paediatric urology Flashcards
presentation of paediatric urological problems
systemic:
- fever, vomiting
- FTT
- anaemia
- HT
- renal failure
local:
- pain
- changes in urine
- abnormal voiding
- mass
- visible abnormalities
- incidental
antenatal:
- asymptomatic
- permits immediate postnatal assessment
what does this hx suggest:
- 9mth old male
- lump in left groin noticed which was then gone the next morning
- baby happy and feeding
inguinal hernia
features of inguinal hernia
GROIN swelling
2% boys will have one at some point during life
boys 9: 1 girls
increased risk with prematurity
if <1yr old: 33% incarcerate
management of inguinal hernia
<1y/o:
- URGENT referral
- repair - no place for observation
>1y/o:
- elective referral and repair
incarcerated:
- reduce and repair on same admission
what happens in an inguinal hernia
loop of bowel comes down through defective inguinal canal
what does this hx suggest:
- 9mth old male
- lump in left scrotal swelling, bluish colour
- gone the next morning
- baby happy and feeding
hydrocele
hydrocele features
SCROTAL swelling
very common in newborns
painless - increases w/ crying, straining, evening
bluish colour
management of hydrocele
conservative until 5y/o
what does this hx suggest:
- 9mth old male
- scrotum empty
- normal neonatal discharge examination
- baby happy and feeding
possible undescended testes
what is cryptorchidism
- undescended testis
- any testis that cannot be manipulated into the bottom half of the scrotum
can be either:
- true undescended testis
- retractile testis - normal, very vigorous cremasteric reflex
- ascending testis - don’t keep up w/ growth
why are the testis in the scrotum
enzymes in the testis that produce sperm work at 33 degrees
incidence of cryptorchidism
roughly proportional to age
premature babies - very high risk (testes don’t normally descend until 3rd trimester)
- the majority will resolve
- if still undescended by 1yr - needs intervention
indications for orchiodopexy in cryptorchidism
- improve fertility - 1% loss germ cells per month undescended
- risk of malignancy - relative risk 3x (probably intra-abdo only), lifetime risk <1%
- trauma
- torsion
- cosmetic
what does this hx indicate:
- 4y/o male w/ non-retractile foreskin
- recurrent balanitis
- o/e: pinhole meatus
normal non-retractile foreskin
normal non-retractile foreskin
area of tightness is just off the tip
not tight and not obstructing
what does this hx indicate:
- 14y/o male w/ non-retractile foreskin
- struggling to pass urine
- o/e: scarred foreskin, narrow meatus
BXO: balanitis xerotica obliterans
balanitis xerotica obliterans
point of constriction of foreskin is very tight
‘bullet like’ penis
white scarring when looking at the tip
management of balanitis xerotica obliterans
steroid cream - dermovate
50% will end up needing circumcision
circumcision - indications
removal of foreskin
- absolute: BXO
- relative: balanoprosthitis, religious, UTI (recurrent, abnormal anatomy)
what is balanoprosthitis
severe inflammation and infection of glans penis and shaft
recurrent
advantages of circumcision
- UTI - 120 circs prevent 1 UTI
- ?malignancy - penile cancer is very rare
- ?sexual enhancement - increased nerve endings in prepuce
- ?AIDS/STD’s - sub-saharan africa
overall minimal evidence of medical benefit
disadvantages of circumcision
- painful
- complications: bleeding, meatal stenosis, fistula, cosmetic
- ?look different
what does this hx suggest:
- 14y/o male w/ 4hr hx of R sided testicular pain
- o/e: red scrotum, asymmetry, acutely tender to touch
testicular torsion - until proven otherwise
why is testicular torsion important
testicle twists on the spermatic cord
cuts off blood supply
testicles become gradually ischaemic
~6hrs time frame to salvage the testis
appearance of testicular torsion
as it twists it tends to shorten and is usually higher up than the other side
VERY TENDER
what does this hx suggest
- 14 y/o m w/ 4hr hx R sided testicular pain
- o/e: scrotum red, NO asymmetry, blue spot seen, tender to touch
torsion appendix testis
what is the appendix testis
embryological remnant that sits on top of the epididymis
what is torsion appendix testis
appendix testis teists and becomes necrotic → blue spot visible on skin
what does diagnosis of acute scrotum depend on
semi age related
DDx:
- torsion testis, torsion appendix testis
- rarely epididymitis - has been misdiagnosed in cases of testicular torsion
- unusual: trauma, haematocele, incarcerated inguinal hernia
- if in doubt - explore
- do not miss testicular torsion, only way to avoid losing testis/rule out torsion is to explore
why do we investigate UTI in children
- prevent renal scarring - reflux nephropathy and chronic renal failure
- prevent HT
when to investigate UTI in children
all <6/12
atypical
recurrent
definition of UTI
pure growth of bacteria >105
pyuria
systemic upset - fever vomiting
mixed growth bacteria, no pyuria, no systemic Sx - less significant
assessment of UTI
hx and exam - FHx renal problems, bowel habit, voiding dysfunction
USS to check kidneys - number, size, position, shape, hydronephrosis
renography -
- MAG3 - drainage, function, reflux
- DMSA - function, scarring
micturating cystourethrogram (MCUG) - unpleasant, avoid where possible
grades of vesicoureteric reflux
- urine going into ureter
- into kidney w/ no dilation of renal tract
- more significant: dilation
- dilated calyces
- massively significant: massive reflux, gross hydronephrosis, dilated and torturous ureter
what is grade 5 VUR associated with
almost always some form of dysplasia of the kidney
management of VUR
conservative: voiding advice, avoid constipation, fluids
abx prophylaxis: best treatment if diagnosed young - continue until toilet trained, trimethoprim (2mg/kg nocte)
surgical: STING (mild/moderate VUR w/ Sx), submucosal teflon injection under ureter to stop reflux, effective; ureteric reimplantation (high grade reflux, much bigger operation) - take ureter out and put it back in a different place w/ a tunnel to stop reflux
what is hypospadias
urethral meatus on ventral aspect of penis
classification of hypospadia
anterior - relatively minor, cosmetic rather than functional issue
middle - more of an issue, usually requires surgery
posterior - very severe, challenging to fix
associated anomalies w/ hypospadias
upper tract - unusual, not routinely checked for
ambiguous genitalia - often severe hypospadias, undescended testis
investigations for hypospadias
US
karyotye only if severe
management of hypospadias
anterior - single stage procedure
more severe - 2 stage procedure
- important to straighten penis as part of surgery
- difficulty urinating
- ability to have penetrative intercourse
