Peds GU

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wackojacko
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183154
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Peds GU
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2012-11-12 11:47:23
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Peds GU
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  1. TOILET TRAINING:
    when do kids gain control?
    ways to assess readiness?
    • control at 18-36months
    • readiness:
    • shows interest in potty
    • understand and follow simple directions
    • able to communicate needs
    • BM at regular intervals everyday
    • able to sit for short periods
    • remains dry throughout 2hr nap
    • knows when they defecate
  2. TOILET TRAINING:
    when kid shows signs of readiness:
    • provide potty and place in bathroom
    • sit on potty chair with clothes on at first
    • give child's book/video on potty training
    • place on potty when anticipating #1 or 2
    • praise for results (stickers, etc) AVOID candy/food
    • stop if not interested dont force issue (restart when become interested)
  3. UTI:
    types
    • 1. uncomplicated:
    • cystitis and pyelo develop in absence of structural abnormality, obstruction, or other dz
    • 2. complicated:
    • cystitis and pyelo develop in presence of structural abnormality, obstruction, or other dz
  4. UTI:
    developmentally...
    • 1. newborn= male >female 5x
    • 2. 6mo=female > male 10x
    •   increase incidence girls potty training
    •   3-5yr girls with detrusor instability
    •   sexual activity
    •   pregnancy
  5. UTI:
    cz
    • bacteria
    • viral
    • fungal
    • STI
    • congenital obstructive lesion
    • nonobstructive cz
    • acquired nonobstructive cz
  6. UTI:
    bacterial organisms
    uncomplicated vs complicated
    • uncomplicated:
    •  E. coli 85%
    •  S. saprophyticus
    • complicated:
    •  E. coli 20%
    •  S. aureus
  7. UTI:
    pathophysiology
    • short female urethra
    • uncircumsized male in 1st 6 months (10x higher incidence)
    • incomplete bladder emptying
  8. UTI:
    fever as presenting symptom 38.5 degrees
    infants
    <3yrs
    • infants= no other source identified, <2months associated w/sepsis
    • <3yrs= due to UTI in 13% girls and 7% boys
  9. UTI:
    presenting symptoms
    fever, poor feeding, vomiting, irritability, weight loss, FTT, foul smelling urine
  10. UTI:
    risk factors
    • uncircumsized male <6mo
    • lack of breast feeding
    • female
    • constipation
    • VU reflux
    • obstruction
    • recent ATB use
    • family HX
    • pregnancy
  11. UTI:
    predisposing to UTI
    • poor hygiene
    • bubble bath use
    • type of undergarment
    • pinworms
  12. UTI:
    DX
    gold standard
    not toilet trained
    toilet trained
    • gold= urine C&S
    • not trained= straight cath
    • trained= mid stream clean void in AM
  13. UTI:
    TX
    uncomplicated
    how many days?
    • uncomplicated=
    • Bactrim DS, Amoxi, Augmentin, Gantrisin, Macrobid DS
    • TX for 10-14 days
  14. UTI:
    F/U urine C&S after TX when?
    • F/U 1-2wks after completion of meds
    • 1-3 months until free of infection for 1yr
    • then F/U yearly
  15. UTI:
    Follow up

    PX reinfection
    • prophylactic ATB's= recurrent UTI >3 in 6month period (refer)
    • sexually active adolescent postcoital

    prognosis reinfection: 40% female, 32% male
  16. UTI:
    education uncomplicated UTI
    • increase fluid intake
    • frequent complete voiding of bladder
    • perineal hygiene- front to back wipe
    • white cotton undies
    • avoid bubble bath
    • F/U if sx not improved
  17. Cystitis sx
    • wetting
    • frequency, urgency
    • dysuria relieved by voiding
    • may/may not have fever
  18. Pyelonephritis sx
    • fever
    • flank, back pain
    • CVAT
    • WBC casts in urine
    • elevated ESR and CRP
  19. Hemolytic uremic syndrome:
    etiology
    patho
    etiology: >80% E. coli 0157:H7, undercooked meat and unpastuerized milk

    • patho- toxin produced and absorbed form intestine
    • endothelial cell injury leads to intravascular coagulopathy
    • microangiography results hemorrhagic colitis
  20. Hemolytic uremic syndrome:
    sudden onset sx
    • oliguria/anuria
    • HTN
    • pallor
    • lethargic
    • watery D+= after 3 days becomes bloody and painful
    • petechiae, purpura, bruising
    • mild hematuria
    • microangiopathic hemolytic anemia
    • thrombocytopenia (90%)
  21. Hemolytic uremic syndrome:
    TX
    • hospitalized
    • supportive care
    • dialysis
    • contraindicated ATB's (avoid bc makes bacteria worse)
  22. Hemolytic uremic syndrome:
    F/U
    Prognosis
    • long term F/U
    • PX= mortality <10% (w/appropriate mgmt)
    • 9% develop ESRD
    • late findings appear after 20yrs
    •    HTN
    •    CRI
    •    proteinuria
  23. Acute Post Streptococcal Glomerulonephritis:
    patho
    • immune response of the kidney to group A beta-hemolytic streptococcus (GABHS)
    • most common form of nephritis in kids 5-12yrs peaks at 7yrs
    • male >female (2:1)
  24. Acute Post Streptococcal Glomerulonephritis:
    latent phases after what illness and for how long?
    • enlargement and inflammatory response of the glomeruli
    • latent 7-14 days after pharyngitis (winter)
    • latent 21-42 days after impetigo (winter)
  25. Acute Post Streptococcal Glomerulonephritis:
    HX
    • HX
    • sudden onset gross hematuria/proteinuria
    • oliguria
    • lethargy
    • anorexia/vomiting
    • abdominal pain
    • fever
    • periorbital edema
  26. Acute Post Streptococcal Glomerulonephritis:
    PE
    • HTN (60%)
    • CVAT
    • periorbital edema
  27. Acute Post Streptococcal Glomerulonephritis:
    labs
    • UA: RBC casts, leukocytes, > protein 2+++
    • CBC:
    • lytes: K, BUN, Crea elevated
    •           TP, Na decreased
    • ASO elevated
    • ESR elevated
    • Cult: neg
  28. Acute Post Streptococcal Glomerulonephritis:
    mgmt
    • treat effects of HTN and renal insufficiency
    • 10 day course ATB's to limit spread of nephritogenic organism
    •     low Na diet
    •     daily weights
    •     UOP measured
    •     follow closely
    •     refer to nephrologist
    •     hospitalized
    •     diuretics, vasodilators, fluid and sodium restriction,
    •     rest
  29. Acute Post Streptococcal Glomerulonephritis:
    PX
    • 95% complete receovery in 6-8wks
    • hematuria may persist for 1-2yrs
    • recurrences are rare
    • BP monitor monthly for 6 months
    • monitor lytes Q3months for 1 year
  30. Vesicoureteral reflux (VUR):
    prevalence
    etiology
    • prevalence:
    • <1yr old w/UTI, >50% DX w/VUR
    • reflux found in 35-50% siblings
    • 1% kids have VUR
    • mean age 2-3yrs
    • 80% DX after UTI
    • girls>boys
  31. Vesicoureteral reflux (VUR):
    patho
    • flow of urine from the bladder into the ureter and renal pelvis
    • different degree of involvement and graded
  32. Vesicoureteral reflux (VUR):
    Grades
    • I-III: low grade= reflux to renal pelvis w/little to no distention
    •     self limiting
    •     70-80 % by follow up
    •     20-30% resolve in 2 yrs
    • IV-V: high grade= distention of ureters and renal pelvis
  33. Vesicoureteral reflux (VUR):
    DX
    • VCUG (voiding cystourethrogram) is gold standard
    • U/S
    • IVP
  34. Vesicoureteral reflux (VUR):
    Mgmt grades I-III
    • urine C&S every 6months or if symptomatic
    • ATB's 1/3 or 1/2 dose QHS: prophylactic to prevent scarring
    •      Bactrim
    •      Augmentin
    •      Cephalosporin
    • VCUG Q18months
    • how long to TX asymptomatic: 6-8yrs age, 1-2neg VCUG's
  35. Vesicoureteral reflux (VUR):
    mgmt grades IV-V
    surgical
  36. Vesicoureteral reflux (VUR):
    prognosis PX
    grades I-II
    grade III
    grade IV-V
    long term complications
    • I-II= 80% resolve in kids <5yr
    • III= unilateral 46% resolve, bilateral 10% resolve
    • IV-V= surgical 95% corrected
    • LTC= HTN
    •      renal scarring
    •      pyelonephritis
    •      ESRD
  37. indications for recurrent UTI prophylaxis
    • VUR
    • pyelo in kids <1yr
    • recurrent cystitis (>3x in one year)
    • renal scarring in girl <10yrs
  38. Nocturnal enuresis:
    Define...
    HX
    def- involuntary urination at night w/o dry period of any sustained length by kid >5yr

    • HX-
    • UTI
    • allergies
    • DM
    • delayed neuro development
    • family HX
    • changes at home or school
  39. Nocturnal enuresis:
    primary
    secondary
    DDX
    primary: kid has never been dry, no UTI, PE normal

    secondary: kid has been dry >6-12 months, no UTI

    DDX- UTI, VUC, primary or secondary nocturnal enuresis
  40. Nocturnal enuresis:
    TX
    • watchful waiting <7yr
    • behavior modification
    • hypnotherapy (no evidence yet)
    • enuresis alarm pads (75% success)
    • bladder training- during day hold urine longer to increase bladder capacity
    • short term- camp or sleepovers (DDAVP)
  41. Nocturnal enuresis:
    education
    PX
    • explain child is not doing it on purpose
    • dont punish
    • talk with siblings
    • support and reinforce success
    • PX:
    • cure rates 60-80% long term
    • alarm and behavior therapy works best
  42. Proteinuria:
    origin...
    sx...
    • benign or symptom of dz
    • origin: golmerulus or tubules
    • clinical findings:
    •    asymptomatic
    •    polydipsia, polyuria, edema (periorbital),HTN,malaise,
    •    fatigue
  43. Proteinuria:
    labs
    • UA= 75% asymptomatic pts repeat UA then normal findings
    • **significant if**
    •    protein +1 and SG <1.015
    •    protein +2 and SG >1.015
  44. Orthostatic Proteinuria:
    define...
    labs
    body excretes abnormal amts of protein when upright but normal amounts when lying down

    labs: morning void trace > protein +1
  45. Persistent Proteinuria:
    happens in what syndrome?
    define syndrome...
    sx
    mgmt
    • nephrotic syndrome
    • define- changes in the renal tubule without inflammation
    • sx- orbital edema, low UOP, anoreix, FTT
    • mgmt- refer to nephrologist
  46. Indications for renal imaging studies:
    • sx pyelonephritis regardless of age and gender
    • UTI kids <8yrs
    • male w/first infection
    • female w/second infection
    • child w/suspicious factors:
    •    HTN
    •    FTT
    •    abnormal urine stream
  47. GU diagnostics:
    renal U/S
    • evaluates structural and developmental abnormalities
    • weak in identifying scarring or VUR
  48. GU diagnostics:
    VCUG
    only way to eval for reflux
  49. GU diagnostics:
    DMSA
    (dimercaptosuccinic acid scintigraphy)
    • nuclear study
    • ID scarring and examines renal fxn
  50. Hernia:
    prevalence
    • 10-20/1000 births
    • male > female (6:1)
    • 55-70% R side
    • increased incidence w/preemies (30%)
    • 12-17% incarcerated
  51. Inguinal Hernia:
    how does it happen?
    indirect vs direct?
    process vaginalis fails to obliterate

    indirect= congenital= bowel or omentum is forced into scrotum via the inguinal canal

    • direct= acquired r/t obesity, weight lifting, family HX
    • increased incidence after 3 yrs

    mgmt= surgery
  52. Testicular torsion:
    common?
    sudden onset
    risks?
    • common in infant to adult
    • sudden onset
    • risks-
    •      anatomical= poor fixation at birth
    •      strenuous activity
    •      HX of intermittent torsion
  53. Testicular torsion:
    TX
    • color doppler U/S if not clinically clear
    • irreversible ischemia after 12 hrs
    • immediate surgical intervention
    • detorsion and fixation of testicles
  54. Bacterial epididymitis:
    • rare
    • risk factors=
    • UTI/sepsis
    • instrumentation
    • unprotected intercourse w/infected partner
  55. Bacterial epididymitis:
    sx
    • exquisite tenderness
    • swelling at epididymis
    • fever
    • increased WBC w/sepsis
    • negative UA and urine C&S
  56. Bacterial epididymitis:
    common bacteria
    • STD:
    • Chlamydia
    • Gonorrhea

    • Typical:
    • E. coli
    • pseudomonas
  57. Bacterial epididymitis:
    assess and treat
    sepsis?
    Chlamydia or Gonorrhea?
    other gram negs?
    F/U?
    • hospitalize if sepsis
    • Chlamydia or Gonorrhea- Rocephin 250mg IM, Doxy100mg x10days
    • other gram negs- Cipro/Levaquin x2wks
    • F/U- 2-3wks
  58. Varicocele:
    define...
    • dilatation of the pampiniform plexus of spermatic veins
    • 15-20% post pubertal males
    • 70% left
    • 30% bilateral
  59. Varicocele:
    sx
    • dull, aching L scrotal pain, typically worse w/standing and relieved by recumbency
    • testicular atrophy
    • 25% males infertile w/varicocele
  60. Varicocele:
    assess and TX
    • indicated in younger males for infertility/testicular atrophy
    • referral to urologist
    • surgical TX ligating the gonadal vein to stop retrograde blood flow
    • scrotal support/NSAIDS
  61. Spermatocele:
    • cystic masses, vary in size
    • arise from the caput of the epididymis
    • always located superior to the testis
    • epididymal cyst are one size 0.5mm-1cm
  62. Spermatocele:
    • 2cm-5cm in size (epididymal cyst smaller)
    • palpated distinct from the testis
    • U/S
    • assurance
    • pain= scrotal support and NSAIDS
    • rarely require surgery
  63. Hydrocele:
    • peritoneal fluid between parietal and visceral layers of tunica vaginalis
    • small to massive
    • idiopathic
    • inflammatory
  64. Hydrocele:
    H&P
    • slow accumulation
    • trauma or infection
    • infants w/communicating patent processus vaginalis
    • pain and disability increase with size
    • illuminates w/penlight in dark room
  65. Paraphimosis
  66. Phimosis
    physiologic adherence of uncircumsized foreskin to gland
  67. Hypospadias:
    define...
    mgmt
    PX
    • 1:250 live births
    • genetic
    • 5x higher incidence in infants conceived through IVF
    • mgmt- surgical repair 6-12 months
    • PX- erection normal, fertility unaffected

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