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What is the normal urine excretion rate per hour?
Normal urine excretion is 1.5 to 3 mL / kg / hour.
what is the recommended culture method on a child less than 24 months old?
sterile catheterization were super pubic bladder tap.
Why would you perform a 24 hour sample of urine collection?
Collecting a 24 hour sample of urine is done to determine calcium excretion, the calcium creatine ratio, and quantification of protein.
What does the BUN measure?
BUN estimates urea concentration in serum or blood of toxic metabolites that can cause uremic syndrome.
What is the most accurate test to evaluate reflex of urine from the bladder back into the ureters kidneys?
Voiding cystrourethrogram (VCUG)
What are nuclear imaging scans most helpful with in evaluating the kidney?
Nuclear scans are especially helpful in the early identification of pyelonephritis and parenchymal scarring in the monitoring reflux.
What is most commonly seen serious bacterial infection in young febrile children without an obvious source of infection?
What are the clinical signs thought to indicate pyelonephritis in an infant or an older child?
clinical signs thought to indicate pyelonephritis are a febrile infant with no other signs of infection or an older child with significant bacteruria, systemic symptoms, or renal tenderness.
How is a complicated UTI defined?
A complicated UTI is defined as a UTI with fever, toxicity, and dehydration or occurring in a child younger than 3 to 6 months old.
it is also defined as a UTI associated with structural or functional abnormality.
What is the organism most commonly associated with UTI?
E. coli 75 to 95%.
What is the most important risk factor for the development of pyelonephritis and children?
Review the following UTI child flow chart.
How is cranberry juice helpful in preventing a UTI?
Cranberry juice is considered helpful in preventing the adhearance of E. coli in the urethra.
Define vesicoureteral reflux? Differentiate between primary and secondary vesicoureteral reflux?
Regurgitation of urine from the bladder or update your to the kidney is called vesicoureteral reflux or VUR.
Primary VUR is the most common type and is cause by congenital, abnormally short ureter and ineffective valve.
Secondary VUR is due to bladder outlet instruction in can be functional or structural.
Describe the rating of VUR?
VUR is graded 1 through 5. Grading 1 does not reach the renal pelvis. Grade 5 includes distention of ureters and renal pelvis and includes hydronephrosis.
What causes scarring, infection VUR or infection?
VUR does not cause scarring but infection does. VUR is a risk factor for pylonephritis and therefore scarring.
Hematuria is caused by?
Hematuria is a symptom of disease or injury to the urinary system.
What percentage of children with gross hematuria have a UTI?
What might you expect to find in a child with significant proteinuria?
Significant proteinuria may cause hypoprotienemia, leading to a loss of oncotic pressure and subsequent edema.
What is the cause of nephrotic syndrome?
Nephrotic syndrome is due to excessive excretion of protein in urine.
The main mechanism of the massive protein loss is increased glomerular permeability.
The protein loss can be selective (albumin only) or not selective (most protiens) in such selectivity is important in diagnosis.
Differentiate between primary nephrotic syndrome and secondary nephrotic syndrome?
Primary nephrotic syndrome is unrelated to any systemic disease and is responsible for 80 to 90% of all cases. Primary the nephrotic syndrome is resolved in response to steroids.
Secondary nephrotic syndrome occurs secondary to systemic disorders. This type is responsible for 10% of cases.
What is a cardinal clinical feature of nephrotic syndrome?
The cardinal clinical feature of nephrotic syndrome is edema. Periorbital in the morning and dependent in the evening.
What is the primary treatment for nephrotic syndrome?
Prednisone 2 mg per kilogram per day for maximum of 60 mg, to induce remission, which could occur as early as 14 days as evidenced by diuresis.
At what level is proteinuria considered significant?
Relapses nephrotic syndrome may begin with persistent proteinuria of greater than 2+ every day for 3 days.
What is nephritis?
Nephritis (AKA glomerulonephritis) is a noninfectious, inflammatory response of the kidneys.
What is the typical etiology of acute nephritis?
Acute nephritis most commonly occurs as a poststreptococcal glomerol nephritis.
A history of streptococcal infection within the prior 2 weeks and an acute onset of edema, oliguria, hypertension and gross hematuria.
What is the most common form of nephritis in childhood?
PSGN Post strep glomerol nepphritits.
What is Berger disease?
Berger disease is the most common chronic GN in children of European and Asian descent and is uncommon in blacks.
AKA: IgA neprhopathy
What is the primary treatment of Post Strep Glomerol Nephritis (PSGN)?
PSGN treatment is supportive because resolution occur spontaneously in 90% of the cases within 6 to 24 months.
True or false hypertensive encephalopathy or congestive heart failure can occur secondary to PSGN?
True. Irreversible parenchymal damage causes hypertension and renal insufficiency.
What is renal tubular acidosis?
Dysfunction of renal tubular transport capability results in a condition known as renal tubular acidosis.
3 distinct types:
type I, classic or distal RTA occurs when the defect is in the distal tubule.
Type 2 is when the defect occurs in the proximal tubal.
Type 3 has been reclassified as a subtype of type I.
Type 4 also known as hyperkalemia RTA occurs with problems in the functioning of aldosterone most commonly following releif of obstructive uropathy.
What lab values would make you suspicious of RTA?
RTA is suggested by serum carbon dioxide level below 20, especially if anion gap is normal.
How to differentiate the different types of RTA based on lab values?
Type I: hypokalemia, hypercholemia, serum CO2 less than 16, URINE PH > 5.5
Type II: hypokalemia, hypercholemia, serum CO2 less than 16, URINE PH < 5.5
Type IV: suggested by hyperkalemia
What is the most common type of RTA in children?
The most common type of RTA seen in children is pRTA also known as type II
What is the pathology that differentiates pRTA from dRTA?
A defect in the ability of the distal renal tubule to excrete hydrogen is the cause of dRTA.
A defect in the proximal tubule to reabsorb HCO3 from filtered urine is the cause of pRTA.
What are the goals of management of RTA?
Goals of management include correcting the acidosis and maintaining normal bicarbonate, thereby restoring growth and minimizing complications.
- This is performed by giving oral alkalizing medications.
- To maintain as normal a bicarbonate levels possible, doses should be given frequently throughout the day and as late as possible at night.
What are the complications of pRTA in dRTA?
It is rare that complications with pRTA. pRTA a usually results spontaneously without recurrence of symptoms within one to 2 years.
Hypercalciuria leading to nephrocalcinosis, nephrolithiasis, renal parenchymal desrtuction and occasionally renal failure can occur with dRTA. dRTAusually lasts a lifetime.
What a typical physical examination findings nephrolithiasis?
What typical diagnostic studies might one order for nephrolithiasis?
Examination findings include abdominal, flank or pelvic pain.
Diagnostic studies include urine ua and culture ( hematuria 33-90% of cases)
X-ray, ultrasound and CT
What is the 1st line management for all urinary stones regardless of the cause?
Increase fluid intake is the 1st line of therapy for all stone types regardless of the cause.
In adolescence, a goal of 2 liters of urine output per day would be beneficial.
What is the most common malignancy of the genitourinary tract?
Wilms tumor, most common malignancy of the Genitourinary tract is typically recognized as a firm smooth mass in the abdomen or flank.
- Stage I: limited to the kidney.
- Stage II: extends beyond the kidney can be completely excised.
- Stage III: has post surgical residual and non-hematogenous extension confined to the abdomen.
- Stage IV: has hematogenous metastasis most frequently to the lungs.
- Stage V: bilateral kidney involvement.
True/False Congenital anomalies frequently accompany Wilms tumor.
True. Important feature of Wilms tumor is the occurrence of associated congenital anomalies in 15% of children, including renal abnormalities.
What is the most frequent clinical finding of Wilms tumor?
The most frequent finding is increasing abdominal size or an actual palpable mass.
What is the key differential diagnosis for wilms tumor on a plain film x-ray.
Neuroblastoma - which is usually calcified
What is hypospadias?
Hypospadias is a common condition in which the urethral mediators is located anywhere from the proximal glans to the perineum on the ventral (underside) surface of the penis.
When should surgery be performed to correct hypospadias?
Surgery to correct hypospadias is best done around 6 to 18 months old. Circumcision should not be performed because the skin may be used during surgical correction.
Cryptorchidism is a testis that does not reside in and connot be manipuated into the scrotum.
Testes should descend during the seventh fetal mounth to the upper part of the groin, through the inguinal canal and into the scrotum. The vast majority descend spontaneously by 6 mo old.
If undescended by 6 months, unlikely to descend spontaneously. Surgery recommended by 1 year.
What is a hydrocele?
Differentiate between a noncommunicating and communicating hydrocele.
Which is more likely associated with a hernia?
A hydrocele is a collection of painless serous fluid in the scrotal sac.
Noncommunicating hydrocele has fluid collection only in the scrotum.
Communicating hydrocele describes fluid movement from the abdomen to the scrotum through a patent processus vaginalis and is more likely associated with a hernia. Hydroceles that persist beyond 1 year are assumed to be communicating.
What clinical findings may you find on examination for hydrocele?
Intermittent or constant bulge or lump in the scrotum. Scrotal size increases with activity, decreases with rest. Skin may be tense.
Translucent on transillumination ( pink or red glow)
Does a noncommunicating hydrocele typically require surgery?
Does a communicating hydrocele typically require surgery?
Noncommunicating - no treatment is indicated unless the hydrocele is so large it is uncomfortable or persists longer than one year.
Communicating - because more likely to develop hernia, surgery recomended after one year.
What is a spermatocele?
A benign, painless scrotal mass or cyst on the head of the epididymis or testicular adnexa containing sperm. No treatment is required unless the cyst is large and painful. A varicocele and epididymal cyst are identical in appearance but do not contain sperm.
Describe a varicocele?
A varicocele is a benign enlargement or dilation of testicular veins causing a painless scrotal mass of varing size that may feel like a "bag of worms". Typically found on the LEFT side. Rare before 10 years old. Can be painful with strenous physical activity.
Painful or Grade II or III should be referred to a urologist for management. Serial ultrasounds maybe performed q6mo to rule out mor ominous findings.
Describe and inguinal hernia?
A scrotal or inguinal swelling that includes abdominal contents. In females, inguinal hernias cause swelling in the inguinal area and labia majora.
More likely to occur on the right. Indirect are congenital, direct hernias increase in incidence after 3 years old.
Management: refer for surgery within 1-2 weeks if reduceable, refer immediately if red, painful and appears strangulation is ongoing for emergent surgery.
Name physical findings of inguinal hernias
Reducible with pressure on the distal end.
Direct hernias push outward through the weakest point in the abdominal wall.
Indirect hernias push downward at an angle into the inguinal canal.
Silk glove sign - a sensation of two surfaces rubbing against each other while one palpates the spermatic cord as it crosses the pubic tubercle.
A mass located on the testical is most often a......
Malignancy. Testicular tumors are most common between 15-35 years old.
This is different from EXTRA-testicular masses such as hernia, vericocele, hydrocele or spermatocele. Must be referred immediately for further evaluation.
Hard, painless lump the size of a pea is palpated on the testis that does not transluminate. Hydrocele is also present in 10% of the cases.
What is Phimosis?
What is Paraphimosis?
Phimosis referes to foreskin that is too tight to be retracted over the glans penis. Primary phimosis occurs during the first 6 mo of life and is considered congenital. Secondary is aquired, possibley from infection. Tignt pinpoint opening of the foreskin with minimal ability to retract. Pathologic phimosis - thickened rolled foreskin
Paraphimosis is a retracted foreskin that is cannot be reduced. Causes constriction of the penis and results in edema of the glans, pain and possible necrosis. Para is most commonly seen in adolecents follow masterbation, sexual abuse or forceful retraction. Para- maybe edemetous bluish discoloration of the glans and foreskin.
What are the treatments for:
Phimosis and Paraphimosis?
Phimosis - normal cleansing with gentle stretching. Circumcision if urinary obstruction or infection
Paraphimosis - Ice may reduce swelling and allow retraction. Surgical intervention required if unsuccesful to prevent necrosis.
What is balanitis?
What is Balanoposthitis?
Balanitis is an inflamation of the glans.
Balanoposthitis is inflamation of the foreskin and glans penis occurring in males with phimosis or in uncircumcised males. Due to poor hygiene.
Treated with antibiotics, both orally and topically.
What is scrotal trauma?
Older children ususally report a specific mechanism of injury as well as time and place (no shit).
Clear translumination maybe comprised if hematoma present.
Ultra sound may help to identify testicular rupture.
NSAIDS, cool compreses, scrotal support or elevation may help.
Describe testicular torsion....
Severly painful condition of acute onset in which blood supply to the testis is interupted. EMERGENT surgical intervention.
Any age, most commonly in adolescenc, 15 to 16 y/o.
LEFT side more likely involved due to the longer spermatic cord.
Ill appearing, anxious, gradual progressive swelling of the involved scrotum. Transillumination reveals solid mass. Cremasteric reflex absent on torsion side.
Diagnosistic Ultrasound. If surg occurs with in 3 hours 100% recovery, declines after 3 hours.
Inflamation of the epididymis that is painful and acute usually STI in origin. Commonly caused by N. gonorrhoeae or C. trachomatis in the sexually active adolescent. Also has other bacterial and viral causes.
Scrotal edema and erythema noted. Epididymis is hard, indurated, enlarged, and tender. Spermatic cord is tender. Cremasteric reflex is normal.
PREHN's sign - elevation of the testes releives pain. (increases pain in torsion)
Urethral discharge purulent in gonorrhea maybe present, prostate tender on exam.
- TX - Bed rest, scrotal support and elevation. Apply ice packs, sitz baths and analgesics.
- ABX - first line - ceftriaxone IM plus doxycycline.
Treat sexual partners.