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Pediatric GU

Terms in this set (73)

Who should be present during GU exam in pediatric pt?
Chaperone/parent
Should you ever do a GU exam without having the pants down?
No ( have pt lied down pants down all the way, parents can help hold legs in double triangle poison or crisscross applesauce! make sure you look for signs of abuse)
Vesicoureteral Reflux (VUR)
reflex of urine from bladder to upper urinary tract (urine goes up rather than down)
What is primary VUR caused by?
Incompetent or inadequate closure of UVJ
What is secondary VUR caused by?
high pressure in bladder (functional bladder obstruction, posterior urethral valves)
VUR presents in __% of new borns usually more common in assigned males less than ___ years of age with strong ____ history
1, 2, family
____-___% if kids with febrile UTI with VUR
30-40
What is the gold strand for dx of VUR
voiding cystourethrogram (VCUG)
What are some of the dx (not the gold standard of VCUG) can be used for dx of VUR
Prenatal US showing hydronephrosis, US should be done in ALL peds with UTI, radionuclide cystogram
Grade 1 and II VCUG Reflux has ___% chance of spontaneous resolution. What is the tx?
80, monitor for spontaneous resolution, consider prophylactic antibiotics
Reflux fills and mildly dilates the ureter and collection system, mild blunting of the calyces
VCUG reflex
Name the Grade of VCUG Reflex.
● fills/mildly dilates ureter and collecting system, mild blunting of calyces
○ Spontaneous resolution 70% < 2years to 20% > 5years
Grade III
Name the Grade of VCUG Reflex:
fills/grossly dilates ureter and collecting system, blunting calyces
○ tortuosity of ureter
○ Spontaneous resolution 60% unilateral, 10% bilateral
Grade IV
Name the Grade of VCUG Reflex:
● Massive reflux grossly dilates collecting system, calyces blunted, significant ureteral dilation/tortuosity
○ Rarely spontaneously resolves
Grade V
Grade III-V VCUG reflexes
regardless of age antibiotic prophylaxis.. What do we give??
● _____ or _____
■ Monitor for spontaneous resolution
■ Trial of therapeutic intervention before surgery
● Surgical correction: with stent to keep junction open
○ Grade __reflux with scarring
○ Grade __reflux >6yo
○ Only if.. Failed medical therapy or side effects from antibiotics
TMP-SMX or nitrofurantoin, V, V
Membranous folds in the posterior urethra that obstruct urinary flow
Posterior urethral valves
Presentation of PUV (posterior urethral valves)
assigned male infants, UTIs, Respiratory distress syndrome, straining with urination, weak stream/dry diapers
Congenital obstructive posterior urethral membrane same as PUV but abbreviated as
COPUM
How is PUV/COPUM diagnosed?
Prenatal US (will show bilateral hydronephrosis, distended and thickened bladder and possible oligohydramnios (low amniotic fluid), Postnatal VCUG and cystoscopy
What is prenatal tx of PUV?
Vesicoamniotic shunt (this is experimental-distal end in the fetal bladder and the proximal end in the amniotic cavity to allow drainage of fetal urine)
What is postnatal tx of PUV?
Correction of electrolyte abnormalities, Foley catheter, Surgical correction
What is it called when there is involuntary urination that often occurs at night. 15% of kids at age 5 have this condition but by 18 only 1% have it and only 1% have onset after age 7
enuresis
When a child has never had night time dryness
Primary enuresis (80%)
Enueriss after period of night time dryness often d/t psychological stress
Secondary enuresis
How is enuresis diagnosed?
UA
Additional considerations for day time wetting include: (5)
VCUG, US, MRI of spine, abdominal X-ray, referral (urology, nephrology, neurosurgery)
What model model helps to direct treatment fo eneureis?
Three system model
What are some pharm options for enuresis?
Desmopressin, anticholingeric meds
For day wetting what are some tx options?
Behavioral therapy (Main one), anticholinergics (oxybutynin)
Urotherapy tx options for enuresis include (3)
charting, fluid restriction at bedtime, night lifting and alarms (Sensor can detect how much fluid in bladder and put off alarm so child wakes up to use bathroom)
An open inside out bladder? More common in white infants and newborns
Exstrophy
What is Extrophy of bladder associated with
Epispadias, cloacal extrophy
What are the 3 main causes for enuresis? What do all three types used as tx?
Night time polyuria, OAB/small capacity bladder, Lack of arousal, urotherapy
Night time polyuria tx
-This is large voided amounts before or around midnight
Urotherapy, desmopressin or desmopressin and alarm therapy
OAB/ small bladder capacity tx

-This is variable voided amounts, multiple times through the night
urotherapy, anticholinergic tx
Lack of arousal enuresis tx
-Early morning voids, reluctance to leave the bed
urotherapy, alarm therapy
Dx of exstrophy of bladder
Prenatal US, MRI
Treatment of exstrophy of bladder
Prenatal education and counseling of parents. Induced C-Section and surgery within 72 hrs of delivery
What is the term for ventrally displaced urethral opening. Pt may have dribbling of urine when the child urinates, will see chordee (ventral curvature of penis), phimosis present (inability to retract foreskin), possible cryptochidism
Hypospadias
should children with hyposapdisas be circumsized?
No since foreskin will be used for repair
What should we also check for in pts with hypospadias?
Inguinal hernias via US
When doing PE of hypospadias and you ____ the foreskin put it back!
retract (to help prevent phimosis)
Isolated hypospadias tx
repair before 18 months (using skin from foreskin-NO circumsicion at birth)
Hypospadias and cryptorchidism tx
Have increased risk of ___ genitilia so perform a pelvic ___ and ___
intersex, US, karyotype
Female phenotype, male genotype, X-linked recessive, dysfunctional androgen receptor. Male brain and body are unreponsive to androgens and are feminized d/t maternal estrogens
Androgen insensitivity syndrome
In puberty people with AIS S/S include
Testes not ____
Female secondary sexual characteristics
___ development
Vagina
___ Uterus
A____
descend, breast, absent, amenorrhea
AIS hormone and metabolic profile
Increased plasma _____, e___, and t____ concentration
___ levels are often normal or slightly increased
Resistance to androgenic and metabolic affects of t___
LH, estradiol, testosterone, FSH (normal/increased), testosterone
What is the most common identifiable cause of intersex genitalia?
Androgen insensitivity
What has been reported in AIS d/t testes being predisposed to malignant transformation?
Carcinoma in situ and seminoma
AIS tx
1. Sex assignment determined by age of dx, pt and family _____
2. Generally reared as ____ in complete form of androgen sensitivity
3. Remove ___ d/t risk of malignancy
4. Shortened ____ (will need surgical intervention
5. ____ tx after gonacdectomy
6. Genetic ____ and family therapy recommended
decision, female, testes, vagina, estrogen, counseling
Undescended, absent or atrophic testes
cryptorchidism
Cryptorchidism tx
palpable-orchiopexy, non-palpable- explorative surgery
Bell clapper=? ABSENT cremaster reflex
Testicular torsion
Twisting of testes on spermatic cord, known as "bell clapper" deformity. Results in venous compression, edema of testical and cord, ischemia of testicle
testicular torsion
What are 2 peak incidences of testicular torsion?
Neonatal period, puberty
S/S/PE of Testicular Torsion include
Abrupt onset of SEVERE ___ or __ pain
<__hrs duration
Associated n/v
scrotum is e___ indurated and e___
Tender swollen and slightly elevated and testes may lie h____
testicular, scrotal, 12, edematous, erythematous,horizontally
How is diagnosis for testicular torsion made?
Clinically (often happens during sleep) US or nuclear scan of scrotum to assess for decreased perfusion
Tx if both testes viable for testicular torsion
Surgical detorsion and fixation
What if Testicular torsion testes are NOT viable?
○ Orchiectomy if testicle nonviable
■ Detorsion within __ to __ hours — 100 percent viability
■ Detorsion after __ hours — 20 percent viability
■ Detorsion after ___ hours — 0 percent viability
4-6, 12, 24
Is manual detorsion recommended in tx of testicular torsion?
No b/c you can't confirm if you have rotated it back all the way and you can twist it even more than it already is
Collection of peritoneal fluid in tunica vaginalis that is common in newborns and resolves spontaneously by first birthday
Hydrocele
Process vaginalisDOES NOT close (size can vary in different positions and time of day can be reduced by milking)
Communicating hydrocele
Process vaginals is closed (may increased in size but does not decrease.. can't reduce by milking)
Non-communicating
Dx of hydrocele
transillumination, US
What is tx of hydrocele if not spontaneously resolved by first birthday?
Surgical repair
Collection of dilated and tortuous veins surrounding the spermatic cord. More common on LEFT side. Feels like a Bag of worms.
Varicocele
Management of Varicoceole
Managed conservatively with ___
○ surgical ligation or testicular vein embolization when:
■ Loss of testicular_____ associated with a decreased ___ count
■ Alleviate symptoms: pain, heaviness, swelling
■ Bilateral varicoceles
observation, volume, sperm
Obstructive lesions of female genital tract diagnosed as newborn
Imperforate hymen
Treatment Imperforate hymen
surgical repair under anesthesia, elliptical incision of membrane, evacuation of obstructed material
Excess androgen acting on fetus
Congenital virilizing adrenal hyperplasia
What does congenital virilizing adrenal hyperplasia cause in females?
androgenization of external genitalia
What is appearance of congenital viriilizing adrenal hyperplasia?
Mild clitorial enlargement that appear as scrotal sac, testes and penis, may have salt wasting and abnormal electrolytes
Condition in which individual has single chromosomal and gonadal sex but combines features of both sexes in external genitalia causing doubt as to true sex
intersex genitalia
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