
Postinfectious GN
Membranoproliferative GN
Clinical features of GN?
HEMATURIA!
TEA or COLA colored urine
Dysmorphic RBCs
Variable proteinuria
Oliguria
Edema of face and eyes in morning, feet and ankles in the evening
Which urinary laboratory abnormality is most suggestive of the diagnosis of acute glomerulonephritis?
RBC casts
Diagnostic studies for GN?
Antistrepolysin-O titer
UA - hematuria, RBC casts, proteinuria
Renal biopsy
Treatment for GN?
Steroids and immunosuppresive drugs
Low Na diet
Fluid restriction
Dialysis if azotemia is present
ACE-I for chronic GN
What is Cystitis?
Bladder infection AKA UTI
What are the the most common bacteria that cause UTIs?
E. coli
Proteus
What are clinical features of a UTI?
More common in women
Irritative voiding symptoms (frequency, dysuria, urgency)
Suprapubic discomfort
Gross hematuria
Diagnostic studies for UTI?
UA shows +WBCs, +Nitrites, +RBCs
+Culture
What is first line for uncomplicated cystitis?
Nitrofurantoin 100mg PO BID for 5 days
TMP/SMX 160/80mg 1 DS (double strength) PO BID x 3 days
Fosfomycin 3g PO x 1 day
Cipro (second line but used often 1st line)
If a male is diagnosed with a UTI, how long is the course of treatment?
14 days
Symptomatic tx for UTI?
Phenazopyridine (Pyridium) <----will turn urine orange and stain
Fluids
What is a Wilm's tumor?
AKA Nephroblastoma. It is the most common solid renal tumor of childhood.
Clinical features of a Wilm's tumor?
Asymptomatic abdominal mass usually found by a caretaker or during PE.
Anorexia
N/V
Fever
Abdominal pain
Hematuria
HTN - caused by elevated renin levels
Diagnostic studies for a Wilm's tumor?
UA - hematuria
U/S - initial study of choice
Abdominal CT or MRI - assesses tumor extension and regional lymph nodes
CXR - assesses mets to lungs
Tx of Wilm's tumor?
Multi-modal approach: Surgery, chemo, radiation (in select patients) is most effective therapy
Radical nephrectomy is TOC in surgically resectable tumors
What is Phimosis?
Inability to retract the foreskin over the glans penis. Can be congenital or acquired
Tx for phimosis?
Asymptomatic phimosis should be left alone
If symptomatic, circumcision is usually necessary
Abx if infection is present
What is Paraphimosis?
Inability to return the retracted foreskin over the glans penis. Predisposing factors include forcibly retracting the foreskin where there is phimosis, vigorous sexual activity, or frequent caths. Medical emergency!
Clinical features of paraphimosis
Pain and edema
Tenderness
Erythema of glans
Tx of paraphimosis?
Manual reduction should be tried initially (squeeze the glans for 5 min to reduce swelling and then try to pull foreskin)
Definitive tx is circumcision
What is a Hydrocele?
Mass of fluid-filled congenital remnants of the tunica vaginalis, usually resulting from a patent processus vaginalis.
Clinical features of a hydrocele?
Soft, non-tender fullness of the hemiscrotum that transilluminates
May wax and wane in size
Tx for hydrocele?
Elective repair
What is Testicular torsion?
Testis is abnormally twisted on its spermatic cord which compromises arterial supply and venous drainage leading to ischemia. Surgical emergency!
Risk factors for testicular torsion?
Postpubertal boys ages 12-18, especially with a history of cryptorchidism
Clinical features of testicular torsion?
Sudden onset of severe unilateral pain and scrotal swelling
Testes are painful to palpation
Negative Phren's sign
Diagnostic studies for testicular torsion?
Clinical diagnosis
Doppler U/S demonstrates decreased blood flow
Tx for testicular torsion?
Mild analgesics
Manual detorsion (twist outward and laterally)
Surgical detorsion and orchiopexy are definitive therapies
Elective orchiopexy for contralateral testis is recommended
What is cryptorchidism? Who is at highest risk?
Absence of one or both testes from the scrotum. Highest risk is in premies
How do you differentiate between retractile testicle and undescended testicle?
Pull and hold until cremaster is fatigued. Retractile testicle will descend.
What percent of boys with undescended testes when they are born will still have undescended testes after a year?
1%
What is medical treatment for cryptorchidism?
Hormonal therapy - hCG 2000 IU twice a week for up to 10 weeks. Resolves 50% of cases.
What is surgical treatment for cryptorchidism?
Orchiopexy - Incision over inguinal canal is made. Testis, cord, and blood supply are brought in to scrotum and sutured to scrotum tissue. Vaginal process is closed to prevent inguinal hernias. If testis are in abdomen, multi-stage surgeries are needed.
What is Hypospadias?
Abnormal placement of the urethra where the meatus is proximal and ventral to its normal or anterior location.
Tx for hypospadias?
Do not circumcise
Bilateral renal U/S to rule out ascending pathology
Pediatric urology referral is needed
What is Enuresis?
Repeated voiding 2x a week for 3 months in a child at least 5 years old. Can be primary or secondary (resumed wetting at night after being dry for 6 months). Primary is more common and boys are more affected than girls.
What is first line treatment for enuresis?
Non-pharm therapy
What are non-pharm therapies for enuresis? Which is most effective?
Education
Journal keeping
Fluid restriction
Nighttime awakenings to void
Moisture bed alarm <---most effective
What is pharm therapy for enuresis?
DDAVP - nasal or PO <----DOC
Imipramine
What is Vesicourethral reflux (VUR)?
Retrograde passage of urine from the bladder into the upper urinary tract. It is the most common urologic finding in children, occurring in approximately 1 percent of newborns, and as many as 30 to 45 percent of young children with a urinary tract infection.
Clinical presentation of VUR?
Hydronephrosis
Recurrent UTIs
Dx of VUR?
Contrast voiding cystourethrogram (VCUG) <---best test
Radionuclide cystogram (RNC)
Tx of VUR?
Can resolve spontaneously
Antibiotics for UTI
Surgery
What is the most common solid renal tumor in children?
Wilm's tumor
What is it called when we can't retract the foreskin over the glans penis?
Phimosis
What leads to paraphimosis?
Frequent catheterizations without reducing the foreskin
Which two scrotal masses trans-illuminate?
Hydrocele and Spermatocele
Blue dot sign
Torsion of the appendix testis