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Pediatrics Exam 4 > Pediatric Urology > Flashcards

Pediatric Urology Flashcards

1
Q

Normal Penile Development and Hygiene

A

● At birth, the foreskin adheres to the glans of the penis
○ Physiological phimosis
■ Nearly all will resolves with time
● Hygiene
○ Gentle washing
○ If retractable, wash the glans (remember to reduce)
○ Never forcibly retract a foreskin that isn’t retractable

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2
Q

Benefits of male circumcision

A

●↓ risk of UTIs (absolute risk is really low)
●↓ penile cancer (again, what’s the absolute risk?)
●↓ cervical cancer in female partners
●↓ penile inflammation & retractile disorders
● ↓ sexually transmitted diseases including HIV
● Hygiene: Easier

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3
Q

Risks to Male Circumcision

A

● Surgical risks (minor and infrequent with good technique and pain management)
● Diminished sexual sensation…
○ Permanent externalization of the glans penis results in desensitization due to keratinization of the glans that buries nerve endings deep into the glans
○ A systematic review of 36 studies showed
circumcision was NOT associated with decreased sexual arousal, sensitivity, or satisfaction

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4
Q

Medical indications for circumcision

A

○ Phimosis – inability to retract the prepuce
○ Paraphimosis – prepuce trapped behind
the corona of the glans penis
○ Balanitis – inflammation of the glan
○ Posthitis – inflammation of the prepuce
○ Balanoposthitis – inflammation of both
the glans and prepuce

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5
Q

Four common ways to collect urine from a child:

A

A. Midstream clean catch
B. “Clean voided” bag for collection
C. Straight catheterization
D. Suprapubic bladder aspiration

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6
Q

“Clean voided” bag for collection

A

● Noninvasive
● Properly clean, rinse, & dry perineum before applying
● Bag must be immediately removed after urine voided
● Should NOT be used for culture → high rate of false positives
○ DO NOT administer antibiotics on the basis of a urinalysis from a clean voided bag urine specimen

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7
Q

Straight Catheterization

A

● “In-&-Out”
○ Useful for culture & sensitivity
○ Post void residual

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8
Q

Suprapubic Bladder Aspiration

A

● Reserved for males difficult to catheterize
○ Usually limited to infants younger than 6 months
1. Immobilize the child
■ Do not attempt if the child has voided within the last
hour

  1. Palpate & percuss the limits of the bladder above the
    pubic symphysis
    ■ The bladder sticks out high above the pubis in a young
    child when it is full
    ■ May occlude the urethra in boys by holding the penis &
    in girls by inserting a finger in the rectum to exert
    pressure
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9
Q

“The Quick-Wee Method”

A

Suprapubic Cutaneous Stimulation
● A gauze pad soaked in cold fluid placed on the suprapubic region
○ Contamination rate with Quick-Wee was 27%
■ Standard clean-catch, it was 46% (not significant)
● Parents (and clinicians) were more satisfied with the kinder, gentler, and faster
method

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10
Q

The prevalence of UTI in children <2 years presenting with fever is
approximately ____

A

7%

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11
Q

Risk Factors for UTI in children

A

● Vesicoureteral Reflux
○ Most common urologic anomaly in children
● Urinary Obstruction
● Voiding Dysfunction
● Uncircumsized
● Sexually active

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12
Q

Urinary Tract Infection imaging for kids

A

○ Renal ultrasonography (RUS) & voiding cystourethrogram (VCUG)
■ Girls < 3 years of age, 1st UTI
■ Boys of any age, 1st UTI
■ Children of any age with a febrile UTI
■ Children with recurrent UTI & no previous imaging

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13
Q

Treatment for UTI in children

A

● Urine culture and sensitivity
● Antibiotics
■ Trimethoprim-sulfamethoxazole (Septra®, Bactrim®)
■ Cefixime (Suprax®)
■ Cephalexin (Keflex®)

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14
Q

Recommended duration of antibiotics for UTI in kids

A

■ 5-7 days for simple UTI
■ 7-14 days for febrile UTI at ages 2-24 months
■ 10-14 days for severe UTI (pyelonephritis)

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15
Q

When are IV antibiotics indicated for UTI

A

■ Infants < 3 months old
■ Inability to tolerate oral treatment
■ Poor response to oral treatment
■ Severe illness with vomiting & dehydration

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16
Q

When is surgical treatment recommended for UTIs

A

○ Vesicoureteral Reflux
■ Mild cases are likely to resolve over time
○ Circumcision
○ Meatal Stenosis
■ Meatotomy
○ Urethral Stricture
■ Dilatation or urethroplasty

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17
Q

Complications of UTI in Kids

A

● Hypertension, renal scarring, and end-stage renal dysfunction
● Recommended initiation of antibiotics

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18
Q

Hypospadias

A

Congenital urethral meatus on ventral surface of penis, scrotum, or perineum

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19
Q

Hypospadias most often occurs where on the penis?

A

(50%)
● Anterior/Glanular – meatus is on the inferior surface of
the glans penis
● Coronal – meatus is in the balanopenile furrow

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20
Q

Epispadias

A

Congenital urethral meatus on dorsal surface of penis or near the pubic bone

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21
Q

Hypospadias/Epispadias diagnosis

A

● Clinical assessment
● Nearly all will also present with curvature of
the penis
● Do not circumcise

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22
Q

Treatment of Hypospadias/Epispadias

A

● Minor cases – meatus is located up toward the tip of the glans
○ May not require surgical repair – observation
● Surgical correction
○ Distal and proximal penile
○ Between 6 months – 2 years old

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23
Q

Hypospadias/Epispadias
Treatment Goals

A
  1. Create a straight penis by repairing any curvature (orthoplasty)
  2. Create a urethra with its meatus at the tip of the penis (urethroplasty)
  3. Re-form the glans into a more natural conical configuration (glansplasty)
  4. Achieve cosmetically acceptable penile skin coverage
  5. Create a normal-appearing scrotum
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24
Q

What will Forcible Retraction of a phimosis cause in kids?

A

● Can tear the foreskin from the head of the penis & leave an open wound
○ Risk for infection – Balanoposthitis
○ Adhesions – Healing surfaces can form adhesions between the foreskin & the
glans (permanent problems with retraction)
○ Phimosis – Small tears in the foreskin can heal to form non-elastic scar tissue
○ Paraphimosis – Foreskin can get “stuck” behind the head of the penis

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25
Q

Physiologic Phimosis treatment

A

● Let it be – Almost all resolve with time
● If pathologic, conservative treatment with corticosteroid ointment or cream
(0.05%-0.1%) twice daily for 20-30 days
● Circumcision

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26
Q

Paraphimosis is Typically seen in one of the following populations

A

○ Children whose foreskins have been forcefully retracted
○ Children who forget to reduce their foreskin after voiding or bathing
○ Adolescents following vigorous sexual activity

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27
Q

Paraphimosis treatment

A

● Urological Emergency
● Reduction
○ Anesthesia (dorsal penile block or “ring” block)
○ Manual reduction
■ Circumferentially compress the foreskin
and hold for 2-10 minutes to reduce the
edematous fluid

28
Q

Hydrocele

A

Fluid collection within the tunica vaginalis of the scrotum or along the spermatic cord

29
Q

Etiology of a hydrocele

A

● In children, most hydroceles are communicating type
○ Patency of the processus vaginalis allows
peritoneal fluid into the scrotum, esp. with
Valsalva maneuvers
○ Clinical hydroceles evident in only 6% beyond
the newborn period (12-18 months)

30
Q

Hydrocele Diagnosis

A

● Soft, non-tender fullness within the scrotum
○ The testis is generally palpable along the posterior aspect of the scrotum
● Transillumination reveals a homogenous glow, without internal shadows

31
Q

Treatment for Hydrocele

A

● Observe
○ Communicable hydrocele under 12-18 months old
● Hydrocelectomy
○ Inguinal approach – ligation of the processus
vaginalis high within the internal inguinal ring

32
Q

Varicocele

A

Dilatation of the pampiniform venous plexus and internal spermatic vein

33
Q

Etiology of Varicocele

A

● Unknown
● Varicoceles are much more common (~80-90%) in the left testicle than in the
right because of several anatomic factors

34
Q

Varicocele diagnosis

A

● History
○ Usually asymptomatic, may report scrotal
pain or heaviness
● Physical Exam – Primary method of detection
○ Enlarged, potentially visible, veins in the scrotum –
“Bag of Worms”
■ Grade 1 – Palpable only with Valsalva
■ Grade 2 – Palpable without Valsalva
■ Grade 3 – Visible externally with or without
Valsalva

35
Q

Varicocele imaging

A

● High-resolution color-flow Doppler
ultrasonography

36
Q

Treatment of Varicocele

A

● Surgical Ligation
○ Occlusion of the varicosity

37
Q

Testicular Torsion

A

Twisting of the testicle/spermatic cord restricting blood to the testicle
Emergent condition

38
Q

Etiology of Testicular Torsion

A

● 90% related to “bell-clapper deformity”
● Left > Right
● Usually related to sports/physical activity, but can be spontaneous
● Fixation of the epididymal-testicular complex posteriorly, effectively prevents twisting
of the spermatic cord

39
Q

Testicular Torsion presentation

A

● Sudden onset of severe unilateral pain
● Significantly swollen and erythematous scrotum
● 1⁄3 may have nausea, vomiting, and GI upset
● Affected testicle WILL BE higher
● Negative prehn’s sign
● Refer to ER - this is an emergency!!

40
Q

Testicular Torsion treatment

A

● Surgical detorsion – restore blood flow
● Ischemia within 4 hours after torsion & is almost
certain after 24 hours
● Salvage rates after detorsion
○ 90% if within 6 hours
○ 50% if within 12 hours (25%)
○ < 10% if after 24 hours

41
Q

Most common solid malignancy affecting males aged 15-35 yo

A

Testicular Cancer

42
Q

Diagnosis of Testicular Cancer

A

● Painless mass is typical
● Some may have dull ache and/or present with pain (mass effect)

43
Q

Imaging for Testicular cancer

A

● Ultrasound
○ Scrotal US showing hypoechoic mass is diagnostic of testicular cancer

44
Q

Treatment of Testicular Cancer

A

● Radical inguinal orchiectomy
○ Subsequent histology confirms diagnosis
● “Pure” seminoma – very sensitive to radiation

45
Q

Cryptorchidism

A

(Undescended Testis)

46
Q

Most common congenital abnormality affecting genitalia in newborn males

A

Cryptorchidism (Undescended Testis)

47
Q

Etiology of Cryptorchidism (Undescended Testis)

A

● Congenital cryptorchidism
○ Undescended testis – testis deviates/stops along path of normal descent during fetal development
○ Absent/vanishing testis due to in utero or perinatal spermatic cord torsion/vascular accident
● Acquired cryptorchidism
○ Ascending testis – retracted by spermatic cord that remains short during somatic growth

48
Q

Diagnosis of Cryptorchidism (Undescended Testis)

A

● If the testilce is palpable, physical exam is usually sufficient for diagnosis
○ Ultrasound for non-palpable

49
Q

Treatment of Cryptorchidism (Undescended Testis)

A

● Clinical management depends on location and presence of testes
○ Must determine if the gonads are palpable or nonpalpable (~70% are palpable)
● Surgery is routinely used for treatment of undescended testis (Orchiopexy)
○ Refer to urology if undescended testis persists or presents at age > 6 months
(corrected for gestational age)

50
Q

A newborn with _____ is
potentially a genetic female (46 XX) with Congenital Adrenal
Hyperplasia (CAH) until proven otherwise

A

a male phallus and bilateral non palpable gonads

51
Q

_____ becomes gonads based on chromosomal sex

A

Genital ridge

52
Q

Precursors of external genitalia are

A

urogenital
tubercle, swelling, and folds

53
Q

Precursors of internal genitalia are ___

A

genital ridge, sex ducts, and germ cells

54
Q

Dihydrotestosterone causes

A

■ Urogenital tubercle → glans penis
■ Urogenital swelling → scrotum
■ Urogenital folds → penile shaft

55
Q

Absence of Dihydrotestosterone causes

A

■ Urogenital tubercle → clitoris
■ Urogenital swelling → labia minora
■ Urogenital folds → labia majora

56
Q

Ambiguous Genitalia
Disorders of Sex Development (DSD)

A

DSD are congenital conditions in which development of chromosomal,
gonadal, or anatomic sex, is atypical
● In infants, DSD typically manifest a
○ Congenital ambiguous genitalia
○ Malformed genitalia
○ Discordant genotypic and phenotypic sex

57
Q

DSD can be classified as…

A

● 46, XX DSD = Virilized female (female develops characteristics associated with male hormones/androgens)
○ Disorders of androgen excess
● 46, XY DSD = Undervirilized male
○ Disorders of androgen action or synthesis

58
Q

DSD can be classified with chromosome abnormalities including:

A

● Klinefelter syndrome (47, XXY)
○ Male phenotype, (typically)
● Turner syndrome (45, XO)
○ Female phenotype (typically)

59
Q

Management of Ambiguous Genitalia
Disorders of Sex Development (DSD)

A

● Stabilize infants with suspected Congenital Adrenal Hyperplasia or hypopituitarism
presenting with adrenal crisis
● Multidisciplinary team, along with parents, involved with all gender
assignment and treatment decisions
● Goals
○ Sex-appropriate appearance
○ Stable gender identity
○ Good sexual and reproductive function (if possible)
● Surgery
○ Masculinizing surgery
○ Feminizing surgery

60
Q

Most common renal tumor of childhood

A

Wilms Tumor

61
Q

Diagnosis of Wilms Tumor

A

Suspected clinically based on –
○ Abdominal mass in previously healthy child
○ Physical anomalies & /or developmental delay characteristic of Wilms tumor
predisposition syndromes
■ Denys-Drash syndrome
■ Perlman syndrome
■ “WAGR” syndrome
● Abdominal ultrasound used to detect or evaluate renal mass
● Biopsy confirms diagnosis

62
Q

Denys-Drash syndrome

A

Congenital nephropathy, disorders
of sexual development in affected
males, and Wilms tumor

63
Q

Perlman syndrome

A

Overgrowth of different parts of
the body (head, liver, kidneys)

64
Q

“WAGR” syndrome

A

Wilms tumor, aniridia, genital
anomalies, retardation

65
Q

Treatment of Wilms Tumor

A

● Protocols use a combination of
nephrectomy and/or chemotherapy,
with or without radiation therapy for
most patients
● Five-year overall survival rates
approach 90 percent

Pediatrics Exam 4 (7 decks)

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