Pediatric Urology - Exam 3 Flashcards

1
Q

What is the normal length of male genitalia? What is average? When does it begin to form? When is it completely covered by glans?

A

Normal length is 2.8cm - 4.2cm, with an average of 3.5cm

Develops beginning at 12 weeks gestation

Covers entire glans by 18-20 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What does shallow rugae of the scrotum indicate? What does an empty scrotum indicate?

A

preterm infant

cryptorchidism

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is the age range for puberty in boys? What is average? What are the earliest sign of puberty?

A

9-14 years old

average 11.5

increase in testicular size and volume

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are later male signs of puberty?

A

pubic hair development and increase in penile length

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is considered male menarche?

A

Sperm in urine and nocturnal emissions occur close to end of puberty

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What percentage of US males are circumscribed?

A

60-90% of males in the US are circumcised

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

When are circumcisions commonly performed? Why?

A

male child is between 1 and 10 days, at least 24 hours old

Infant should preferably be 24 hours old, this interval allows time for identification of other health issues that may take precedence over an elective circumcision

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are the 2 CI to circumcision? What is the strong caution?

A

unstable or significantly premature infants

penile abnormalities: hypospadia, chordee, concealed penis, large suprapubic fat pad

bleeding disorders is strong caution

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is chordee of the penis?

A

curvature of penis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is hypospadias?

A

when the urethal meatus is not where it should be, usually on the posterior side of the penis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What are some benefits of circumcision?

A

easier genital hygiene

lower rates of UTIs during infancy

Decreased incidence of invasive penile cancer

Decreased incidence of VIRAL STDs

Decreased incidence of cervical cancer in female partners

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Why does circumcision decrease incidence of viral STIs?

A

Variation may result from site of infection: gonorrhea/chlamydia infect urethra, while viral infections tend to involve the foreskin, where dendritic cells play a prominent role

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are the risks of circumcision?

A

procedure related risks

improper skin removal

bleeding/infection

glans injury

development of epidermal inclusion cysts

adhesions/scarring/skin bridge

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is the pain cocktail for a circumcision?

A

Local anesthesia by dorsal penile nerve block or circumferential ring block using 1% lidocaine without epinephrine or 4% lidocaine topical cream

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

______ is the blind technique for circumcision. What is sometimes the unintentional SE?

A

Mogen clamp

This type has an occasional amputation of the glans

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What are the 2 circumcision techniques that allow for visualization of the glans? What are the major differences?

A

plastibell and gomco clamps

plastibell: plastic bell stays in place after the procedure

gomo clamps: bell shaped clamp is placed over glans during procedure while foreskin is cut but then removed at the end of the procedure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What is the post circumcision care? What should you NOT due?

A

Apply barrier ointment (vaseline) with diaper changes to the glans and the part of the diaper where glans would hit to reduce risk of adhesions, infection, or meatal stenosis for 2 weeks after procedure

The shaft skin should NOT be forcibly retracted

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

In an uncircumcised penis, how far does the redundant skin extend?

A

extends 1cm beyond glans

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is normal with regards to foreskin retraction in newborn males?

A

usually incomplete in most male infants at birth and retractability increases yearly!

90% by 3
92% by 6-7
99% by adolescence

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What is the care of an uncircumcised penis? What should you NOT due?

A

Wash penis regularly non-irritant soap

May GENTLY retract foreskin with diaper changes and bathing to clean and dry beneath but need to replace foreskin after cleansing

Do NOT force retraction:

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What is phimosis? Is it normal?

A

Phimosis-narrowing of the opening of the foreskin so that it CANNOT be retracted

Most phimosis is physiological at birth, most boys have physiologic phimosis: the inner surface of the foreskin is developmentally fused to the glans penis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

______ foreskin becomes stuck behind the glans of the penis

A

paraphimosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

_____ inflammation of glans penis and the foreskin

A

Balanoposthitis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What am I? What is the tx?

A

smegma: (epithelial debris generated during desquamation) can sometimes be seen under the foreskin as pearls

tx: no intervention needed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
What can phimosis lead to?
recurrent UTIs, paraphimosis, and recurrent balanoposthitis
26
What are 4 causes of phimosis?
Chronic nonspecific inflammatory process Repeated infections that cause scarring and stricture Forcible premature retraction of foreskin, causing scarring and adhesions Balanitis xerotica obliterans (BXO
27
What is Balanitis xerotica obliterans (BXO)?What can it lead to? What is the tx?
a chronic dermatitis Can lead to urethral stenosis and negatively affect sexual function Surgery is often necessary
28
Irritation bleeding dysuria painful erection recurrent balanoposthitis chronic urinary retention with ballooning What am I? What are the non sx tx?
phimosis 6 week BID course of topical steroid (betamethasone cream, .05%) AND routine stretching exercises
29
What are the sx tx options for phimosis?
circumcision dorsal slit sx
30
_____ occurs when foreskin is retracted and is not replaced immediately and becomes trapped behind the corona. What should you do next?
paraphimosis ED, urologic emergency!!
31
Why is paraphimosis an emergency?
Impairment of lymphatic and venous flow from the constricting ring of foreskin causes venous engorgement of the glans penis with swelling Ultimately, arterial flow to the glans penis becomes compromised over a period of hours to days aka shuts off lymph and blood flow
32
What am I?
phimosis
33
What am I?
paraphimosis
34
Edema/tenderness of glans swelling of foreskin constricting band of tissue proximal to glans (donut) and flaccid shaft What am I? What is the tx? What is the goal?
paraphimosis ED -> urology consult, with manual compression, dorsal slit or multiple punctures in glans Goal is to replace foreskin in its normal position
35
Erythema and edema of prepuce that produces purulent discharge from preputial orifice What am I? What structures? What are the normal causes?
BALANOPOSTHITIS (BALANITIS) Inflammation of the glans penis and foreskin bacterial, fungal, viral, trauma, irritation from soaps/detergents or poor hygiene
36
What is balanitis?
Balanitis is inflammation of glans penis only
37
38
Preputial swelling, tenderness, erythema Swelling, tenderness, and erythema of glans penis, meatus, or shaft Exudate, foul odor Scarring between the glans and prepuce Lymphadenopathy What am I? What is the tx?
balanoposthitis good hygiene (sitz baths and avoid irritants) tx based on underlying cause
39
What is the tx for GAS causing balanoposthitis?
amoxicillin
40
_____ is the MC penile abnormality. What is it due to? 10% of cases, there is an association with _____
HYPOSPADIAS The urethral folds fail to completely or partially close and the urethral meatus opens on the VENTRAL surface of the penis, often on the DISTAL shaft cryptorchidism
41
Can you still perform a circumcision with hypospadias? What is the tx? How old?
NO!!! send to urology for surgical repair Most urologists recommend surgical repair anywhere from 6-12 months
42
What is epispadias? How common is it? What is the tx?
Urethral meatus located dorsally Much less frequent Meatus formed on dorsum at various points along glans/shaft surgical correction by urologist
43
____ is the most common congenital abnormality of the GU tract
CRYPTORCHIDISM
44
When do testicles normally descend? If one is NOT going to drop, which one is more likely?
Generally, spontaneously descend by 4-6 months, very rare after 6 months Most commonly the left testicle
45
Where are the 6 places a testicle could be in the body if NOT in the scrotum?
46
What are the referral indications for cryptorchidism?
47
What should be included in the work-up in a pt with cryptorchidism?
initial labs karyotype for sex determination pelvic US adrenal hormones: Hydroxyprogesterone, testosterone, cortisol, DHEA LH, FSH, mullerian inhibiting substance
48
What is the tx for cryptorchidism? What time frame?
Orchiopexy: sx to place and fix viable undescended testes into normal scrotal position Surgery recommended asap after four months of age for congenitally undescended testis and should absolutely be completed by 1 years of age
49
What is the tx for a retractile/ascending testes?
Retractile/Ascending testes should also be treated with orchiopexy within 6 months of finding
50
Historically, _____ has not proven to be efficacious in testicular descent, often used as an adjunct. Which one in particular?
hormonal therapy Can treat with hCG
51
What does the success of hormonally treating cryptorchidism with hCG depend on?
Success is dependent on the initial location of testis, with greater success reported with lower positioned but this tx is controversial!!
52
What are complications of cryptorchidism?
Increased risk for developing testicular cancer (5-10 times greater risk) Infertility Testicular torsion Decreased sexual function Testicular cellular damage increases with each passing year, probably not reversible after age 4 or 5 aka the longer the testicles sit in the body, the more atrophy
53
______ discrepancy between external genitalia and gonadal/chromosomal sex
disorder of sex development Infants born with genitals that do not appear typically male or female or that have an appearance discordant with the chromosomal sex
54
What is the MC cause of a disorder of sex development? What does it cause?
congenital adrenal hyperplasia Can cause severe electrolyte and mineralocorticoid imbalances
55
____ week gestation the external genitalia become differentiated. When do male external genital development complete? Female?
9th week Initial male external genital development complete around 12-16 weeks Separation of vagina and urethra is complete in female around 12 weeks
56
What is the initial work-up for a pt with ambiguous genitalia?
Evaluation of sex chromosomes via karyotype Assessment of gonadal function after birth: FSH LH Testosterone, Dihydrotestosterone Anti-mullerian hormone adrenal steroids
57
Why should you order an 17-OH progesterone test in ambiguous genitalia?
worried about adrenal steroids and concerned about salt wasting
58
What are 4 ongoing medical concerns for a pt with ambiguous genitalia?
Potential for malignancy in gonadal tissue Effects of altered levels of sex steroid exposure Decreased bone mineral density Psychosocial concerns
59
What is a hydrocele? What are the 2 different types?
Peritoneal fluid between layers of the tunica vaginalis (serous membrane covering testes) communicating or noncommunicating
60
_____ hydrocele: A patent processus vaginalis where fluid flows into the tunica vaginalis and may increase over the course of a day or with straining/crying
communicating hydrocele
61
_____ hydrocele: processus vaginalis closed, fluid trapped , not reducible and does not change in size/shape with crying/straining
noncommunicating hydrocele
62
cystic scrotal mass common in infants with some scrotal swelling/bulge +/- gets bigger throughout the day or with valsalva What am I? How do you dx?
hydrocele scrotal US with transillumination
63
What is the tx for hydrocele?
Supportive until about 1-2 years of age then surgery if not resolved by 1-2 yrs, symptomatic or compromising skin integrity
64
What are the 2 different types of hernia? Which one is MC in kids? What age range?
Indirect: patent inguinal canal/processus vaginalis- MC in kids Direct: external inguinal ring only - rare in kids Most common in boys and children < 10 months
65
Intermittent bulge in groin that may have been noted at times of increased intraabdominal pressure, such as straining or crying painless inguinal swelling What am I? What are the 2 major concerns?
inguinal hernia incarceration and strangulation
66
______ of a inguinal hernia -> firm, discrete inguinal mass can be palpated in groin. Mass usually tender and often surrounded by edema and erythema of overlying skin that CANNOT be reduced by manipulation
incarcerated
67
______ of a inguinal hernia -> Vascular compromise of the contents of an incarcerated hernia and may see gangrene of testis/ovary or bowel loop
strangulation
68
What is the tx for a inguinal hernia? At what level?
sx! to prevent incarceration as the risk increases with time The sac is isolated from the cord structures and ligated at the level of the INTERNAL ring
69
What is the presentation of a testicular torsion?
testicle will be lying horizontal in the scrotum and lose the cremasteric reflex
70
What is the dx of choice for testicular torsion? What is the tx?
US with doppler!! urgent urology consult and sx! orchiopexy to anchor testicle to scrotal wall
71
What is the viability of a torsed testicule?
within 4-6 hours: 100% viability after 12 hours: 20% after 24 hours: 0% viability
72
______ is most common in late adolescents but may occur in younger boys without sexual activity. What is is caused by?
acute epididymitis Caused by sexual activity, heavy physical exertion, direct trauma, structural GU abnormalities
73
What is a sexually active pt with acute epididymitis the likely underlying cause? What about not sexually active males?
Chlamydia (MC), Gonorrhea, E. Coli, viruses mycoplasma, enteroviruses, adenoviruses
74
Scrotum red Scrotal edema Possible inflammatory nodule felt Normal cremasteric reflex dysuria urethral discharge +/- fever What am I? What makes it better?
acute epididymitis Pain relief with elevation of testis (positive Phren sign)
75
What is included in the work-up for acute epididymitis? What dx imaging?
UA and urine culture US with doppler will show increased blood flow to the epididymis
76
What is the tx for suspected STD epididymitis? enteric organisms? suspected UTI?
STD: Ceftriaxone 250mg IM once +Doxycycline 100mg PO BID 7 days Enteric: Levo UTI: cefdinir or bactrim
77
pruritis! burning, soreness and irritation may have discharge erythema of vulva and vaginal mucosa with vulvar edema with/without discharge What am I? How do you dx?
vulvovaginitis vaginal swab and microscopy
78
What are risk factors for vulvovaginitis?
Diaper use Broad-spectrum antibiotic use Immunosuppression (steroid therapy, diabetes, cancer) Adolescents with certain contraceptive devices Poor hygiene Bubble baths, shampoos, soaps Choice of clothing
79
What is the normal pH of a the vagina? What happens during vulvovaginitis?
normal pH is 4-4.5 and will be elevated in VV
80
What is the tx for bacterial vaginitis? fungal?
metro or clinda topical or oral fluconazole
81
What is the MC pt for labial adhesions? Why do they develop?
Prepubertal girls in the first 5 years of life are most prone (think hypoestrogenic) Develop as the result of fusion of the adjacent mucosal surfaces of the labia minora. Think likely d/t chronic irritation and inflammation of the hypoestrogenic vulva but the exact cause is unknown
82
Often asymptomatic and typically discover at routine well child visits Can have minute spotting due to partial dehiscense UTI urinary retention altered urine stream What I am? How do you dx?
labial adhesions through visual inspection
83
What is considered uncomplicated labial adhesions? What is the tx?
no s/s present then should not be treated because it is benign
84
What is considered complicated labial adhesions? What is the tx?
If the child has accompanying symptoms such as pain on urination or ambulation, altered stream, retention, or hx of UTI topical estrogen bid for 2 weeks and after the labia have separated then topical Vasaline to affected area daily to ensure complete healing
85
What is considered an unsuccessful labial separation? What is the next step?
if labial separation has not occurred within 8 weeks or if cannot tolerate estrogen Topical anesthetic, firm traction on opposing edges and manual separation can be performed. Then daily vasaline for several months
86
What is the tx for thick labial adhesions?
will need surgical lysis by pediatric urologist or gynecologist
87
______ consist of tiny areas of fusion between the foreskin and corona. What is the tx?
penile adhesions Most resolve with time or gentle retraction can be used, then vasaline to prevent new adhesions from developing
88
What is the tx for penile adhesions if gentle traction is NOT effective? What is the prevention?
low potency topical steroid Most adhesions can be prevented by instructing the parents to retract and clean any skin covering the glans
89
______ 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. What is the tx?
penile skin bridge Should be referred to pediatric urologist for lysis of adhesions via scalpel after application of topical anesthetic aka these do NOT go away with traction
90
What is the MC girl population to get an UTI? Boy? What bacteria is MC?
Girls >6 months have more commonly than boys Uncircumcised boys < 3 months have more UTIs MC: E coli
91
Fever, hypothermia, poor feeding, irritability, vomiting, FTT, sepsis What am I?
UTI in newborn/infant
92
Abdominal/flank pain, vomiting, fever, urinary frequency, dysuria, urgency, enuresis What am I?
UTI in preschool age kiddo
93
frequency, dysuria, urgency + fever, N/V, flank pain What am I? When will you see CVA tenderness?
UTI in school-aged kiddo rare in young children, may be seen in school-aged children
94
What will the urine dipstick be positive for in a UTI? Do you always need to culture it?
leukocyte esterase and nitrites YES! urine culture is required for the dx of UTI
95
What age pt with an UTI can be safely managed outpt?
Most infants older than 2 months can be safely managed as outpatients as long as close f/u is possible
96
What are the indications to hospitalize for an UTI?
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
97
____ should be used if > 15% local resistance to E. coli when treating an UTI. When is cipro used? How long?
3rd generation cephalosporins ceftriaxone, cefotaxime, ceftazidime, cefdinir cipro only if pseudomonas 10 days for febrile kiddos 5 days without fever and immunocompetent
98
kiddos should respond to UTI tx within ______. If they do not respond or get worse, what should you do?
within 24-48 broadening antimicrobial therapy may be indicated if culture/sensitivity results not yet available AND renal/bladder US to rule out renal abscess
99
What are the indications for a renal and bladder US?
aka 3 UTIs in 12 months
100
What are the indications for a Voiding Cystourethrogram (VCUG) ?
101
____ is the retrograde passage of urine from the bladder into the upper urinary tract. What are these patients at an increased risk for?
VESICOURETERAL REFLUX acute pyelonephritis, recurrent UTI and kidney damage due to renal scarring
102
What is the prenatal finding of vesicoureteral reflux? How is the dx made postnatally?
suggested by the finding of hydronephrosis on prenatal ultrasound usually made after diagnosis of a febrile UTI and reflux of urine on VCUG
103
Once the dx of vesicoureteral reflux is made, what should you do next?
order renal function test: UA looking for proteinuria serum creatinine monitor blood pressure
104
What are the different grades of VUR staging?
105
What is the tx for VUR grades 1-2?
Watchful waiting due to high rate of spontaneous resolution May give daily abx in children not potty-trained
106
What is the tx for VUR grades 3-5?
Antibiotic prophylaxis daily on the assumption that continuous use results in sterile urine and won’t cause renal scarring 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 Generally handled by pediatric urologist
107
What is enuresis defined by? What are the 2 types?
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 diurnal (daytime) and nocturnal (nighttime)
108
What are the differences between mono symptomatic and polysymptomatic enuresis?
Monosymptomatic - nocturnal enuresis when no daytime symptoms Polysymptomatic - associated with symptoms such as urgency, frequency, dribbling, or daytime enuresis
109
enuresis has a strong ____ component
hereditary
110
What are 5 reasons that may contribute to monosymptomatic nocturnal enuresis?
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
111
When do you commonly see diurnal enuresis? What age group?
Diurnal enuresis can occur when urine is held until the last minute and UTIs common in preschoolers
112
What should be included as part of your enuresis work up? What are you looking for?
UA-> making sure urine is concentrated!! urine culture consider US consider voiding cystourethrogram
113
What is the mainstay of tx for enuresis tx? How long?
alarm therapy and CBT (the child must be motivated!!!!) Parents also need to be highly motivated!! need to wear alarm nightly for at least 3 months!
114
What is the pharm tx option for enuresis? What type?
Desmopressin: used mainly to treat monosymptomatic and may give more rapid short term results but relapse is common
115