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UON Paediatric Society Teaching Series – Urology & Nephrology Made by: Elle Spencer Session Plan Testicular Penile Bladder & Kidneys • Cryptorchidism • BXO • UTI • Torsion • Hypospadias & • Nephrotic Syndrome • Epididymitis & Orchitis Epispadias • Wilm’s TumourTesticular Definition Investigations Congenital absence of one or both Clinical diagnosis but, if clinically testes in the scrotum, due to failure to Cryptorchidism indicated can: descend 1. Hormonal assay Epidemiology 2. Karyotype analysis 6% of newborns “hidden” “testicle” 3. Diagnostic laparoscopy 3% of 3-month-olds Risk Factors Clinical Features Management Prematurity / low birth weight History Urgent Exposure to teratogens / smoking 1. Has the testes ever been in the scrotum ?CAH if bilateral cryptorchidism Other genital abnormalities & DSDs 2. Ask about risk factors or genital abnormalities → same day Family history paediatric review Examination Timeline Week 8 Physiology All newborns should have their testicles Start treatment by 6 months old Testicles begin checked at birth, and again at 8 weeks. Finish by 18 months old descending from abdomen, guided by the >70% of testicles can be palpated Medical Management gubernaculum HCG or GRH Surgical Management Week 25 You may have to push the testicle down Orchidopexy Androgens contract the from the inguinal area – this could reveal a Orchidectomy if post-pubertal / gubernaculum again, and retractile testis atrophic testis testicles descend further through the processus vaginalis *Testes may also be found intra- Sequaele Week 33 torsion infertility testicular cancer Testicles are fully abdominally or can be entirely 90% if unilateral 2-3x more common than descended into scrotum absent (agenesis / atrophy) 53% if bilateral general population TO SURGERY Definition When the spermatic cord Testicular Torsion twists, cutting off blood supply to the testis – causing ischaemia and Epidemiology necrosis Most common in Urological Emergency! Investigations neonates or 12-25 years An acutely red, swollen, painful, or hot If it delays surgery → don’t do it testicle is in torsion until proven otherwise Ultrasound may show whirlpool sign Risk Factors Family history of torsion Clinical Features Management Undescended testes 4-6 hours before the testicle dies → Horizontal testes or previous surgeries History move quickly! Previous torsion / non-specific testicular pain Acute testicular or abdominal pain Sudden onset Consider manual detorsion (reduces Triggered by exercise? pain – doesn’t cure) Pathophysiology Nausea & vomiting Nil by mouth, analgesia, anti-emetics Intravaginal Torsion Extravaginal Torsion Urgent senior urologist review • Occurs inside the tunica vaginalis • Gubernaculum fails to Examination • Posterolateral side not fixed fixate the testis Higher lying testis • “Bell-clapper deformity” • Tunica vaginalis is twisted Horizontal testis Surgery • Most common (12-25) • Rare – often in neonates Firm / swollen / red Orchidopexy of both testes Inflammation & oedema Orchidectomy if necrotic Cremasteric reflex absent How the Testes Torts Remains painful despite Post-op scrotal support & bed rest. 1. Testis is mobile elevation (Prehn’s) Advise limited activity whilst 2. Testis rotates recovering 3. Spermatic cord twists 4. Blood flow reduced 5. Venous congestion Sequaele 6. More twisting Salvage rates are 90-100% if operated on within 6 hours of symptom onset 7. Reduced arterial supply Delays in care lead to testicular infarction & necrosis 8. Necrosis Loss of a testicle can lead to reduced fertility & massively affect mental healthEpididymitis Epididymo-orchitis Orchitis Inflammation of the epididymis Inflammation of both the epididymis and the testicle Inflammation of the testicle Causes Epidemiology Clinical Features Management E. Coli Ages 15-30 Antibiotics & analgesia Chlamydia Ages >60 Testicular pain Urethral Gonorrhoea with palpation discharge or Can treat PO in Mumps* Rare for testicle with elevation (Prehn’s) LUTS community if *commonly only to be solely affects testis affected systemically well. Dragging / heavy Swelling & sensation in testis redness of If enteric origin Pathophysiology testicle ofloxacin / levofloxacin* Commonly caused by local extension (or co-amoxiclav) of infection from UTI / STI Cremasteric Fever & systemic If STI symptoms reflex IM ceftriaxone present Doxycycline +/- azithromycin Investigations Advise patients to Urine MC&S abstain from sexual Serum antibodies if ?mumps activity until Abx USS if needed finished Mumps Orchitis Routine bloods (FBC, CRP, etc) Key Differential 40% of people with mumps get orchitis Torsion is a key differential for *quinolones can cause tendon 4-8 days following onset of parotitis Do not delay if there is any epididymo-orchitis – treat as damage and lower seizure Can lead toNotifiable diseasey / infertility possibility of torsion! torsion until proven otherwise thresholdQuestion You are an F1 in paediatric A&E. A 16-year-old male presents with an acutely painful and swollen testicle that came on suddenly 4 hours ago. He denies any recent sexual activity whilst his mother is in the room. He says the pain is making him feel sick. Upon examination, one testis is extremely swollen and red. Cremasteric reflex is absent. What is the most appropriate course of action? A) Stat page urology for review & surgery B) Urine MC&S C) STI test D) IV Abx E) Discharge home with RICE adviceQuestion You are an F1 in paediatric A&E. A 16-year-old male presents with an acutely painful and swollen testicle that came on suddenly 4 hours ago. He denies any recent sexual activity whilst his mother is in the room. He says the pain is making him feel sick. Upon examination, one testis is extremely swollen and red. Cremasteric reflex is absent. What is the most appropriate initial course of action? A) Stat page urology for review & surgery B) Urine MC&S C) STI test TO SURGERY D) IV Abx E) Discharge home with RICE advicePenile Balanitis Xerotica Obliterans “Inflammation of the foreskin” “dryness” “obstruction due to inflammation & fibrosis” At birth If not, Definition BXO is also known as lichen sclerosis atrophicus •Adhesions between Adhesions break By ~age 10-16, the pathological •Ballooning of foreskin down over the foreskin should be phimosis may be It is a chronic inflammatory condition that during micturition is years fully retractable present affects the foreskin, glans, and urethral meatus normal up to 4 years •95% of phimosis is caused by BXO Clinical Presentation Management Commonly presents ages Circumcision is first-line to 9-11 with: prevent further scarring • Irritation • Dysuria Follow surgery with 6/52 course • LUTS of hydrocortisone to prevent • Haematuria meatal stenosis • Frequent infection • Weak urine flow Complications Untreated BXO can lead to meatal • Unretractable stenosis, phimosis, and erosions of • Tightness the glans / prepuce. White, fibrotic, or Post-op, swelling and discharge, along scarred preputial tip with bleeding and infection, may occur Epispadias Hypospadias When the urethral meatus is displaced to Definition the dorsal (top side) of the penis When the urethral meatus is displaced to the ventral (underside) of the penis Do Not Miss! Pathophysiology Hypospadias & epispadias can both Occurs when the penile raphe is not fully formed indicate a DSD if associated with (think of a zipper not being fully zipped up) cryptorchidism! Do not miss a potential diagnosis of Clinical Presentation Congenital Adrenal Hyperplasia – can Ventral opening of the urethral meatus be indicated by hypospadias Dorsal hooded foreskin May be associated with ventral curve / chordee Often diagnosed on newborn examination Complications The catheter post-surgery should be Management carefully managed due to risk of blockage / No circumcision – can cause further damage displacement Up to 30% of cases develop a urethral Surgical management at 3-4 months aims to fistula, even after repair correct meatus position and straighten penis Increased risk of meatal stenosisQuestion You are an F2 in general practice doing a series of 8-week baby checkups. Two parents mention that they are concerned about their 8-week-old baby boy. They state that whenever he passes urine, his foreskin seems to “balloon” and is not retractable. They have not noticed any blood in the urine or discharge. What is the most appropriate course of action? A) Prescribe 6 weeks of topical steroids B) Urgent paediatric urology referral C) Offer reassurance that this is normal D) Standard referral for circumcision E) Advise soaking in warm salt waterAnswer You are an F2 in general practice doing a series of 8-week baby checkups. Two parents mention that they are concerned about their 8-week-old baby boy. They state that whenever he passes urine, his foreskin seems to “balloon” and is not retractable. They have not noticed any blood in the urine or discharge. What is the most appropriate course of action? A) Prescribe 6 weeks of topical steroids B) Urgent paediatric urology referral C) Offer reassurance that this is normal D) Standard referral for circumcision E) Advise soaking in warm salt waterBladder & Kidneys Urinary Tract Infections An infection of the urinary tract (urethra, bladder, ureter, kidneys)… did we really need to spell that out for you? Cystitis Pyelonephritis All children with >38C temp should have a urine MC&S Clinical Features Causative Organisms Investigations Most commonly 1. Urine dipstick Older Child enterococcal bacteria 2. If nitrites or leucocytes (or both!) are present… Fever Fever >38C 3. MC&S Suprapubic pain E. Coli Vomiting Loin pain Gram –ve USS, Micturating cystourethrogram, or DMSA Scintigraphy Dysuria may be considered for recurrent or atypical UTIs Urinary Frequency Pyelonephritis Klebsiella and Staph Incontinence saprophyticus are also Management common ASAP referral to paeds & IV Abx Septic screen & consider LP If >3 months + lower UTI Oral Abx for 3/7 (local guidelines) with advice to return in 24 Risk Factors hours if no improvement Age <12 months Previous UTI If >3 months + upper UTI Voiding dysfunction 7-10 days of Abx (often ciprofloxacin or co-amoxiclav) Constipation IV if symptoms of pyelonephritis <3 months = more likely Babies & Infants >3 months = more likely Complications Renal scarring, renal failure, CKD Definition A glomerular disorder in which Nephrotic Syndrome excess protein leaks through a faulty basement Clinical Features membrane. Alongside the classical triad: Management Changes in blood pressure High dose corticosteroids for Characterised by: Impaired renal function 4/52, then weaned over 8/52 Oedema Deranged lipid profile Proteinuria Hypercoagulability Hypoalbuminaemia Frothy urine Low salt diet Pallor Reduces oedema Prophylactic Abx Epidemiology Henoch-Schonlein Purpura Due to Ig being excreted 2 – 5 years old Inflammation of the blood vessels – can cause More common in nephrotic syndrome & kidney damage! Diuretics, ACEis, and albumin boys and children of Investigations infusions may be required Asian descent Minimal Change Disease Standard: Unknown cause - can occur in Urine dip Urine protein:creatinine ratio Causes previously healthy children U&E Complications Minimal change FBC Hypovolaemia & hypotension disease is most Renal biopsy → no abnormality Serum albumin Infection common Urinalysis → SMW proteins & hyaline casts Further investigations: Acute / chronic kidney failure Can be secondary to Autoimmune screen Thrombosis int/ systemic illnessase Mx = corticosteroids – good prognosis Varicella Zoster serology Relapse Definition A type of kidney cancer that affects Wilm’s Tumour young children. Also known as a DDx Investigations nephroblastoma Polycystic kidney disease Hydronephrosis Management Urine dip → ?haematuria Initial Epidemiology Baseline bloods Supportive care Affects 80 Neuroblastomas present similarly! children/year in UK More associated with abdominal mass that USS crosses midline, bone marrow infiltrate, and Stage 1/2 Average age – 3.5yr periorbital ecchymosis Surgery – either debulking CT/MRI required for or nephrectomy staging Clinical Features Biopsy → definitive Stage 3/4 diagnosis As above, but with Abdominal mass potential for chemotherapy Abdominal swelling Abdominal pain Fever Haematuria Complications & Prognosis 85% of patients are cured Uni/bilateral renal If only one kidney – keep BP stable & avoid contact sports masses on palpation If had chemotherapy – monitor for long term effects (e.g., Hypertension cardiotoxicity)Question You are an F2 in general practice. A parent makes a same-day emergency appointment to speak to you, as their 2-month-old baby has a fever o (38.4 C) and increased urinary frequency. They say the baby is not feeding properly and is more lethargic than usual. A urine dipstick reveals ++ nitrites and – leucocytes. What is the best course of action? A) Send home with oral Abx B) Send home with advice and reassurance C) Prescribe a short dose of corticosteroids D) Admit urgently to paediatrics for IV Abx E) Perform a urine MC&SAnswer You are an F2 in general practice. A parent makes a same-day emergency appointment to speak to you, as their 2-month-old baby has a fever (38.4 C) and increased urinary frequency. They say the baby is not feeding properly and is more lethargic than usual. A urine dipstick reveals ++ nitrites and – leucocytes. What is the best course of action? A) Send home with oral Abx B) Send home with advice and reassurance C) Prescribe a short dose of corticosteroids D) Admit urgently to paediatrics for IV Abx E) Perform a urine MC&SQuestion You are an F2 in urgent-care paediatrics. A wise F2 in general practice has just referred a 2-month-old baby with a high fever and increased urinary frequency to you. You take a urine sample, send it for MC&S, start antibiotics and escalate to a consultant. A few days later, a urine MC&S returns having grown gram negative bacilli. What is the most likely causative organism? A) Group B Streptococcus B) Klebsiella C) S. saprophyticus D) S. aureus E) E. coliAnswer You are an F2 in urgent-care paediatrics. A wise F2 in general practice has just referred a 2-month-old baby with a high fever and increased urinary frequency to you. You take a urine sample, send it for MC&S, start antibiotics and escalate to a consultant. A few days later, a urine MC&S returns having grown gram negative bacilli. What is the most likely causative organism? A) Group B Streptococcus B) Klebsiella C) S. saprophyticus D) S. aureus E) E. coliQuestion You’re doing some locum work in paediatric A&E. A 3-year-old child presents with generalised oedema, lethargy, and pallor. They have previously been a very healthy child. On questioning, the parents remark that the urine has been cloudier recently. A urine dipstick is normal, except for +++ protein. What is the most likely underlying cause? A) Nephrotic syndrome B) Henoch-Schonlein Purpura C) Nephritic syndrome D) Haemolytic Uraemic Syndrome E) Post-streptococcal glomerulonephritisAnswer You’re doing some locum work in paediatric A&E. A 3-year-old child presents with generalised oedema, lethargy, and pallor. They have previously been a very healthy child. On questioning, the parents remark that the urine has been cloudier recently. A urine dipstick is normal, except for +++ protein. What is the most likely underlying cause? A) Nephrotic syndrome B) Henoch-Schonlein Purpura C) Nephritic syndrome D) Haemolytic Uraemic Syndrome E) Post-streptococcal glomerulonephritisThank You! sparkles fill out the Feedback Form :) if you do!cess to the slides