Urology Flashcards
1
Q
Phimosis
- Inability to retract foreskin
- Physiologic phimosis (most common)
- Parents should be advised to cleanse the uncircumcised penis without retraction.
- Most foreskins are easily retracted by 4 years of age (80-90% of uncircumcised boys will have retractile foreskins by 3yo, and 99% will have fully retractile foreskins by adolescence) . Physiologic phimosis is quite common up to age 5-6 yo and is often present in older children as well.
- Pathologic phimosis is the inability to retract the foreskin because of distal scarring.
- Tx is gentle retraction, topical steroid
- Complication: Posthitis, which is preputial inflammation and cellulitis. If it progresses to the glans, it is called balanitis.
- In most cases, treat balanitis with topical and/or oral antibiotics and steroid cream with local hygiene.
- Tx if evidence of obstruction exists: Requires opening the preputial ostium (foreskin’s distal opening) with a hemostat.
A
Phimosis
- Inability to retract foreskin
- Physiologic phimosis (most common)
- Parents should be advised to cleanse the uncircumcised penis without retraction.
- Most foreskins are easily retracted by 4 years of age (80-90% of uncircumcised boys will have retractile foreskins by 3yo, and 99% will have fully retractile foreskins by adolescence) . Physiologic phimosis is quite common up to age 5-6 yo and is often present in older children as well.
- Pathologic phimosis is the inability to retract the foreskin because of distal scarring.
- Tx is gentle retraction, topical steroid
- Complication: Posthitis, which is preputial inflammation and cellulitis. If it progresses to the glans, it is called balanitis.
- In most cases, treat balanitis with topical and/or oral antibiotics and steroid cream with local hygiene.
- Tx if evidence of obstruction exists: Requires opening the preputial ostium (foreskin’s distal opening) with a hemostat.
2
Q
Paraphimosis
- Retracted foreskin cannot be reduced.
- Tx:
- Emergency that necessitates immediate urology referral to prevent ischemia/necrosis.
A
Paraphimosis
- Retracted foreskin cannot be reduced.
- Tx:
- Emergency that necessitates immediate urology referral to prevent ischemia/necrosis.
3
Q
Balanitis
- Pt: Erythema and inflammation of glans penis only.
- Tx:
- Conservative tx includes mild soap, keeping the glans areas clean and dry. Sitz baths may help with itching and skin tenderness
- Tx underlying cause: Antifungal creams. Bacterial infection.
A
Balanitis
- Pt: Erythema and inflammation of glans penis only.
- Tx:
- Conservative tx includes mild soap, keeping the glans areas clean and dry. Sitz baths may help with itching and skin tenderness
- Tx underlying cause: Antifungal creams. Bacterial infection.
4
Q
Hypospadias
- Hypospadias occurs most commonly as an isolated malformation, and no imaging to look at the upper GU system is required.
- Management
- Circumcision should be avoided until 6-12 months because the foreskin is used for repair and the risk for anesthesia at this age is similar to older children.
- Perform surgery before 2 years of age.
- For proximal hypospadias (penoscrotal, scrotal, perineal) associated with cryptorchidism or ambiguous genitalia, a more extensive evaluation should be performed; evaluate for intersex condition.
- Bilateral cryptorchidism warrants screening for salt-wasting forms of CAH
A
Hypospadias
- Hypospadias occurs most commonly as an isolated malformation, and no imaging to look at the upper GU system is required.
- Management
- Circumcision should be avoided until 6-12 months because the foreskin is used for repair and the risk for anesthesia at this age is similar to older children.
- Perform surgery before 2 years of age.
- For proximal hypospadias (penoscrotal, scrotal, perineal) associated with cryptorchidism or ambiguous genitalia, a more extensive evaluation should be performed; evaluate for intersex condition.
- Bilateral cryptorchidism warrants screening for salt-wasting forms of CAH
5
Q
Meatal Stenosis
- Frequently overdiagnosed. Visual inspection is not satisfactory. You must observe the voiding process. Look for evidence of straining and assess the strength and angle of the urinary stream.
- Tx: Ventral meatotomy
A
Meatal Stenosis
- Frequently overdiagnosed. Visual inspection is not satisfactory. You must observe the voiding process. Look for evidence of straining and assess the strength and angle of the urinary stream.
- Tx: Ventral meatotomy
6
Q
Microphallus / Micropenis
- Central causes:
- ______
- ____ syndrome
- _____
- Definition
- For a term infant, a stretched phallic length of
A
Microphallus / Micropenis
- Central causes:
- Panhypopituitarism
- Kallman syndrome
- Prader-Willi
- Definition
- For a term infant, a stretched phallic length of <2.5cm meets the definition for micropenis. Normal stretched length is 2.5-3.5cm.
- Management: Babies with micropenis should undergo evaluation in the immediate newborn period to detect and treat potentially life-threatening conditions. If genital ambiguity is present, the neonate should be evaluated for disorders of sexual differentiation and monitored to prevent any potentially associated adrenal crisis. For neonates with micropenis without other genital ambiguity, monitoring for hypoglycemia and evaluation for other pituitary hormone deficiencies should occur.
- Tx: Early tx with testosterone is beneficial in some boys.
7
Q
Priapism
- Painful, unremitting erection in which the ____ is rigid but the glans and ____ are flaccid.
- RF: ______ is the most common cause of priapism. Priapism is sometimes the presenting symptom of sickle cell disease
- Tx: In patients with sickle cell disease, hydration, pain control, oxygen, transfusion. Other therapies include corporal aspiration and irrigation with phenylephrine and caudal anesthesia. If the priapism does not respond in 24-48 hours, perform surgery with cavernoglandular shunting.
A
Priapism
- Painful, unremitting erection in which the corpora cavernosa is rigid but the glans and corporus spongiosum are flaccid.
- RF: Sickle cell disease is the most common cause of priapism. Priapism is sometimes the presenting symptom of sickle cell disease
- Tx: In patients with sickle cell disease, hydration, pain control, oxygen, transfusion. Other therapies include corporal aspiration and irrigation with phenylephrine and caudal anesthesia. If the priapism does not respond in 24-48 hours, perform surgery with cavernoglandular shunting.
8
Q
Polyuria
- Definition: 24-hour urine output >2L/m2/day or anytime >3L/day
- In children >2yo, the expected bladder capacity in mL = (age in years + 2) x 30
Work-up of polyuria
- Initial work-up: Serum glucose, plasma sodium, plasma osmolality, urine osmolality
- Low plasma sodium (<137) + low urine osmolality (<50% plasma osmolality) = water overload from primary polydipsia
- High plasma sodium (>142) with urine osmolality less than plasma osmolality = DI (central or nephrogenic)
A
Polyuria
- Definition: 24-hour urine output >2L/m2/day or anytime >3L/day
- In children >2yo, the expected bladder capacity in mL = (age in years + 2) x 30
Work-up of polyuria
- Initial work-up: Serum glucose, plasma sodium, plasma osmolality, urine osmolality
- Low plasma sodium (<137) + low urine osmolality (<50% plasma osmolality) = water overload from primary polydipsia
- High plasma sodium (>142) with urine osmolality less than plasma osmolality = DI (central or nephrogenic)
9
Q
Enuresis (bedwetting) is diagnosed in children >_____ years old who void in bed or their clothes >2x/week for 3 consecutive months
A
Enuresis (bedwetting) is diagnosed in children >5 years old who void in bed or their clothes >2x/week for 3 consecutive months
10
Q
Evaluation after 5yo
- Underlying causes should be considered but are rare (<25% of cases); especially consider in secondary enuresis: UTI, diabetes, chronic renal failure, constipation, hyperthyroidism, OSA, psychological stressors, seizure disorders, sickle cell disease
- Rule out infection with urinalysis and urine culture
- _______ must be performed on all children with daytime incontinence.
- For sensory defect or detrusor instability, try timed voiding and anticholinergics as initial therapies.
- Giggling incontinence is also treated with anticholinergics and stress incontinence with perineal exercises and alpha-adrenergic agonists.
- If presents later in childhood, typically presents with recurrent UTIs, diurnal enuresis in pts >5yo or secondary diurnal enuresis, pain with voiding, voiding dysfunction, or an abnormal urinary stream. VCUG is specific for the diagnosis.
- Primary daytime and nocturnal enuresis in the setting of poor linear growth and proteinuria is concerning for ______
- Psychological factors are more often implicated in _____ enuresis.
A
Evaluation after 5yo
- Underlying causes should be considered but are rare (<25% of cases); especially consider in secondary enuresis: UTI, diabetes, chronic renal failure, constipation, hyperthyroidism, OSA, psychological stressors, seizure disorders, sickle cell disease
- Rule out infection with urinalysis and urine culture
- Ultrasound of the kidneys and bladder must be performed on all children with daytime incontinence.
- For sensory defect or detrusor instability, try timed voiding and anticholinergics as initial therapies.
- Giggling incontinence is also treated with anticholinergics and stress incontinence with perineal exercises and alpha-adrenergic agonists.
- If presents later in childhood, typically presents with recurrent UTIs, diurnal enuresis in pts >5yo or secondary diurnal enuresis, pain with voiding, voiding dysfunction, or an abnormal urinary stream. VCUG is specific for the diagnosis.
- Primary daytime and nocturnal enuresis in the setting of poor linear growth and proteinuria is concerning for chronic kidney disease.
- Psychological factors are more often implicated in secondary enuresis.
11
Q
NOCTURNAL ENURESIS
- Occurs in 10% of 5 year olds and spontaneously resolves at a rate of about 15% per year.
- RF
- Note the importance of a detailed___
- Nocturnal enuresis factors: Defective sleep arousal, delayed maturation of the cortical mechanisms that allow voluntary control of the micturition reflex, reduced ADH at night, constipation, UTI, and genetic factors.
- Causes:
- ____ can cause nocturnal enuresis.
- Dx:
- Urinalysis and culture to rule out infection.
- Imaging studies (an ultrasound and a VCUG) are not routinely recommended unless a child >10 years has continued enuresis.
- Management
- Limit fluid intake before bedtime, empty bladder before going to sleep, void again at night (before parents go to bed), and establish a consistent bedtime routine.
- “Potty alarms,” which work fairly well in younger children
- If daytime urgency and frequency are also a problem, then use ___ in the daytime and ____ at night.
A
NOCTURNAL ENURESIS
- Occurs in 10% of 5 year olds and spontaneously resolves at a rate of about 15% per year.
- RF
- If one parent had nocturnal enuresis, there is a 40% risk to the child of having the condition, this increases to 70% if both parents had nocturnal enuresis as children. Note the importance of a detailed family hx
- Nocturnal enuresis factors: Defective sleep arousal, delayed maturation of the cortical mechanisms that allow voluntary control of the micturition reflex, reduced ADH at night, constipation, UTI, and genetic factors.
- Causes:
- Ask if the pt snores. Obstructive apnea can cause nocturnal enuresis.
- Dx:
- Urinalysis and culture to rule out infection.
- Imaging studies (an ultrasound and a VCUG) are not routinely recommended unless a child >10 years has continued enuresis.
- Management
- Limit fluid intake before bedtime, empty bladder before going to sleep, void again at night (before parents go to bed), and establish a consistent bedtime routine.
- “Potty alarms,” which work fairly well in younger children
- Medications are effective for older children: Desmopressin acetate (DDAVP), oxybutynin, and imipramine (rarely used now due to potential life-threatening side effects when overdosed).
- If daytime urgency and frequency are also a problem, then use oxybutynin in the daytime and desmopressin at night.
- Oxybutynin is used in children with a small-capacity bladder or a hyperactive bladder when 1st line medication treatment with desmopressin has failed.
- Intranasal desmopressin has had FDA approval revoked for nocturnal enuresis because of safety issues (ie cases of fatal hyponatremia).
- If daytime urgency and frequency are also a problem, then use oxybutynin in the daytime and desmopressin at night.
12
Q
Testicular mass
- Evaluation of a testicular mass should always begin with ___
A
Testicular mass
- Evaluation of a testicular mass should always begin with US
13
Q
Indirect inguinal hernia
- Dx: Manual reduction of an inguinal hernia should be attempted at the time of diagnosis by gentle applying upward and lateral pressure
- After successful manual reduction, a non urgent but timely referral to pediatric surgeon is warranted.
- If reduction is not successful, the hernia is defined as incarcerated
A
Indirect inguinal hernia
- Dx: Manual reduction of an inguinal hernia should be attempted at the time of diagnosis by gentle applying upward and lateral pressure
- After successful manual reduction, a non urgent but timely referral to pediatric surgeon is warranted.
- If reduction is not successful, the hernia is defined as incarcerated
14
Q
Hydrocele
- Dx: Clinical. Supported by transillumination of scrotum which confirms the fluid-filled mass
- Hydrocele and hernias will transilluminate when light placed behind mass while other masses will not.
- Tx:
- Observation as most resolve on their own
- Repair indicated for: Hydroceles that last past ______ year of age require surgical repair.
A
Hydrocele
- Dx: Clinical. Supported by transillumination of scrotum which confirms the fluid-filled mass
- Hydrocele and hernias will transilluminate when light placed behind mass while other masses will not.
- Tx:
- Observation as most resolve on their own, usually before patient’s 1st birthday.
- Repair indicated for: Hydroceles that last past 1 year of age require surgical repair.
15
Q
Varicocele
- Congenital dilation of ____ venous plexus and _____ vein
- Pt:
- Almost exclusively on ___ side (85-95%).
- Most pts are asymptomatic
- Asymmetry of scrotal size with painless scrotal masses as “________”
- Tx: Controversial
- No treatment when _____
- Indications for surgical repair: _____, abnormal ___, ____, and ____.
- Perform surgery at 1st sign of ___.
- Unilateral R varicoceles are very rare and are often due to underlying pathology, such as ___ or ____.
- Isolated R sided varicocele should raise concern for ____ as should a varicocele in a child <10 yo.
A
Varicocele
- Congenital dilation of pampiniform venous plexus and testicular vein
- Pt:
- Almost exclusively on left side (85-95%).
- Most pts are asymptomatic
- Asymmetry of scrotal size with painless scrotal masses as “bag of worms”
- Tx: Controversial
- No treatment when asymptomatic
- Indications for surgical repair: Significant loss of testicular volume (L side 2-3mL less volume than R side), abnormal semen analysis, very large varicoceles, and pain/discomfort.
- Perform surgery at 1st sign of reduced testicular growth. Follow with semen analysis
- Unilateral R varicoceles are very rare and are often due to underlying pathology, such as IVC obstruction from a clot or tumor.
- Isolated R sided varicocele should raise concern for abd/retroperitoneal mass as should a varicocele in a child <10 yo.
