Paed Urology

Question 1

Male and female hernias - differences?

Indirect or direct - which is more common

Answer 1

Mostly boys- bowel
Girls can get ovaries in it as well
99% are indirect hernias

Question 2

How does an inguinal hernia present? [1]

Increased risk of inguinal hernia with…

Answer 2

A groin swelling

Often associated with prematurity

Question 3

How do you manage an inguinal hernia? [2]

Answer 3

If <1yr –> Urgent referral and repair as can incarcerate easily

If >1yr –> Elective referral and repair

Question 4

What do you do if an inguinal hernia incarcerates? [2]

Answer 4

Reduce and repair immediately as it can compress the vessels –> Death of testes

Question 5

What dx is likely if you see a scrotal swelling in an infant?

Answer 5

Hydrocele

Question 6

What features of a swollen scrotum fit with hydrocele? [3]

How to investigate hydrocele on examination [2]

Answer 6

• Painless
• Bluish colour
• Increases with crying, straining or in the evening (esp if walking)
  Transillumination - chinese lantern sign

Question 7

How do you treat a hydrocele? [3]

Answer 7

Most spontaneously resolve so just observe till 5yo then surgery

Question 8

Types of UDT [4]

Answer 8

1) True absence of testes
2) Retractile - physiological response to cold
3) Ectopic - superficial femoral pouch
4) Ascending

Question 9

Ascending testes:
Presentation [1]
Etiology [2]

Answer 9

Documented normal at birth then present at 5-7yo with no testes
?Body grows faster than spermatic cord –> testes pulled up into the canal

Question 10

Indications for orchidopexy [5]

Answer 10

1) Fertility
2) Malignancy
3) Trauma (more at risk if stuck in canal)
4) Torsion (more likely)
5) Cosmetic

Question 11

What is an absolute indication for a circumcision? [1]

Answer 11

Balantitis Xerotica Obliterans
White scarring of foreskin
(Bullet vs sausage on lateral view)

Question 12

Relative indications for circumcision [3]

Answer 12

• Religious/cultural reasons
• Balanoposthitis
• to reduce UTI risk in high risk people with dilated urinary tracts/renal failure

Question 13

What is the acute scrotum? [1]

Answer 13

Acute onset swelling and/or pain of the scrotum

Question 14

What are 2 causes of Acute Scrotum and at what age does each occur?

Answer 14

Testicular Torsion and epididymitis similar epidemiology - occurs in neonates and >10yo

Torsion Appendix Testes (increases in likelihood from infancy to puberty)

Question 15

Management of acute scrotum [2]

when to leave it alone? [2]

Answer 15

Unless you’re certain it’s not torsion do surgical exploration to repair.

As you only have 6-8hrs to recover the testes before permanent damage occurs

Blue dot sign on examination – torsion of the appendix testis
(leave it alone!)

Question 16

How do we investigate and manage hypospadias?

Answer 16

US if severe –> Surgical repair

Question 17

UTIs are common in kids, which ones do we investigate? [4]

Whats the main aim of investigating

Answer 17

Aim: Prevent renal scarring

• <6m
• Atypical buds
• Atypical presentation e.g. pyelonephritis
• Recurrent UTI - more than 2 upper tract infections or more than 3 lower tract infections

Question 18

Define the presentation of a UTI? [3]

Answer 18

Pure growth bacteria >10^5
Pyuria
Systemic Upset (fever, vomiting etc)

Question 19

What tests can we do when investigating UTIs? [3]

Answer 19

US (do within 6 weeks following infection)

Renography (MAG3 & DMSA)
MCUG (micturating cystourethrogram)

Question 20

The main cause of abnormal/recurrent UTIs in kids is [1]

Answer 20

Vesicoureteric Reflux

Question 21

What warrants conservative tx [3]

What is the management for VUR?

Answer 21

Mixed growth bacteria, no pyuria, no systemic symptoms
Conservative e.g. voiding advice, managing constipation & fluids

Abx prophylaxis till age 4 (Trimethoprim)

Surgery:

• STING (if mild/mod symptoms)
• Ureteric Reimplantation

Question 22

How is fertility affected in UDT?

Explain association between malignancy and UDT [2]

Answer 22

1% loss germ cells per month of undescent
 RR 3 x (probably intra-abdominal only – severe cases)
 Fixing does not reduce risk but makes cancer easier to detect

Question 23

Hypospadias
Define [2]
Associated anomalies [2]
Ix [1]

Answer 23

proximally displaced urethral meatus on ventral aspect of penis
• Associated anomalies of upper tract, can be intersex (ambiguous genitalia)
• Investigations: US if severe

Question 24

What is defined as recurrent UTI in children [3]

Answer 24

1. > 2 episodes of upper urinary tract infection, or
2. 1 episode of upper urinary tract infection plus >1 episode of lower urinary tract infection, or
3. three or more episodes lower urinary tract infection.

Question 25

Phimosis
Ax [3]
Symptoms [2]
Mx [2]
Complications

Answer 25

Ax: physiological, balanitis, balanoposthitis
Symptoms: non-retractile foreskin and or ballooning during micturition
Mx:
• <2y/o: physiological phimosis that will resolve in time with expectant mx and good hygiene
• >2y/o or recurrent balanoposthitis or UTI: circumcision
Complications: penile carcinoma

Question 26

Unilateral undescended testis

Referral guidelines

Answer 26

Unilateral undescended testis
NICE CKS (2020) now recommend referral should be considered from around 3 months of age, with the baby ideally seeing a urological surgeon before 6 months of age
- Orchidopexy: Surgical practices vary although the majority of procedures are performed at around 1 year of age

Question 27

Bilateral undescended testes Management

Answer 27

Bilateral undescended testes
Should be reviewed by a senior paediatrician within 24hours as the child may need urgent endocrine or genetic investigation