Paeds - Urology

Question 1

Types of Enuresis

Primary Nocturnal Enuresis
Secondary Nocturnal Enuresis
Diurnal Enuresis

Answer 1

1. ) Primary Nocturnal Enuresis - bedwetting at night and has never been consistently dry at night
   - the most common cause is a variation in normal development (esp if <5yrs), often an FH is present
   - other causes: overactive bladder, fluid intake before bedtime (esp fizzy drinks, juice, caffeine), failure to wake during deep sleep, psychological distress
   - secondary causes: chronic constipation, UTI, learning disability or cerebral palsy
2. ) Secondary Nocturnal Enuresis - bedwetting at night when they’ve previously been dry for at least 6mths
   - more indicative of an underlying illness/problem:
   - UTI, constipation, type 1 diabetes, new psychosocial distress, maltreatment, abuse and safeguarding
3. ) Diurnal Enuresis - daytime incontinence, occurring when the person has become dry at night
   - more common in girls, types of incontinence:
   - urge and stress incontinence
   - other causes include: recurrent UTIs, constipation, psychosocial problems

Question 2

Management of Enuresis

General Management
Management of Primary Nocturnal Enuresis
Enuresis Alarms
Pharmacological Treatment

Answer 2

1. ) General Management
   - reassure children <5yrs w/ primary nocturnal enuresis as it is likely to resolve without any treatment
   - monitoring: 2-week diary of toileting, fluid intake, and bedwetting episodes
   - Mx of secondary nocturnal enuresis is based on treating the underlying cause (e.g. UTI, constipation), referral to secondary care for other problems
2. ) Management of Primary Nocturnal Enuresis
   - lifestyle changes: reduced fluid intake in evenings, pass urine before bed, ensure easy access to a toilet
   - encouragement and positive reinforcement, avoid blame/shame, punishment should be avoided
   - treat any underlying causes/exacerbating factors
   - enuresis alarms are the first line after the above
   - desmopressin if enuresis alarm is ineffective or if short-term control is needed e.g. sleepovers
3. ) Enuresis Alarms - make a noise at the first sign of bedwetting, waking the child to help stop urination
   - requires quite a high level of training and must be used consistently for a prolonged period (>3mths)
   - sometimes maybe good, sometimes maybe shit
4. ) Pharmacological Treatment
   - desmopressin: ADH analogue
   - oxybutynin: overactive bladder/urge incontinence
   - imipramine (TCA): unclear mechanism but it may relax the bladder and lighten sleep

Question 3

Cryptorchidism (undescended testes)

Pathophysiology
Clinical Features
Management
Retractile/Ascending Testicles

Answer 3

1. ) Pathophysiology - testes do not make it out of the abdomen and reach the scrotum prior to birth
   - occurs in 5% of newborns, 1.5-3.5% after 3 months
   - risk factors: FH, low birth weight, SGA, prematurity, maternal smoking during pregnancy, other genital abnormalities (e.g. hypospadias)
2. ) Clinical Features
   - often picked up on the NIPE
   - 80% of cryptorchidism is palpable, if not, it can be ectopic, intra-abdominal, absent or, impalpably small
   - true undescended testis: located along the normal decent pathway (abdominal, inguinal, suprascrotal) but cannot be manipulated to the base of the scrotum
3. ) Management
   - urgent referral if there is bilateral cryptorchidism OR ambiguous genitalia OR hypospadias at birth
   - at birth: review at 6-8 weeks of age
   - 6-8wks: If unilateral, re-examine at 3 months
   - 3mths: refer to urology for an orchidopexy which should be done between 6-12 months of age
   - complications in older children: higher risk of testicular torsion, infertility and testicular cancer
4. ) Retractile Testicles - when the testes moves into the inguinal canal when cold, or cremasteric reflex
   - considered a normal variant in prepubertal boys
   - usually resolves as they go through puberty but an annual follow up is advised sue to risk of ascension
   - occasionally they may fully retract or fail to descend and require surgical correction with orchidopexy

Question 4

Hypospadias

Pathophysiology
Clinical Features
Management

Answer 4

1. ) Pathophysiology - the urethral meatus is displaced to the ventral side of the penis, towards the scrotum
   - due to arrest of penile development, leading to hypoplasia of the ventral tissue of the penis
2. ) Clinical Features - often diagnosed at the NIPE
   - ventral opening of the urethral meatus can be at the glans (90%), shaft, scrotum, perineum
   - other features: ventral curvature of the penis (chordee), a dorsal hooded foreskin
3. ) Management - referral to a paediatric urologist
   - mild cases may not require any treatment
   - corrective surgery is typically performed around 12 months of age
   - it is essential that the child is not circumcised prior to the surgery as the foreskin may be used in the corrective procedure
   - complications: difficulty directing urination, cosmetic and psychological concerns, sexual dysfunction

Question 5

Balanitis Xerotica Obliterans (BXO)

Pathophysiology
Clinical Features
Management

Answer 5

1. ) Pathophysiology - keratinisation of the tip of the foreskin causes scarring so it remains non-retractile
   - 95% of pathological phimosis is due to BXO
   - peak incidence for BXO is 9-11 years of age (75%)
2. ) Clinical Features
   - the ballooning of the foreskin during micturition
   - non-retractile foreskin (normal aged 2-4 years)
   - scarring of the urethral meatus presents with irritation, dysuria, haematuria and local infection
   - urinary obstruction if there is extensive scarring
   - examination: foreskin appears as a white, fibrotic and scarred foreskin tip, difficult to see the meatus
3. ) Management
   - circumcision, send the foreskin off to histopathology in order to confirm the diagnosis
   - complications if untreated: meatal stenosis, phimosis and erosions of glans and foreskin which can extend to the urethra

Question 6

Testicular Torsion

Pathophysiology
Clinical Features
Investigations
Management
Complications

Answer 6

1. ) Pathophysiology
   - spermatic cord twists within tunica vaginalis –> ↓blood flow –> ↓venous return –> oedema + infarction
   - ‘bell-clapper deformity’ more prone due to ↑mobility due to abnormal attachment to the tunica vaginalis
   - R.F: age (12-25), previous history, FH, cryptorchidism
2. ) Clinical Features
   - sudden onset of severe unilateral testicular pain
   - can be associated w/ N/V and referred abdo pain
   - testis is tender, swollen, has a higher horizontal lie
   - cremasteric reflex is absent and -ve Prehn’s sign
3. ) Investigations - clinical diagnosis
   - Doppler US to investigate blood flow
   - urinalysis to rule out differentials (epididymo-orchitis)
4. ) Management
   - surgical emergency, 4-6hrs until ischaemic damage
   - urgent surgical exploration for evidence of torsion
   - bilateral orchidopexy (untwisted, fixed to the scrotum)
   - orchidectomy if the testis is non-viable
5. ) Complications
   - testicular atrophy, chronic pain, infertility, future torsion

Question 7

Epididymitis (and Epididymo-orchitis)

Pathophysiology 
Clinical Features
Mumps Orchitis
Investigations/Imaging
Management

Answer 7

1. ) Pathophysiology
   - local extension of infection from UTIs or STIs
   - <35s, STI: N.gonorrhoea, C.trachomatis, E.coli (anal)
   - >35s, UTI/enteric: E.coli, Klebsiella pn. P.aeruginosa
   - enteric RF: catheters, bladder outlet obstruction
2. ) Clincal Features
   - gradual onset unilateral scrotal pain and swelling
   - fevers and rigors can also be present
   - associated UTI/STI sx, reactive hydrocoele
   - cremasteric reflex intact, Prehn’s sign positive (pain relieved by elevation of the scrotum)
3. ) Investigations/Imaging
   - bloods: FBC, CRP, blood cultures
   - urinalysis +/- urine culture
   - STI: first void urine for nucleic acid amplification test (NAAT), further STI screening may be warranted
   - US Doppler to rule out complications (e.g. abscess)
4. ) Management
   - analgesia, antibiotics, bed rest, scrotal support
   - enteric: PO Ofloxacin BD for 14 days
   - STI: IM Ceftriaxone + PO Doxycycline BD for 10-14d

Question 8

Scrotal Lumps

Definition
Clinical Features
Investigations
Differential Diagnoses

Answer 8

1.) Definition - abnormal mass or swelling within the scrotum

2. ) Clinical Features
   - diagnoses often made from examination alone
   - hx: onset, associated sx, previous episodes
   - site, size, shape, symmetry, scars, skin changes
   - palpate testes, epididymis and vas deference
3. ) Investigation
   - USS of the scrotum is first-line for the majority
   - mass from testes requires USS to rule out cancer
4. ) Differential Diagnoses
   - extra-testicular: hydrocoele, varicocele, epididymal cysts, epididymitis, inguinal hernia
   - testicular: cancer, torsion, orchitis, benign lesions

Question 9

Hydrocoele

What is it?
Aetiology
Clinical Features
Management

Answer 9

1.) What is it? - abnormal collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis

2. ) Aetiology
   - imbalance of fluid production and resorption between tunica albuginea and tunica vaginalis
   - primary or secondary (trauma, infection, malignancy)
   - congenital often regress spontaneously (few months)
   - in infants, can be due to patent processus vaginalis
3. ) Clinical Features
   - painless, fluctuant swelling, can be uni/bilateral
   - transilluminates: due to being fluid-filled
   - testis not palpable separately, can ‘get above’
   - can get bigger in young boys when they cough/cry due to connection between peritoneum and scrotum
4. ) Management
   - urgent USS to rule out cancer in 20-40-year-olds
   - surgical removal if large/symptomatic or not resolved in 1-2 years if congenital

Question 10

Wilms Tumour

Pathophysiology
Clinical Features
Management

Answer 10

1. ) Pathophysiology - nephroblastoma
   - one of the most common childhood malignancies
   - typically presents in children <5, (median age is 3)
2. ) Clinical Features
   - often presents w/ a (unilateral) abdominal mass
   - painless haematuria, flank pain
   - fever, lethargy, hypertension, weight loss/anorexia
   - mets found in 20% of patients (often in the lungs)
3. ) Management
   - arrange a paediatric review within 48 hours for any child with an unexplained enlarged abdominal mass
   - investigations: kidney US, CT/MRI for staging, biopsy for histology is required to make a definitive diagnosis
   - Tx: surgical excision with nephrectomy and adjuvant chemotherapy and/or radiotherapy
   - good prognosis at 80% cure rate