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Pediatrics (GU Disorders)
Terms in this set (92)
T or F. The younger the child, the less specific, more generalized, and more systemic the symptoms are
What should always be r/o in a child with unexplained fever
UTI's are more common (2:1) in males under 1 y.o. but more common in girls thereafter (9:1)
Who are UTIs more common in?
10x more common in uncircumsized males in the first year of life than in circumsized males
In males, when are UTIs most common?
1) FTT / feeding
2) Vomit / diarrhea
3) CNS Sxs
What is the clinical presentation of a newborn with a UTI?
2) Strong urine
3) UTI Sx
What is the clinical presentation of a child from 2-6 years of age with a UTI?
1) Must be > 50,000 Colony Forming Units/High Power Field(one pathogen)
- Cath specimen
2) 1,000 - 50,000 Colony Forming Units/High Power Field should have repeat Urine culture
- Unless suprapubic tap
What is the gold standard for diagnosing a UTI?
1) Cath or suprapubic tap are the only reliable urine source
2) Bag urines are highly inaccurate (85% false positive) and are only helpful if UA is negative (rare)
3 )Leukocyte esterase (a dipstick test for WBCs) moderately sensitive, nonspecific
4) Nitrite not sensitive, but specific
5) WBC > 10 mod sens & specific (unspun)
6) Bacteria mod sens & specific (unspun)
What is another diagnosing tool for a UTI?
1) > 2 months old
2) Non-toxic, stable, and tolerating PO
3) Close follow-up available
When can a patient be treated outpatient for a UTI?
Based on local resistance rates and culture sensitivity results
- Gentamicin or third-gen cephalosporin
- Augmentin, Bactrim
- Children < 3 y.o. = 10-14 days
- Children > 3 y.o. = 7-10 days
How are antibiotics chosen for the treatment of a UTI?
Are routine follow-up UA / UC indicated post treatment of a UTI?
2) Perinephric abscess
What are the complications of inadequate treatment of a UTI?
1) Be associated with abnl GU anatomy
2) Be associated with vesicoureteral reflux (VUR)
3) VUR (Vesico refers to the bladder so VUR is reflux of urine from the bladder back into the ureter—wrong direction.) and UTI's can both cause renal scarring leading to HTN
Recurrent UTIs are likely to:
Image All children no matter what!!!!!
- But especially with 2nd UTI (recurrence)
- Unresponsive to antibiotics
2) All males
With fever (pyelo)
Age < 3 y.o.
**When is imaging recommended for a patient with a UTI?
1) Renal / Bladder Ultra Sound
2) Voiding cystourethrogram (VCUG)
- Contrast (better anatomy resolution)
- Radionucleotide (more sensitive, safer, cheaper)
What is the imaging order of precedence with a UTI?
True From normal to Grade I-V
T or F. There are varying degrees of Vesicoureteral Reflux (VUR)
Look for others
If you find one GU anomaly, what should you do?
1) 90% of Grade I & II VUR resolve by 5 y.o.
2) Children with Grade I - IV VUR should be followed clinically
- Children with a second UTI are candidates for suppressive abx therapy
- Yearly VCUG's
3) Children with Grade V reflux should consider surgical correction (unless < 1 year-old)
4) Children with anomalous GU anatomy should undergo correction
- These patients should be co-managed with pediatric urology
What is the management of Vesicoureteral Reflux (VUR)?
**This is described as:
1) Proteinuria > 1 g / m² / 24 hrs
2) Hypoproteinemia (serum albumin < 2.5 g/dL)
Renal damage allowing excessive protein excretion
In Nephrotic syndrome, what causes hypoalbuminemia?
Minimal change disease
**What is the most common cause of nephrotic syndrome?
In the urinary tract, only the kidney can be a source of proteinuria—the bladder, ureters and urethra are not a source of protein leakage into the urine.
**In the urinary tract, what is the cause of protein in the urine?
Minimal Change Disease
This is thought to be due to T cell release of cytokines causing glomerular damage
- Most cases are idiopathic but can be secondary to NSAIDS, cancer, SLE
What is the onset of Minimal Change Disease?
T or F. Generalized edema and erythema are seen on Physical exam for Minimal Change Disease
What is another term for generalized edema?
Quick review: what syndrome caused extremity edema at birth?
1) Low serum protein
2) 24 hour urine protein > 50 mg/kg/d
4) Hypocomplimentemia (C3) with minimal change disease
5) Tissue biopsy if patient not responsive to steroids (i.e. not minimal change disease)
What labs are diagnostic in minimal change disease?
What is a differential diagnosis for systemic edema?
1) Orthostatic proteinuria
2) Exercise-induced proteinuria
3) Febrile-induced proteinuria
What is a differential diagnosis for proteienuria?
Orthostatic proteinuria = abnormal amounts of protein excreted when upright, normal when lying down.
What is the #1 cause of isolated proteinuria?
1) Steroid trial
- Prednisone 2mg/kg/day
o 'Til trace or neg protein (max 8 wks)
o Then every other day x1 month
o Then taper off over 2-3 months
2) Salt restriction diet
3) Gentle diuresis with Lasix
4) Albumin can be given in severe cases for temporary relief
What is the treatment of minimal change disease?
1) Infections ---Increased infection risk due to low complement levels, tissue fluid stasis and maybe steroid treatment.
2) Thromboemboli = mobilization, heparin
4) DVT risk is due to intravascular hypovolemia
What are complications of minimal change disease?
Refer them to pediatric nephrology
What should be done if a patient relapses after therapy?
This is glomerular damage resulting in microscopic or gross hematuria (tea-colored urine)
Ig A nephropathy
What is the most common cause of Nephritis (Glomerulonephritis)
Post-Strep glomerulonephritis (PSGN)
What is the most common cause of "proliferative" glomerulonephritis?
1) Beet ingestion
3) Other chemicals, foods, etc.
What is considered if a patient has red urine, but has UA negative for blood?
Hemoglobinuria or myglobinuria (hemolysis, Diffuse Intravascular Coagulation (DIC), rhabdo, burns, myositis)
What is considered if a patient has red urine, is UA positive for blood, but no RBC's on microscopy
Bleeding distal to the renal tubules
What is considered if a patient has red urine, UA positive for blood, RBC's on microscopy, but no casts?
Bleeding from the renal tubules or glomeruli
What is considered if a patient has red urine, UA positive for blood, RBC's on microscopy, and casts are present
source is in the kidney
source is collecting system to urethra
No casts =
Ig A Nephropathy (Berger's)
What is the most common cause of Nephritis (Glomerulonephritis)?
Onset 1-2 days post URI
What is the onset of Ig A Nephropathy (Berger's)
- Poorer prognosis
- Steroid may be helpful
Can Ig A Nephropathy (Berger's) coexist with nephrotic syndrome?
Second episode of asymptomatic hematuria after URI x 1 day
Describe the classic patient that has Ig A Nephropathy (Berger's)?
Recall the nephrotic syndrome's 4 components?
- Complement levels will be normal, unlike PSGN or the membranoproliferative diseases
- Renal biopsy is definitive but rarely needed
What is the diagnosis of based Ig A Nephropathy (Berger's) based on?
This presents with asymptomatic hematuria 10-14 days post strep infection
- May also have edema and / or HTN
Asymptomatic hematuria and sore throat 2 weeks ago
What is the classic patient with post-strep glomerulonephritis?
NO. It is usually Self limiting (95%) ~ 2 weeks unless there is a Strep infection
Is there treatment needed for post-strep glomerulonephritis?
ASO = antistreptolysin O (a blood test).
What should confirm a recent strep infection?
This is a mild to severe disease that presents with an "acute onset hematuria" and generalized edema with or without hypertension
How is diagnosis of Membranoproliferative Glomerulonephritis confirmed?
HTN and Acute Renal Failure common
Nephrotic syndrome common (60-80%)
What is common in Membranoproliferative Glomerulonephritis?
Hereditary Nephritis (Alport's Syndrome)
This is autosomal dominant or X linked
This has the Classic triad of:
3) Renal failure
Hemolytic Uremic Syndrome (HUS)
This is described as glomerulovascular injury usually caused by a toxin / infection
- Microangiopathic hemolytic anemia
- Acute renal failure
The endothelial layer of small vessels is damaged with resulting fibrin deposition and platelet aggregation. As red blood cells travel through these damaged vessels, they are fragmented resulting in intravascular hemolysis.
What happens during Hemolytic Uremic Syndrome (HUS)?
Associated with E. coli 0157:H7 and Shigella (shigatoxin)
**What bacteria is associated with Hemolytic Uremic Syndrome (HUS)?
More severe in younger children
Is Hemolytic Uremic Syndrome (HUS) more severe in younger children or older children?
1) Severe abd pain, vomiting and bloody diarrhea with toxic appearance
2) Progressing to decreased urine output, renal failure and hypertension
What is the clinical presentation of Hemolytic Uremic Syndrome (HUS)?
- IV fluids
Antibiotics won't help because It's the toxin, not the bacteria itself, that causes the problem.
What is the treatment for Hemolytic Uremic Syndrome (HUS)?
-Most recover in 2-3 weeks
-Death from renal failure or DIC (5%)
What is the prognosis of Hemolytic Uremic Syndrome (HUS)?
Polycystic kidney disease (PKD)
AD gene mutations resulting in cystic, dysfunctioning kidneys
Children develop renal failure and hypertension with poor prognosis
Renal Aplasia aka Renal Agenesis = oligohydramnios
No kidney developed
Small kidney developed
A bad kidney developed
Sudden onset, intense unilateral testicular pain often in males (>13)
Triggered by sudden movement / sports
Nausea & vomiting may occur
1) High riding testicle
2) Testicle with transverse lie (Bell clapper deformity, a risk factor)
3) Tender, edematous testicle with scrotal edema
4) Absent unilateral Cremasteric reflex
5) Negative Prehn's sign
What would be seen on physical exam of a patient with testicular torsion?
Failure of normal posterior anchoring of the gubernaculum, epididymis and testis
So called because it leaves the testis free to swing and rotate within the tunica vaginalis of the scrotum much like the gong (clapper) inside of a bell. Trauma can also be causative.
What is a Bell clapper deformity?
1) UA may be abnormal
2) No scrotal erythema / edema
3) Positive Prehn's sign
1) Small, blue dot on top of scrotum
2) Small swelling on upper pole of testicle
Incarcerated inguinal hernia
1) Should feel hernia on Valsalva
2) Exam can be difficult due to pain
1) Immediate Urology consult
2) Immediate testicular US to document blood flow
3) Torsion must be relieved in < 6 hours to save testicle
4) Reduction = External rotation "Open the book"
What should be done if torsion is suspected?
This is Non-descent of a testis into the scrotum
In premature infants
When is Cryptorchidism common?
1) Testicular cancer (20-40 times normal)
2) Infertility (spermatodysgenesis)
What are the concerns for Cryptorchidism?
1) Observe until 6 months of age
2) 80% of term infants will descend by 1 y.o.
3) If still undescended, refer to Urology at 6 m.o. (definitely before 12 m.o.)
What should be done in the case of Cryptorchidism?
At 1-2 yrs of age by Urology
- Cancer risk does not return to "normal" after surgical fixation
When is Orchiopexy done?
"Retractile testes" which can often be expressed down into the superior scrotum.
What is a common condition that cannot be confused with Cryptorchidism?
This is Fluid collection in the tunic vaginalis and common in neonates
With the peritoneal space
What is a communicating hydrocele?
Communicating will be smallest in the AM, enlarge during the day. Tend to persist.
-Refer for surgical correction
What is the treatment of a communicating hydrocele?
Processus vaginalis obliterated
What is a Noncommunicating hydrocele?
Most are noncommunicating and resolve by 12 m.o.
-Refer to GU by 18 m.o.
What is the treatment of a Noncommunicating hydrocele?
This is the failure of the ventral penile folds to fuse results in proximal and ventral urethral opening on penile shaft
Occurs 1 in 500 males
Consider congenital adrenal hyperplasia or androgen insensitivity syndrome
What should be considered If Hypospadias IS present with bilateral cryptorchidism?
Done at 6-12 m.o. ideally
When is surgical correction done for a patient with Hypospadias?
DO NOT CIRCUMCISE
**What SHOULD NOT BE DONE with a patient that has Hypospadias?
1) Decreased UTI risk (in first year life)
2) Decreased risk of phimosis / paraphimosis
3) Decreased risk of penile cancer
4) Most American males are circumcised
What are the benefits of circumcision?
Procedural risks (bleeding, infection, poor cosmetic outcome)
What are the disadvantages of circumcision?
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