Pediatric Urology Flashcards
What is the normal appearance of male genitalia at birth?
Foreskin tightly adherent to glans
Deep rugae and testes bilaterally
When does foreskin develop?
Beginning at 12 weeks gestation
Covers entire glans by 18-20 weeks
What are abnormal findings for neonatal male genitalia?
Shallow rugae: preterm infant
Empty scrotum: cryptorchidism
When does puberty normally occur in boys?
9-14 ys, avg 11.5 yrs
What is an early and later sign of male puberty?
early: increase in testicular size and volume
later: pubic hair development and increase in penile length
What happens in male development at the end of puberty?
Sperm in urine and nocturnal emissions aka male menarche
When does penile enlargement occur?
Tanner stages 2-5
mean length at 1 year: 3.75 cm
by late childhood: slow increase to 4.84 cm
by late puberty: sharp increase to 9.5 cm
what is circumcision?
surgical removal of foreskin
the US is unique in that it is the only country that does what related to circumcision?
Most male infants circumcised for non-religious purposes
What does circumcision in the US vary according to?
Geographic area
Socioeconomic status
Religious affiliation
Insurance coverage
Hospital type
Racial/ethnic group
Father’s circumcision status
Opinions of others
Desire for conformity of son’s appearance
Easier to keep clean
When is circumcision usually done? What is the preferred timeline?
Male child between 1 and 10 days
Infant 24 years old (to allow for ID of health issues)
What are contraindications to circumcision?
Unstable or significantly premature infants
Infants
Penile abnormalities ie hypospadias with foreskin abnormalities, chordee/curvature of penis, concealed penis/buried or large suprapubic fat pad
bleeding disorders: not full CI (procedure with clinicians experienced in circumcision)
benefits of circumcision
easier genital hygiene
lower UTIs
decreased invasive penile cancer
decreased viral STDs (no decrease in gonorrhea/chlamydia)
decreased cervical cancer in female partners
what is phimosis
narrowing of opening of foreskin so it can not be retracted
what is paraphimosis
foreskin stuck behind glans of penis
what is balanoposthitis
inflammation of glans penis and foreskin
risks of circumcision
procedure related risks
improper skin removal
bleeding
infection
pain
glans injury
development of epidermal inclusion cysts
adhesions and scarring
skin bridges
how is a circumcision performed?
local anesthesia by nerve block (dorsal or circumferential) with 1% lidocaine without epi or 4% lidocaine
Mogen clamp: occasional amputation of glans
Plastibell: clamp stays in place
Gomco: clamp removed at end of procedure
what is post circumcision care for circumcision?
barrier ointment: petroleum or vaseline with diaper changes to glans and part of diaper where glans would hit
shaft skin not forcibly retracted
if skin of shaft lays on glans, gently retract
for 2 weeks until skin healed
What is a normal uncircumcised penis appearance?
extends 1 cm beyond glans
What is the relationship between foreskin retraction and age?
Can’t retract (incomplete) at birth (50%) can’t be retracted to see urethral meatus
Retractability increases yearly
By age 1: 50% have retractile foreskins
90% by age 3
92% by age 6 to 7
99% @ adolescence
At birth, most boys have —— phimosis, meaning what?
Physiologic: inner surface of foreskin developmentally fused to glans penis
What is sometimes seen under foreskin as pearls?
smegma
foreskin care and hygiene
routine (as rest of body)
wash penis with non-irritant soap
frequent diaper changes
may gently retract foreskin with diaper changes and bathing to clean and dry underneath, replace after cleansing
what could happen if retraction is forced?
Bleeding
Fibrosis
Pathologic phimosis
What can phimosis lead to?
Recurrent UTIs
Paraphimosis
Recurrent balanoposthitis
What generally causes secondary non-retractability of foreskin?
Chronic nonspecific inflammatory process
Repeated infection cause scarring and stricture
Forcible premature retraction of foreskin, causing scarring and adhesions
Balanitis xerotica obliterans (a chronic dermatitis)
Signs and symptoms of phimosis
irritation
bleeding
dysuria
painful erection
recurrent balanoposthitis
chronic urinary retention with ballooning
treatment of phimosis
topical steroid (betamethasone .05% MC) BID x 6 wks
routine stretching exercises
creams from tip of prepuce and down to junction with glans BID
Surgery: circumcision or dorsal slit surgery
advantages of creams for phimosis
less invasive
avoids risks of surgery
preputioplasty: stretches foreskin without removing it
much more cost effective
prevent emotional problems for boys who undergo circumcision at later age
What is paraphimosis?
Urologic emergency
Foreskin retracted and not replaced and becomes trapped behind corona
During cleaning or during catheterization, sexual activity, or trauma
Impairment of lymphatic and venous flow and venous engorgement of glans with swelling
Arterial flow ultimately becomes compromised (hours to days)
Presentation of paraphimosis on physical exam?
Collar of swollen foreskin at coronal sulcus
Ischemia and necrosis of glans (can result)
Edema/tenderness of flans
Swelling of foreskin
Constricting band of tissue proximal to glans and flaccid shaft
S/s of paraphimosis
pain
swelling
irritability
dysuria
treatment of paraphimosis
urology consult
goal to replace to normal position
if early, manual replacement
manual compression with penile block, sedation, or anesthesia to decrease edema and allow reduction
dorsal slit, multiple punctures in glans or foreskin
what is balanoposthitis
erythema and edema of prepuce that produces purulent discharge from preputial orifice
inflammation and edema of glans penis and foreskin
what is balanitis?
inflammation of the glans penis only
causes of balanoposthitis
infection
bacterial: normal flora, STDs for older adolescents
fungal: candida albicans
viral: HPV
trauma
irritation from soaps or detergents, poor hygiene
signs and symptoms of balanoposthitis
preputial, glans penis, meatus, or shaft
swelling
tenderness
erythema
exudate
foul odor
scarring between glans and prepuce
lymphadenopathy
treatment of balanoposthitis
sitz baths, avoid irritants
nonspecific: topical antibiotic ointment such as bacitracin/mupirocin
irritant: avoidance of precipitating factors, topical low-potency corticosteroid cream bid for 3-5 says
candidal infection: topical antifungals, nystatin, clotrimazole, or fluconazole
bacterial: topical antibiotics, if severe, oral antibiotics for GAS (amoxicillin)
what is the most common penile abnormality
hypospadias
what is hypospadias
urethral folds fail to completely or partially close
urethral meatus opens on ventral surface of penis often on distal shaft or proximal point along shaft or scrotum or perineum
what can hypospadias do?
interfere with ability to urinate and sexual function
treatment of hyospadias?
severity of the deformity and position of meatus on undershaft influences surgical decisions
sent to urologist for surgical repair, usually 6-12 months
what is epispadias?
urethral meatus located dorsally
can interfere with urination and sexual function
meatus formed on dorsum along glans/shaft
proximal deformity of epispadias may be associated with what?
urinary incontinence because of involvement of bladder neck area with distortion of normal architecture of pubic bones
treatment of epispadias
surgical correction by urologist
what is the mc congenital abnormality of GU tract
cryptorchidism
what is cryptorchidism
hidden testis not in scrotum
can be absent, undescended, ascending, ectopic
retractile d/t overactive cremasteric reflex
what usually happens with cryptorchidism?
generally spontaneously descend by 4-6 months, very rare after 6 months
where is cryptorchidism MC?
left testicle
what are types of cryptorchidism?
abnormal descent: 1) abdominal 2) inguinal 3) suprascrotal: 4) suprapubic 5) femoral 6) perineal
indications for referral of cryptorchidism
phenotypically male newborn infants with bilateral nonpalpable testis
unilateral non-palpable testis with hypospadias
suspected disorder of sexual development
congenital palpable undescended testis in infant (ideally between 4-12 months of age)
ascending testis in boys beyond infancy
palpable tissue in scrotum thought to be atrophic testes
difficulty differentiating between undescended, retractile, or ectopic (ideally between 4 and 12 months of age)
work up for cryptorchidism
initial lab evaluation
karyotype if absent or non palpable
US of pelvic structures looking for gonads and uterus
adrenal hormones and metabolites to evaluate CAH: hydroxyprogesterone, testosterone, cortisol, DHEA
LH, FSH, Mullerian inhibiting substance
treatment of cryptorchidism
hormonal therapy used as adjunct
surgery mainstay –> orchiopexy
retractile/ascending testes treated with orchiopexy within 6 months
what are hormone treatments for cryptorchidism?
hCG
hastens descent of test
greater success with lower positioning of testis
drawbacks of hormone therapy for cryptorchidism
can retract after discontinuation of hCG
can hasten puberty
can cause testicular damage and sterility
long-term studies lacking
complications of cryptorchidism
increased risk for developing testicular cancer
infertility
testicular torsion
decreased sexual function
testicular cellular damage increases with each passing year, probably not reversible after age 4 or 5
what causes ambiguous genitalia
Developing tissue doesn’t respond to hormones
Gonads don’t form appropriately and function to secrete hormones
What is disorder of sex development?
discrepancy between external genitalia and gonadal/chromosomal sex
genitals that do not appear typically male or femal or appearance discordance with chromosomes
What is the MCC of DSD (disorder of sex development)?
Congenital adrenal hyperplasia
What does congenital adrenal hyperplasia cause in addition to abnormal sex hormones?
severe electrolyte and mineralcorticoid imbalances
when are external genitalia sexually differentiated
around 9th week
initial male external genital development is complete when? What about female?
around 12-16 weeks
12 weeks
phenotypic female ambiguous genitalia appearance
enlarged clitoris
fused labial folds
palpable gonads
phenotypic male ambiguous genitalia appearance
bifid scrotum
severe hypospadias
micropenis
cryptorchidism
initial work up of ambiguous genitalia
expedited evaluation of sex chromosomes – karyotype
assessment of gonadal function after birth: FSH, LH, testosterone, dihydrotestosterone, AMH
adrenal steroids: 17-hydroxyprogesterone
baseline electrolytes
ACTH, hCG if indicated
gender assignment and surgery following counseling
treatment of ambiguous genitalia
stabilization of medical and pyschosocial needs including CAH (most life threatening)
multidisciplinary therapeutic plan
what are ongoing medical concerns in ambiguous genitalia patients?
potential for malignancy in gonadal tissue
effects of altered levels of sex steroid exposure
decreased bone mineral density
psychosocial concerns
what is a hydrocele
peritoneal fluid between layers of tunic vaginalis
types of hydrocele
communicating: patent processus vaginalis with flow into tunica vaginalis, increases over course of day or with straining
noncommunicating: processus vaginalis closed, fluid trapped, not reducible and does not change in size/shape with crying/straining
presentation of hydrocele
cystic scrotal mass
common
asymptomatic with some scrotal swelling/bulge: communicating may enlarge throughout day or with valsalva, noncommunicating does not enlarge
diagnosis of hydrocele
scrotal transillumination, scrotal US
tx of hydrocele
supportive until 1-2 years of age
surgery if not resolved by 1-2 or symptomatic or compromise skin integrity
hernia
protrusion of organ or tissue through abnormal opening in wall
who more commonly gets hernias
premature newborns >newborns
male > female
MC in boys and children <10 months
what is an indirect hernia? Direct?
indirect: patent inguinal canal/processus vaginalis
direct: external inguinal ring only rare in kids
presentation of inguinal hernia
intermittent bulge in groin
noted at times of increased intrabdominal pressure (straining or crying)
painless inguinal swelling
may retract when cold, active, frightened, agitated
can be reduced
what are s/s/pe of incarcerated hernia
cannot be reduced by manipulation
intestinal obstruction
pain
vomiting
PE: firm, discrete inguinal mass palpated in groin
mass tender and surrounded by erythema and edema
what is strangulated hernia?
vascular compromise of contents of incarcerated hernia
may see gangrene of testis/ovary/bowel loop
treatment of inguinal hernia
reapir on diagnosis to prevent incarceration (increases with time)
laporoscopic surgery
if open processus vaginalis, be aware of risk of contralateral hernia
diagnosis of testicular torsion
doppler US DO NOT DELAY
treatment of testicular torsion
urgent urological consult and surgery
orchiopexy if viable
orchiectomy if not viable
prognosis of untreated testicular torsion
100% viability within 4-6 hrs
after 12 hrs 20% viability
after 24 hrs 0%
when would you attempt manual detorsion and how?
If pts present before scrotal swelling (surgery still done if successful)
testis twisted clockwise/counterclockwise
if successful rapid return of blood flow and pain relief
what is acute epididymitis
acute inflammation of epididymis
who mc gets acute epididymitis
late adolescents, may occur in younger boys without sexual activity
mc causes of acute epididymitis
sexual activity
heavy physical exertion
direct trauma
structural GU abnormalities
sexually active: chlamydia (MC), gonorrhea, E. Coli, viruses
not sexually active: mycoplasma, enteroviruses, adnoviruses
signs/symptoms of acute epididymitis
acute/subacute onset of pain/swelling isolated to epididymis
possible history of frequency, dysuria, urethral discharge
physical exam of acute epididymitis
scrotum red
scrotal edema
possible inflammatory nodule
normal cremasteric reflex
pain relief with elevation of testis —> Phren sign
work up for acute epididymitis
UA/urine culture
diagnosis with findings consistent and gram stained and smear culture of urethral exudates
or intraurethral swab specimen
OR nucleic acid amplification tests for N. gonorrhea and C. trachomatis
AND urine culture/first void urine for leukocytes
syphilis and HIV testing
imaging of acute epididymitis
doppler US with increased blood flow to affected epididymis
treatment of acute epididymitis
abx
scrotal support
bed rest
should improve in 3 days
if suspected STD what abx should be given for acute epididymitis
ceftriazons IM once + doxycycline PO BID 7 days
if enteric organisms what abx should be given for acute epididymitis
levofloxacin 500 mg PO QD 10 days
if suspected UTI, what abx should be given for acute epididymitis
cefdinir or bactrim
signs and symptoms of vulvovaginitis
vulvar pruritis
vulvar burning
vulvar soreness
vulvar irritation
dysuria
discharge that is white, thick, adherent to vaginal sidewalls, clumpy
PE of vulvovaginitis
erythema of vulva and vaginal mucosa
vulvar edema with or without discharge
risk factors for vulvovaginitis
diaper use
broad-spectrum antibiotic use
immunosuppression
adolescents with certain contraceptive devices
poor hygiene
bubble baths, shampoo, soaps
choice of clothing
diagnosis of vulvovaginitis
most clinical in pediatric office
can swab vaginal sidewall and discharge: assess vaginal pH (normal 4-4.5), elevated in BV
perform microscopy: wet mount test
treatment of candidal vaginitis
fluconazole
treatment of bacterial vaginosis
metronidazole, clindamycin
what can be used for uncomplicated vulvovaginitis or young children not able to swallow pill?
clotrimazole, miconazole
topical nystatin 12 and under
patient education for vulvovaginitis
wear cotton underwear
avoid tights
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
front to back wiping
avoid letting child sit in wet swimsuits
what causes labial adhesions
fusion of adjacent mucosal surfaces of the labia minora via thin and transparent or thick and fibrous layer
likely due to chronic irritation and inflammation
who is most prone to labial adhesions and why?
prepubertal girls in first 5 years of life
rise in endogenous estrogen levels prepubertal –> decrease in labial adhesions, improved hygiene
symptoms of labial adhesions
often asymptomatic
minute spotting d/t partial dehisce
uncommonly, vaginal pain, pain with ambulation or urination
UTI
urinary retention
altered urinary stream
diagnosis of labial adhesions
visual inspection
labia majora stretched apart with membrane at midline
management of uncomplicated labial adhesions
if no accompanying symptoms, not treated
inform parents and reassure
educate on potential symptoms
management of complicated labial adhesions
if pain on urination or ambulation, altered stream, retention, or hx of UTI
first line tx: topical estrogen bid x 2 weeks
after separated labia, topical lubricant for 30 days
what should be done if labial separation doesn’t occur within 8 weeks or if can’t tolerate estrogen?
manual separation
topical anesthetic, firm traction
daily lubrication for several months
rarely, thick adhesions will need surgical lysis by urologist or gynecologist
penile adhesions
tiny areas of fusion between foreskin and corona most resolve with time
tx of penile adhesions
gentle retraction followed by application of petroleum jelly or abx for one week to prevent new adhesions
if not effective, low potency steroid
prevent via education to retract and clean skin covering glans
what is a penile skin bridge?
foreskin adheres higher up on glans results in dense adhesions
what can penile skin bridge cause?
tethering of penis, visually displeasing
treatment of penile skin bridge
refer to pediatric urologist for lysis via scalpel
can be done in office or OR
who more commonly gets UTIs?
girls >6 months
uncircumcised boys <3 months
MCC of UTIs
E. Coli
Klebsiella
Proteus
occasionally enterococcus or staphylococci
risks for UTI
dysfunctional voiding
constipation
neurogenic bladder
poor hygiene
structural abnormalitiesc
complications of uti
renal parenchymal scarring
HTN
renal disease
renal failure later in life
pyelonephritis
s/s of UTI in newborns/infants
fever
hypothermia
jaundice
poor feeding
irritability
vomiting
FTT
sepsis
s/s of UTI in preschool
abdominal/flank pain
vomiting
fever
urinary frequency
dysuria
urgency
enuresis
s/s of uti in school aged children
frequency, dysuria, urgency
+fever, N/V, flank pain if pyelo
CVA tenderness rare in young children may be seen in school-aged
how can a urinalysis/culture be collected if not toilet trained?
suprapubic aspiration
transurethral bladder catheterization
clean catch voided urine: through bladder stimulation or bag specimen
techniques for UA/urine culture
females: labia spread apart and perineum cleansed 2-3 times iwth non-foaming antiseptic
males: meatus cleansed and foreskin retracted
what is required for diagnosis of UTI?
urine culture with growth of >100,000 from clean-voided sample or 50,000 from catheter both single pathogen
goals of UTI tx
elimination of infection and prevention of urosepsis
relief of symptoms
prevent recurrence and long term complications
acutely manage via antimicrobial therapy
when would you hospitalize UTI?
age less than 2 months
clinical urosepsis
immunocompromised patient
vomiting or inability to tolerate oral meds
lack of adequate outpatient f/u
treatment failure
uti treatment
third gen cephalosporin (cefdinir, cefpodoxime, ceftriaxone, cefotaxime)
cipro for pseudomonas
10 days in febrile children
3-5 days for immune-competent children without fever
clinical response to treatment in uti
improves within 24-48 hrs
if worsens or fails to respond, broadening antimicrobial
repeat urine culture
indications for RBUS (renal US)
children younger than 2 yrs old with first febrile UTI
children at any age with recurrent UTI
children of any age with a UTI who have family hx of renal or urologic disease, poor growth, or hypertension
children who do not respond as expected to approp antimicrobial therpay
VCUG indications
children at any age with 2+ febrile UTIs OR
children of anyage with first febrile UTI AND
any anomalies on renal US or combo of temp of 102.2 and pathogen other than e. coli or poor growth or hypertension
what is vesicoureteral reflux
retrograde passage of urine from bladder into upper urinary tract
predisposes to acute pyelonephritis
predisposes to recurrent UTI –> scarring, hypertension, end stage rneal disease
diagnosis of VUR
post or pre-natal: finding of hydronephrosis on prenatal US
postnatal VCUG
renal function with UA to detect proteinuria, serum cr
grades of VUR
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
management of grade 1-2 VUR
watchful waiting d/t spontaneous resolution, can give daily abx in children not potty-trained
management of grade 3-5 VUR
abx prophylaxis daily on assumption that continuous use results in sterile urine and wont cause renal scarring
surgery to correct anatomy by pediatric urologist for 4-5 and stage 3 with no compliance or breathrough infections
what is enuresis
voiding on bed or on clothes at least twice per week for at least 3 consecutive months in child at least 5 years of age
types of enuresis
diurnal wetting in daytime
nocturnal passage of urine during nighttime
monosymptomatic: no daytime symptoms
polysymptomatic: urgency, frequency, dribbling, or daytime enuresis
what can be related to enuresis
hereditary
delayed speech and walking
what can cause polyuria that exceeds bladder capacity —> monosymptomatic nocturnal enuresis
decreased ADH at night
apnea
anatomic abnormlaities
constipation
lesions of spinal cord –> neurogenic bladder
diurnal when urine held until last minute –> UTIs
PE of enuresis
most often normal
labs for enuresis
UA
urine culture
US if daytime symptoms or initial positive studies
voiding cystourethrogram
treatment of enuresis
treat constipation or UTIs first
if both day and night, tx day first
underlying cause
NE: minimize fluid intake, wake to urinate before parents go to bed
encourage to go often during day, no shame or blame, positive reinforcement
alarm therapy, CBT
DDAVP
what is alarm therapy?
alarms throughout night, every time alarm sounds child gets up to void
continue x 3 mos
moa of DDAVP
tx monosymptomatic
NE due to antidiuretic activity
may take 2-3 mo
