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Pediatric GU

Terms in this set (162)

hypospadias
_____ is when the urethral meatus is located below and proximal to its normal position
-ventral surface of the penile shaft
hypospadias
-usually an isolated anomaly but may be found with multiple congenital anomalies
-10% have undescended testicles
-inguinal hernias are more common
-increased incidence of chordee
inguinal hernias
_____ _____ are more common with hypospadias
chordee
with hypospadias, there is an increased incidence of _____ which is a ventral penile curvature with erection
circumcision
with hypospadias _____ is contraindicated
surgical correction
Tx for hypospadias
-in healthy infants 6-12 months old
-usually 1 stage procedure
-may require 2 stages in proximal cases
complications in untreated hypospadias
-deformity of urinary stream
-sexual dysfunction secondary to penile curvature
-infertility
-metal stenosis (congenital) rare
epispadias
_____ is when the urethral meatus is on the dorsal of the penis
bladder exstrophy
epispadias may be associated with _____ _____ - in most severe form, bladder protrudes from the abdominal wall and mucosa is exposed
reconstruction
Tx for epispadias
-surgical _____ of urethra and penis
cryptorchidism
_____ is an issue of undescended testicles
lingual canal
-failure of the testes to descend through the _____ _____ and into the scrotum
unilateral and right sides
-10% are bilateral
cryptorchidism is most often _____ and _____ sided
incidence in full term brith: 2-4%
incidence in premature infants: 9-30%
what is the incidence for cryptorchidism... when do we see this more?
4-6 months
how long do we wait to see if the testes spontaneously descend?
U/S, CT, or MRI
if the testes do not spontaneously descend after 4-6 moths then may need _____, _____, or _____ to locate abdominal testes
U/S
_____ has been shown to be unreliable in some studies when trying to locate the abdominal testes
diagnostic laparoscopy
if U/S, CT, and MRI cannot locate the abdominal testes then a _____ _____ may be necessary
infertility
tumor
torsion
3 main risks with cryptorchidism?
infertility
-_____ if untreated
-if bilateral only 1/3 will be fertile even if treated
tumor
-increased risk of _____ especially if untreated
-5-10x higher risk than the general population
-may be on contralateral side
torsion
pts with cryptorchidism also have an increased risk of _____
refer for surgical orchidopexy by 6-12 months old
Tx for cryptorchidism?
retractable testes
exaggerated creamasteric reflex causes testes to retract into inguinal canal
palpation
careful _____ can lower testicles into the scrotum
adolescence
usually will remain in the scrotum by _____
-about 1/3 become acquired undescended testicle
does not have the associated complications of cyrptorchidism
do retractable testes have the same associated complications (infertility, tumor, torsion) of cryptorchidism?
phimosis
-inability to retract the foreskin after approximately 3 years old
paraphimosis
-inability of retracted foreskin to be reduced
-usually will lead to painful venous stasis in retracted foreskin
paraphimosis
acute treatment for _____
-lubrication of foreskin and glans
-compression of glans with distal traction of foreskin
-rarely emergent surgical correction
circumcision
_____ ti prevent recurrences of phimosis and paraphimosis
testicular torsion
_____ _____ is a twisting of the testicle on itself resulting in impairment of blood flow to the testicle
testicular torsion
what the the most common cause of acute testicular pain in boys > 12 y/o?
uncommon before 10 years old
testicular torsion is uncommon before what age?
absent
testicular torsion S/S
-acute onset pain
-swelling
-creamasteric reflex _____
-N/V
diagnosis methods for testicular torsion
-U/S = 1 number choice
-isotopic scan
isotropic scan
an _____ _____ us used in diagnosis of testicular torsion; it detects reduced blood flow
prompt
Tx of testicular torsion
-_____ surgical correction
6hrs
90% of viable if testicular torsion is corrected within _____
scrotal orchipexy
_____ _____- detorsion and fixing of testicle to scrotum with non-absorbed suture
epididymitis
inflammation of the epididymis
epididymitis
-rare before adolescence
-#1 cause of acute scrotal pain >18 y/o
causes/ etiology of epididymitis
-bacterial (gonorrhea or chlyamydi, E.coli)
-viral
-inflammatory
-HSP (a vasculitis that can affect the spermatic cord)
epididymitis
-scrotal pain
-swelling
-may have h/o sexual activity or recent UTI
tenderness
_____ of scrotum localized to epididymis
pain may be received by lifting the scrotum --> Prehn Sign
how may pain be relived in epididymitis?
pyuria
labs: U/A usually shows _____
-epididymitis
epididymitis
Tx for _____
-bed rest
-scrotal elevation
-antibiotics usually doxycycline in adolescents
-must rule out torsion
urinary tract infection
most common genitourinary disease in children?
unexplained fever
UTI should be considered in children 2 months to 2 years old with _____ _____
males
who is more likely to have a UTI... first month of life?
female
who is more likely to have a UTI... after 1 month?
E. Coli

also Klebsiella, Proteus, enterococci, staphylococcus
most common cause of UTI by 75-90%?
predisposing factors of UTI
-5-20x higher incidence in uncircumcised males compared to circumcised males
-short urethra in girls
-position of the urethral opening in relation to the anus
-toilet training: wiping back to from = no good
-vesicourteral reflex
-hydronephrotic kidney
-holding of urine
-irritation: bubble baths, certain soaps, sprays
-tight clothing
-constipation / diarrhea
-sexual activity
neonates
UTI in what age group?
-failure to thrive
-V/D
-feeding problems
-jaundice
-hypothermia
1 month to 2 years
UTI in what age group?
-unexplained fever
-diarrhea
-feeding problems
-"colic"
-"irritability"
2-6 years old
UTI in what age group?
-vague abdominal pain
-vague genital complaints
-vomiting
-fever
-enuresis
-may have classic UTU symptoms
6 years and older
UTI in what age group?
-fever
-urgency
-dysuria
-nocturia
-suprapubic tenderness

-in this age group vomiting, fevers and or back pain is indicative of upper urinary tract infection (pyelonephritis)
urinary tract infection
diagnosis for _____?
U/A
-first AM specimen is best
-may show WBC, RBC
-nitrites very suspicious
urine culture
_____ _____ is still the gold standard--- colony count >50,000 colonies / mL if a single pathogen and >100,000 in bag sample with a single pathogen
catheterize, suprapubic aspiration
if infants and young children may have to _____ or use _____ _____
not reliable
collection of urine in a bag is _____ _____, especially in pts who are ill enough to immediately being antibiotic treatment
-can only be used if culture negative or single uropathogen is identified
neonates
treatment for what age group quirk a UTI?
10-14 days of parenteral antibiotics; often associated with bacteremia
Amoxicillin
Nitrofurantoin
Bactrim or 1st gen Ceph

-continue antibiotic for 7-14 days in 2 months to 2 year old
-otherwise 3-5 days is usually enough
most children with uncomplicated lower UTI treatment? (3)
true
True or False:
with UTI...repeat U/A 4-7 days after therapy if responding to treatment
repeat culture
_____ _____ in 2-3 days if the pt has not had the expected clinical response
broad spectrum antibiotic x 10 days
if signs of pyelonephritis but NOT toxic what treatment?
hospitalization

third generation Ceph: Cefriaxone

Ampicillin and Gentamicin
if toxic looking, dehydrated or unable to retain oral intake what treatment?
indications for radiologic workup
-UTI in male
-UTI first year of life (AAP states under 2 y/o)
-UTI with pyelonephritis or unresponsive to Rx
-recurrent infection
radiologic work up for UTI
1) U/S of urinary tract

2)VCUG (void cystourethrogram): preferred for initial workup

3)RUG (radionuclide cystography): used more for follow up our to less radiation than VCUG)
vesicoureteral reflux
reflux of urine from bladder up the ureter due to incompetence of the valave at the ureterovesical junction
grade 1
reflux of urine into nondilated ureter
grade 2
reflux into renal pelvis, still without dilation
grade 3
dilation of ureter or blunting of calyceal fornices
grade 4
reflux into grossly dilated ureter
grade 5
massive reflux with ureteral dilation and tortuosity and dilation and effacement of calyces Detials
asymptomatic
is vesicoureteral reflux symptomatic / asymptomatic
vesicoureteral reflux
_____ may be found during a work up for:
-UTI
-renal failure
-voiding dysfunction
-problem in a sibling (30-40%)
voiding cystouurethrogram (VCUG)
-cannot be performed while there is a UTI
diagnosis for vesicoureteral reflux?
kidney
if reflux is present, further testing may be indicated to rule out damage to _____:
-BP
-creatinine clearance
-U/S to determine kidney size
-IVP to determine extent of scarring and function
treatment for grade 1-2
treatment of what grade of vesicoureteral reflux...
-spontaneous resolution is high
-expectant waiting with or without prophylactic antibiotics:Sulfa or Nitrofurantoin
-urine cultures every month at first
grade 3
treatment of what grade of vesicoureteral reflux...
-same as grade 1-2 treatment
-same as above but routine parenchymal scans to watch for new scaring
-50% will need surgery
treatment for grade 4-5
treatment of what grade of vesicoureteral reflux...
-spontaneous resolution unlikely
-surgery after brief period of prophylaxis and confirmation of grade
renal parenchymal scarring
end stage renal disease
2 main complications of vesicoureteral reflux?
poststreptococcal glomerulonephritis
epidemiology
-follow strep infection in 7-14 days
-only certain strains of strep cause this
-most common in children 5-12 years old
poststreptococcal glomerulonephritis
-antigen antibody complex is deposited in glomerular basement membrane
-activated complement
-inflammatory response
poststreptococcal glomerulonephritis
most frequent initial signs
-edema: periorbital, facial, extremities
-tea or cola colored urine

-may have asymptomatic hematuria
poststreptococcal glomerulonephritis
typical findings of
-hematuria
-edema
-hypertension (headache)
-oliguria
-fever is uncommon
-may ave acute renal failure
poststreptococcal glomerulonephritis
labs...
U/A
-RBCs
-mild to moderate protein
-concentrate urine (> specific gravity)
-microscopic RBC and granular casts
anti-streptococcal antibody test
verify previous strep infection with what?
low C3 levels
what indicated activation of complement system?
antibiotics is strep infection still present
treatment for poststreptococcal glomerulonephritis?
diuretics
_____ can be used for
-hypertension
-pulmonary edema
-heart failure
-oliguria

-in Tx of poststreptococcal glomerulonephritis
hydralazine
_____ for hypertension alone

-Tx of poststreptococcal glomerulonephritis
hemodialysis or peritoneal dialysis
in poststreptococcal glomerulonephritis... may require _____ or _____ _____ for renal failure
proteinuria and edema
_____ and _____ decline in 5-10 days
microscopic hematuria
_____ _____ may persist for months to years
C3
_____ returns to norma in 6-8 weeks
Rena failure
if present, _____ _____ in 2-3 weeks
poststreptococcal glomerulonephritis
overall, 85-95% recover completely in _____ _____
-encephalopathy
-renal failure
-heart filature (secondary to HTN or hypervolumeia)
-nephrotic syndrome
complications of poststreptococcal glomerulonephritis?
hemolytic uremic syndrome
-4 months to 4 years of age
-most common cause of renal failures in children
infection with Shiga Toxin Producing Shigella or E. Coli
hemolytic uremic syndrome cause?
hemolytic uremic syndrome
-infection with Shiga Toxin Producing Shigella or E. Coli
-from undercooked beef or unpasteurized foods
-many different stereotypes but most common pathogen in US is E. coli
hemolytic uremic syndrome
-circulating toxins bind to specific receptor on endothelium
-swelling and cell injury occur
-localized clotting and platelet activation
-microvascular occlusion
hemolytic uremic syndrome
symptoms
-lethargy
-weakness
-irritability
-oliguria
---all 7-10 days after onset of gastroenteritis (blood diarrhea, abdominal pain, vomiting)

signs
-pallor
-edema
-petechiae
-heptaosplenomegaly

-may develop seizures or HTN
triad of...
Anemia (form hemolysis)
Thrombocytopenia
Renal Insufficiency
what is the triad seen in hemolytic uremic syndrome?
thrombocytopenia (profound)
anemia (profound)
hemolytic uremic syndrome
-CBC?
schistocytes
helmet and burr cells
fragmented erythrocytes (a hemolytic anemia)
hemolytic uremic syndrome
-blood smears?
elevated
hemolytic uremic syndrome
-reticulocyte count?
negative
hemolytic uremic syndrome
-coombs tets?
WNL
hemolytic uremic syndrome
-serum complement?
hematuria, proteinuria, casts
hemolytic uremic syndrome
-U/A?
Tx of hemolytic uremic syndrome
-therapy for acute renal failure
-control HTN and fluid balance
-many require dialysis
-blood and or plasma transfusion
complications of hemolytic uremic syndrome
-renal failure
-seizures
-severe bleeding
hemolytic uremic syndrome
course for ?
-most recover from acute episodes in 2-3 weeks
-residual renal disease (may include HTN) in 30% and 5% remain dependent on dialysis
-end stage renal disease 15%
-mortality 3-5% (usually from CNS or cardiac complications)
proteinuria
hypoproteinemia
hypercholesterolemia
edema
nephrotic syndrome consists if what 4 things?
proteinuria
-due to increased permeability of mealy albumin through the basement membrane
->2 gm/m2/s4hrs or >3.5 g/24hrs
-if +1 one a UA must confirm
hypoproteinemia
-serum albumin <2.5 gm/d
hypercholesterolemia
-hypoproteinemia stimulates hepatic lipoprotein synthesis
-total cholesterol > 200 mg/dl
idiopathic (minimum change) nephrotic syndrome of childhood
most common form nephrotic syndrome in children is what?
nephrotic syndrome
-male 2:1 predominance
-usually < 6 years old at onset
-children 7-14 years old... 50% will be idiopathic
nephrotic syndrome
most common presentation is:
-periorbital edema
-dependent pitting edema
-weight gain
-ascites
dyspnea
with marked edema, _____ due to pleural effusions
absent
-severe or persistent hematuria
-renal insufficiency
-hypertension
-hypocomplementia

all of these are present / absent in nephrotic syndrome
Prednisone 2mg
treatment of nephrotic syndrome?
5 days or maximum 6 weeks

-then single every other day dose x 6 weeks
-then taper over 2-5 months
in nephrotic syndrome... Prednisone 2mg should be continued until urine protein is negative for how long?
renal biopsy
if not responsive in initial 4 weeks what should we do with pts who have nephrotic syndrome?
edema
in nephrotic syndrome... _____ treated with salt restriction and fluid restriction
-usually 2 gram sodium diet
-sometimes a diuretic is used but must be careful not to decrease plasma volume any further
potassium
in nephrotic syndrome
-_____ supplementation may be necessary
peritonitis
in nephrotic syndrome
-treat infections such as _____ with antibiotics
Pneumococcal (vaccine)
in nephrotic syndrome
-pts should get the _____ vaccine
beta blockers or CCB
in nephrotic syndrome
-hypertension treated with _____ _____ or _____
nephrotic syndrome
-relapse common 80%
-treatment is same for each recurrence
infection
hypercoagulability
thromboembolic events
3 main complications in nephrotic syndrome?
Strep Pneumonia or E. Coli
-treat with 3rd generation Ceph
in nephrotic syndrome... infections especially peritonitis with what 2 strains of bacteria?
enuresis
involuntary discharge of urine after an age when bladder control is expected (usually around 5 years old) at least 2x per week for 3 months
diurnal enuresis
-daytime wetting
-not as common
-most common case is urge incontinence
-giggle or stress incontinence
diurnal enuresis
more associated with...
-stress
-psychiatric disorders
-UTI
-DM
-DI
nocturnal enuresis
-nght time wetting
primary and secondary
enuresis categories?
primary
-the pt never achieved a sustained period of bladder control
secondary
-wetting after a period of bladder control
-most consider 6 months of control

more associated with:
-UTI
-stress (new home, parent problems)
-sibiling rivalry
-DM
-DI
primary nocturnal enuresis
90% of enuresis is what kind?
primary nocturnal enuresis
at 5 y/o
-7% inn males; 3% in females

at 10 y/o
-3% in males; 2% in females

at 18 y/o
-1% in males; rare in females
familial primary nocturnal enuresis
-usually history in parent or sibling
-1 parent = 44% incidence
-2 parents = 77% incidence
true
true or false:
-each year of increasing age has decreases in incidence of problems
probably immaturity of sleep arousal system, bladder capacity, or neuroendocrine system
etiology of primary nocturnal enuresis may include...?
LOWER
-most recent theory is immaturity of neuroendocrine system with _____ amount of ADH / vasopressin
ADH / vasopressin
_____ usually decreased the amount of urine produced at night
baseline
need to take the pts _____ which includes
-number of lights per week
-times per night
-past attempts at treatment
deep sleeper
parents usually blame this on the fact that the pt is a _____ _____
negative
U/A is _____

-primary nocturnal enuresis
urinary stream
observation of _____ _____ can r/o lower tract obstruction
no
are U/S, IVP, VCUG necessary in primary nocturnal enuresis?
judgmental or shaming
avoiding being _____ or ______ the child
fluid restriction
_____ _____ after dinner (limited value); avoid sugar and caffeine at bedtime
not helpful
awakening of child through the night is usually _____ _____- only produced an irritable child the next day
alarms
-some studies have shown this to be the most effective treatment... effective in 30-60% of pts
-not a good option if sharing a room with a sibling or lack of parent compliance
DDAVP (synthetic ADH)
-nasal spray
-tablets
medical treatments for primary nocturnal enuresis?
3 months
after _____ _____ of successful treatment, can try to taper off dose of medication
wetting starts again
if _____ _____ _____< return to last effective dose and continue for 3 months
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