Paediatric Urology Flashcards
Presentations of Paediatric Urological problems: what things may they present with systemically, locally, and antenatally?
Case:
9 month old boy
mum noticed lump in left groin at bath time
gone next morning
baby happy and feeding
Diagnosis?
inguinal hernia
what is an inguinal hernia and who does it occur in?
GROIN swelling (not in scrotum)
2% boys
boys 9:1 girls (due to association with descent of testes)
increase risk with prematurity
< 1 year 33% incarcerate! (can get stuck)
Bowel coming out and down the inguinal canal
what is the management of inguinal hernias?
management
< 1 year = URGENT referral , repair - no place for observation
> 1 year = elective referral and repair
incarcerated - reduce and repair on same admission
Case:
9 month old boy
mum noticed lump in left SCROTAL swelling at bath time. bluish colour
gone next morning
baby happy and feeding
Diagnosis?
hydrocele
what is a hydrocele? who does it occur in? and what does it cause?
SCROTAL swelling (History very important)
Fluid down into testicle instead of bowel
very common in newborns
painless - increases with crying, straining, evening
bluish colour
how do you manage hydroceles?
conservative until 5 yrs of age
Hernia management is surgery but for this its conservative as most go away
Groin swelling = ???
Scrotal swelling = ???
hernia
hydrocele
Case:
9 month old boy
mum noticed scrotum empty at bath time
normal neonatal discharge examination
baby happy and feeding
Diagnosis?
Possible undescended testes
what is Cryptorchidism (undescended testis)?
Any testis that cannot be manipulated into the bottom half of the scrotum
true undescended testis
retractile testis (comes down and goes back up again)
(ascending testis) – ones that are down but don’t keep up with growth
what is the incidence of cryptochidism
Testes don’t descent till 3rd trimester
Most of the ones undescended at birth will come down
what are indicaitons for Orchidopexy?
a surgery to move a testicle that has not descended or moved down to its proper place in the scrotum
fertility (Operate to maintain fertility) - 1% loss germs cells / month undescent……
malignancy - RR 3 x (probably intra-abdominal only), lifetime risk - <1%
trauma
torsion
cosmetic
Longer you leave them the more damaged they become
Primary reason is to improve function
case:
“4 year old boy with non retractile foreskin”
“recurrent balanitis”
o/e “pinhole meatus”
Diagnosis?
Normal non retractile foreskin
Can argue phimosis
Normal development
Case:
“14 year old boy with non retractile foreskin”
“struggling to pass urine”
o/e “scarred foreskin, narrow meatus”
Diagnosis?
BXO – Balinitis Xerotica Obliterans
Bit older now so more of a problem
History is slightly different
what is Balanitis Xerotica Obliterans?
Scarring condition of the foreskin
Point of restriction is right at the end, hasn’t got bit on top like the other one did (normal non retractable foreskin)
White scarring at top
These wont get better
You can use steroid cream
At least 50% will get circumcision
circumcision - removal of foreskin
what are the indications?
absolute - Balanitis Xerotica Obliterans (BXO) (Only real indication in BXO as doesn’t really get better with anything else)
relative:
Balanoprosthitis – severe inflammation & infection of the glands in the shaft of penis – if need repeated antibiotics then may do circumision
religious
xTI – if a boy has a very dilated urinary tract, high risk urinary tracts
Circumcision – what are the suggested advantages?
?UTI - x120 circs prevent 1 UTI
?malignancy - Penile cancer VERY rare – very low in population anyway
?sexual enhancement - ↑nerve endings in prepuce – doesn’t hold up
?AIDS / STD’s - Sub-Saharan Africa – it does reduce HIV but just use barrier contraception
Overall, minimal evidence of medical benefit
what are the disadvantages of circumcision?
painful
complications - bleeding, meatal stenosis, fistula, cosmetic
? look different
Case:
“14 year old boy with 4 hour history of right sided testicular pain”
o/e scrotum red, asymmetry, acutely tender to touch
Diagnosis?
Testicular torsion
Age and length of history is important here
what is testicular torsion?
testical twists on spermatic cord (so one is higher thats why asymetry)
Acute event
Short period (6 hours) to salvage testis as they become ischaemic, testicular higher up as its shortens
Testicular torsion occurs when a testicle rotates, twisting the spermatic cord that brings blood to the scrotum. The reduced blood flow causes sudden and often severe pain and swelling. Testicular torsion is most common between ages 12 and 18, but it can occur at any age, even before birth
Case:
“14 year old boy with 4 hour history of right sided testicular pain”
o/e scrotum red, NO Asymmetry, blue spot seen, tender to touch
Diagnosis?
Torsion Appendix Testis
what is Torsion Appendix Testis?
Red swelling
Appendix testes is a embryological remnant sitting on top of epididymis, what would of been female parts
Twists and becomes ischaemic and necrotic and goes black and that’s the blue dot you can see
Torsion of the appendix testis is a twisting of a vestigial appendage that is located along the testicle. This appendage has no function, yet more than half of all boys are born with one. Although this condition poses no threat to health, it can be painful. Usually no treatment other than to manage pain is needed
what is Acute Scrotum?
age related ….. Ish (older you are more likely a torsion but not absolute - More torsion as you get older and go through puberty as you get a bigger mass of testes so more likely to twist)
differential diagnosis:
- torsion testis, torsion appendix testis,
- RARELY epididymitis (get in new born babies with congenital abnormalities of the urinary tract)
- trauma, haematocele, incarcerated inguinal hernia
if in doubt – explore (if you cant say it’s a torsion then explore)
6- 8 hours to recover testis
why investigate UTI and who should you investigate?
why investigate UTI?
prevent renal scarring - reflux nephropathy and chronic renal failure
prevent hypertension
who to investigate?
NICE guideline on UTI - all <6/12, atypical, recurrent
what is the definition of a UTI?
pure growth bacteria > 105
pyuria
systemic upset - fever, vomiting
mixed growth bacteria, no pyuria, no systemic symptoms - less significant
how do you assess a UTI?
history and examination - FH, bowel habit, voiding dysfunction
ultrasound scan - number, size, position, shape, hydronephrosis
renography:
- MAG3 - drainage, function, reflux
- DMSA - function, scarring
icturating cystourethrogram (MCUG) (gold standard for picking up reflux)
what is VUR and its grades?
Vesicoureteral reflux (VUR) is when the flow of urine goes the wrong way. This condition is more common among infants and young children
This can cause UTI – when urine goes back upto kidney
Grade 3 is where it gets more significant
what is the management of VUR?
Conservative (initially) - voiding advice, constipation, fluids
antibiotic prophylaxis - ? until toilet trained?, Trimethoprim (2mg/kg nocte)
STING - mild/moderate with symptoms
ureteric reimplantation (much bigger procedure)
what is Hypospadias?
zurethral meatus on the ventral aspect (under aspect) of the penis
Anterior is relatively minor
Hypospadias is a condition in which the opening of the urethra is on the underside of the penis instead of at the tip. The location of the opening can vary and can be anywhere from underneath the tip of the penis (more common) to the base of the penis (less common)
Hypospadias - what are associated anomalies, investigations and management?
associated anomalies:
- upper tract (unusual)
- (ambiguous genitalia)
investigations - US, Karyotype only if severe
management - one stage or 2 stages procedure
