Pediatric Urology Flashcards
normal length of neonatal male genitalia
2.8 - 4.2cm, avg 3.5cm
Neonatal male genitalia begins developing at ___ weeks gestation
12
Covers entire glans by 18-20 weeks
how should a normal neonatal male genitalia look like
Normal scrotum-fully developed, with deep rugae and testes bilaterally
Shallow rugae is indicative of?
NEONATAL MALE GENITALIA
preterm infant
Empty scrotum is indicative of ?
NEONATAL MALE GENITALIA
cryptorchidism
what age does puberty start for boys?
9-14 yrs, avg 11.5 yrs
earliest and latest sign of puberty for boys?
- Earliest sign: increase in testicular size and volume
- Later: pubic hair development and increase in penile length
what is male menarche
- Sperm in urine and nocturnal emissions occur close to end of puberty
Penile Enlargement occurs at what tanner stages?
2-5
when is Elective circumcision done?
- done only in healthy, stable infants
- 1-10 days old - preferably 24 h old
- allows to find other health issues that may take precedence over an elective circumcision
circumcision CIs
- Unstable or significantly premature
- penile abnormalities
- Bleeding disorders - only a relaive CI; need further eval
benefits of circumcision
- Easier hygiene
- less UTIs during infancy
- dec in invasive penile CA
- dec in viral STDs (HSV, HPV, HIV; no change in gonorrhea or chlamydia)
- Dec incidence of cervical CA in female partners
narrowing of the opening of the foreskin so that it can not be retracted
Phimosis
foreskin becomes stuck behind the glans of the penis
Paraphimosis
inflammation of glans penis and the foreskin
Balanoposthitis
risks of circumcision
- Procedure related risks (.2% risk)
- Improper skin removal (too much/little)
- Bleeding
- Infection
- Pain
- Glans injury (including amputation)
- Development of epidermal inclusion cysts
- Adhesions and scarring
- Skin bridges
anesthesia for circumcision?
- dorsal penile nerve block
- circumferential ring block
1% lidocaine NO EPI or 4% topical lidocaine
which clamp is the blind technique for circumcision
mogen clamp - has occasional amputation of glans
what are the two techniques that allow for visulization of glans during circumcision
- Plastibell- clamp stays in place
- gomco clamps- clamp removed at end of procedure
post-circumcision care
- barrier ointment
- shaft skin should not be forcibly retracted
- Vaseline with diaper changes to glans and part of diaper where glans would hit
- 2 weeks
- Foreskin
- Redundant Skin
- 1cm beyond glans
- Provides protection to urethral meatus and glans penis
uncircumcised penis
how does retraction of penis change throughout the years?
- Retractability increases yearly
- By age 1: 50% of uncircumcised boys have retractile foreskins
- 90% by age 3
- 92% by age 6 to 7
- 99% by adolescence
what is physiologic phimosis
the inner surface of the foreskin is developmentally fused to the glans penis
Most phimosis is physiological
epithelial debris generated during desquamation is seen under the foreskin as pearls, what is the intervention?
none needed
Accumulation of smegma
foreskin care and hygiene recommendations
- Routine hygiene
- Wash regularly w/ non-irritant soap
- Frequent diaper changes
- GENTLY retract foreskin with diaper changes and bathing to clean and dry beneath
- Always replace retracted foreskin afterwards to avoid paraphimosis
Secondary non-retractability of foreskin generally caused by:
- Chronic nonspecific inflammatory process
- Repeated infections = scarring and stricture
- Forcible premature retraction of foreskin = scarring and adhesions
- Balanitis xerotica obliterans (BXO) - chronic dermatitis
- Can lead to urethral stenosis and negatively affect sexual function
- Surgery is often necessary
s/s phimosis
- Irritation
- bleeding
- dysuria
- painful erection
- recurrent balanoposthitis
- chronic urinary retention with ballooning
phimosis tx
- topical steroid - betamethasone .05% MC
- routine stretching exercises - Retraction as far back as appearance of stricture for 1 min QID x 1-3 m
- Creams to tip of prepuce and down to junction with the glans BID
- Surgery - circumcision, dorsal slit
advantages of using creams for phimosis instead of surgery
- less invasive
- Avoids risks of surgery - Preputioplasty: stretches foreskin w/o removing it
- cost effective
- Can prevent emotional problems
- Urologic emergency
- foreskin is retracted and is not replaced immediately and becomes trapped behind the corona
- happen during cleaning or during a procedure such as catheterization, sexual activity, trauma
paraphimosis
- Swelling of glans with a collar of swollen foreskin at coronal sulcus
- Ischemia and necrosis of glans can result
- Pain, swelling, irritability (infant), dysuria
- Edema/tenderness of glans, swelling of foreskin, constricting band of tissue proximal to glans (donut) and flaccid shaft
paraphimosis
tx paraphimosis
- consult urology
- early - manual compression w/ penile block, sedation/anesthesia
- dorsal slit, multiple punctures in glands or foreskin
- Erythema and edema of prepuce that produces purulent discharge from preputial orifice
- Inflammation of glans penis and foreskin
- Can have some edema of penile shaft
balanophosthitis
causes of balanoposthitis
-
Infection
- Bacterial: nml Flora (E.coli, GAS, Staph), STDs
- Fungal: Candida Albicans
- Viral: HPV - trauma
- irritation from products, poor hygiene.
- Preputial swelling, tenderness, erythema
- Swelling, tenderness, and erythema of glans penis, meatus, or shaft
- Exudate, foul odor
- Scarring between the glans and prepuce
- LAD
BALANOPOSTHITIS
tx balanopsthitis
- hygiene - sitz bath, avoiding irritants
- Nonspecific: Bacitracin/Mupirocin
- Irritant: Avoidance of precipitating factors, topical low-potency corticosteroid cream bid x 3-5 d
- Candidal infection: topicals, nystatin, clotrimazole, or fluconazole 150mg one dose
- Bacterial: topical abx, if severe, PO abx for GAS (Amoxicillin)
Most common penile abnormality
hypospadias
- The urethral folds fail to completely or partially close
- The urethral meatus opens on the ventral surface of the penis, located most often on the distal shaft, including the glans (60%)
- May be located at any proximal point along the shaft or scrotum (25%) or perineum (15%)
- 10% of cases have association w/ cryptorchidism
hypospadias
tx hypospadias
- A circumcision should not be performed
- refer to uro for surgical repair from 6-12 months
- Urethral meatus located dorsally
- Meatus formed on dorsum at various points along glans/shaft
- Much less frequent
epispadias
at what location is the deformity more associated with urinary incontinence b/c of involvement of the bladder neck area along with distortion of the normal architecture of the pubic bones
epispadias
more proximal
MC congenital abnormality of GU tract
cryptoorchidism
- MC spontaneously descend by 4-6m, very rare after 6m
- MC left testicle
abnormal descent types of cryptorchidism
- abdominal
- Inguinal
- suprascrotal
ectopic types of cryptorchidism
- suprapubic
- femoral
- perineal
indications for referral for cryptorchidism
- Phenotypically male newborn infants with BL nonpalpable testis, unilateral non-palpable testes with hypospadias, or suspected disorder of sexual development
- Congenital palpable undescended testis in infants (ideally 4-12 months of age)
- Ascending testis in boys beyond infancy
- Palpable tissue in scrotum thought to be atrophic
- Difficulty differentiating between undescended, retractile, or ectopic (ideally 4-12 months of age)
cryptorchidism w/u
- Karyotype - if absent and nonpalpable
- US - look for gonads and/uterus
- adrenal hormones and metabolites to evaluate CAH - Hydroxyprogesterone, testosterone, cortisol, DHEA
- LH,FSH, Mullerian inhibiting substance - to evaluate presence and function of testicular tissue
tx cryptorchidism
-
Orchiopexy: 4 months - 1 y/o
- Retractile/Ascending testes should also be treated with orchiopexy within 6 months of finding - hCG - Success is dependent on the initial location of testis, with greater success reported with lower positioned
drawbacks of hormone tx for cryptorchidism
- Can retract after discontinuation of hCG
- Can hasten puberty
- Can cause testicular damage and sterility
- Long-term studies lacking
complicationsof cryptorchidism
- Increased risk for developing testicular CA (5-10x greater risk)
- Infertility
- Testicular torsion
- Decreased sexual function
- Testicular cellular damage increases with each passing year, probably not reversible after age 4 or 5
what is Disorder of sex development (DSD)?
MCC?
- discrepancy between external genitalia and gonadal/chromosomal sex
- MCC congenital adrenal hyperplasia
- Can cause severe electrolyte and mineralocorticoid imbalances
External genitalia are indistinguishable up to about the ? week of gestation
At around the ? week, external genitalia become sexually differentiated
- 8th
- 9th
- Initial male external genital development complete around ? weeks
- Separation of vagina and urethra is complete in female around ? weeks
12-16
12
ambiguous genitalia seen in female and males?
- Phenotypic Female: enlarged clitoris, fused labial folds, palpable gonads
- Phenotypic Male: bifid scrotum, severe hypospadias, micropenis, cryptorchidism
w/u for ambiguous genitalia
- Karyotype
- FSH, LH, Testosterone, DHT, AMH
- 17-hydroxyprogesterone
- BMP
- ACTH, hCG
- gender assignment and surgery following counseling
ambiguous genitalia tx
- initial stabilization
- Medically most important: life-threatening adrenal crisis in CAH
- Psychosocial issue arises from anxiety experienced by most parents
- eval by endocrinologists, geneticist, and surgeons, psychosocial support
Ongoing medical concerns of ambiguous genitalia
- malignancy
- altered levels of sex steroid exposure
- decreased bone mineral density
- psychosocial concerns
Peritoneal fluid between layers of the tunica vaginalis (serous membrane covering testes)
HYDROCELE
2 types of hydrocele
- Communicating: a patent processus vaginalis where fluid flows into tunica vaginalis; May increase over course of a day or with straining/crying
- Noncommunicating: Processus vaginalis closed, fluid trapped, not reducible and does not change in size/shape with crying/straining
s/s hydrocele
- cystic scrotal mass
- Common in infants
- asx, with some scrotal swelling/bulge
- Communicating may enlarge throughout day or with valsalva
- Noncommunicating does not enlarge
w/u & tx for hydrocele
- Dx: Scrotal transillumination, scrotal US to check contents
- TX: Supportive until 1-2 y/o; surgery if not resolved, or symptomatic or compromise the skin integrity
protrusion of an organ or tissue through an abnormal opening in the wall that normally contains it
Hernia
Hernia MC in who?
- 1-5% of all newborns; 9-11% premature newborns
- 9:1 male to female - MC in boys and children < 10 mo
difference between indirect vs direct hernia
- Indirect: patent inguinal canal/processus vaginalis
- Direct: external inguinal ring only rare in kids
- Intermittent bulge in groin that may have been noted at times of increased intraabdominal pressure
- Painless inguinal swelling
- May retract when cold, active, frightened, agitated
- An inguinal mass that has not spontaneously reduced, but can be reduced
inguinal hernia
- an inguinal mass that cannot be reduced by manipulation
- intestinal obstruction, pain, vomiting
- firm discrete inguinal mass can be palpated in groin, mass usually tender and often surrounded by edema and erythema of overlying skin
incarcerated hernia
- Vascular compromise of the contents of an incarcerated hernia
- May see gangrene of testis/ovary or bowel loop
strangulation hernia
tx for inguinal hernia
- incarcerated - repaired ASAP
- Surgery via laparoscopically inguinally
- If open processus vaginalis, 10% chance of contralateral hernia risk
dx/tx for testicular torsion
- doppler US - DO NOT DELAY
- Tx: Urgent urological consult and surgery - detorsion and anchored to scrotal wall, if viable, orchiectomy if not
- Testis twisted clockwise/counterclockwise
- surgery is still done even if detorsion is successful
Viability of detorsion for testicular torsion
- Detorsion within 4-6 hrs: 100% viable
- Detorsion within 4-6 hrs: 100% viable
- After 24 hours: 0% viability
Acute inflammation of epididymis
Most common in late adolescents but may occur in younger boys without sexual activity
acute epididymitis
causes of acute epididymitis
- sexual activity, heavy physical exertion, direct trauma, structural GU abnormalities
-Chlamydia (MC), Gonorrhea, E. Coli, viruses
-mycoplasma, enteroviruses, adenoviruses
s/s of acute epidiymitis
- acute/subacute onset of pain/swelling isolated to epididymis
- h/o frequency, dysuria, urethral discharge, and fever possible
- Scrotum red
- Scrotal edema
- Possible inflammatory nodule felt
- Normal cremasteric reflex
- Pain relief with elevation of testis (positive Phren sign)
w/u for acute epididymitis
- UA/urine cx
- Gram-stained and smear cx of urethral exudates or intraurethral swab specimen OR Nucleic acid amplification tests for N. gonorrhea and C. trachomatis + Urine cx/first void for leukocytes
- Syphilis and HIV testing
- Doppler US
tx epididymitis
- scrotal support, analgesics, bed rest
- Suspected STD: Ceftriaxone IM once + doxy PO BID x 7d
- Enteric organisms: levofloxacin PO
- Suspected UTI (MC younger children): Cefdinir or Bactrim
vulvovaginitis s/s
- Vulvar pruritus is the dominant feature
- Vulvar burning
- Vulvar soreness
- Vulvar irritation
- Dysuria
- Discharge that is white, thick, adherent to vaginal sidewalls, clumpy
- often worse during wk prior to menses
- erythema of vulva and vaginal mucosa Vulvar edema +/- discharge
vulvovaginitis RF
- Diaper use
- Broad-spectrum antibiotic use
- Immunosuppression (steroid therapy, diabetes)
- Adolescents certain contraceptive devices
- Poor hygiene
- Bubble baths, shampoos, soaps
- Choice of clothing
w/u for vulvovaginitis
- clinical
- swab vaginal sidewall and discharge - nml pH 4-4.5; >pH = BV
- microscopy - Wet mount test can see budding yeast, pseudohyphae, and hyphae
mgmt for vulvovaginitis
- Candidal Vaginitis: Fluconazole
- BV: Metronidazole, Clindamycin
- Short course topical formations effective for uncomplicated or young children not able to swallow pill - Clotrimazole, miconazole for >12y; nystatin < 12y
pt ed for vulvovaginitis
- Wear Cotton underwear
- Avoid tights: skirts and loose fitting pants allow air circulation
- Frequent diaper changes
- Daily warm bath as follows: allow child to soak in clean water, use soap to wash regions other than the genital area right before exiting bath, gently pat dry
- No bubble baths
- Review hygiene with child - Emphasize front to back after bowel movements
- Avoid letting children sit in wet swimsuits for long periods of time after swimming
Develop as the result of fusion of the adjacent mucosal surfaces of the labia minora
Prepubertal girls in the first 5 years of life are most prone
labial adhesions
s/s labial adhesions
- Often asx and typically discover at routine well child visits
- Can have spotting d/t partial dehisce
- Uncommonly, affected girls may complain of vaginal pain, pain with ambulation or urination
- UTI
- Urinary retention
- Altered urinary stream
tx for uncomplicated labial adhesion
- If asx - no tx
- Inform parents of diagnosis and an opportunity to visualize
- Reassurance of benign, self-limiting nature of this condition and education about potential symptoms should be provided
tx for complicated labial adhesion
- topical estrogen BID x 2 wks
- After estrogen therapy has separated labia, a topical lubricant (petroleum jelly) x 30 days
Considered unsuccessful if labial separation has not occurred within ? weeks or if cannot tolerate estrogen
mgmt then?
- 8
- Manual separation can be performed
- Topical anesthetic, firm traction on opposing edges
- apply daily lubricant for several months
- Rarely, thick adhesions will need surgical lysis
Minor adhesions are commonly found after circumcisions
Consist of tiny areas of fusion between the foreskin and corona
dx? mgmt?
peniel adhesions
- Most resolve with time; Gentle retraction; topical petroleum jelly or abx ointment x 1 week; If gentle traction is not effective, low potency topical steroid
- Most can be prevented by retracting and clean any skin covering the glans
More complex fusion where foreskin adheres higher up on the glans and may result in dense adhesions
Can be visually displeasing and cause tethering of the penis
dx?
mgmt?
penile skin bridge
- referred to pediatric urologist for lysis of adhesions via scalpel after application of topical anesthetic
- Can be in office or OR
UTI is MC in who?
- Girls >6 mo > boys
- Uncircumcised boys < 3 mo have more UTIs
MCC of UTI
E. Coli (>85%), Klebsiella, Proteus, occasionally Enterococcus or Staphylococci
RF & complications of UTI
- Risks: dysfunctional voiding, constipation, neurogenic bladder, poor hygiene, structural abnormalities
- Complications: Renal parenchymal scarring, HTN, renal disease, renal failure later in life, pyelonephritis
s/s of UTI
- Newborns/infants: F, hypothermia, jaundice, poor feeding, irritability, vomiting, FTT, sepsis
- Preschool: abd/flank pain, vomiting, fever, urinary frequency, dysuria, urgency, enuresis
- School-aged: classic signs of frequency, dysuria, urgency; fever, N/V, flank pain if pyelonephritis; CVA tenderness-rare in young children, may be seen in school-aged children
how to collect UA/cx for UTI in toilet trained kids
Clean voided urine samples
for urinalysis and culture
how to collect UA/cx for UTI in not toilet trained kids
- Suprapubic Aspiration
- Transurethral bladder catheterization
- Clean catch voided urine
- Through bladder stimulation or bag specimen
- Bag specimens are noninvasive, however, have higher rates of contamination - Transurethral Bladder Catheterization or SPA
techniques for collecting UA/cx
- For clean voided samples
- Females: labia spread apart and perineum cleansed 2-3 times with non-foaming antiseptic
- Males: meatus cleansed in similar fashion. Foreskin retracted before cleansing for those uncircumcised - Transurethral Catheterization
- Child restrained in supine position and frog leg positioned
- First few drops of urine obtained may be discarded to prevent contamination of the urine with urethral organisms or cells
which lab is required for the diagnosis of a UTI
urine cx
Usual indications for hospitalization or IV therapy for UTI include:
- Age less than 2 mos
- Clinical urosepsis (toxic appearance, hypotension, poor capillary refill)
- Immunocompromised patient
- Vomiting or inability to tolerate oral medication
- Lack of adequate outpatient f/u (no telephone/reliable transportation)
- Treatment failure
tx for UTI
- 3rd gen cephalo - cefdinir, cefpodoxime, ceftriaxone, cefotaxime
- cipro only for Pseudomonas
- Nitrofurantoin not recommended in UTI in febrile infants and young children with renal involvement
- 10 days for febrile children
- 3-5 days for immune-competent children without fever
mgmt if clinical condition worsens or fails to respond within 48 hours for UTI
broadening antimicrobial therapy may be indicated if culture/sensitivity results not yet available
US to rule out renal abscess
Indications for RBUS for UTI
- < 2 y/o w/ first febrile UTI
- any age w/ recurrent UTIs
- any age w/ UTI + FHx renal or urologic dz, poor growth, or HTN
- do not respond to abx
VCUG indications for UTI:
- Children of any age with two or more febrile UTIs OR
- Children of any age with a first febrile UTI AND
- Any anomalies on renal ultrasound, or the combination of temperature of 102.2F and a pathogen other than E. Coli, or poor growth or hypertension
The retrograde passage of urine from the bladder into the upper urinary tract
predisposes to recurrent UTI, which may lead to renal scarring, hypertension, and end stage renal disease
vesicoureteral reflux
w/u for VUR
- post/pre-natal: hydronephrosis on prenatal US
- postnatal: febrile UTI, demonstration of reflux of urine from the bladder to the upper urinary tract by VCUG
- renal function, growth parameters, and BP
- Renal function with following tests: UA + Serum Creatinine
VUR staging
- Grade 1: reflux into ureter
- Grade 2: into kidneys
- Grade 3: into kidneys, dilation of ureter
- Grade 4: into kidneys, dilation of ureter, and mild blunting of renal calyces
- Grade 5: into kidneys, dilation of ureter, and moderate to severe blunting of renal calyces
mgmt for grades 1-2 VUR
Watchful waiting d/t spontaneous resolution, can give daily abx in children not potty-trained
ngmt for grades 3-5 VUR
- abx prophylaxis
- Surgery for children with grades 4-5, and for stage 3 with no compliance with medical mgmt., or breakthrough infections on abx
- Surgery corrects anatomy at the refluxing UV Junction
- handled by pediatric urologist
- Defined as voiding in bed or on clothes that occurs at least twice per week for at least 3 consecutive months in a child who is at least 5 years of age
- Has a strong hereditary component
- Developmental factors, such as delayed speech and walking speculated; however studies yield conflicting results
enuresis
two types of enuresis
- Diurnal-wetting in daytime
- Nocturnal-passage of urine during nighttime
what is monosymptomatic vs polysymptomatic enuresis?
- Monosymptomatic is nocturnal enuresis when no daytime symptoms
- polysymptomatic is associated with symptoms such as urgency, frequency, dribbling, or daytime enuresis
complications of monosymptomatic nocturnal enuresis
- children have polyuria that exceeds child’s bladder capacity
- Can have decreased ADH release at night
- Been reported with sleep disorders such as apnea
- Anatomic abnormalities (urethral obstruction, ectopic ureters)
- Strong association with constipation
- Lesions of spinal cord results in neurogenic bladder
what is Diurnal enuresis
occur when urine is held until the last minute, common in preschoolers
UTIs
w/u for enuresis
- Urinalysis (hematuria, rbc casts, proteinuria, glucosuria)
- Urine culture
- Can add ultrasound if daytime symptoms present or if initial studies are positive
- Can proceed to voiding cystourethrogram
mgmt for enuresis
- treat constipation or UTIs first
- If both day and nighttime sx present, treat daytime first
- Treat underlying cause if needed
- Can be frustrating for parents and children
- Mainstay of NE is alarm therapy, cognitive behavioral therapy
- Conservative measures for NE such as minimize fluid intake before bed; Wake child to urinate before parents go to bed; During day, encourage child to go completely and often; Positive reinforcement with charts, gifts
- desmopressin: tx monosymptomatic NE d/t antidiuretic activity; In short term, may give more rapid result; Relapse is common
- Oxybutynin-ditropan-anticholinergic: tx overactive bladder and daytime enuresis
