Other facts

Question 1

potential medical advantages to circumcision (5)

Answer 1

1. prevent phimosis
2. prevent balanoposthitis (superficial infection of glans and foreskin)
3. eliminate risk of penile cancer
4. decreased risk STI, HIV, and cervical cancer
5. Decreased UTI in newborns

Question 2

when do 90% of boys have completely retractable foreskin?

Answer 2

by 3 years

-at 6 months, only 20% do

Question 3

phimosis

Answer 3

narrowing of the opening of the prepuce, preventing it from being drawn back over the glans

TX: trial of topical betamethasone 0.05% ointment for 6-8 weeks

Question 4

four major techniques of circumcision

Answer 4

1. Dorsal Slit
2. Shield technique (Mogen clamp)
3. Gomco clamp or plastibell clamp
4. Freehand surgical excision

Question 5

common complications from circumcision

Answer 5

1. bleeding
2. adhesions of mucosal skin to the glans penis (prevented at 1 wk visit to push skin at head of penis back so the groove of the glans is visible)

Question 6

hypospadius

Answer 6

congenital defect of the penis

• results in incomplete development of the anterior urethra, corpora cavernosa, and prepuce
• due to incomplete development of the glandular urethra which does not allow for preputial folds to fuse –> foreskin absent on ventrum, excessive on dorsum

-can be associated with abnormal penile curvature

NOT associated with increased risk of UTI

Question 7

Classification of hypospadius

Answer 7

based on where meatus is after penile straightening

1. anterior hypospadius (meatus on glans or subcoronal) (50%)
2. penile shaft meatus (20%)
3. meatus between perineum and penoscrotal junction (30%)

Question 8

is hypospadius associated with other anomalies?

Answer 8

nope

not associated with other abrnomalities because external genitalia are formed much later than the kidneys, ureter, and bladder

Question 9

timing of hypospadius correction

Answer 9

best performed between 6-18 months before toilet training

Question 10

Ectopic ureteral orifices

Answer 10

ectopic ureter = a ureter that does not insert into the trigone

• usually presents with UTI
• more common in girls than boys
• Girls –> can have incontinence if insertion is distal to urinary sphincter, associated with a DUPLICATED SYSTEM
• Boys –> no incontinence (usually inserts into bladder neck or proximal urethra), NOT associated with a duplicated system

Question 11

complete duplication of the collecting system - ureter arising from lateral orifice

Answer 11

can have a ureter arising from the lateral orifice –> drains lower pole, causes reflux, can get UPJ obstruction

Question 12

complete duplication of the collecting system - ureter arising from medial orifice

Answer 12

–> drains upper pole of kidney
associated with an ectopic ureterocele
-commonly obstructed, more likely to be ectopic

Question 13

ureterocele

Answer 13

caused by incomplete or delayed dissolution of CHWALLA’S MEMBRANE (separates ureteral bud from urogenital sinus)

Question 14

complete ureteral duplication

Answer 14

caused by the presence of 2 ureteric buds on the Wolffian duct (mesonephros)

Question 15

Meyer-Weigert law

Answer 15

complete ureteral duplication

idea that a LOWER ureteric bud merges with the urogenital sinus, migrates LATERAL on the trigone and becomes the lower pole ureter…

UPPER ureteric bud merges with urogenital sinus and does no migrate as fare lateral –> upper pole is more medial

Question 16

incomplete ureteral duplication or bifid renal pelvis caused by…

Answer 16

a single ureteric bud that bifurcates prematurely

Question 17

UPJ obstruction is caused by…

Answer 17

a later atresia of the ureter after ureteric ingrowth into the metanephros

Question 18

Multicystic dysplastic kidney caused by…

Answer 18

early atresia of the ureter after ureteric ingrowth into the metanephros (kidney)

Question 19

horseshoe kidney caused by…

Answer 19

fusion of the lower poles of both metanephros –> abnormal ascendence (caught on IMA) and abnormal rotation

Question 20

Thoracic kidney

Answer 20

due to incomplete closure of posterior diaphragm, kidney is in the chest

Question 21

Bochdalek hernia

Answer 21

herniation of the kidney and other abdominal contents through an opening in the diaphragm (Bochdalek’s foramen)

Question 22

pathophys behind VUR

Answer 22

ureterovesical junction competence depends on trigone tone
-if the trigone is week, then the ureteral orifice migrates towards the ureteral hiatus where ureter penetrates bladder –> shorter submucosal tunnel –> VUR

Question 23

what are the mechanisms that prevent reflux

Answer 23

1. trigone contraction - move ureteral orifice away from the ureteral hiatus and lengthens the submucosal tunnl
2. filling of the bladder - stretches trigone and increases length of the submucosal tunner
3. submucosal ureteral tunnel of adequate length.

Question 24

Bowel-Bladder Dysfunction

Answer 24

any abnormal pattern of urination and defecation
-constipation, dysuria, incontinence, and abnormal voiding interval

-increased risk of damage from VUR and UTI

Question 25

Grade of VUR

Answer 25

Grade 1 - reflux into ureter - no dilation - no tortuous ureter Grade 2 - reflux into ureter and pelvis - no dilation, no tortuous ureter Grade 3 - reflux into ureter, pelvis, infundibulum - MILD dilation of affected structures, no tortuous ureter Grade 4 - reflux into ureter, pelvis, infundibulum, and calyces - MODERATE dilation of affected structures, MILD tortuous ureter Grade 5 - SEVERE dilation of ureter, pelvis, infundibulum, and calyces, SEVERE tortuous ureter

Question 26

Complications of VUR

Answer 26

1. UTI (pyelo) - MOST COMMON 2. Hydroureteronephrosis 3. Renal scarring (from infection) --> HTN later on 4. Reflux nephropathy --> HTN later on

Question 27

Where does renal scarring most often occur?

Answer 27

more likely at poles of the kidney because these areas have more confluent papillae that allow intra-renal reflux

Question 28

VUR presentation

Answer 28

1. most present with UTI 2. Age - 3-6 yrs 3. 85% of VUR are females

Question 29

VUR in girls vs. boys

Answer 29

boys --> younger age presentation, higher grade VUR, less associated with voiding dysfunction

Question 30

goal of treating VUR

Answer 30

prevent recurrent febrile UTIs and prevent renal scarring

Question 31

VUR surgical treatment - Ureteroneocystomy (ureteral reimplant)

Answer 31

1. Resect lower 2-3 cm of ureter because its muscle is underdeveloped. 2. put intravesical portion of ureter into a submucosal tunnel 3. submucosal tunnel should be 3x as long as ureter diameter 4. tension free anastomosis between bladder and ureter 5. taper mega-ureters before reimplantation

Question 32

Complications of ureteral reimplant surgery for VUR

Answer 32

1. Ureteral obstruction (1-2 wks postop, abd pain, nausea, vomiting) --> ureteral edema if perioperative, ischemic stricture if later 2. persistent reflux --> 2/2 voiding dysfunction, contralateral VUR

Question 33

f/u after surgery for ureteral re-implant for VUR

Answer 33

1. ppx abx continued 2. renal and bladder US 4-6 wks post op to look for ureteral obstruction 3. VCUG 3 months post-op to check for resolution of VUR 4. stop ppx abx if VCUG and US are normal

Question 34

Contents of spermatic cord (7)

Answer 34

1. testiscular artery 2. cremasteric artery 3. genital branch of the genitofemoral nerve (cremaster muscle) 4. testicular verves 5. Vas deferens 6. pampiniform plexus 7. Lymphatic vessels **ilioinguinal nerve runs along the spermatic cord

Question 35

An undescended testicle can be...

Answer 35

absent, undescended, retractile, or ectopic