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a_GYNGU > 11/17- Pediatric Urology > Flashcards

11/17- Pediatric Urology Flashcards

1
Q

What are causes of acute scrotum?

A
  • Testicular torsion
  • Torsion of the appendix testes
  • Epididymo-orchitis, epididymitis
  • Trauma
  • Incarcerated hernia
  • Scrotal wall process: HSP, Fournier’s
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2
Q

What are the 2 types of testicular torsion?

When does each typically occur?

A

1. Extravaginal- perinatal (almost exclusively)

2. Intravaginal- perinatal and older (most common in 8-30 yo)

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3
Q

What is extravaginal torsion? Treatment?

A

Torsion of entire cord proximal to tunica vaginalis attachment

  • Tx: Salvage of torsed testis unlikely; surgery to protect contralateral testis is controversial
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4
Q

What is intravaginal torsion?

A

Torsion distal to tunica vaginalis attachment

  • Bell-Clapper or horizontal lie predisposes to torsion
  • (Recall: most common in 8-30 yo, rare in older, but not uncommon in younger)
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5
Q

What is shown here?

A

Bell Clapper Deformity

  • Risk factor predisposing someone to torsion (intravaginal)
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6
Q

What is the presentation of testicular torsion?

A
  • Acute, severe pain
  • Scrotal swelling
  • N/V
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7
Q

What are physical exam findings of testicular torsion?

A
  • Erythema, edema, loss of cremasteric reflex, high riding testis
  • Caveat: Not all older children/adults have a cremasteric reflex
  • Absence does not mean torsión
  • Hard, non-tender testis in infant: antenatal/neonatal torsion
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8
Q

How is testicular torsion diagnosed?

A

Ultrasound (see lack of blood flow) is definitive but not mandatory if:

  • high index of suspicion
  • obtaining study will delay care
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9
Q

How are pts with suspected testicular torsion managed?

A

Manual reduction with narcotics

  • ONLY IF SURGERY NOT AVAILABLE
  • “Open the Book”
  • Both inward and outward rotation occurs

Prompt surgical exploration

  • Detorsion of testis with orchiopexy or orchiectomy
  • Orchiopexy for contralateral testis
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10
Q

What are salvage rates by time?

A

- 0-6 hrs: 85-90%

- 6-12 hrs: 50%

- >24 hrs: 5% or less

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11
Q

What are the embryological sources of the appendix testes? Appendix epididymis?

A
  • Appendix testes: Mullerian system
  • Appendix epididymis: Mesonehpros
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12
Q

What is the presentation of torsion of the appendix testes/epididymis?

A
  • Slow, gradual onset over days
  • Less nausea and vomiting
  • Pain related to inflammation caused by necrotic structure
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13
Q

What are physical exam findings of torsion of the appendix testes/epididymis?

A

“Blue Dot” Sign

  • Necrotic appendage seen through thin scrotal skin
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14
Q

What is treatment for torsion of the appendix testes/epididymis?

A

If diagnosis certain, then treat with comfort care:

  • Anti-inflammatories
  • Analgesics
  • Scrotal support
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15
Q

What are infectious processes that contribute to epididymo-orchitis, epididymitis, and orchitis? Non-infectious?

A

Infectious:

  • Children: UTI
  • “Young man’s”: STD
  • “Old guy’s”: UTI
  • TB and mumps are rare

Non-infectious

  • Medications (amiodarone)
  • Urine reflux into ejaculatory ducts
  • Trauma
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16
Q

Describe the presentation of epididymo-orchitis, epididymitis, and orchitis?

A
  • Gradual, progressive onset of pain
  • Irritative, voiding symptoms
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17
Q

What are physical exam findings for epididymo-orchitis, epididymitis, and orchitis?

A

Tenderness posterior and lateral to the testis (the usual location of the epididymis)

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18
Q

Describe diagnosis of epididymo-orchitis, epididymitis, and orchitis

A
  • Urinalysis and culture if indicated
  • Imaging with scrotal ultrasound
  • Enlarged, hypervascular epididymis
  • Normal or increased testicular blood flow
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19
Q

What is the treatment for epididymo-orchitis, epididymitis, and orchitis?

A

If infectious cause:

  • Antibiotics, scrotal elevation, analgesics, rest
  • Evaluate for possible urinary anomaly

If non-infectious process:

  • Anti-inflammatories
  • Analgesics
  • Scrotal elevation
  • Rest
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20
Q

Which gender has highest risk/rate of UTI in 1st year of life?

A

Males

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21
Q

What is one main determining risk factor for male UTIs?

A

Circumcision status

  • Uncircumcised UTI risk is 3-12x circumcised
  • Routine neonatal circumcision for medical benefit is not supported by the AAP
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22
Q

What are congenital GU causes of UTIs in males?

A
  • Nonfunctioning renal segments
  • Obstructive defects in the GU tract
  • Vesicoureteral reflux (VUR)
  • Neurogenic bladder
  • Poor emptying
  • Clean intermittent catheterization (CIC)
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23
Q

What are acquired GU causes of UTIs in males?

A
  • Kidney stones
  • Voiding dysfunction
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24
Q

What are pathologic consequences of UTI?

A
  • Cystitis
  • Acute and Focal Pyelonephritis
  • Pyonephrosis
  • Perinephric or Renal Abscess
  • Renal Scarring
  • Xanthogranulomatous Pyelonephritis (XGP)
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25
Q

What are symptoms of UTIs?

A

Infants/young children: vague symptoms

  • Fever*, irritability, poor feeding, vomiting, diarrhea

Older children

  • May describe localizing symptoms: dysuria, suprapubic pain, incontinence, voiding dysfunction
  • May have generalized symptoms: fever, vomiting
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26
Q

What are physical exam findings with UTI?

A
  • Flank or abdominal tenderness
  • Perineum
  • Labial adhesions
  • Ectopic ureteroceles
  • Scrotal changes: epididymitis
  • Phimosis
  • Sacral dimple, skin lesion, hair
  • Neurogenic bladder
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27
Q

What are diagnostic tests for UTIs?

A
  • Urinalysis
  • Urine culture (gold standard); may take 24-48 hrs for result

(According to AAP guidelines, whether/not to pursue workup on infants [2-24 mo] with fever depends on likelihood of UTI)

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28
Q

Describe the methods of obtaining a reliable urine specimen

A

Most -> Least reliable:

- Suprapubic aspirate

  • Use a 21-22 gauge needle to 1-2 cm above pubic symphysis

- Catheterized

- Midstream voided

  • Generally not reliable in young girls and young uncircumscribed males

- Bagged specimen

  • High false positive rate (perineal and rectal flora)
  • Negative bagged specimen may be sufficient for survival
29
Q

What indirect tests may support diagnosis of UTI?

A
  • Microscopic WBC > 5 pHPF
  • Any number of bacteria pHPF
  • Urinary leukocyte esterase (high sensitivity, low specificity)
  • Urinary nitrite (low sensitivity, high specificity)
  • Gram positive bacteria do not reduce urinary nitrates If last 3 are present: sensitivity for UTI almost 10)%
30
Q

What is the definition of UTI based on urinalysis?

A

100,000 (>105) cfu/mL of voided urine

  • AAP guidelines (2-24 mo):
  • 50,000 cfu/mL or a uropathogen culture from a urine specimen obtained through catheterization or SPA

AND

  • Urinalysis with pyuria and/or bacteruria
31
Q

How are pediatric UTIs classified?

A
  • Initial
  • Recurrent
  • Complicated vs. uncomplicated
  • Upper vs. lower tract (febrile/nonfebrile)
32
Q

What makes a recurrent UTI?

A
  • Unresolved bacteruria during therapy
  • Bacterial resistance to therapeutic agent
  • Inadequate urinary concentration of antimicrobial
  • Infection by multiple organisms
  • Bacterial persistance (anatomic source)
  • Reinfection
33
Q

Who should get a renal bladder US?

A

Boys and girls with 1st febrile UTI

  • Immediate imaging if very ill or not responding to abx
  • After resolution of UTI in most cases

Recurrent UTIs

34
Q

What are you looking for in renal bladder US?

A
  • Enlarged kidneys
  • Hypoechogenicity or hyperechogenicity
  • Thickened renal pelves
  • Ureteral dilatation
  • Bladder wall thickening
  • Urologic abnormalities: hydronephrosis, duplication, ureterocele, or stone etc.
35
Q

Who gets a voiding cystourethrogram (VCUG)?

A

(Controversial test; catheter into urethra, fill bladder with contrast, take spot xrays)

  • Infants under 2 mo diagnosed with UTI
  • Abnormal renal bladder ultrasound
  • Recurrent febrile UTI NOT recommended after 1st febrile UTI and a normal renal bladder US
36
Q

When is VCUG performed?

A

As soon as urine is sterile

37
Q

What are the types of imaging?

  • Relative radiation doses
  • What is seen
A

Fluoroscopic VCUG:

  • Higher radiation doses
  • Demonstrates urethral and bladder abnormalities
  • Demonstrates VUR and degree
  • Evaluates colon

Nuclear cystogram

  • Lower radiation doses
  • Does not demonstrate urethral anatomy
38
Q

Who gets a CT?

A

Obtain if patient not improving:

  • Enlarged kidney
  • Renal abscess
  • Lobar nephronia
  • Decreased perfusion
39
Q

What does nuclear renography (DMSA scan) detect?

A
  • Can detect acute inflammation and scarring
  • DMSA is a renal cortical imaging agent
  • May be difficult to assess old vs. new renal scarring unless serial studies done
40
Q

How are UTIs treate?

  • Goals
  • Uncomplicated
A

Goals

  • Minimize renal damage during acute UTI
  • Minimize risk of future renal damage Uncomplicated UTI
  • 7-14 day course of appropriate antibiotic
  • Address dysfunctional voiding
  • Indicated radiologic workup
41
Q

Case Clinical Scenario:

  • A 22-month-old boy is referred for dysuria and two UTIs.
  • At the time of his diagnosis, he had no or low grade fever. He is uncircumcised and is not toilet trained.
  • According to his mother, a bag was used to collect the urine, the most recent was E. Coli >100K cfu/ml.
  • A renal US was recently performed demonstrating normal appearing kidney parenchyma with left pelviectasis, no hydroureter and a normal bladder.

What is your next step?

A. Obtain VCUG

B. Repeat renal US in 6 mo

C. Recommend circumcision

D. Observe

(TEST QUESTION)

A

A. Obtain VCUG

B. Repeat renal US in 6 mo

C. Recommend circumcision

D. Observe

42
Q

What are two big anomalies of GU tract that may predispose to UTIs?

A
  • Obstructive defects in urinary tract
  • Vesicuoureteral reflux
43
Q

What do the obstructive defects predisposing to UTIs include?

A
  • UPJ (ureto-pelvic junction)
  • UVJ (ureto-vesicular junction)
  • Posterior urethral valves
  • Ureterocele
44
Q

What is seen here?

A

UPJ Obstruction

45
Q

What is seen here?

A

UPJ Obstruction

  • Point 0: administer tracer
  • Tracer taken up in first few min (determine differential function of each kidney)
  • Look to see how well kidney drains function (here, relatively fast with downward sloping curve for one kidney, but accumulates in other kidney)
46
Q

What are indications for correcting a UPJ obstruction?

A
  • Infections
  • Loss of renal function
  • Pain
47
Q

What are surgical corrections of UPJ obstruction?

A

Pyeloplasty

  • Open: flank, dorsal or subcostal

incision

  • Laparoscopic/Robotic: transperitoneal or retroperitoneal
48
Q

What is seen here?

A

UVJ Obstruction

49
Q

What are indications for correcting a UVJ obstruction?

A
  • UTI
  • Loss of renal functi
  • Pain
50
Q

What are surgical corrections of UVJ obstruction?

A

Ureteral reimplant: may need tapering

51
Q

Describe posterior urethral valves

  • Potential consequences
  • Prognosis
A

Obstructing leaflets in the prostatic urethra

  • Occurs only in males
  • Traditional cause of renal failure, but rare
  • Now most commonly identified prenatally and treated immediately after birth (sometimes occurs in young infant or older child)
52
Q

Presentation of posterior urethral valves varies based on age. What does prenatal presentation look like?

A
  • Hydronephrosis
  • Dilated bladder
  • “Key hole” sign: dilated posterior urethra
  • Oligohydramnios
53
Q

What is seen here?

A

“Key Hole” Sign on fetal ultrasound (posterior urethral valves)

54
Q

What is treatment/intervention for posterior urethral valves when caught prenatally?

A

Fetal intervention: vesicoamniotic shunting

55
Q

Presentation of posterior urethral valves varies based on age. What does presentation at birth look like?

A

Varies depending on renal damage and degree of oligohydramnios

  • Septic shock
  • Pulmonary failur
  • Renal failure
  • Asymptomatic
56
Q

Presentation of posterior urethral valves varies based on age. What does presentation as a child look like?

A
  • UTI
  • Incontinence
  • Enuresis
  • Renal Failure
57
Q

What does management of posterior urethral valves diagnosed at birth involve?

A
  • Resuscitation
  • Antibiotics
  • Renal us
  • Placement of Foley or feeding tube
  • Await negative urine culture
  • VCUG
  • Nadir creatinine
  • Transurethral ablation (TUR)
  • Vesicostomy (exteriorize bladder to skin)
58
Q

What is seen here?

A

VCUG provides definitive diagnosis (right)

  • Dilated posterior urethra
  • Notched area classic for valves
59
Q

What are other clinical problems with posterior urethral valves?

A
  • Renal Failure / Renal Dysplasia
  • Vesicoureteral reflux
  • Incontinence/Enuresis
  • High volume dilute urine
  • Poor bladder compliance
60
Q

What is seen here?

A

Ureterocele (another obstructive defect)

61
Q

What is treatment for ureterocele?

A

Individualized

  • Incision of ureterocele
  • Upper pole nephrectomy
  • Lower pole reimplant
  • Ureteroureterostomy
62
Q

What is seen here?

A

Vesicoureteral reflux

63
Q

Describe the grading of vesicoureteral reflux

A

Grade I-V

  • Grade I: urine just into ureter
  • Grade V: significant distance with blown out renal calyces
64
Q

What are proposed causes of VUR?

A
  • Abnormal anatomy or ureterovesicular junction?
  • 5:1 ratio of tunnel length:ureteral diameter
  • Adequate intramural length
  • Anatomy of the ureterovesical musculature Superficial trigone: formed by ureteral muscle
  • Deep trigone: formed by Waldeyer’s sheath
65
Q

What are causes/classes of primary reflux?

A

Congenital

  • Inadequate tunnel length
  • Deficiency of trigone muscle complex
  • Associated with complete ureteral duplication, ureteral ectopia, ureterocele

Familial/genetic

  • 1/3 of siblings of index case will have VUR
66
Q

What are causes/classes of secondary reflux?

A

Functional

  • Neurogenic bladder
  • Non-neurogenic neurogenic bladder
  • Voiding and elimination dysfunction

Anatomic

  • Posterior urethral valves
  • Eagle Barrett (Prune Belly) Syndrome
67
Q

Management of VUR is aimed at what?

  • What does treatment/mgmt entail
A

Avoiding renal damage

  • Antibiotic prophylaxis with periodic VCUG and upper tract imaging
  • Surgery
  • Observation off prophylaxis
68
Q

Controversies with VCUG and other components of VUR management?

A
  • VCUG as a diagnostic test is painful, uncomfortable
  • While reflux can lead to renal scarring, the risk is undefined and is thought to be decreasing
  • Long term antibiotic prophylaxis leads to resistance
  • VUR must be managed on a case by case basis with parents involved in the management decisions.

a_GYNGU (17 decks)

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