Week 5 - GU

Question 1

Enuresis

Answer 1

voluntary or involuntary urination at an age when toilet training should be complete

Question 2

Primary enuresis

Answer 2

Children who never established control have primary enuresis

Question 3

Secondary enuresis

Answer 3

present when children have been dry for more than 6 to 12 months and then begin wetting

Question 4

Nocturnal enuresis

Answer 4

incontinence during sleep

Question 5

Diagnosing enuresis requires:

Answer 5

‣ a minimum age of 5 years old
‣ one episode a month for a duration of 3 months

Question 6

Cause of enuresis

Answer 6

‣ Constipation
‣ Familial disposition
‣ Neurologic developmental delay
‣ Behavioral comorbidities – links with ADHD, OCD, & other mental health concerns
‣ Functional small bladder capacity
‣ OSA
‣ Stress and family disruptions (divorce, moving, new family member)
‣ Inappropriate toilet training (parents are overly demanding or punitive with child)

Question 7

Assessment of enuresis

Answer 7

‣ Determine if there are underlying comorbid conditions that require pediatric urology referral
‣ Establish best approach to treat this particular child’s condition
‣ Ask about
‣ Voiding characteristics (urgency, dribbling, postponement behaviors, number per day, cluster voiding, frequency of wetting day and night, type of urinary
‣ Fluid intake
‣ UTI
‣ Family history
‣ Toilet training history (when started, how handled, was child ever dry, for how long?
‣ Effect of enuresis on child and family
‣ How is it dealt with at home?
‣ Bowel patterns
‣ Sleep patterns
‣ Other conditions (diabetes, ADHD, OCD…)
‣ Changes in home environment

Question 8

Refer an enuresis patient to urology when…

Answer 8

‣ Weak or interrupted stream
‣ Need to use abdominal pressure to urinate
‣ Combined daytime incontinence and nocturnal enuresis

Question 9

Physical assessment for enuresis

Answer 9

‣ Assess the external genitalia for signs of irritation, infection, labial fusion, and/or meatal stenosis.
‣ Examine the abdomen for masses, especially at the suprapubic midline and in the left lower quadrant.
‣ Examine the lower back for dimples and hair tufts.
‣ Assess for neurologic function and deep tendon reflexes.

Question 10

Diagnostic studies for enuresis

Answer 10

UA and culture if symptoms warrant it

Question 11

Organic causes of enuresis

Answer 11

• Diabetes mellitus
  ‣ * Diabetes insipidus
  ‣ * Sickle cell disease due to forced fluids leading to increased urine output
  ‣ * Chronic renal failure secondary to kidneys’ inability to concentrate urine
  ‣ * Structural anomalies, such as ectopic ureter (constant leakage is noted) or a vesicovaginal fistula
  ‣ * Neurologic abnormalities, including neurogenic bladder
  ‣ * Hypercalciuria
  ‣ * Obstructive uropathy other than that due to BBD
  ‣ * Eosinophilic cystitis
  ‣ * Vaginitis
  ‣ * Sleep apnea
  ‣ * Pinworms

Question 12

management of enuresis

Answer 12

• urotherapy
• enuresis alarms
• Drug therapy

Question 13

Urotherapy

Answer 13

increases daytime urination by establishing a regular voiding schedule—not waiting until the micturition urge is felt

‣ Regulation of fluid intake
‣ Goal of bladder to hold urine overnight – void prior to bed and upon wakening
‣ Proper posture while urinating
‣ Aggressively treat constipation

Question 14

Enuresis alarms

Answer 14

‣ More effective in children with decreased maximal voided volumes
‣ Use of an alarm requires commitment and effort on the part of children and parents and support from the PCP

Question 15

Drug therapy for enuresis

Answer 15

‣ has high initial success rates. Unfortunately, drug therapy can be expensive, and high relapse rates occur when the drug is discontinued. When the wetting recurs, it can be very upsetting to the child, which is a factor that needs to be considered when prescribing. However, it can be very useful for overnight stays (e.g., camp) when staying dry is important to the child.
‣ Desmopressin (antidiuretic) – most effective for children with large nocturnal urine production and normal bladder capacity
‣ Oxybutynin -day time enuresis

Question 16

Testicular torsion

Answer 16

twisting of the spermatic cord which compromises the blood supply to the testicle (Surgical emergency

Question 17

Cause of testicular torsion

Answer 17

Can occur after physical exertion, trauma, or on arising at any age, Common in adolescence.

Question 18

Physical exam findings for Testicular torsion

Answer 18

‣ Slight elevation of the testis illicit pain
‣ Cremasteric reflex absent in affected side
‣ History of intermittent testicular pain
‣ May be described as abdominal or inguinal pain by embarrassed child
‣ Fever is minimal or absent

Question 19

Diagnostics for testicular torsion

Answer 19

‣ UA is normal
‣ Doppler ultrasound
‣ Testicular flow scan if doppler is normal

Question 20

Management of Testicular torsion

Answer 20

‣ Surgical emergency
‣ Manual reduction may be possible
‣ Surgery should follow in 6-12 hours to prevent retorsion, preserve fertility, prevent abscess and atrophy
‣ Contralateral orchiopexy may be done due to a 50% risk of torsion in non-fixed testis

Question 21

Varicocele

Answer 21

benign enlargement or dilation of testicular veins causing a painless scrotal mass of varying size that may feel like a “bag of worms.” It is usually found on the left side.

Question 22

Cause of varicocele

Answer 22

Valvular incompetence of the spermatic vein resulting in dilated or varicose veins.

Question 23

Symptoms of varicocele

Answer 23

Usually, a painless swelling is noted in the left side of the scrotum, occasionally a “dull ache” or “heavy” feeling if large.
‣ Scrotal swelling with prolonged standing causes pain; swelling and pain resolve upon reclining. Pain can occur with strenuous physical activity.”

Question 24

Clinical findings with varicocele

Answer 24

‣ Painless welling in left side of scrotum
‣ Dull achy, heavy feeling scrotum
‣ Scrotal swelling with prolonged standing
‣ Bag of worms to posterior and superior testis that collapses on lying down and enlarges with the Valsalva maneuver
‣ Cremasteric reflex is present

Question 25

Diagnostics for varicocele

Answer 25

‣ US to rule out malignancy in children
‣ Serial US to measure testicular size every 6-12 months

Question 26

Management for varicocele

Answer 26

‣ Asymptomatic grade 1 varicocele with normal testicular volumes usually does not require intervention in adolescence but involves ultrasonographic monitoring of testicular size every 12 months.
‣ Surgical referral for grades 2 or 3.

Question 27

Orchiopexy

Answer 27

A surgical procedure used to treat an undescended testicle

Question 28

Indications for orchiopexy

Answer 28

‣ Failure of the testis to spontaneously descend by eight months of age
‣ Acute or intermittent testicular torsion

Question 29

Phimosis

Answer 29

Foreskin that is too tight and unableto be retracted over the glans penis

Question 30

Cause of phimosis

Answer 30

‣ congenital or acquired from infection and foreskin inflammation

Question 31

Symptoms of phimosis

Answer 31

‣ penis constriction and results in pain, glans edema, and possible necrosis
‣ tight, pinpoint opening of the foreskin with minimal ability to retract the foreskin; foreskin flat and effaced

Question 32

Management for phimosis

Answer 32

‣ Normal cleansing with gentle stretching of the foreskin until resistance is felt.
‣ Most foreskins are retractable by 5 or 6 years old.
‣ Never forcefully retract the foreskin.
‣ Circumcision is indicated if urinary obstruction or infection is present.
‣ Persistent phimosis can be treated with 0.05% betamethasone cream twice daily for 2 to 4 weeks. This frequently allows successful retraction of the foreskin, promotes awareness of improved hygiene, and offers an alternative to circumcision