Common Pediatric Urinary Problems
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| Repeated voiding of urine into clothes or bed at least twice a week for at least 3 consecutive months in a child who is at least 5 yr of age ? | * Enuresis
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| Enuresis at night and during the day ? | * Nocturnal ....... * Diurnal
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| Enuresis occurs in a child who has NEVER achieved consistent night time dryness ? | * Primary
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| Enuresis occurs in a child who has been consistently dry for at least 6 months and then has resumption of wetting ? | * Secondary...commonly associated with an underlying trauma/issue
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| Enuresis with no associated daytime or night time symptoms ? | * Monosymptomatic
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| Enuresis that has at least one associated daytime symptom, no matter how subtle ? | * Nonmonosymptomatic
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| Prevalence of monosymptomatic nocturnal enuresis decreases with age ? | * the percentage seems to decrease by 15% each year
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| Common causes of incontinence ? | * Under/over active bladder or other neurologic issues --
Anatomic anomalies --
Giggle incontinence or vaginal voiding
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| Etiology of Enuresis ? | * lower spinal cord controls it at birth (why boys pee when diaper is off) .... * Control is made when we can contract the detrusor muscle and activate sphincter to void
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| Some possible causes of Enuresis ? | * possibly a smaller bladder ..... * ADH issue ... * Will of the kid to stop it
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| Some things to have on a Differential Dx for Enuresis ? | * Obstructive Sleep Apnea.... * Neuro issues.... * Genito-Urinary issues with anomalies/kidneys issues...... * Parasitic Infection....* Sickle Cell ...... *HyperThy, DM, DI.... * Somatization or Stress
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| Associated Symptoms ? | * weight loss, fever, failure to thrive... * snoring, apnea..... * constipation... * possible seizures
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| Important when looking at urinary issues ? | * ask questions on stool habits
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| Family Hx ? | * If one parent had enuresis, the kid can have it also ... *If both had it, there is even a higher chance... * Seizure and DM/DI Hx also
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| Social Hx ? | * Look for clues that have caused stress or even sexual abuse (wetting can be the only sign of sexual abuse).... * Ask about physical punishment
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| PE ? | * most will have a NORMAL exam ... * ALWAYS look at Gentials and neuro issues.... * Chapman’s point in the periumbilical region (bladder)
..... * T11-L2 dysfunction (bladder)
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| Laboratory Investigation ? | * Only need a UA
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| Imaging ? | * no image really needed ... * Xray for constipation, MRI if spine defect, CT for Brain/Neuro issues
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| When to treat ? | * the best is when the parents are involved and the kid sees it as a problem and is motivated to make it stop
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| What to do if the Non-pharm approach to fix Enuresis doesn't work ? | * usu try if 3 -6 months of non-pharm tmt isn't working.... * If the kid isn't bothered by the wetting, then NO tmt will really work.... * Meds = desmopression (DDAVP) followed by tricyclic antidepressants (TCA)
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| ** UTI's in Kids to Follow ** | .
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| UTIs in kids 24months and younger ? | * they really can't complain, so anyone of them with a FEVER should be worked up for a UTI
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| Some pediatric Pathophysiology on UTIs ? | * improper voiding or holing can increase bacteria content in bladder ...... * Reflux, usu due to inflammation, that allows urine to retrograde and can cause kidney issues.... * If no reflux, bacteria usu only invade the bladder
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| Hematogenous Route UTI route ? | * Neonates with bacteremia and children with endocarditis are the most likely population to acquire pyelonephritis in this fashion
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| Usu. UTI causative agent ? | * E. Coli in retrograde... * Staph and E.Coli in hematogenous spread
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| 3 Components of a UTI ? | * Cystitis --- Asymptomatic bacteriuria --- Pyelonephritis
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| Cystitis basics ? | * Bladder Inflammation.... * look for bubble bath HX or parents saying the kids always "touch" themselves..... * Also, FEVER is the predominant feature in kids under 2... * once again, LOOK AT THE GENITALS ! ...* suprapubic pain is us present too
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| Special Note on Teenagers ? | * If sexually active, ask about sex toys, spermicide use, sexual Hx, and always screen for STDs
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| Asymptomatic Bacteriuria basics ? | * Presence of bacteria on a UA but no white cells (pyuria) is appreciated
..... * child has no CxSx.... * No tmt needed if no complications are seen
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| Pyelonephritis basics ? | * Most serious Infection of the UTI spectrum! .... * Upper Tract UTI --> Bacterial infection of the tubules, interstitum, and renal pelvis..... *
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| Pyelonephritis CxSx ? | * Older pts: may be short stature, abdominal pain, HTN, dysuria, chills .... * Younger: F/V, poor feeding, and abdominal pain...... * Can cause Renal Abscesses and Renal Scarring
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| Some UTI risk factors ? | * catheters, not circumcised, sexual HX, Fam Hx
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| Vesicoureteral Reflux imaging ? | * only do it if we get an abnormal ultrsound or a second febrile UTI...* use VCUG (voiding cystourethrogram) ..... * Can cause End Stage Renal Disease (ESRD) in kids
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| Some Anatomic Obstructions that can cause UTIs in kids ? | * Why a visual genital exam is important ! ..... * Labial Adhesions, penile scarring ,webbed penis, prepuce issues, and unusual meatus opening/course
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| Circumcision basics ? | * Helps prevent penile cancer, UTIs, and transmission of STDs
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| Posterior urethral valves ? | * Seen in males .... * Persistent urogenital membrane that impedes urine flow from the bladder.....* usu see when baby is in septic shock and has a low urine stream....... * Dx: with VCUG
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| Neurogenic Bladder and Associated Disorders ? | * occurs when innervation to the bladder is distorted....* often with myelomeningocele and cerebral palsy patients ....* need a catheter to void
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| Neurogenic bladder TmT = ? | * treat infection if there, give oxybutinin to relax muscles to avoid void frequency, and catheter placement to void
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| Dysfunctional Voiding ? | * Willful holding urine, having an abnormal elimination pattern, and/or incontinence
.....* Leaves bacteria in the bladder to grow and cause issues
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| Diagnosis - Laboratory UTI ? | * Diagnosis of UTI must be a URINE CULTURE that grows at least 50,000 colonies.... * UA is a good start, but may need other tests to see whats going on
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| Dx UTI Imaging ? | * Us if pt is not getting better, and VCUG if a recurrent issue/febrile kid
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| UTI TmT = ? | * start antimicrobials if UTI is suspected and wait for a culture.... * if unsure/ low suspicion , get a culture first..... * severe and babies under 2 mths need IV meds.... * upon culture return, get appropriate meds
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| Renal and bladder ultrasound ? | * needed for any child 2months to 2 years following their first febrile UTI
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