Peds Urology Flashcards
The inability to retract the foreskin is referred to as…
Phimosis
Can be either physiologic or pathologic
Normal state where foreskin adheres to the glans
Physiologic phimosis
Adhesions decrease with age naturally
Incidence of fully retractable foreskin highly variable
NO NEED TO TREAT unless pathologic
Non-retractable foreskin due to scarring/fibrosis that occurs secondary to infection or inflammation or early forcible retraction
Pathologic phimosis
Treatment typically required
Clinical presentation for pathologic phimosis
Secondary non-retractability after having had fully retractable foreskin
Painful erections
Irritation or bleeding
Dysuria and/or urinary retention
Recurrent infections (balanitis, UTI)
Treatment options for pathologic phimosis
Stretching exercises (gently pulling foreskin back BID)
Topical corticosteroid
Circumcision (rarely indicated)
How do you take care of an uncircumcised penis?
Avoid forcible retraction at any age
Stop retraction if met with any resistance
Foreskin requires no special care other than what is provided to the rest of the body (cleaning with mild soap and water)
Return foreskin to natural position after cleaning
If you don’t return the foreskin to its natural position after cleaning b/c if not, it can lead to …
Paraphimosis - and you’ll have to call the PARAmedics
Urologic emergency in which a retracted foreskin cannot be returned to natural position
Paraphimosis
Pathophysiology: entrapment —> impaired venous flow —> engorgement —> arterial compromise
Causes of paraphimosis
Forcible retraction of partially phimosis skin by caretaker
Infection or inflammation
Genitourinary procedures (iatrogenic)
Sexual activity, penile trauma (less frequent)
Penile piercings
SSx of paraphimosis
Sx: Swelling of the penis, penile pain, irritability in a preverbal infant
Exam: Edema/tenderness of the glans, tender swelling of the distal retracted foreskin (constricting band), color change (blue/black) if ischemia is present
How do you treat paraphimosis
Pain control
Timely, manual reduction in office or ED
Surgical intervention by urology
Surgical removal of the foreskin
Circumcision
Families usually consider religious, family or cultural factors before medical factors in deciding whether or not to circumcise
Overall prevalence of circumcision in the US
80% - higher than in other western countries but declining
Highest rates in Midwest, lowest in West
Benefits of circumcision
Decreased rate of UTI (4-10x less likely, but male UTIs typically uncommon)
Decreased rate of penile cancer (from studies before HPV vaccine came into use)
Decreased penile inflammation/dermatoses
Decreased rates of SOME STIs (no effect on susceptibility to gonnorhea or chlamydia)
Benefits greater in infants with congenital uropathy
Risks of circumcision
Procedure related complications (0.2-2%)
Inadequate skin removal, bleeding, infection, urethral complications
Female partner of an uncircumcised male is at higher risk for…
Cervical cancer due to HPV susceptibility
Potential concerns of circumcision that have not been supported by studies
That it leads to sexual dissatisfaction and breast feeding failure
That no anesthesia is used (truth: AAP and major guidelines recommend pharmacological analgesia)
Contraindications for circumcision
Unstable infant
Congenital penile anomalies (ie hypospadias, chordee) b/c might need the tissue later for surgical repair of such abnormalities
The AAP stance on circumcision
The health benefits of newborn male circumcision outweigh the risks, but the benefits are NOT great enough to recommend routine circumcision for all newborn boys
The final decision should still be left to parents to make in the context of their religious, ethical and cultural beliefs
ACOG has also endorsed this stance
Two different types of circumcision
Gomco - metal device holds foreskin for cutting
Plastibell - stays in place until it falls off together with foreskin
Congenital anomaly with abnormal dorsal displacement of the urethral opening
Epispadias
May occur with bladder extrophy - exposed bladder, onto the lower abdomen (many times found on prenatal ultrasound)
Congenital anomaly that results in the abnormal ventral displacement of the urethral opening
Hypospadias
Displacement varies - glans, shaft, scrotum, perineum
Incidence: 0.3-0.7% of live male births - much more common than epispadias
May also involve chordee
What the heck is a chordee?
Abnormal penile curvature
Diagnosis of hypospadias and chordee usually occurs…
During newborn exam
PE may include:
• Abnormal foreskin
•A second opening, with one a false opening
• Abnormal penile curvature (chordee)
You diagnosed hypospadias and/or chordee. Now what?
If FH of hypospadias, do through exam (look for other congenital anomalies)
Check for palpable testes
• If cryptorchidism, consider Disorder of Sexual Development (ambiguous genitalia)
Referral to urology
Treatment
• DO NOT circumcise newborn
•Surgery usually performed ~6 months of age to fix
The most common GU congenital abnormality
Cryptorchidism (hidden or absent testis)
A testis that is not within the scrotum and does not spontaneously descend into the scrotum by 4 months of age
2 to 5% of term infants and up to 30% of premature infants
70% resolve spontaneously
Cryptorchidism should be monitored closely, as it my increase risk of …
Testicular torsion (10x more common)
Subfertility (risk improves if corrected before 1 year of age)
Testicular cancer
Different classifications of cryptorchidism
ABSENT testis - from a genesis or atrophy (possibly torsion in utero)
UNDESCENDED testes: stopped short along normal descent
RETRACTILE testes: overactive cremasteric reflex pulls testis back inside
Other less common possibilities:
ASCENDING testes
ECTOPIC testes
Clinical presentation of cryptorchidism
Absent testicle usually unilaterally (10% BL) with flat, underdeveloped scrotum
Further testing recommended if BL
Good physical exam is the key
Most cases descend spontaneously by 3-4 months age. If not, refer.
Most common location for undescended testis is…
Suprascrotal
Treatment for cryptorchidism
Urology referral
Spontaneous descent is rare after 6 months of age
Surgery recommended as soon after 6 months as possible (ideally before 1 year)
Orchiopexy: Testicle is brought down and attached into the scrotum
Allows for improved testicular growth and fertility potential
Twisting of the spermatic cord due to a poorly anchored testicle
Testicular torsion —> Risk of vascular compromise
Incidence: 1 in 4000 males < 25 years
The two peak periods of incidence of testicular torsion
Neonatal period (only about 10%)
During puberty (12-18)
Clinical presentation of testicular torsion
ABRUPT onset of SEVERE testicular or scrotal pain
Pain usually constant
Nausea and vomiting (90%)
PE:
• Edematous, infuriated, erythematous scrotum
• Affected testis tender, swollen and slightly elevated (high riding)
• Absent cremasteric reflex (stroking inner thigh)
• Negative Prehn’s sign
What is Prehn’s sign
Elevation of scrotum —> pain relief
(+) with epididymitis
(-) with testicular torsion
Diagnosing testicular torsion
History and physical can indicate a high likelihood even without imaging
Doppler ultrasound (shows position of testes and blood flow) is the confirmatory test of choice
Treatment for testicular torsion
IMMEDIATE consult with urologist
Surgical decoration and fixation (orchiopexy) of both testes (b/c high risk for it happening again)
Prognosis depends on duration and completeness of torsion
Differing prognosis of testicular torsion depending on timing
Detorsion within 4-6 hours = 100% viable
Detorsion after 12 hours = 20 % viable
Detorsion after 24 hours = 0 % viable
The two different types of urinary tract infection
Cystitis (just the bladder)
Pyelonephritis (affecting kidneys) —> CVA tenderness
Etiology of UTIs
Usually from ascending bacteria
~80% from E.coli
Klebsiella, Proteus, Enterococcus, S.aureus possible as well
Viruses or fungi less common
Risk factors for UTIs
Female gender Urinary tract anomalies Bowel and bladder dysfunction (chronic constipation) Vesicoureteral Reflux (VUR) Sexual activity Bladder catheterization Hx of previous UTI Lack of circumcision
Clinical presentation of UTIs in younger children
May have non-specific symptoms • Fever w/o another clear source (fever may be the only Sx) • Vomiting • Irritability • Poor appetite
Clinical presentation of UTIs in older children
May have more classic symptoms
Dysuria, frequency, urgency
Abdominal/suprapubic pain
Back/flank pain
New-onset urinary incontinence
Physical exam for UTI
Vitals: BP, temp, and growth parameters
Abdominal exam for tenderness or mass
Suprapubic and CVA tenderness
Examination of the external genitalia (look for abnormalities or STI)
Search for other sources of fever
How exactly do you get a kid to give you a urine sample
If potty trained:
Clean-voided specimen
If not potty trained:
Catheterized specimen recommended
Suprapubic aspiration when catheterization not feasible (rare)
Do NOT use a bag collection
If clinical suspicion for UTI, you should…
Obtain UA and culture
UA:
• Significant bacteriuria with (usually) pyuria
•(+) leukocyte esterase (created upon WBC breakdown)
• (+) nitrite (produced by gram negative rods)
Culture and sensitivities:
• Sensitivities help to direct treatment
UTI treatment options
Consider PO vs IV (agent of choice should be guided by local resistance pattern)
Duration of treatment in peds: 3-10 days (if no fever, maybe 3-5)
Choice of Abx: begin with empiric therapy and adjust per C&S
• Cephalosporin (cephalexin or cefdinir)
• Amoxicillin
• Augmenting
• Bactrim
(Increasing rates of resistance to the latter three)
Do you need to do a follow up UA for UTIs?
No f/u UA is recommended when using C&S if you do it when initially diagnosing
Other UTI follow up modalities
Renal Bladder Ultrasound (RBUS) - Firstline imaging study in patients with UTI if indicated (noninvasive)
Voiding cystourethrogram (VCUG) Renal scintigraphy
Some controversy related to use of VCUG and RS
Who gets a RBUS?
Firstline imaging study in pts with complicated UTI
• <2 years with first febrile UTI
• Children of any age with recurrent UTI
• Children with a UTI and FH of renal or urologic disease, poor growth, or HTN
• Children who do not respond to appropriate antibiotic therapy
When do we do a voiding cystourethrogram?
Invasive (radiation and catheter)
Test of choice to detect vesicoureteral reflux
Children of any age with ≥2 febrile UTIs
Children of any age with 1st febrile UTI and:
• Any anomaly on RBUS or
• Temp > 102.2 and pathogen other than E.coli or
• Poor growth or HTN
Retrograde flow of urine from the bladder into teh upper urinary tract, usually due to inadequate closure of ureterovesicular junction (UVJ)
Vesicoureteral Reflux (VUR)
Occurs in 1% of newborns and 30-45% of children with a UTI
Impact of VUR and management is controversial
Clinical presentation: Hydronephrosis (prenatal) or post natal febrile UTI
How do you diagnosis vesicoureteral reflux
VCUG - catheter placed and contrast injected, under fluoroscopy, movement of contrast and anatomy watched while pt voids
VCUG allows us to grade severity I (mild) to V (severe)
Possible risks in patients with VUR
Recurrent infections
Scarring and damage to kidney
Many cases spontaneously resolve
Must weigh the benefit of VCUG with the radiation risk, cost, and discomfort
What’s the deal with the controversy regarding optimal management of VUR?
Watchful waiting/surveillance - hard in infants so rare
Low dose prophylactic abx
Surgical correction only if grade 4/5
Monitoring of reflux
Aggressive screening (UA) in febrile/symptomatic pts with repeat testing at 18 months
Nuclear medicine scan using radioisotope dimercaptosuccinic acid (DMSA) to detect acute pyelonephritis and renal scarring
Renal scintigraphy
Areas of decreased uptake of DMSA indicate scarring or inflammation
DMSA scans expensive, invasive, involve radiation
Role in acute UTI is controversial
Not recommended in routine evaluation of kids with first UTI
Indications for referral in kids with UTI
Severe VUR (Grade III-V) or obstruction
Renal abnormalities
Impaired kidney function
Elevated BP
Bowel and bladder dysfunction refractory to primary care measures
The most common type of renal fusion
Horseshoe kidney - fusion of one pole of each kidney, caused by abnormal migration of kidneys (5th-9th week gestation)
Usually asymptomatic but occasionally may have pain, hematuria (from infection or obstruction)
Anomalies and syndromes associated with horseshoe kidney
VUR, hypospadias, undescended testes
1/3-1/2 of patients have another urological or genital abnormality
May also be associated with other genetic disorders (ie Turner, Downs)
A patient with horseshoe kidney has a small increased risk for …
Wilms Tumor (most common renal malignancy in kids)
Diagnosing horseshoe kidney
Ultrasound, VCUG (if UTI), serum creatinine
If CR is normal and no hydronephrosis, no further eval.
If CR elevated or hydronephrosis present, additional renal scans required
Excellent prognosis in post patients without any intervention
If VUR present, consider prophylactic abx
Medical term for bed wetting
Nocturnal Enuresis
Urinary incontinence during sleep is common in kids ≥ 5
15% of all 5 year olds have some nocturnal enuresis, but 15%/year have spontaneous resolution
Etiologic considerations in cases of nocturnal enuresis
Genetic tendency (if 1 parent, 50% affected; if 2 parents, 75% affected; if 0 parents, 15% affected)
Bladder maturation
Organic cause
First line treatment for enuresis
Educational/motivational therapy
Emphasis it is not the fault of the child or the caregiver
Void regularly during day and multiple times just before bed
Attention to timing of fluid intake (increase hydration in am and afternoon)
Motivation - sticker charts, enuresis alarms
Most effective long term therapy for nocturnal enuresis?
Enuresis alarms - those creepy electronic gadgets that hook up to a maxi pad looking thing and let you know when the kid wets the bed.
Second line treatment for nocturnal enuresis if pt ed fails
Pharmacotherapy (if greater than 6 months of problems)
DDAVP/Desmopressin (synthetic ADH) - effective short term but high relapse rate
Why do AAP guidelines no longer recommend routine screening UA in asymptomatic healthy peds patients?
High false positive for proteinuria/hematuria
Costly, exhaustive workup/concerned families
Still occurring in some offices though
What to do first if you notice a change in urine color to red or brown…
Determine if it is truly blood or something else
DDx for hematuria
UTI, kidney stone, malignancy Mental or perineal irritation Trauma Glomerular disease (post-infectious glomerulonephritis, Henoch-Schonlein purpura, HUS, Alpert syndrome) FH of SLE, sickle cell, early menses
Discoloration that may not be hematuria - beeturia, pyridium use, food dyes
Hx questions to ask in cases of hematuria
Recent vigorous exercise or trauma?
UTI symptoms?
Flank pain (+/- radiation, fever)
Brown vs red urine (upper vs lower urinary tract)
Hx of recent illness (last 2-3 weeks)
Personal or FH of medical conditions (sickle cell or coagulopathy)
Physical exam suggestions for patients with hematuria
BP
Evaluate for periorbital or peripheral edema, weight gain
Skin exam for rash (purpura)
Palpable kidneys or CVA tenderness
Visualization of the genitals
Abdominal exam (for discomfort or masses)
________% of kids have a + blood on urine dipstick
3-4
If microscopic hematuria (> 3 RBCs per HPV), if asymptomatic, repeat UA dip and microscopy in 2-3 weeks —> if resolved, f/u prn
Consider the following:
• Urine Cx if UTI suspected
• Renal/bladder US
• Referral
What to do in cases of gross hematuria
UA with micrscopy/urine Cx
Serum CR
Serum complement (low level seen in SLE, glomerular etiology)
Consider antistreptolysin Ab (ASO), ANA
Imaging: RBUS/CT without contrast
If persistent - refer
What does “Throat, Bloat, Coke” refer to?
Post-Infectious Glomerulonephritis
Typically follows (7-14 days) infection with group A ß-hemolytic strep (usually PHARYNGITIS or impetigo)
COLA-colored urine
EMEMA (peri-orbital, peripheral) b/c kidneys aren’t removing waste and fluid efficiently
Will have some degree of renal insufficiency and elevated BP
Lab results that confirm post-infectious glomerulonephritis
Gross hematuria - dark colored urine (coffee, COLA, tea)
Urine microscopy with RBC too numerous to count (TNTC)
Urine microscopy with RBC casts (pathognomonic for GN)
Increased serum CR
(+) ASO (antistreptolysin Ab) titer
Low complement (C3, C4)
What do we do then? Supportive care (varies based on severity)
Another sweet name for Immunoglobulin A Vasculitis
Enoch-Schonlein Purpura (HSP)
Immune mediated response (IgA), cause unknown
Classic tetrad for Hemochromatosis-Schonlein Purpura/IgA vasculitis
Abdominal pain
Typical maculopapular purpura rash (1/4 of the time its the last symptom) - usually on lower extremities
Arthralgias (knees and ankles most common)
Renal involvement - severity varies
Ok, you’re a rock star and suspect HSP. What do you do to treat it?
Supportive care (whomp whomp)
Symptoms will spontaneously resolve
One of the main causes of acute kidney injury in kids, associated with shiga toxin producing E.coli in 90% of cases
Hemolytic-Uremic Syndrome (HUS)
SSx of HUS
Usually prodromal illness with abdominal pain, vomiting, diarrhea (usually bloody) followed by classic triad:
• Hemolytic anemia
•Thrombocytopenia
• Acute kidney injury (hematuria, proteinuria to severe renal failure)
Initial labs: CBC, peripheral smear, renal function, UA
Do we treat HUS with abx?
Nope
Supportive care (ICU, possibly dialysis) but abx therapy NOT recommended
Rare inherited, progressive glomerular disease caused by genetic mutations that affect collagen proteins in kidneys, eyes, ears
Alpert Syndrome (Hereditary Nephritis)
Consider if (+) FH of end-stage renal failure
Syndrome includes:
• Glomerular disease (microhematuria initial finding)
• Deafness (sensorineural hearing loss)
• Visual disturbances
Foamy urine is indicative of what?
Proteinuria (excessive amount of protein in the urine)
DDx for Proteinuria
Benign/transient (fever, hypovolemia, exercise) SLE DM Glomerulonephritis Nephrotic Syndrome
Renal disease (intrinsic or post-infectious) causing massive renal protein loss in urine
Nephrotic Syndrome
Four main characteristics of NephrOtic Syndrome?
NephrOtic range prOteinuria
HypOalbuminemia
Edema (usually face - round O-shape) due to Na and H2O retention
Hyperlipidemia (O=donuts?) - body compensates protein loss by increasing the synthesis of albumin, as well as other molecules including LDL and VLDL
What do you do to evaluate a patient with proteinuria?
BP
UA with microscopy (urine dipstick helpful as a screen)
First AM void UA to check for proteinuria prior to meal/activity
Protein/CR ratio
CMP
Other testing as indicated by H&P
Refer to nephrology
