Lecture 6 - Peds Renal/GU

Question 1

Inguinal Hernia

Answer 1

1-5% of all newborns
9-11% of premature infants (higher in premies due to time of testicular decent)

boys > girls
R > L

highest incidence in 1st year of life (peak at 1 month of life)

Question 2

How can you tell the difference between incarcerated inguinal hernia and hydrocele?

Answer 2

hernia might have signs of bowel obstruction and testicle may appear blue

hydrocele stools appropriately, and may be consolable

Question 3

Incarcerated Inguinal Hernia

Answer 3

Signs of bowel obstruction
mass typically firm, discrete
tender
often surrounded by erythema and edema of overlying skin

testicle may appear blue
pressure on spermatic cord –> venous congestion

Question 4

Hydrocele

Answer 4

uncomfortable, but consolable
tolerates feeds (stools appropriately)
mass may be somewhat mobile, irreducible, non-tender
transillumination (bowel will also transilluminate – so this can be misleading)
area of “swelling” does typically involve only the scrotum

Question 5

Incarcerated Inguinal Hernia

Answer 5

Not reducible

12-15% of inguinal hernias

if left untreated may progress to strangulation

Question 6

What is the treatment for an inguinal hernia?

Answer 6

depends on if it is incarcerated are not

if it is NOT:
-refer to surgeon, not emergent but should be taken care of promptly
(repair should be made promptly since 13% of children awaiting elective repair progress to strangulation)

If it IS incarcerated:
- emergently reduced
manual attempts unless child appears ill or has signs of peritonitis, obstruction, or toxicity
-emergent surgical repair if ill or not manually reduced

Question 7

What is the treatment for an incarcerated inguinal hernia?

Answer 7

emergently reduced
manual attempts unless child appears ill or has signs of peritonitis, obstruction, or toxicity
-emergent surgical repair if ill or not manually reduced

Question 8

Which side is more commonly involved for inguinal hernias?

Answer 8

right side MC

Question 9

Blue dot sign

Answer 9

tender nodule with blue discoloration on the upper pole of the testis seen with torsion of appendix testis

Question 10

Is hydrocele painful or painless?

Answer 10

painless

Question 11

Is inguinal mass painful or painless?

Answer 11

painless

Question 12

Is inguinal hernia painful or painless?

Answer 12

painful if incarcerated

otherwise painless

Question 13

Variocele

Answer 13

dilation of pampiniform plexus

typically painless but may cause “dull ache’

“bag of worms” - most always on left side

may not be obvious when supine

Question 14

Bag of Worms

Answer 14

seen with varicocele d/t dilation of pampiniform plexus

most common on the LEFT SIDE

if seen on the right sing you best get some imaging

Question 15

Grade 1 Varicocele?

Answer 15

present only with valsalva

Question 16

Grade 2 varicocele?

Answer 16

present without valsalva but not visible

Question 17

Grade 3 varicocele?

Answer 17

visible with inspection

carries the greatest risk of arrested testicular growth

Question 18

What are the 3 causes of an empty scrotum?

Answer 18

undescended (1 testicle is much less worrisome than 2)
absent
retractile (hyperactive creamasteric reflex)

Question 19

What do you do for retractile testes?

Answer 19

often due to brisk creamasteric reflex in boys >1 year

monitor for 6 - 12 months for fear of it being permanent

Question 20

Cryptorchidism

Answer 20

MC disorder of sexual differentiation in boys

failure of testicles to drop into scrotum –typically resolves spontaneously in first 3 months of life

if undescended by 4 months –likely permanent

Question 21

What is the MC disorder of sexual differentiation in boys?

Answer 21

cryptorchidism

Question 22

When to testicles typically descend?

Answer 22

7-8 months gestation

Question 23

What are the potential consequences of cryptorchidism?

Answer 23

infertility
testicular malignancy
associated hernia
torsion of cryptorchid testis

Question 24

What is the management of cryptorchidism?

Answer 24

surgery at 6 months of age

NO later than 9-15 months of age

Question 25

What referrals do you make for a pt with ambiguous genitalia?

Answer 25

endocrine genetics urology these referrals are done immediately

Question 26

What is micropenis defined as?

Answer 26

<2.5 SD for gestational age

Question 27

What is the cause of micropenis?

Answer 27

result of primary or secondary testicular failure during fetal life after morphogenesis is complete

Question 28

What should you suspect if you have a pt with micropenis and hypoglycemia?

Answer 28

hypopituitarism

Question 29

What is the evaluation of micropenis?

Answer 29

karyotype assessment of anterior pituitary function assessment of testicular function MRI to assess pituitary, hypothalamus and other midline CNS structures

Question 30

What are the potential benefits of circumcision?

Answer 30

``` reduction in UTIs reduction in STIs easier hygiene reduced phimosis and paraphimosis squamous cell penis cancer ```

Question 31

What are the risks of circumcision?

Answer 31

really just related to the procedure

Question 32

When is it preferred to have circumcision?

Answer 32

24 hours old (can be as soon as 12 hour) | infant must have voided at least once since birth

Question 33

What are the contraindications of circumcision?

Answer 33

hypospadias chordee without hypospadias dorsal hood derformity micropenis (delay until urology consult) wandering raphe (RELATIVE contraindication) bilateral undescended tests (until after eval) ambiguous genitalia known bleeding diathesis (until post heme consult)

Question 34

What is the post circumcision care?

Answer 34

some swelling expected blood on diaper should be less than a quarter in size clean with mild soap and water if soiled petroleum jelly to precent adhesion to diaper

Question 35

What is the second most common congenital defect of male genitalia?

Answer 35

hypospadias

Question 36

Hypospadias

Answer 36

congenital defect in which opening of urethra is on underside of penis rather than at the top incidence 1/150-300 newborns

Question 37

What are the different degrees of hypospadias?

Answer 37

first degree (distal) - 50% second degree (midpenile) - 20% third degree (proximal) - 50%

Question 38

Of the different locations for hypospadias, which might have prostatic utricle?

Answer 38

3rd degree -- consider VGUG - voiding cystourethrogram 2nd and 3rd degree may indicate disorder of sexual differentiation 2nd and 3rd degree get surgical repair for functional and cosmetic deformities

Question 39

Phimosis/Paraphimosis

Answer 39

inability to retract the prepuce at an age when it should be retractable normally: (physiologic phimosis) in infant you can NOT retract the foreskin until around age of 3

Question 40

When should you be able to retract the foreskin of the penis?

Answer 40

age 3 | until then it should NOT be retracted

Question 41

Pathologic phimosis?

Answer 41

if previously retractable, or after puberty

Question 42

Paraphimosis

Answer 42

retract but then cannot extend ---EMERGENCY -- loss of blood supply to the glans

Question 43

Non-specific vulvovaginits

Answer 43

accounts for 25-75% of vulvovaginitis cases contributing factors: - lack of estrogenization - lack of protective hair and labial fat pad - proximity of vagina to anus - poor hygiene/chemical irritants

Question 44

What is the treatment for non-specific vulvovaginitis?

Answer 44

keep area dry and aerated cotton underpants loose fitting clothing avoid prolonged exposure to moisture from bathing suits leave underwear off for periods of time (bedtime) decrease irritants Sitz baths twice daily with 3 tablespoons of baking soda while symptomatic

Question 45

Labial Adhesions

Answer 45

affects 2% of girls | peak incidence is 2 years of life

Question 46

What are the clinical findings of labial adhesions?

Answer 46

fusion of labia minora often no sxs recurrent UTIs

Question 47

How do you treat labial adhesions?

Answer 47

often resolves spontaneously gentle traction to separate labia followed by 3-5 days of topical estrogen cream hormonal cream used 1-2 times a day for several weeks occasionally surgery by pediatric urologist

Question 48

Febrile UTI

Answer 48

F >M | slightly more common <12 months

Question 49

What are the sxs of UTI?

Answer 49

older children: - cystitis: - -dysuria - -frequency, urgency - -enuresis - -suprapubic pain - pyelonephritis: - -all of the above plus fever, chills, N/V, flank pain infants/toddlers: (less specific) fever, irritability, vomiting, decrease appetite, lethargy, hyperbilirubinemia, failure to thrive CONSIDER UTI IN ALL FEBRILE CHILDREN < 24 MONTHS

Question 50

What are important complications associated with UTI?

Answer 50

renal scarring with resulting HTN and chronic kidney disease difficult to distinguish cystitis from pyelonephritis in young children (fever is often used to increase suspicion for pyelonephritis)

Question 51

Many febrile UTIs resolve on their own, but delay in treatment might be associated with what complication?

Answer 51

urosepsis abscess formation renal scarring

Question 52

How do you dx UTI?

Answer 52

urinalysis | urine culture

Question 53

What is the treatment for UTI in 2-24 month old?

Answer 53

oral ABX (or IV ---equal efficacy) cephalosporin, amoxicllin, augmentin, bactrim 7-14 days (3 days if child is older)

Question 54

What kind of follow up is recommended for children with UTIs?

Answer 54

US to identify anatomic abnormalities this includes all boys kids not yet potty trained girls potty trained with recurrent UTIs

Question 55

When is VCUG recommended?

Answer 55

urinary dilation, scarring, or findings suggestive of vesicoureteral reflux or bladder outlet obstruction on US recurrent febrile UTI (even if normal US) "atypical" or "complex" clinical circumstances (basically clinical judgment)

Question 56

What is the grading for VUR?

Answer 56

Vesicoureteral reflex Graded 1 -5 1 and 2 typically resolve spontaneously 4 and 5 less likely to resolve

Question 57

What is the treatment for VUR?

Answer 57

ABX prophylaxis | +/- surgery

Question 58

Why is VUR important?

Answer 58

identifies risk for recurrent UTI - treatment can prevent URI risk for VUR nephropathy --children can be monitored for signs of progressing CKD such has HTN and proteinuria

Question 59

What is the recommended prophylaxis for VUR?

Answer 59

Bactrim

Question 60

Enuresis

Answer 60

Primary - children who have not had 6 months of dry nights Secondary - children who previously attained 6 months of dry nights - most likely caused by stressors or medical conditions

Question 61

What are the different types of enuresis?

Answer 61

Monosymptomatic --only sx is nighttime bed wetting Nonmonosymptomatic --daytime incontinence or daytime lower urinary tract infections

Question 62

At what age group is it considered nocturnal enuresis?

Answer 62

5 years of age

Question 63

Primary vs secondary nocturnal enuresis?

Answer 63

primary -inability to awaken from sleep in response to full bladder secondary - recurrent UTI - urinary tract malformations - neurologic disorders

Question 64

How do you evaluate enuresis?

Answer 64

ask about: - frequency - timing - volume - daytime lower urinary tract sxs

Question 65

What is the treatment for enuresis treatment?

Answer 65

behavioral modification limit fluid intake before bed dry bed training - waking child at night to urinate bladder stretching exercises -- hold urine for longer periods of time Bed alarm therapy --most effective treatment --moisture sensory underneath child so they stop urinating and go to the toilet pharmocotherapy --should be reserved for children >7 years --if other therapies were unsuccessful -Desmopressin (DDVAP) most commonly used

Question 66

Child with fever of no source, what needs to be high on your ddx?

Answer 66

febrile UTI