GENERAL SURGERY UROLOGY SN Flashcards
What are common associated anomalies seen with omphalocele?
- Trisomy syndromes (30%) 2. Cardiac defects (20%) 3. Bladder extrophy 4. Beckwidth-Wiedemann syndrome
What are common associated anomalies seen with gastroschisis?
- Intestinal atresia 2. Cryptochordism 3. Malrotation
When should undescended testicles be repaired?
12 months of age or shortly after 75% of full-term infants and 90% of prem babies with cryptorchidism will have full testicular descent by the age of 9 months. After that spontaneous testicular descent is unlikely.
What are the clinical manifestations of testicular torsion? (4)
- Acute onset of scrotal pain 2. Nausea and vomiting (common) 3. Acutely tender, high riding and swollen testis 4. Absent cremasteric reflex
What is the differential diagnosis of testicular torsion? (4)
- Epididymitis: ask about dysuria, pyuria, discharge. Often caused by chlamydia or gonorrhea. History of STIs is suggestive. 2. Orchitis: usually slower in onset, other systemic symptoms (nausea/vomiting/fever) as a result of diffuse viral infection 3. Torsion of testicular appendix: sudden onset of pain, localized, isolate tender nodule at upper pole -blue dot sign (bluish discoloration) 5. Incarcerated hernia: acute onset; usually palpable inguinal mass, testes not painful, symptoms and signs of bowel obstruction
What is the Prehn sign?
Positive Prehn sign: relief of pain with elevation of the testis in epididymitis Negative Prehn sign: generally indicative of testicular torsion ***non-specific though
If complete testicular torsion has occurred, how long is it before irreversible changes develop?
4-6 hours
What is the difference between a communicating hydrocele and a non-communicating hydrocele? -Time course of hydrocele (small vs. large) -Possible complication of hydrocele
Communicating hydrocele: patent processus vaginalis and thus mass will be soft, fluctuant -risk for hernia formation Non-communicating hydrocele: closed processus vaginalis and thus mass will be tubular, firm Time course: small generally resolve by 9-12 months; large may not resolve Complication: if does not resolve, may cause vascular compromise and testicular atrophy
What are red flags pointing to an underlying surgical cause in children with abdominal pain?
- Children < 5 years old 2. Bilious vomiting 3. Return to ED with same pain within 72 hrs of discharge home 4. Previous abdominal surgery 5. Progression of pain 6. Pain far away from umbilicus 7. Vomiting without diarrhea 8. Disturbance in gait 9. No pain like this before
What age group is intussusception most commonly seen in? -If intussusception is seen in age < 3 mo or > 2 yo, what is the clinical significance of this?
80% occur in children < 2 yo (Highest incidence between 5-9 mo) -if outside of this age range, more likely to have a lead point (hyperplasia of intestinal Peyer’s patches, Meckel’s, polyps, Burkitt’s lymphomas)
What is the classic triad of intussusception? -in what percentage of children is this triad seen in? -classic exam finding? -diagnostic imaging? -definitive treatment?
- Colicky abdo pain 2. Vomiting 3. Bloody stools -seen in only 20% of intussusception presentation -classic exam finding: sausage shaped mass in RUQ (if ileocecal intussusception) -ultrasound is best imaging modality (99% sensitive, 90% specific) -definitive treatment: air enema (more effective at reduction than barium and less risk of perforation)
What are risk factors for developing pyloric stenosis aka in which groups does pyloric stenosis tend to occur in? (6)
- Males (4-6x more likely than females) 2. Offspring of mother with history of pyloric stenosis 3. Those with blood group B or O 4. Caucasian 5. History of erythromycin use (especially in the first 2 weeks of life) 6. Certain syndromes (ie. Apert, Trisomy 18, etc.)
What is the recurrence risk of intussusception in the first 24 hrs?
10% in the first 24 hrs -this is why all patients need to be admitted post-reduction via air enema
What is Rigler’s sign?
On an AXR, if you see air on both sides of the bowel wall, this is perforation or free intraabdominal air -may also see triangle of air
What is the most common type of intussusception? -what is the most common pathological lead point for intussusception? -what is the gold standard test for intussusception? -what is the treatment for intussusception? -which type of intussusception cannot be managed with the usual treatment?
Ileo-colic = 85% -most common pathological lead point: Meckel’s diverticulum -gold standard test for intussusception: ultrasound = see target sign, then do air enema once dx confirmed for treatment -cannot use air enema for jejuno-ileo intussusception because the air enema can’t create enough pressure to resolve a small bowel intussusception
What are absolute contraindications for air enema?
- Peritonitis 2. Persistent hypotension 3. Free air/pneumoperitoneum
What is the rule of 2s for Meckels?
2:1 male to female 2% population Present by 2 yo 2 types of tissue: gastric or pancreatic Within 2 feet of ileocecal valve 2 inches long
When does the repair for congenital diaphragmatic hernia occur? -what are the first 3 steps you take when a baby with CDH is born (aside from NRP)?
Only repair when the baby has been stable x 24-48 hr after birth -first two management steps: 1. Intubate on first breath so the stomach doesn’t get distended in the chest cavity 2. Put in NG for decompression asap 3. Need to get an ECHO to see if cardiac function has been compromised by the bowel in the chest and also, CDH is associated with cardiac abnormalities as well
Which major anomaly occurs most frequently with EA-TEF?
Cardiac! = needs work up for VACTERL
What is the acute management of malrotation and volvulus?
- NPO 2. NG to low intermittent suction 3. IV fluids 4. IV abx: amp/gent/clinda 5. UGI asap 6. Ladd’s procedure
What is the gold standard test for diagnosis of Hirschsprung’s? -2 signs you see on rectal biopsy? -treatment?
Rectal biopsy! 1. Absent ganglionic cells 2. Increased acetylcholinesterase staining Treatment: rectal decompression with saline irrigations q6h (5 ml at a time) = irrigation fluid is removed completely by keeping rectal tube in place until surgery (definitive pull-through)
What is the most common cardiac malformation seen with omphalocele?
Tetralogy of Fallot
What is the management of pediatric hernias? -what is an indication for contralateral exploration during surgery? -treatment for incarcerated hernia?
- Should be surgically repaired within 2 weeks of diagnosis (doubled risk of incarceration if wait > 30 d) -contralateral exploration should only be done for infant with history of prematurity (but does increase risk of injury to vas deferens or the testicle) -incarcerated hernia: attempt reduction with sedation and then repair in 24-48 hrs! Don’t want to operate right away because bowel is too edematous and want to give it a chance to resorb. For strangulated hernias, have no choice but to repair asap
WHAT ARE THE Steps in the Development of Male & Female
Internal Genitalia?
WHAT ARE THE Steps in gonaldal development?
DSD What are the two most common forms of DSD?
- 46XX Congenital adrenal hyperplasia (CAH)
. Virilized female
. Most common form of DSD
- 45X/46XY Mixed gonadal dysgenesis (MGD)
. 2nd most common form of DSD
DSD How does 45X/46XY Mixed Gonadal Dysgenesis (MGD) Present?
- Partially virilized external genitalia
- Variable assortment of mullerian & wolfian structures
- Impalpable gonads
+/- inguinal hernias
DSD How doyou manage 45X/46XY Mixed Gonadal
Dysgenesis (MGD)?
Management:
– Gender assignment (multidisciplinary team approach)
– Surgery: Gender concordant surgery
–Medical: Sex hormone replacement for puberty and
adulthood
ANH What are the Canadian Urology Guidelines on ANH?
CAP= Continuous Antibiotic prophylaxis
Hydronephrosis: What is the most common cause of
Acquired Hydronephrosis? Sx and tests?
Often UPJ obstruction
. Typically presents with symptoms:
. Recurrent abdominal pain/flank pain
. Recurrent pyelonephritis
. Vomiting (+/-pain) after increased fluid intake
. Investigations:
. Initial: RBUS
. If HN, Urology may confirm obstruction w/ diuretic renal scan
What is the most common cause of daytime urinary incontinence?
Most common non-infectious cause: Idiopathic overactive
bladder (OAB)
• Note:
a. bacterial cystitis and bladder outlet obstruction may
cause 2o OAB
b. Consider other etiologies if signs & symptoms not
consistent with OAB
What are the clinical features of Daytime Urinary Incontinence
Idiopathic Overactive Bladder (OAB)?
What s the 1st line Rx for Daytime Urinary incontinence
Idiopathic Overactive Bladder (OAB)?
- Treat constipation (diet/PEG 3350)
- Treat UTIs
- Timed voiding (every 1.5-2h)
- Observation is an option if not bothersome to family/child (usually resolves eventually)
What s the 2nd line Rx for Daytime Urinary incontinence
Idiopathic Overactive Bladder (OAB)?
Anticholinergics (AKA Antimuscarinics) oxybutinin, tolteridine (offlabel), solifenacin (off-label)
• Note: Anticholinergics may worsen constipation & aggravate OAB
ANH What are the investigations urologists order for ANH when patients are referred to them?
Daytime incontinence When to Consider other etiologies if not consistent with OAB?
What are the Ddx of Pelvic & Abdominal Masses based on probability?
For neuroblastoma what are the tests, Stave 4 features and management?
Lab:
Elevated urinary catecholamines, vanillylmandelic acid
(VMA) & (HVA) homovanillic acid in >90% of patients
Stage IV-S:
Infants w/ small Primary tumor w/ liver, skin & bone
marrow mets, but NO radiographic evidence of bone mets.
Many undergo spontaneous regression
Skin mets look like “blueberry muffins” in infants
Treatments: Surgery, chemotherapy & radiation – need
individualized to patient
Newborn Male Circumcision What are the essential features?
2015 (reaffirmed 2018) CPS Position Statement :
What is the Rate of Canadian newborn circumcision?
What % of foreskins retract by 6 and 17 yrs?
What are uncircumcised boys at risk of?
What hastens retraction of foreskin and release of adhesions?
What can prevent meatal stenosis post corcumcision?
The CPS does not recommend the routine circumcision of every newborn male
. Rate of Canadian newborn circumcision: 32%
. Age 6 years: 50% of foreskins retract
. Age 17 years: 95% of foreskins retract
Increased risk of STI transmission and penile cancer does not justify recommendation of routine circumcision
Topical steroids recommended for hastening retraction of foreskin and release of adhesions
Meatal stenosis (seen following 2-10% of newborn circumcisions) can be prevented by applying petroleum jelly to the glans for up to 6 mo following circumcision
What is the care of foreskin based on age?
Diaper, pre puberty and puberty?
In diapers:
. To wash, retract as far as it wants to go
. Do NOT retract to the point of pain or bleeding
. Always “reduce” to normal position, to prevent a paraphimosis
• Pre-puberty & asymptomatic:
- No intervention required
- Note: non-obstructive ballooning of the foreskin is not pathological
Approaching puberty & still does not retract:
- Child to start routinely making attempts at foreskin retraction
- If fails, add application of topical steroids twice daily for 6 weeks to weaken skin and release adhesions. Options include betamethasone 0.05%, triamcinilone 0.1% (my preference, as an ointment), & mometasone furoate 0.1% (CPS 2015)
Indications for circumcision?
- Scarred phimosis
- Recurrent balanoposthitis
- Recurrent UTIs
- Delayed retraction of the foreskin >10 years of age
UTI UTI in infants and children: How do you invetigate using the following tests?
2014 (reaffirmed 2017) CPS Position Statement: UTI in infants and children: Diagnosis and management
IMAGING - when should you order the following?
- RBUS
- VCUG
Antibiotic prophylaxis - when indicated?
How do you manage VUR 4-5 or a child with or a child with significantly abnormal RBUS findings?
How do you manage Children w/ recurrent UTIs?
IMAGING - when should you order the following?
- RBUS after 1st febrile UTI
- VCUG (or Nuclear Cystogram in female) is reserved for those w/ an abnormal RBUS or if have a 2nd febrile UTI
Antibiotic prophylaxis
No Antibiotic prophylaxis for VUR I-III, even w/ hx of febrile UTI
How do you manage VUR 4-5?
Referral/discussion with Urologist or Nephrologist for VUR 4-5 or significantly abnormal RBUS findings
How do you manage Children w/ recurrent UTIs?
should be managed individually
What are the focus points in UTIs: Recurrent cystitis?.
Unlike febrile UTIs, investigation & management of
recurrent cystitis focuses on behavioral anomalies rather
than anatomical ones
. Do NOT look for structural anomalies – ie RUS and VCUG not routinely indicated
Look for bladder and bowel dysfunction
. Constipation
. Infrequent voiding
. Voiding postponement
. Daytime urinary incontinenc/Overactive bladder (OAB)
. Incomplete emptying
Prophylactic antibiotics for children with recurrent UTIs - what are the essential points?
(2015 CPS Position Statement)
.
- Managing constipation appropriately may be helpful for decreasing UTI recurrences
-
CAP:
a. If CAP used, should be used for no more than 3 – 6 mo & use reevaluated thereafter
b. Choice antimicrobial is TMP/SMX or nitrofurantoin
c. Switch antimicrobial if urine culture shows resistant organism, even if suspect contamination
d. If urine isolate shows resistance to both TMP/SMX & nitrofurantoin, consider stopping CAP rather than using broad spectrum antimicrobial for CAP
UTI
A 18 month old M is diagnosed with his 1st febrile UTI.
RBUS shows bilateral SFU II HN. A VCUG was ordered and
shows bilateral grade 3 VUR and a normal posterior urethra.
What is your management?
Only observation is required for grade III VUR (bilateral or
unilateral) identified following single febrile UTI
CPS Position Statement 2014/17
Repeat cystogram will not alter management if child remains UTI free off prophylactic antibiotics
