Other facts Flashcards
potential medical advantages to circumcision (5)
- prevent phimosis
- prevent balanoposthitis (superficial infection of glans and foreskin)
- eliminate risk of penile cancer
- decreased risk STI, HIV, and cervical cancer
- Decreased UTI in newborns
when do 90% of boys have completely retractable foreskin?
by 3 years
-at 6 months, only 20% do
phimosis
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
four major techniques of circumcision
- Dorsal Slit
- Shield technique (Mogen clamp)
- Gomco clamp or plastibell clamp
- Freehand surgical excision
common complications from circumcision
- bleeding
- 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)
hypospadius
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
Classification of hypospadius
based on where meatus is after penile straightening
- anterior hypospadius (meatus on glans or subcoronal) (50%)
- penile shaft meatus (20%)
- meatus between perineum and penoscrotal junction (30%)
is hypospadius associated with other anomalies?
nope
not associated with other abrnomalities because external genitalia are formed much later than the kidneys, ureter, and bladder
timing of hypospadius correction
best performed between 6-18 months before toilet training
Ectopic ureteral orifices
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
complete duplication of the collecting system - ureter arising from lateral orifice
can have a ureter arising from the lateral orifice –> drains lower pole, causes reflux, can get UPJ obstruction
complete duplication of the collecting system - ureter arising from medial orifice
–> drains upper pole of kidney
associated with an ectopic ureterocele
-commonly obstructed, more likely to be ectopic
ureterocele
caused by incomplete or delayed dissolution of CHWALLA’S MEMBRANE (separates ureteral bud from urogenital sinus)
complete ureteral duplication
caused by the presence of 2 ureteric buds on the Wolffian duct (mesonephros)
Meyer-Weigert law
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
incomplete ureteral duplication or bifid renal pelvis caused by…
a single ureteric bud that bifurcates prematurely
UPJ obstruction is caused by…
a later atresia of the ureter after ureteric ingrowth into the metanephros
Multicystic dysplastic kidney caused by…
early atresia of the ureter after ureteric ingrowth into the metanephros (kidney)
horseshoe kidney caused by…
fusion of the lower poles of both metanephros –> abnormal ascendence (caught on IMA) and abnormal rotation
Thoracic kidney
due to incomplete closure of posterior diaphragm, kidney is in the chest
Bochdalek hernia
herniation of the kidney and other abdominal contents through an opening in the diaphragm (Bochdalek’s foramen)
pathophys behind VUR
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
what are the mechanisms that prevent reflux
- trigone contraction - move ureteral orifice away from the ureteral hiatus and lengthens the submucosal tunnl
- filling of the bladder - stretches trigone and increases length of the submucosal tunner
- submucosal ureteral tunnel of adequate length.
Bowel-Bladder Dysfunction
any abnormal pattern of urination and defecation
-constipation, dysuria, incontinence, and abnormal voiding interval
-increased risk of damage from VUR and UTI
Grade of VUR
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
Complications of VUR
- UTI (pyelo) - MOST COMMON
- Hydroureteronephrosis
- Renal scarring (from infection) –> HTN later on
- Reflux nephropathy –> HTN later on
Where does renal scarring most often occur?
more likely at poles of the kidney because these areas have more confluent papillae that allow intra-renal reflux
VUR presentation
- most present with UTI
- Age - 3-6 yrs
- 85% of VUR are females
VUR in girls vs. boys
boys –> younger age presentation, higher grade VUR, less associated with voiding dysfunction
goal of treating VUR
prevent recurrent febrile UTIs and prevent renal scarring
VUR surgical treatment - Ureteroneocystomy (ureteral reimplant)
- Resect lower 2-3 cm of ureter because its muscle is underdeveloped.
- put intravesical portion of ureter into a submucosal tunnel
- submucosal tunnel should be 3x as long as ureter diameter
- tension free anastomosis between bladder and ureter
- taper mega-ureters before reimplantation
Complications of ureteral reimplant surgery for VUR
- Ureteral obstruction (1-2 wks postop, abd pain, nausea, vomiting) –> ureteral edema if perioperative, ischemic stricture if later
- persistent reflux –> 2/2 voiding dysfunction, contralateral VUR
f/u after surgery for ureteral re-implant for VUR
- ppx abx continued
- renal and bladder US 4-6 wks post op to look for ureteral obstruction
- VCUG 3 months post-op to check for resolution of VUR
- stop ppx abx if VCUG and US are normal
Contents of spermatic cord (7)
- testiscular artery
- cremasteric artery
- genital branch of the genitofemoral nerve (cremaster muscle)
- testicular verves
- Vas deferens
- pampiniform plexus
- Lymphatic vessels
**ilioinguinal nerve runs along the spermatic cord
An undescended testicle can be…
absent, undescended, retractile, or ectopic
