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Paediatrics > Paed Surg - Penis and Foreskin (+some inguinoscrotal) > Flashcards

Paed Surg - Penis and Foreskin (+some inguinoscrotal) Flashcards

1
Q

How does the foreskin change throughout childhood and puberty?

A

Glans of uncircumcised penis protected by loose skin layer = foreskin. During childhood / adolescence part or all of undersurface of foreskin is adherent to glans. Adherence slowly separates, usually complete by puberty.

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2
Q

What is smegma?

A

Accumulates beneath adherent foreskin. Appears as asymmetrical accumulations of yellow tinged material predominately in coronal groove beneath foreskin. Can cause significant swelling.

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3
Q

What is balanitis?

A

Infection can develop beneath the foreskin. If severe pus may appear from the end of the foreskin. Balanitis often associated with phimosis. Can cause significant redness and swelling of penile shaft.

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4
Q

What is phimosis?

A

Opening at the tip of the foreskin has narrowed so foreskin cannot be retracted. External urethral meatus not visible.

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5
Q

Mx phimosis?

A
  • Topical steroid e.g. betamethasone valerate application to tight shiny part of foreskin.
  • Circumcision
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6
Q

When is circumcision indicated in phimosis?

A
  • Marked previous inflammation
  • Skin splitting
  • Balanitis xerotica obliterans
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7
Q

What are the signs of severe phimosis?

A
  • Ballooning of foreskin on micturition

- Urinary retention and bladder distension

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8
Q

What is paraphimosis?

A

Occurs when a mildly phimotic foreskin has been retracted over the glans and become stuck behind the coronal groove. Cause oedema of itself and the glans penis. Painful and progressive.

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9
Q

Mx paraphimosis?

A

Gentle manipulation of foreskin forwards. May require GA.

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10
Q

appearance of hypospadias?

A

Foreskin looks square and hangs off penis. Shaft of penis is bent ventrally.

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11
Q

What are the two main problems in hypospadias?

A

1) Location of the urethra - venal side of shaft of penis, proximal to correct position.
2) Chordee (ventral angulation of shaft and glans).

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12
Q

What is chordee?

A

Ventral angulation of shaft and glans

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13
Q

Why is correction of chordee important?

A

To allow later successful sexual function

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14
Q

When is hypospadias usually corrected?

A

Single stage operation at 9-12m

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15
Q

Can circumcision be used in patients with hypospadias?

A

NO - absolute CIx. Skin of prepuce is used in repair of hypospadias.

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16
Q

What may severe hypospadias indicate?

A

intersex abnormality

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17
Q

What are the complications of circumcision?

A
  • Septicaemia
  • Meningitis
  • Removal of too much or too little foreskin
  • Post op bleeding
  • Infection
  • Abrasion and ulceration of glans, esp near urethral meatus
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18
Q

What are the complications of ulceration of glans following circumcision?

A

Ulceration of glans near urethral meatus may result in metal stenosis as it heals and require meatotomy to reestablish adequate urinary stream.

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19
Q

What is epispadias?

A

Urethra opens onto dorsal aspect of base of penis. Boys often incontinent of urine as bladder neck sphincter also deficient.

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20
Q

What conditions are associated with epispadias?

A

Spectrum of lower abdo wall defects. Most severe:

  • ectopia vesicae (bladder exstrophy)
  • cloacal exstrophy
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21
Q

What is the processus vaginalis and how is it implicated in congenital anomalies?

A

After the testis has descended into the scrotum in the seventh month of pregnancy, the canal down which it migrates (p. vaginalis) should obliterate. Failure of obliteration may produce an inguinal hernia, hydrocele or an encysted hydrocele of the cord.

22
Q

What may be contained within an indirect inguinal hernia?

A

If processsus vaginalis is widely patent, may allow bowel (and ovary in females) into indirect inguinal hernia

23
Q

How do indirect inguinal hernias present?

A

Intermittent swelling overlying the external inguinal ring noticed by a parent. May be more apparent during crying / straining.

24
Q

Why should inguinal hernias be repaired as soon as practicable?

A

Prone to strangulation, esp within first 6 months of life.

25
Q

What are the complications of inguinal hernia strangulation?

A
  • damage incarcerated bowel

- may compress testicular vessels producing testicular atrophy

26
Q

How is inguinal hernia reduced?

A
  • Disimpact hernia at external inguinal ring

- Reduce along lines of inguinal canal

27
Q

What is a hydrocele?

A

Painless, cystic swelling around the testis in the scrotum. Contains peritoneal fluid that has tracked along a narrow but patent processus vaginalis.

28
Q

What is the key sign of a hydrocele?

A

Brilliant transillumination

29
Q

How may a hydrocele be distinguished from an indirect inguinal hernia?

A

Upper limit can be felt distal to external inguinal ring. In indirect inguinal hernia, swelling extends through EIR.

30
Q

What is cryptorchidism?

A

Undescended testis. Describes the testis that does not reside spontaneously in the scrotum. Occurs in ~2% boys.

31
Q

Which infants are more likely to have cryptorchidism?

A

Premature

32
Q

From what age are undescended testis unlikely to descend spontaneously?

A

3 months post term

33
Q

What is a long term complication of cryptorchidism?

A

Impaired fertility. Thought that higher temps impair spermatogenesis.

34
Q

When should cryptorchidism be corrected?

A

9-12months. surigcal orchidopexy

35
Q

How does a retractile testis differ from an undescended testis?

A
  • Can be brought fully to bottom of scrotum
  • Remains in scrotum for a period before retracting
  • Residens spontaneously in scrotum at times
  • Normal size
36
Q

What are the common causes of an acutely painful scrotum?

A
  • torsion of testicular appendage
  • torsion of testis
  • epididymo-orchitis
  • idiopathic scrotal oedema
37
Q

What is the peak age of testicular appendage torsion?

A

11y

38
Q

What is the peak age of testicular torsion?

A

Neonatal and adolescent groups

39
Q

When does epididymoorchitis occur in children?

A

Most common in infancy, associated with urinary tract abnormalities.

40
Q

What are the features of idiopathic scrotal oedema?

A
  • young child
  • bilateral oedema
  • testes not tender
41
Q

How does testicular appendage torsion evolve with respect to clinical signs?

A
  • Early: blue black pea sized swelling seen near upper pole. Extremely tender to touch. Palpation of testis itself causes no discomfort.
  • Later: reactive hydrocele. More difficult to distinguish from testicular torsion.
42
Q

Features of testicular torsion?

A

Both testis and epididymis exquisitely tender. Testis may be lying high within scrotum.

43
Q

What causes separation of the foreskin from the glans?

A
  • Maturation of the skin (keratinised layer comes up)
  • Urine leaks back
  • Trauma from child grabbing penis
  • Erection
44
Q

How does management of phimosis vary with age?

A

Usually commence management at age of 5.
Under 5 yo : do not treat symptomatic phimosis (unless recurrent balanitis), often the foreskin will open by itself
5+ yo: consider treatment (if it has not opened up until this point, then it is likely to cause problems)

45
Q

Conservative management of phimosis?

A
  • Good penile / foreskin hygiene. Gentle retraction during micturition to assist keeping dry.
  • Wash smegma
  • Good drying
46
Q

Pharmacological management of phimosis?

A
  • Topical steroid applied to tight shiny part of foreskin

- Progressive, self retration

47
Q

Surgical management of phimosis?

A

If poor response to topical treatment after 4 -6w then circumcision.
Circumcision required if marked inflammation (skin splitting, BXO, balanitis).

48
Q

What are the indications for circumcision in phimosis?

A 
Indications for circumcision
• Not suitable: too young, cognitive impaired
• Highly symptomatic
• Under age of treatment
• Already having problems
• Those who cannot comply
• Recurernt phimosis
49
Q

What are the complications of balanitis?

A

Complications:
• Ballooning during micturition
• Urinary retention
• Painful splitting during erection and sex
Phimosis causes urine accumulation strips back the adhesions and forms a pocket for urine storage. This urine causes chronic wet skin which leads to minor symptoms: irritates, itching, may get balanitis

50
Q

What is the Mx of paraphimosis and why?

A

Leads to tourniquet effect: blocks the lymphatics first (rarely vasculature), therefore the management is squeezing it (not ice block, or lignocaine)

51
Q

What are the features of hypospadias?

A
  • Urethral opening is not in correct place (ventral surface, proximal to normal position)
  • Penis is bent ventrally (chordee)
  • Foreskin is missing on underside

Paediatrics (31 decks)

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