Pediatric Urology - Exam 3 Flashcards
What is the normal length of male genitalia? What is average? When does it begin to form? When is it completely covered by glans?
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
What does shallow rugae of the scrotum indicate? What does an empty scrotum indicate?
preterm infant
cryptorchidism
What is the age range for puberty in boys? What is average? What are the earliest sign of puberty?
9-14 years old
average 11.5
increase in testicular size and volume
What are later male signs of puberty?
pubic hair development and increase in penile length
What is considered male menarche?
Sperm in urine and nocturnal emissions occur close to end of puberty
What percentage of US males are circumscribed?
60-90% of males in the US are circumcised
When are circumcisions commonly performed? Why?
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
What are the 2 CI to circumcision? What is the strong caution?
unstable or significantly premature infants
penile abnormalities: hypospadia, chordee, concealed penis, large suprapubic fat pad
bleeding disorders is strong caution
What is chordee of the penis?
curvature of penis
What is hypospadias?
when the urethal meatus is not where it should be, usually on the posterior side of the penis
What are some benefits of circumcision?
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
Why does circumcision decrease incidence of viral STIs?
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
What are the risks of circumcision?
procedure related risks
improper skin removal
bleeding/infection
glans injury
development of epidermal inclusion cysts
adhesions/scarring/skin bridge
What is the pain cocktail for a circumcision?
Local anesthesia by dorsal penile nerve block or circumferential ring block using 1% lidocaine without epinephrine or 4% lidocaine topical cream
______ is the blind technique for circumcision. What is sometimes the unintentional SE?
Mogen clamp
This type has an occasional amputation of the glans
What are the 2 circumcision techniques that allow for visualization of the glans? What are the major differences?
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
What is the post circumcision care? What should you NOT due?
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
In an uncircumcised penis, how far does the redundant skin extend?
extends 1cm beyond glans
What is normal with regards to foreskin retraction in newborn males?
usually incomplete in most male infants at birth and retractability increases yearly!
90% by 3
92% by 6-7
99% by adolescence
What is the care of an uncircumcised penis? What should you NOT due?
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:
What is phimosis? Is it normal?
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
______ foreskin becomes stuck behind the glans of the penis
paraphimosis
_____ inflammation of glans penis and the foreskin
Balanoposthitis
What am I? What is the tx?
smegma: (epithelial debris generated during desquamation) can sometimes be seen under the foreskin as pearls
tx: no intervention needed
What can phimosis lead to?
recurrent UTIs, paraphimosis, and recurrent balanoposthitis
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
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
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
What are the sx tx options for phimosis?
circumcision
dorsal slit sx
_____ 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!!
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
What am I?
phimosis
What am I?
paraphimosis
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
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
What is balanitis?
Balanitis is inflammation of glans penis only
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
What is the tx for GAS causing balanoposthitis?
amoxicillin
_____ 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
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
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
____ is the most common congenital abnormality of the GU tract
CRYPTORCHIDISM
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
Where are the 6 places a testicle could be in the body if NOT in the scrotum?
What are the referral indications for cryptorchidism?
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
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
What is the tx for a retractile/ascending testes?
Retractile/Ascending testes should also be treated with orchiopexy within 6 months of finding
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
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!!
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
______ 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
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
____ 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
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
Why should you order an 17-OH progesterone test in ambiguous genitalia?
worried about adrenal steroids and concerned about salt wasting
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
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
_____ 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
_____ hydrocele: processus vaginalis closed, fluid trapped , not reducible and does not change in size/shape with crying/straining
noncommunicating hydrocele
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
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
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
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
______ 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
______ of a inguinal hernia -> Vascular compromise of the contents of an incarcerated hernia and may see gangrene of testis/ovary or bowel loop
strangulation
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
What is the presentation of a testicular torsion?
testicle will be lying horizontal in the scrotum and lose the cremasteric reflex
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
What is the viability of a torsed testicule?
within 4-6 hours: 100% viability
after 12 hours: 20%
after 24 hours: 0% viability
______ 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
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
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)
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
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
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
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
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
What is the tx for bacterial vaginitis? fungal?
metro or clinda
topical or oral fluconazole
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
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
What is considered uncomplicated labial adhesions? What is the tx?
no s/s present
then should not be treated because it is benign
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
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
What is the tx for thick labial adhesions?
will need surgical lysis by pediatric urologist or gynecologist
______ 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
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
______ 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
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
Fever, hypothermia, poor feeding, irritability, vomiting, FTT, sepsis
What am I?
UTI in newborn/infant
Abdominal/flank pain, vomiting, fever, urinary frequency, dysuria, urgency, enuresis
What am I?
UTI in preschool age kiddo
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
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
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
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
____ 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
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
What are the indications for a renal and bladder US?
aka 3 UTIs in 12 months
What are the indications for a Voiding Cystourethrogram (VCUG) ?
____ 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
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
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
What are the different grades of VUR staging?
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
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
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)
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
enuresis has a strong ____ component
hereditary
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
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
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
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!
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
