Tx of enuresis or bed wetting
Behavioral: 1st-line therapy – motivational therapy (children 5-7 years old), education & reassurance
• Bladder training: regular voiding schedule, deliberate voiding prior to sleeping, waking the child up to urinate inter
mittently,A avoid caffeine-based drinks & high sugar content, restrict fluids
Enuresis alarm: most effective long-term therapy, usually used if children fail to respond to behavioral therapy and before medical therapy
• Sensor placed on the bed pad & goes off when wet – continued until minimum of 2w of consecutive dry nights
Desmopressin: used in nocturnal polyuria with normal bladder functional capacity, better for short term use
- MOA: Synthetic ADH which reduces urination & may cause hyponatremia - liberal use of salt to reduce incidence Imipramine: TCA used in refractory cases
- MOA: stimulates ADH secretion, detrusor muscle relaxation & decreases time spent in REM sleep
Immunologic inflammation of the glomeruli→protein & RBC leakage into the urine
Glomerulonephritis (Nephritic Syndrome)
2 types of Glomerulonephritis (Nephritic Syndrome)
- *1. IgA Nephropathy (Berger’s disease): MCC of acute glomerulonephritis**, often affecting young males within days (24-48hours) after URI or GI infection (d/t IgA immune complexes), IgA is the first-line defense in respiratory & GI secretions, so infections may cause IgA overproduction
- *2. Post-infectious: MC after group A streptococcus**, 10-14 day after skin (impetigo) or pharyngeal infection (may occur after any infection)
2-14 year old boy with facial edema up to 3 weeks after Strep with scanty, cola-colored/dark urine
infectious: MC after group A streptococcus = Glomerulonephritis (Nephritic Syndrome)-
Rapidly progressive glomerulonephritis (RPGN): associated w/ poor prognosis (rapid progression to ESRD – weeks/months) – Crescent formation on biopsy*** (crescents formed d/t fibrin & plasma protein deposition collapsing the crescent shape of Bowman’s capsule)
MCC
Goodpasture’s Disease (only presents w/ RPGN): (+) anti-GBM antibodies against type IV collagen of the glomerular basement membrane in kidney & lung alveoli – presents w/ AGN + hemoptysis
Vasculitis: characterized by lack of immune deposits & (+) ANCA antibodies
Microscopic Polyangiitis (vasculitis of small renal vessels): (+) P-ANCA
Granulomatosis w/ polyangiitis (Wegener’s): necrotizing vasculitis: (+) C-ANCA
Glomerular damage→increased urinary protein loss (no RBC loss)
Nephrotic Syndrome
Proteinuria, hypoalbuminemia, edema, HLD* ; Edema = predominant feature (especially in children), may see ascites
Nephrotic Syndrome
Dx of Nephritic syndrome
UA: Proteinuria (usually 3.5g+/day), urine dipstick protein (3+/4+), fatty casts, oval fat bodies “maltese cross”**
Serous fluid collection within the layers of the tunica vaginalis of the scrotum
Hydrocele
MCC of painless scrotal swelling – idiopathic MC, a reactive hydrocele can occur w/ inflammatory conditions (Orchitis, testicular tumor, epididymitis)
Hydrocele
Dx of hydrocele
Testicular U/S – initial test of choice: used to r/o testicular tumor and other masses
Congenital anomaly of the male urethra that results in abnormal ventral placement of the urethral opening, penile curvature & abnormal foreskin development
Hypospadias
Tx of hypospadias
Do NOT circumcise in the neonatal period because the foreskin may be used to repair the defect • Elective surgical correction (arthroplasty) may include penile straightening
• Hypospadias repair usually performed in healthy full-term infants most commonly between 6 months-1 year
Retracted foreskin that can’t be returned to the normal position
Paraphimosis = Emergency
Tx of paraphimosis
Manual Reduction: restore original position of the foreskin, reduce
edema w/ cool compresses or pressure dressing then gentle pressure
to restore the foreskin to normal position
Pharmacologic therapy: granulated sugar, injection of hyaluronidase
Definitive: Circumcision or incision (dorsal slit)
Inability to retract the foreskin over the glans
Phimosis = Not emergent
Tx of phimosis
Normal in children & resolves by age 5
PE findings from testicular torsion
Abrupt onset of scrotal, inguinal or lower abdominal pain
(usually <6 hours), with a swollen, tender retracted testicle
If N&V is present, suspect torsion (usually absent in epididymitis)
(-) Prehn Sign – no pain relief w/ elevation, (-) (absent) cremasteric reflex on affected side – no elevation of the testicle after stroking the inner thigh
Dx & Tx of testicular torsion
Emergency surgical exploration = definitive diagnosis,
preferred over U/S if torsion is very likely
Testicular doppler ultrasound – best initial imaging
modality – decreased/absent blood flow
Radionuclide scan = gold standard – decreased uptake
Tx = Urgent detorsion
Failure of one or more testes to descend by 4 months
Cryptorchidism
Tx of Cryptorchidism
Monitor over first 6m, most descend by 3m – Still not
descended? Orchiopexy as early as 4-6m & definitely by 2 y/o
Detected at puberty? Orchiectomy to reduce ca risk
hCG or GnRH – Prader-Willi Syndrome
Retrograde passage of urine from the bladder into the upper urinary tract
Vesicoureteral Reflux
Tx of Vesicoureteral Reflux
Mild to moderate/ grades I to II: resolves spontaneously – observe or antibiotic prophylaxis to reduce the rusk of recurrent UTI (Bactrim, Trimethoprim, or Nitrofurantoin)
Grades III-IV: Surgical correction is definitive treatment
Dx of Vesicoureteral Reflux
Voiding cystourethrogram – imaging test of choice
