Urological Conditions In Children Flashcards
Define Retractile teste
It is retractile testes
Descended testes which has been displaced upwards by the cremaster muscle
The testes is able to be manoeuvred (milked) in the bottom of the scrotum
What is the normal descent of the testes?
Transabdominal migration
- Initiated by gubernacular swelling
- Under hormonal control via Mullerian Inhibiting substance
Inguinoscrotal descent
- Preceded by protrusion of gubernaculum and process vaginalis into scrotum
- Testosterone is crucial for this phase of decsent
- Actions of androgens are mediated by neuronstransmitters released from genitourinary nerve
- Completed in 80% of testes by 32 weeks
Discuss the presentation of retractile testes
On inspection there is normal scrotal development
If the testes is not initially palpable then attempt to “milk” the testes down
- Run fingers from one hand from ASIS towards the pubic tubercle
- Feel the testes with the other hand
Retractile testes can be brought int the scrotum
30% can be stuck in inguinal canal - orchidopexy
Must be examined annually
Define undescended testes
Testes which has been arrested along the path of testicular descent
How would you diagnose undescended testes?
Examination
- Palpable or impalpable?
- Can the testes be milked down?
- Is it along the path of testicular descent or absent(15%) ?
Bilateral undescended testes may represent an intersex problem - must investigate
What are the complications of undescended testes?
5-10x increased risk of testicular cancer
Infertility - spermatogenesis is affected
Inguinal hernia - ass with PPV
Testicular torsion
Trauma
What is the treatment of undescended testes?
Orcidopexy
- Between 6-12 months coz’ there’s a chance that the testes may still descend by 6 months
- Earlier detection of testicular cancer
Hormone therapy to facilitate descent
- Beta-HCG
- GnHR
What is the clinical presentation of an infant with a UTI?
Pyrexia
* may be febrile
Irritibility
Poor feeding
FTT
Diarrhoea
Vomiting
Jaundice
What is the clinical presentation of an older child with a UTI?
Abdominal pain
Dysuria
Incontinence
Haematuria
How would you collect a urine specimen from a child with a suspected UTI?
Urine bag
* Clean genitalia first
Suprapubic aspiration
- If difficulty obtaining uncontaminated bag specimen
- Coz’ bladder is an abdominal organ in kids
- Most accurate - Any number of organisms are significant
Midstream urine specimen
* For older kids who can understand instructions
What are the dipstick findings of a child with a UTI?
Positive leucocytes
Positive nitrates
Positive blood (maybe)
What patients that present with a UTI should be investigated?
All 1st infections should be investigated
Under 2:
- U/S of kidneys, ureters and blader
- MCUG
Over 2:
- U/S of kidneys, ureters and blader
- MCUG if…
- U/S abnormal
- Temp >38
- Loin pain
- Vomiting
Which investigations would you do for a UTI in children?
Urine Dipstick
U/S
* Non-invasive and ideal for diagnosing obstruction
MCUG
- Gold standard for detecting VUR
- Invasive
- Only after UTI had been treated
Urodynamic studies
* Patients with recurrant UTI, incontinence and constipation
Radionuclide scans
- DMSA - acute pyelonephritis and scarring of
- MAG3 - to detect obstruction
What are the associated abnormalities found in children with UTI?
50% have abnormalities
Vesico-urethral reflux (85%)
Obstructive
- PUV
- PUJ obstruction
- Primary obstructive megaurethra
- Uretherocele
Neuropathic bladder
Caculi
Exctopic ureter
What is the management of a UTI in a child?
Admit
- Infants
- Severe systemic illness with dehydration
- Immunocompromised child
Antibiotics 7-14 days
* Augmentin (15-20mg/kg/dose) due to increased resistance to Ciprofloxacin
Prophylaxis - until imaging completed
- Nitrofurantoin
- Nalidix acid
- Co-amoxiclav (augmentin)?
Prophylaxis for 6 months if investigations normal but patient has recurrent UTIs
What are the medical indications for a circumcision?
True phimosis (Pathological phimosis)
Paraphimosis
Recurrent balanitis / balanoposthitis
Genital warts affecting the foreskin (conylomata acuminata)
Superficial penile carcinoma involving only the foreskin
Foreskin trauma
Inadequate previous circumcision
Define a phimosis
Inability to retract the foreskin over the glans of the penis
Define a paraphimosis
An emergency
A tight foreskin is retracted behind the glans and cannot be reduced
What are the advantages of a circumcision?
Prevention of UTI
Prevention of Penile cancer
Prevention of HIV infection
What are the contraindications for a circumcision?
Prematurity
Neonatal illness
Fam hx of bleeding disorders
Hypospadias
Chordee
Buried penis
Webbed penis
What are the methods of circumcision?
Shields
Clamps
Surgical excision
- Adequate haemostasis
- Double excision - neatest
What are the complications of circumcision?
Haemorrhage
Infection
Meatal ulcer
Skin complications
- Phimosis
- Concealed penis
- Chordee
Glanular injury
Necrosis
Urethrocutaneous fistula
Define the characteristic features of hypospadias
An abnormal opening of the urethral meatus on the ventral side of the penis
Dorsal “hood’ (skin)
Chordee (ventral curvature of the penis)
Discuss the embryology of hypospadias
Occurs in 8th-15th week gestation
There is failure of the tubularisation process to convert the urethral groove into the tubular urethra which leads to hypospadias
Development of a normal urethra requires dihydrotesterone
What is the classification of hypospadias?
Distal (65%)
- Most common
- Least severe
Middle (15%)
Proximal (20%)
* Most severe
What are the clinical features of hypospadias?
An abnormal opening of the urethral meatus on the ventral side of the penis
Dorsal “hood’ (skin)
Ventral curvature of the penis (Chordee)
Spraying of urine (older boys)
If Hypospadias + bilateral UDT»_space; Must exclude intersex
What are the aims of treatment for hypospadias?
Straight stream
Fertility
Cosmetic
What is the management of hypospadias?
Usually done around 2 years
Do NOT circumcise - Need skin for urethral reconstruction
Orthoplasty
* Correction of chordee - straighten penis
Urethroplasty
* Move urethra to tip of penis
