Genitalia

Question 1

Hypospadias

Answer 1

configuration of the urethra varies from mild glanular hypospadias to severe perineal hypospadias with chordee

• When the opening (urethra) of the penis is not at the top/correct location
• can occur anywhere along the penis

Question 2

Chordee

Answer 2

Congenital downward curvature of the penis due to a strand of connective tissue between the urethral opening and the glands, associated with hypospadias

Question 3

Penile Torsion

Answer 3

Abnormal rotation of the glans and urethral meatus

• Can be congenital or acquired
• Most are counterclockwise

Question 4

Micropenis (3)

Answer 4

1. Micropenis results from an interruption in penile growth sometime after the fourteenth week of gestation
2. Penis is smaller than 2SD from the mean, minimum is 2cm at birth
3. Penile size gradually increases due to presence of testosterone

Question 5

Physiologic phimosis

Answer 5

foreskin has not completed the normal separation from the epithelium of the glans penis

Question 6

Pathologic phimosis

Answer 6

foreskin can’t be retracted after it has been previously retractable or when the foreskin cannot be retracted after puberty

Question 7

Paraphimosis

Answer 7

If a tight prepuce is retracted over the glans to the level of the corona (paraphimosis), the constricted ring of skin may act as a tourniquet applied to the distal shaft and glans, and ischemia may result

1. Foreskin is retracted and remains proximal
   to the glans penis
2. It cannot be pulled forward
3. Can constrict the penis and cause edema of the glans.

Question 8

What is priapism associated with? (5)

Answer 8

1. Spinal cord trauma
2. Sickle cell disease
3. Leukemia
4. Pelvic tumors or infection
5. Penile trauma

Question 9

Meatal Stenosis (4)

Answer 9

1. Scarring and narrowing of the urethral meatus; delicate meatal edges lose superficial epithelial lining
2. Acquired problem in circumcised boys
3. One year old- accept 5 French
4. 1-6 year - accept 8 French

Question 10

Clinical Presentation of Meatal Stenosis (3)

Answer 10

1. Narrow, high velocity urinary stream
2. Upward urinary stream dysuria
3. Meatal bridges can also be detected by watching the child void

Question 11

Urethritis

Answer 11

Inflammatory process of the urethra without a concurrent bladder infection that is usually, but not always, caused by sexually transmitted microorganism

Question 12

PA of Testes (3)

Answer 12

1. The testis is best examined by grasping it between the thumb and the first two digits.
2. The epididymis should be palpable as a soft, smooth ridge posterolateral to the testis.
3. The testes are normally the same size.

Question 13

Varicocele (2)

Answer 13

1. Dilated veins of the pampiniform plexus of the spermatic cord; Collection of varicose veins
2. Occur primarily on the left side (but can be bilateral) and may be found before puberty (never before age 9)

Question 14

Pathophysiology of Varicocele (4)

Answer 14

1. Palpable left sided; varicocele occur in 85%-90% of all cases
2. If there is a right sided varicocele, it is usually bilateral
3. Clinically, the varicocele is associated with elevated temperature in scrotum and testes
4. Hallmark of testicular damage in the adolescent with varicocele is testicle atrophy

Question 15

Grading Varicocele (4)

Answer 15

1. Grade 3: Palpable varicocele feels like a bag of worms- visible distention: Palpable and visible at rest
   - Can see it without touching
2. Grade 2: Nonvisible but palpable varicocele
3. Grade 1: Can only be palpable when a patient performs the valsalva maneuver and distends the intrascrotal veins in patient with varicocele
4. Subclinical: Not palpable or visible even with Valsalva maneuver but demonstrable on Doppler

Question 16

Testicular Torsion (3)

Answer 16

1. Testes and spermatic cord twist, resulting in obstructed blood flow
   * Testicle is suspended and gets twisted
2. Tends to follow trauma in adolescents or occurs spontaneously in newborns
3. More common during newborn period or early stages of puberty

Question 17

Signs and Symptoms of Testicular Torsion (4)

Answer 17

1. Vomiting
2. Lower abdominal pain
3. Testicular pain
4. Newborn will be crying and testicle becomes swollen

Question 18

Extravaginal Torsion (5)

Answer 18

1. Testicular torsion can also occur perinatally if the entire testis complex has not yet fused to the scrotum.
2. In this type of torsion, the testis, spermatic cord and tunica vaginalis twist en bloc.
3. Clinically, extravaginal torsion appears as an asymptomatic swelling of the scrotum.
4. Erythema or a bluish discoloration of the scrotum is also frequently seen.
5. As a result, the spermatic cord can twist within the tunica vaginalis (intravaginal torsion)
   - Testicles will be side-lying

Question 19

Pathophysiology of Testicular Torsion (2)

Answer 19

1. Results from bell clapper deformity caused by the peritoneal investiture of the testis lying on the cord rather than the lower pole of the testis
2. The degree of torsion influences the degree of ischemia

Question 20

How do you diagnose testicular torsion?

Answer 20

Ultrasound

Question 21

Clinical Presentation of Testicular Torsion (6)

Answer 21

1. Severe pain of abrupt onset
2. Nausea and vomiting
3. Child may complain of lower abdominal pain or inguinal pain due to embarrassment
4. History of acute pain which resolved spontaneously may indicate testicular torsion that has resolved
5. Less consistent in young infants and older adolescents
6. 100% of normal boys from 30 months to 12 years had an intact cremasteric reflex**

Question 22

Torsion of Testicular Appendages (2)

Answer 22

1. More common in pre-pubertal boys ages 7-12

2. Testis appendix or the epididymal appendix gets twisted

Question 23

Pathophysiology of testicular appendage torsion (3)

Answer 23

1. Testis appendix is a müllerian duct remnant located at the superior pole of the testes
2. The epididymal appendix is located on the head of the epididymis and is a Wolffian duct remnant
3. When either appendage becomes twisted, the testicle will produce similar to spermatic cord torsion

Question 24

Torsion of testicular appendages clinical presentation (7)

Answer 24

1. Mild to moderate pain gradually developing over a few days
2. Assess cremasteric reflex by pinching the skin of upper inner aspect of the thigh; subsequent unilateral elevation of the testes
3. Affected testicle is tender at the top at the superior pole
4. “Blue Dot Sign”: Small Bluish Discoloration over the superior pole of the testicle
5. As pain increases, the physical findings become less specific as scrotal swelling pursue
6. If you elevate testes (ex: on pillow or rolled towel), the pain will be relieved
7. There may be mild swelling of the testes

Question 25

Epididymitis in adolescents and young adults (2)

Answer 25

1. Usually related to sexual activity | 2. Does not present with a urinary tract infection.

Question 26

Epididymitis in pre-pubescent boys (2)

Answer 26

1. Epididymitis is almost always associated with a urinary tract anomaly. 2. Any episode of epididymitis and urinary tract infection in males need investigation renal/bladder sonogram and a voiding cystourethrogram to rule out structural problems.

Question 27

Urethral strictures

Answer 27

Fibrotic narrowing of the urethra caused by scarring

Question 28

bladder outlet obstruction

Answer 28

Diminished force and caliber of the urinary stream

Question 29

When is cryptochidism more common? (7)

Answer 29

1. First born 2. C-section 3. Toxemia of pregnancy 4. Hypospadia 5. Congenital subluxation of hip 6. Low birth weight 7. Winter

Question 30

Cryptochidism

Answer 30

Maldescent of testes 1. Most descend by 6 months of age 2. If not descended by 1 year, refer to urology 3. Risk of malignancy and infertility if left in abdomen 4. Cause of descent the endocrinologic effect on the gubernaculum testis

Question 31

How to examine cryptochidism

Answer 31

Examine child in warm environment * Milk testis from above internal inguinal canal downward. - Some are retractile and can be milked into scrotum

Question 32

Cryptorchid Testis

Answer 32

Testis whose descent has been arrested between the normal pathway in its original abdominal location and scrotal position

Question 33

Ectopic Testes (2)

Answer 33

1. A testicle that has been diverted from a normal pathway to a location outside that which a normal testis travels. 2. Gubernaculum has an abnormal insertion point. - Suprapubic - Penile - Femoral - Perineal - Least common contralateral position

Question 34

Hernia

Answer 34

1. More common on right side 2. Due to failure of processus vaginalis to obliterate 3. Indirect most common in children 4. Bowel forced into scrotum via inguinal canal

Question 35

Inguinal Hernia History and Physical (6)

Answer 35

1. Should be suspected in a child who has a history of intermittent groin swelling History: 2. “Lump” is seen when crying 3. Comes and goes Physical Exam 4. Palpate testes 5. Put the arms over head 6. Have the child cough if older

Question 36

Hydrocele (6)

Answer 36

1. Accumulation of peritoneal fluid inside patent process vaginalis 2. Can be alone or associated with hernia 3. Transillumination reveals a homogeneous glow without shadows; Will see fluid in testicular area 4. Usually resolves by 1 year 5. An infant with a hydrocele and no evidence of a hernia is usually just observed for the first one or two years of life. 6. If the hydrocele persists beyond this time, surgical repair through the groin is recommended.

Question 37

Communicating Hydrocele (3)

Answer 37

1. Communicates with the fluids of the abdominal cavity 2. Caused by the failure of the processus vaginalis (the thin membrane that extends through the inguinal canal and descends into the scrotum) to close completely during prenatal development. 3. If this membrane remains open, there is a potential for both a hernia and a hydrocele to develop.

Question 38

Non-Communicating Hydrocele (3)

Answer 38

1. This condition might be present at birth or might develop years later for no obvious reason. 2. A non-communicating hydrocele usually remains the same size or has a very slow growth 3. Usually needs surgical repair

Question 39

Physical Exam of Female (4)

Answer 39

1. Examine in two different positions 2. No speculum needed unless unknown bleeding 3. Be aware of physiological hymenal changes related to pubertal development 4. Look at anal area