Urology Flashcards
What is the can’t miss diagnosis of an acute scrotum?
TESTICULAR TORSION
Differential Diagnosis for an acute scrotum
- Testicular torsion
- Torsion of the appendix testis or appendix epididymis - - – —- Infectious epididymitis/epididymo-orchitis
. Rare in prepubertal male with normal urinary tract
If afebrile, screen with urine dip
When should you get a scrotal US for suspected testicular torsion?
Role of scrotal US:
US not indicated if you can confidently rule out testicular torsion.
US not indicated to rule in testicular torsion when you strongly suspect it
Surgery consult ASAP! Reserve for equivocal cases
Characteristics of testicular torsion
Testicular Torsion
Pain:Severe
Sudden onset of severity
Nausea & Vomiting: Often
Testis position: +/- High riding, +/- Transverse lie
Testis tenderness: Throughout
Urine dipstick: Negative
Cremasteric reflex: Often absent
Blue dot sign: Never
Characteristics of Torsion of appendix testis or appendix epididymis
Pain: Mild to severe
Gradual onset
Nausea & Vomiting: Occasional
Testis position: Normal location, Normal lie
Testis tenderness: Localized to upper pole
Urine dipstick: Negative
Cremasteric reflex: Often present
Blue dot sign: Rarely present, but pathognomonic
Doppler US findings for testicular torsion
Decreased flow to testis -flow can be entirely normal
+/- reactive hydrocele
Doppler US findings for Torsion of appendix testis or appendix epididymis
Normal or increased flow to testis
Normal or increased flow to head of epididymis Note: may be reported as “epididymitis” on US, but NOT infected, just inflamed from surrounding ischemia
+/- reactive hydrocele
Treatment of testicular torsions
- Surgical reduction, ideally w/in 4-6 hrs of onset of pain
- Attempt at manual detorsion an option, but risk of incomplete detorsion. Reserve for when timely surgery not available
Treatment of Torsion of appendix testis or appendix epididymis
Non-steroidal anti-inflammatories (NSAIDs) & decreased activity until pain settles
What can a VCUG assess?
Indications: Assess for VUR (M & F) & PUV (M)
- Advantages: Provides anatomical detail of refluxing collecting systems, bladder & urethra. Allows for IRS grading (VUR grade I-V) (unlike a NC)
- Disadvantages: Invasive (catheter). Radiation.
What does a nuclear cystogram assess?
Indications: Initial assessment for VUR in F only. Follow-up of VUR in both M & F
- Advantage: Potentially less radiation than VCUG
- Disadvantages: Invasive (catheter). Radiation. Does NOT assess for PUV. Therefore, should NOT be 1 line cystogram for a M w/ congenital hydronephosis or UTI
Nuclear Renal Scans indications
Indications: Multiple. Different radionuclides for different indications:
All provide differential renal function (DRF)
A diuretic is only used for assessing obstruction
Only DMSA detects renal scarring. MAG 3 diuretic shows obstruction.
Advantages: Provides “functional” information
Disadvantages: Invasive (IV +/- urethral catheter). Radiation. Child must be held still
Renal Bladder US indications
Indications: “Anatomical” imaging of the urinary tract
Advantages: Non-invasive. No radiation exposure. Clarifies cystic vs. solid masses
Disadvantages: Not as sensitive as CT. May miss stones/masses
What are the indications for a urodynamic cystogram
Indications in children:
- To diagnose source of urinary incontinence
- To assess bladder pressures in neurogenic bladder
Disadvantages: requires catheters in urethra AND rectum
Invasive (therefore, we will usually trial medication for children with
presumed overactive bladder without a confirmed diagnosis)
Unreliable if crying/upset child
What is hypospadias?
An arrest during embryologic penile development. Results in a combination of 3 separate defects:
- Foreskin is incomplete ventrally
- Urethral meatus not at tip of penis
- Erections curved downward (AKA Chordee)
Should hypospadias have renal imaging?
No role for renal imaging in non-syndromic hypospadias
If hypospadias, and undescended testicles, what would you be thinking of?
Consider Mixed Gonadal Dysgenesis
An otherwise healthy 9 month old boy presents with a persistent intra-abdominal right testis. Left testis is in the scrotum and normal. Indications for right orchiopexy include all except:
A. Improved fertility
B. Decreased risk of left testicular hypertrophy.
C. Decreased risk of future testicular cancer
D. Improved ability to detect testicular cancer
Decreased risk of left testicular hypertrophy:
this may occur if the right testes atrophies but it is not an indication for surgery
There is now evidence to support that bringing testis down prior to age 10 lowers risk of testicular cancer (however, still higher than general population)
Congenital Hydronephrosis is how common?
CH affects 1% of pregnancies (most common fetal anomaly)
Transient in 44-88%
IS there a correlation between the degree of congenital hydronephrosis and the degree of VUR?
No correlation between severity of CH & risk of VUR (all carry a 10-15% risk of VUR)
Congenital Hydronephrosis has what risk of VUR?
10-15%
Which babies with congenital hydronephrosis need postnatal imaging?
All need it. But if APD>15mm in 3rd trimester or if SFU grade 3-4 then need it within 1-2 weeks.
Otherwise can get it within 1-3 months of birth.
Low Grade Congenital Hydronephrosis RBUS
“Minimal” hydronephrosis “Mild” hydronephrosis SFU grade I or II Calyces not dilated APD <10mm
High Grade Congenital Hydronephrosis on RBUS
“Moderately severe” HN “Severe” hydronephrosis Dilated calyces Parenchymal thinning SFU grade III or IV APD >15mm
What imaging should be done on a baby with congenital Hydronephrosis
RBUS
No role for VCUG or Renal scan. refer to urology before that.
Four most common causes of high grade congenital hydronephrosis
- UPJO: Ureteropelvic junction obstruction
- High grade VUR: High grade vesicoureteral reflux
- UVJO: Ureterovesical junction obstruction
- PUV: Posterior urethral valves
UPJO: Ureteropelvic junction obstruction what is it?
Uretero-pelvic junction obstruction
Sig hydronephrosis without hydroureter
What do high grade VUR and UVJO look like on US
Sig hydroureteronephrosis (HUN)
What does PUV look like on US
Bilateral sig hydroureternephrosis in a Male
Due to bladder outlet obstruction
Bladder anomalies would likely be noted
keyhole bladder
When do you suspect PUV in utero?
Often suspected in utero when severe -Male -Bilateral hydronephrosis -Distended, thick walled bladder Keyhole sign -Oligohydramnious
How do you manage PUV post natally
Stabilize if respiratory issues Urgent postnatal RBUS Bladder decompression with a catheter Serial serum creatinine levels Confirmatory VCUG Consultation with Nephrology Fluid, acid-base, electrolyte management Consultation with Urology Surgical management
Most common cause of non infectious day time incontinence
Idiopathic overactive bladder (OAB)
Common features of OAB
No neurologic anomalies
Frequency (>8 voids/day)
Urgency
Urge incontinence
Note: May experience no sense of urgency before a leak w/ OAB
Urine holding postures
Small functional bladder capacity
Commonly associated w/recurrent cystitis
Commonly associated w/ constipation
Commonly associated w/ nocturnal enuresis
How to treat an OAB
1st line treatment of OAB • Treat constipation (diet/PEG 3350) • Treat UTIs • Observation is an option if not bothersome to family/child (usually resolves eventually) • Timed voiding (every 1.5-2h)
2nd line treatment of OAB
• Anticholinergics (AKA Antimuscarinics)
• Commonly: oxybutinin, tolteridine (off- label), solifenacin (off-label)
• Note: Anticholinergics may worsen constipation & aggravate OAB
List the types of Duplex Kidneys
Duplex kidney (kidney w/ 2 renal pelvises)
Complete duplication: Upper & lower pole ureters never merge may both enter bladder or may enter weird locations (Increased risk of UVJO (upper pole) & VUR (lower pole))
Partial duplication: Upper & lower pole ureters merge before entering bladder (no increased risks of obstruction or VUR)
If no hydronephrosis, US cannot distinguish complete from partial
“Uncomplicated duplication”: US term for duplex kidney with no hydronephrosis
What needs to be routinely done for a duplex kidney
Not of concern unless history of febrile UTI (no referral to Urology)
What complications can occur because of a horseshoe kidney?
Increased risk of UPJO (only relevant if HN)
Majority are asymptomatic
Incidental finding of horseshoe kidney is NOT of concern unless HN or current or future development of abdominal pain
Most reliable way to view renal stones
CT KUB
Best first line imaging modality for renal stones
Renal ultrasound
Excellent first line investigation as no radiation
May miss small ureteric stones, especially if no proximally dilated ureter
usually do US looking for evidence of stones…like obstruction etc. then do a CT scan
Treatment of Renal Stones
Conservative treatment of renal colic
Analgesics & α blockers (ex: tamsulosin) to hasten passage of small ureteric stones and hydration
Interventional treatment
Reserved for large stones (too large to pass); unremitting pain; persistent severe obstruction; solitary kidney or; infected, obstructed kidney
What are the characteristics of a hydrocele
Fluid around or adjacent to testis Generally asymptomatic Diagnose with trans-illumination note: fat/omentum can trans-illuminate) Try to see (shadow)/feel testis...can be difficult with large or tense hydroceles
When to refer a communicating hydrocele
Congenital defect, although not always clinical (can be patent with nothing coming through it)
- Risk is development of indirect hernia
- Allow up to age 18 mo for resolution before referral
When to refer a non communicating hydrocele
- May be part of continuum of resolution of communication hydrocele
- May be reactive (infection, trauma, tumour)
- think about tumour in adolescents
- Imbalance of secretion>absorption.
- Refer if large/bothersome
Why would you ultrasound a hydrocele?
- To confirm scrotal testis (>6mo of age);
• To differentiate from inguinal hernia;
• To rule out testis tumor (adolescent age);
• When associated with scrotal pain N YD (? Associated with a more sinister diagnosis)
Initial investigation for abdominal mass?
Abdo US
What is a congenital mesoblastic nephroma
Benign (usually)
Most common solid renal tumor in fetuses, neonates &
infants
Treatment: Complete surgical excision
Where do neuroblastomas typically occur?
Most common extracranial solid tumour in childhood
75% are abdominal; majority are adrenal
Arise from cells of the neural crest (adrenal medulla and sympathetic ganglion)
What is the most common malignancy of infancy?
Neuroblastoma
How do Neuroblastomas usually present?
89% of cases < age 5y
Presentation:
Incidental – Note: small nodules identified on perinatal or neonatal US are often observed as regression likely
Symptomatic: abd. pain or abd. mass; 70% already metastatic
Skin mets look like “blueberry muffins” in infants
How do you treat a Stage IV-S neuroblastoma
Stage IV-S: Infants w/ small 1o tumor w/ liver, skin & bone marrow mets, but NO radiographic evidence of bone mets. Many undergo spontaneous regression
What labs would you order for a suspected neuroblastoma?
Lab: Elevated urinary catecholamines, vanillyl mandelic acid (VMA) & (HVA) homovanillic acid in >90% of patients
Should you biopsy renal masses?
Renal biospy for renal mass discouraged in children, as counts as “tumour spillage” which upstages the tumour
What is the most common primary renal tumour in childhood
Wilms: AKA “Nephroblastoma”
Most common primary renal tumour in childhood
Arise from remnants of immature kidney
Associated syndromes of Wilms Tumours
10% associated with congenital anomalies and syndromes
50% risk of WT in WAGR & Denys Drash syndromes
When should you consider surgical correction of phimosis (ie//circumcision)
Indications for surgical consultation:
Scarred phimosis
Recurrent balanoposthitis
Recurrent UTIs
Delayed retraction of the foreskin >10 years of age
True or false, CPS recommends routine circumscision
The CPS does not recommend the routine circumcision of every newborn male
Rate of Canadian newborn circumcision: 32%
Increased risk of STI transmission and penile cancer does not justify recommendation of routine circumcision`
When do most foreskins retract by?
Age 6 years: 50% of foreskins retract
Age 17 years: 95% of foreskins retract
Topical steroids recommended for hastening retraction of foreskin and release of adhesions
Meatal stenosis (seen following 2-10% of newborn circumcisions) can be prevented by applying petroleum jelly to the glans for up to 6 mo following circumcision
What are basic foreskin caring techniques
In diapers:
To wash, retract as far as it wants to go
Do NOT retract to the point of pain or bleeding
Always “reduce” to normal position, to prevent a paraphimosis
Pre-puberty & asymptomatic: No intervention required
• Note: non-obstructive ballooning of the foreskin is not pathological
Approaching puberty & still does not retract:
- Child to start routinely making attempts at foreskin retraction
- If fails, add application of topical steroids twice daily for 6 weeks to weaken skin and release adhesions. Options include betamethasone 0.05%, triamcinilone 0.1% (my preference, as an ointment), & mometasone furoate 0.1% (CPS 2015)
Imaging needed after first febrile UTI at what ages?
Children Age 2 months - 2 years
RBUS after 1st febrile UTI
VCUG (or NC in female) is reserved for those w/ an abnormal RBUS or if have a 2nd febrile UTI
Which children with febrile UTIs do you refer to urology
No antibiotic prophylaxis for VUR I-III, even w/ hx of febrile UTI
Referral/discussion with Urologist or Nephrologist for VUR IV-V or significantly abnormal RBUS findings
What is vesicle-ureteric reflux
VUR is the retrograde flow of urine from the bladder to the kidneys
Does VUR cause UTIs
- VUR itself does not cause UTIs
- Exception: high volume VUR preventing adequate bladder emptying
- VUR does allow easy access of bacteria in the bladder up to the kidney to cause a pyelonephritis
- Asymptomatic, low grade VUR does not require intervention
- Therefore, diagnostic VCUG should be limited to SFU III-IV CH, febrile UTI work up, and suspicion of PUV
Do children with cystitis need imaging?
No
How long do you treat cystitis
2-4 days
What are the symptoms of cystitis
“cystitis” refers to bacteruria resulting in local “bladder” symptoms only (voiding symptoms/suprapubic +/or lower back pain)
How do you manage recurrent Cystitis
Unlike febrile UTIs, investigation & management of recurrent cystitis focuses on behavioral anomalies rather than anatomical ones
Do NOT look for structural anomalies – ie RUS and VCUG not routinely indicated
Look for bladder and bowel dysfunction
- Constipation
- Infrequent voiding
- Voiding postponement
- Daytime urinary incontinenc/Overactive bladder (OAB) - - Incomplete emptying
What antibiotics do you use for UTI prevention?
Highlights:
Managing constipation appropriately may be helpful for decreasing UTI recurrences
If prophylaxis used, should be used for no more than 3 – 6 mo & use reevaluated thereafter
Choice antimicrobial is TMP/SMX or nitrofurantoin
Switch antimicrobial if urine culture shows resistant organism, even if suspect contamination
If urine isolate shows resistance to both TMP/SMX & nitrofurantoin, consider stopping CAP rather than using broad spectrum antimicrobial for CAP
When to consider not OAB
Infrequent voiding: Leakage after prolonged interval of no void
Voiding postponement: Urine holding postures w/o urinary frequency
Vaginal voiding: Post void dribbling in female
Giggle incontinence: Leaks ONLY with laughter
Ectopic ureter: Continuous dribbling
Cystitis: Positive urine culture – Symptoms resolve w/tx
Bladder outlet obstruction: Slow urinary flow/Symptoms of obstructive voids
Neuropathic: Neurologic conditions or symptoms
Stress incontinence: Leaks w/ ↑ abd pressure
