Week 5 - GU Flashcards
Enuresis
voluntary or involuntary urination at an age when toilet training should be complete
Primary enuresis
Children who never established control have primary enuresis
Secondary enuresis
present when children have been dry for more than 6 to 12 months and then begin wetting
Nocturnal enuresis
incontinence during sleep
Diagnosing enuresis requires:
‣ a minimum age of 5 years old
‣ one episode a month for a duration of 3 months
Cause of enuresis
‣ 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)
Assessment of enuresis
‣ 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
Refer an enuresis patient to urology when…
‣ Weak or interrupted stream
‣ Need to use abdominal pressure to urinate
‣ Combined daytime incontinence and nocturnal enuresis
Physical assessment for enuresis
‣ 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.
Diagnostic studies for enuresis
UA and culture if symptoms warrant it
Organic causes of enuresis
- 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
management of enuresis
- urotherapy
- enuresis alarms
- Drug therapy
Urotherapy
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
Enuresis alarms
‣ 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
Drug therapy for enuresis
‣ 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
Testicular torsion
twisting of the spermatic cord which compromises the blood supply to the testicle (Surgical emergency
Cause of testicular torsion
Can occur after physical exertion, trauma, or on arising at any age, Common in adolescence.
Physical exam findings for Testicular torsion
‣ 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
Diagnostics for testicular torsion
‣ UA is normal
‣ Doppler ultrasound
‣ Testicular flow scan if doppler is normal
Management of Testicular torsion
‣ 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
Varicocele
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.
Cause of varicocele
Valvular incompetence of the spermatic vein resulting in dilated or varicose veins.
Symptoms of varicocele
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.”
Clinical findings with varicocele
‣ 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
Diagnostics for varicocele
‣ US to rule out malignancy in children
‣ Serial US to measure testicular size every 6-12 months
Management for varicocele
‣ 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.
Orchiopexy
A surgical procedure used to treat an undescended testicle
Indications for orchiopexy
‣ Failure of the testis to spontaneously descend by eight months of age
‣ Acute or intermittent testicular torsion
Phimosis
Foreskin that is too tight and unableto be retracted over the glans penis
Cause of phimosis
‣ congenital or acquired from infection and foreskin inflammation
Symptoms of phimosis
‣ 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
Management for phimosis
‣ 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
