GU Disorders in Peds/Circumcision Lecture Powerpoint

Question 1

Posthitis vs balantitis

Answer 1

Inflammation of the foreskin vs infalmamtion of the glans penis

Question 2

Phimosis definition

Answer 2

Tightness of the penile foreskin which prevents retraction over the glans, physiologically normal <5 years old, in adults can often be caused by lichen sclerosis, is NOT a medical emergency only needing immediate actuion of opening occluded and unable to urinate

Question 3

PHimosis treatment

Answer 3

Topical corticosteroid cream 3-4x daily for 6 weeks to loosen the phimotic ring

Question 4

Paraphimosis definition

Answer 4

Inability to reduce proximal foreskin over glans resulting in distal venous congestion and trapped foreskin, contributing factors include infection, masturbation, trauma, hair, failure to return foreskin post exam, IS a medical emergency to prevent necrosis and gangrene

Question 5

Paraphimosis treatment options

Answer 5

-dorsal slit and circumcision (dundee technique)

Question 6

Balanoposthitis definition

Answer 6

Inflammation of glans and foreskin caused by bacterial infection (group A strep), chemical irritation, trauma, drug reaction, STI

Question 7

Priapism definition

Answer 7

Engorgement of dorsal corpora cavernosa resulting in dorsal penile erection and ventral penile flacidity, typically idiopathic but can be caused by sickle cell, spinal cord injury, or many medications, considered a medical emergency if lasting more than 4 hours

Question 8

Priapism treatment options (3)

Answer 8

• lidocaine to anasthetic block
• aspiration of blood
• urination may help

Question 9

Chordee definintion

Answer 9

Ventral curvature of the head of the penis associated highly with hypospadias, best treated surgically in infancy

Question 10

Hypospadias definition

Answer 10

Birth defect in which opening of urethra is on underside of urethra instead of tip, can either be 1st degree (within the glans), 2nd (on the penile shaft) or 3rd degree (on the scrotum or perineum)

Question 11

Hypospadias is a complete contraindicatjion to…

Answer 11

…circumcision

Question 12

Hypospadias is highly associated with…

Answer 12

…undescended testes and inguinal hernia

Question 13

Hypospadias treatment options(1)

Answer 13

surgical repair 6-12 month

Question 14

urethral meatal stenosis

Answer 14

Almost always a complication of cirumcision resulting in scarring that covers the urethral opening leading to obstruction of the meatus that can be treated with a meatotomy

Question 15

Epididymmitis definition and most common infectious causes (5)

Answer 15

Very painful inflammation of epididymous on the superior posterior aspect of the testes sometimes associated with systemic findings, most commonly infectious organisms such as chlamydia, gonorrhea, e coli, viruses, cryptococcus in HIV patients

Question 16

Epididymitis risk factors (3)

Answer 16

• sexual activity (STI)
• heavy phyiscal exertion
• direct trauma

Question 17

Epididymitis treatment options (3)

Answer 17

• antibiotics
• ice
• nsaids

Question 18

Orchitis definition

Answer 18

Inflammation or infection of the testicles, can lead to infertility if left untreated, often caused by infectious agents such as mumps

Question 19

Orchitis symptoms (2)

Answer 19

• hematauria

- hematospermia

Question 20

Testicular torsion characteristic finding, peak age of incidence, and prognosis

Answer 20

• absence of cremasteric reflex
• 13 years old
• good prognosis if treated within 5-6 hours

Question 21

Bell clapper deformity

Answer 21

predisposing factor in testicular torsion in which the tunica vaginalis joins high on the spermatic cord, leaving the testis free to rotate. Bell clapper deformity predisposes to intravaginal torsion of the testes

Question 22

Testiculuar torsion diagnosistic studies (1)

Answer 22

-doppler ultrasound

Question 23

Varicocele definition

Answer 23

Incomplete drainage of spermatic veins that papears like a bag of worms in the scrotum, 95% are left sided***, right side even more pathologic, does not require intervention but if symptomatic such as testicular atrophy or abnormal semen count need to treat

Question 24

Hydrocele definition

Answer 24

collection of fluid in tunica vaginalis of testes, many present at birth, painless and resolves by 18 months, translumination shows enlargement of scrotum, requires referral to surgery/urology as it is associated with a hernia

Question 25

Indirect vs direct inguinal hernia (2)

Answer 25

indirect is much more common, indirect is felt on tip of finger while direct is on the side

Question 26

Cryptorchidism

Answer 26

When one or both testes fail to descend into scrotum before birth, sometimes don’t follow normal path and are “ectopic”, may descend normally but then ascend again later in middle childhood so treated by age 1 (even surgial correction cannot remove potential complications later in life)

Question 27

Cryptorchidism sequelae (4)

Answer 27

• testicular malignancy (on either side of testes)
• subfertility
• testicular torsion
• inguinal hernia

Question 28

Correcting undescended testes does not reduce risk of…

Answer 28

…testicular carcinoma or torsion

Question 29

Most common birth defect of male genitalia

Answer 29

Cryptorchidism

Question 30

UTIs should always be considered in children <2 with…

Answer 30

…unexplained fever (and be aware it can progress to pyelonephritis but they can’t verbalize CVA tenderness and such!)

Question 31

UTI causes in children (3)

Answer 31

• vesicoureteral reflux from bladder
• sexually active females
• e coli

Question 32

Vesicoureteral reflux

Answer 32

Retrograde flow of urine into the upper urinary tract, most common anatomical cause of recurrent UTI, common in pediatric population, foundin almost 70% of male infants presenting with a UTI

Question 33

How do you initially evaluate vesocureteral reflux?

Answer 33

Voiding cystourethrogram (VCUG)

Question 34

1st line treatment for uti in ped patient

Answer 34

• 2nd or 3rd gen cephalosporins

- macrobid (nitrofurantoin) needs to be given more frequently and is more likely to cause GI side effects

Question 35

Wilms tumor

Answer 35

Most common renal tumor and a common malignant abdomen pediatric tumor in patients <15, relatively uncommon but requires abdomen exam in kids under age of 5

Question 36

Posterior urethral valves

Answer 36

Congenital Webs/constrictions where the anterior and posterior urethra join in embryogenesis, can be harmless or a source of obstruction and VU reflux (fatal if complete obstruction) often causing a child to require kidney transplant

Question 37

Most common cause of recurrent urinary tract infections in male and female peds patients

Answer 37

vesicoureteral reflux

Question 38

Circumcision

Answer 38

Surgical removal of all or part of the foreskin in men, in women refers to removal of clitoral foreskin and is often 2ndary to a variety of other genital operations or genital mutilation

Question 39

US and circumcision

Answer 39

US is only country in developed world where majority of male infants are circumcized for nonreligious reasons

Question 40

Circumcision and AAP statement

Answer 40

Neither fully for or against, believe parents should receive factually correct, nonbiased info about potential medical benefits and risks, should understand procedure is elective and consider parental preferences (there are some hygienic benefits and religious reasons to do so)

Question 41

Circumcision in adults

Answer 41

Generally has greater risks and costs, is considered elective, post procedure discomfort, and longer recovery

Question 42

Benefits of circumcision (4)***

Answer 42

• prevention of penile cancer
• reduced incidence of UTI and STI (HSV, HIV, HPV but NOT gonorrhea, chlamydia, trachomoatis, or syphilis)***
• prevention of phimosis and paraphimosis
• hygeine

Question 43

Circumcision contraindications (6)**

Answer 43

• unstable or premature infant
• hypospadius
• penile torsion
• dorsal hood deformity
• congenital micropenis
• complications are very rare but if present will require a graft to repair*** (have parents gently clean around it but don’t mess with it so it can heal and not cause meatal stenosis)

Question 44

Anasthetic choices in circumcision**

Answer 44

Most commonly a dorsal penile nerve block, 1% lidocaine WITHOUT epi***

Question 45

3 methods commonly used in circumcision

Answer 45

gomco clamp (create dorsal slit, clamp and measure and then scalpel circumferentially)
plastibell (dorsal slit, put bell over glans, tie cord around base of glans penis and slowly strangulate the tissue)
mogen clamp (jewish faith, blind procedure where glans penis cant be seen)