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a_GYNGU > 11/17- Pediatric Urology > Flashcards

11/17- Pediatric Urology Flashcards

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1
Q

What are causes of acute scrotum?

A
  • Testicular torsion
  • Torsion of the appendix testes
  • Epididymo-orchitis, epididymitis
  • Trauma
  • Incarcerated hernia
  • Scrotal wall process: HSP, Fournier’s
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2
Q

What are the 2 types of testicular torsion?

When does each typically occur?

A

1. Extravaginal- perinatal (almost exclusively)

2. Intravaginal- perinatal and older (most common in 8-30 yo)

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3
Q

What is extravaginal torsion? Treatment?

A

Torsion of entire cord proximal to tunica vaginalis attachment

  • Tx: Salvage of torsed testis unlikely; surgery to protect contralateral testis is controversial
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4
Q

What is intravaginal torsion?

A

Torsion distal to tunica vaginalis attachment

  • Bell-Clapper or horizontal lie predisposes to torsion
  • (Recall: most common in 8-30 yo, rare in older, but not uncommon in younger)
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5
Q

What is shown here?

A

Bell Clapper Deformity

  • Risk factor predisposing someone to torsion (intravaginal)
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6
Q

What is the presentation of testicular torsion?

A
  • Acute, severe pain
  • Scrotal swelling
  • N/V
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7
Q

What are physical exam findings of testicular torsion?

A
  • Erythema, edema, loss of cremasteric reflex, high riding testis
  • Caveat: Not all older children/adults have a cremasteric reflex
  • Absence does not mean torsión
  • Hard, non-tender testis in infant: antenatal/neonatal torsion
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8
Q

How is testicular torsion diagnosed?

A

Ultrasound (see lack of blood flow) is definitive but not mandatory if:

  • high index of suspicion
  • obtaining study will delay care
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9
Q

How are pts with suspected testicular torsion managed?

A

Manual reduction with narcotics

  • ONLY IF SURGERY NOT AVAILABLE
  • “Open the Book”
  • Both inward and outward rotation occurs

Prompt surgical exploration

  • Detorsion of testis with orchiopexy or orchiectomy
  • Orchiopexy for contralateral testis
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10
Q

What are salvage rates by time?

A

- 0-6 hrs: 85-90%

- 6-12 hrs: 50%

- >24 hrs: 5% or less

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11
Q

What are the embryological sources of the appendix testes? Appendix epididymis?

A
  • Appendix testes: Mullerian system
  • Appendix epididymis: Mesonehpros
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12
Q

What is the presentation of torsion of the appendix testes/epididymis?

A
  • Slow, gradual onset over days
  • Less nausea and vomiting
  • Pain related to inflammation caused by necrotic structure
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13
Q

What are physical exam findings of torsion of the appendix testes/epididymis?

A

“Blue Dot” Sign

  • Necrotic appendage seen through thin scrotal skin
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14
Q

What is treatment for torsion of the appendix testes/epididymis?

A

If diagnosis certain, then treat with comfort care:

  • Anti-inflammatories
  • Analgesics
  • Scrotal support
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15
Q

What are infectious processes that contribute to epididymo-orchitis, epididymitis, and orchitis? Non-infectious?

A

Infectious:

  • Children: UTI
  • “Young man’s”: STD
  • “Old guy’s”: UTI
  • TB and mumps are rare

Non-infectious

  • Medications (amiodarone)
  • Urine reflux into ejaculatory ducts
  • Trauma
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16
Q

Describe the presentation of epididymo-orchitis, epididymitis, and orchitis?

A
  • Gradual, progressive onset of pain
  • Irritative, voiding symptoms
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17
Q

What are physical exam findings for epididymo-orchitis, epididymitis, and orchitis?

A

Tenderness posterior and lateral to the testis (the usual location of the epididymis)

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18
Q

Describe diagnosis of epididymo-orchitis, epididymitis, and orchitis

A
  • Urinalysis and culture if indicated
  • Imaging with scrotal ultrasound
  • Enlarged, hypervascular epididymis
  • Normal or increased testicular blood flow
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19
Q

What is the treatment for epididymo-orchitis, epididymitis, and orchitis?

A

If infectious cause:

  • Antibiotics, scrotal elevation, analgesics, rest
  • Evaluate for possible urinary anomaly

If non-infectious process:

  • Anti-inflammatories
  • Analgesics
  • Scrotal elevation
  • Rest
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20
Q

Which gender has highest risk/rate of UTI in 1st year of life?

A

Males

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21
Q

What is one main determining risk factor for male UTIs?

A

Circumcision status

  • Uncircumcised UTI risk is 3-12x circumcised
  • Routine neonatal circumcision for medical benefit is not supported by the AAP
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22
Q

What are congenital GU causes of UTIs in males?

A
  • Nonfunctioning renal segments
  • Obstructive defects in the GU tract
  • Vesicoureteral reflux (VUR)
  • Neurogenic bladder
  • Poor emptying
  • Clean intermittent catheterization (CIC)
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23
Q

What are acquired GU causes of UTIs in males?

A
  • Kidney stones
  • Voiding dysfunction
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24
Q

What are pathologic consequences of UTI?

A
  • Cystitis
  • Acute and Focal Pyelonephritis
  • Pyonephrosis
  • Perinephric or Renal Abscess
  • Renal Scarring
  • Xanthogranulomatous Pyelonephritis (XGP)
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25
What are symptoms of UTIs?
_Infants/young children:_ vague symptoms - Fever\*, irritability, poor feeding, vomiting, diarrhea _Older children_ - May describe localizing symptoms: dysuria, suprapubic pain, incontinence, voiding dysfunction - May have generalized symptoms: fever, vomiting
26
What are physical exam findings with UTI?
- Flank or abdominal tenderness - Perineum * Labial adhesions * Ectopic ureteroceles - Scrotal changes: epididymitis - Phimosis - Sacral dimple, skin lesion, hair * Neurogenic bladder
27
What are diagnostic tests for UTIs?
- **Urinalysis** - **Urine culture** (gold standard); may take 24-48 hrs for result (According to AAP guidelines, whether/not to pursue workup on infants [2-24 mo] with fever depends on likelihood of UTI)
28
Describe the methods of obtaining a reliable urine specimen
Most -\> Least reliable: **- Suprapubic aspirate** * Use a 21-22 gauge needle to 1-2 cm above pubic symphysis **- Catheterized** **- Midstream voided** * Generally not reliable in young girls and young uncircumscribed males **- Bagged specimen** * High false positive rate (perineal and rectal flora) * Negative bagged specimen may be sufficient for survival
29
What indirect tests may support diagnosis of UTI?
- Microscopic WBC \> 5 pHPF - Any number of bacteria pHPF - Urinary leukocyte esterase (high sensitivity, low specificity) - Urinary nitrite (low sensitivity, high specificity) * Gram positive bacteria do not reduce urinary nitrates If last 3 are present: sensitivity for UTI almost 10)%
30
What is the definition of UTI based on urinalysis?
100,000 (\>105) cfu/mL of voided urine - AAP guidelines (2-24 mo): * **50,000** cfu/mL or a uropathogen **culture** from a urine specimen obtained through catheterization or SPA AND * **Urinalysis** with pyuria and/or bacteruria
31
How are pediatric UTIs classified?
- Initial - Recurrent - Complicated vs. uncomplicated - Upper vs. lower tract (febrile/nonfebrile)
32
What makes a recurrent UTI?
- Unresolved bacteruria during therapy * Bacterial resistance to therapeutic agent * Inadequate urinary concentration of antimicrobial * Infection by multiple organisms - Bacterial persistance (anatomic source) - Reinfection
33
Who should get a renal bladder US?
Boys and girls with **1st febrile UTI** - Immediate imaging if very ill or not responding to abx - After resolution of UTI in most cases **Recurrent UTIs**
34
What are you looking for in renal bladder US?
- Enlarged kidneys - Hypoechogenicity or hyperechogenicity - Thickened renal pelves - Ureteral dilatation - Bladder wall thickening - Urologic abnormalities: hydronephrosis, duplication, ureterocele, or stone etc.
35
Who gets a voiding cystourethrogram (VCUG)?
(Controversial test; catheter into urethra, fill bladder with contrast, take spot xrays) - Infants under 2 mo diagnosed with UTI - Abnormal renal bladder ultrasound - Recurrent febrile UTI NOT recommended after 1st febrile UTI and a normal renal bladder US
36
When is VCUG performed?
As soon as urine is sterile
37
What are the types of imaging? - Relative radiation doses - What is seen
**Fluoroscopic VCUG:** - Higher radiation doses - Demonstrates urethral and bladder abnormalities - Demonstrates VUR and degree - Evaluates colon **Nuclear cystogram** - Lower radiation doses - Does not demonstrate urethral anatomy
38
Who gets a CT?
Obtain if patient not improving: - Enlarged kidney - Renal abscess - Lobar nephronia - Decreased perfusion
39
What does nuclear renography (DMSA scan) detect?
- Can detect acute inflammation and scarring - DMSA is a renal cortical imaging agent * May be difficult to assess old vs. new renal scarring unless serial studies done
40
How are UTIs treate? - Goals - Uncomplicated
Goals - Minimize renal damage during acute UTI - Minimize risk of future renal damage Uncomplicated UTI - 7-14 day course of appropriate antibiotic - Address dysfunctional voiding - Indicated radiologic workup
41
Case Clinical Scenario: - A 22-month-old boy is referred for dysuria and two UTIs. - At the time of his diagnosis, he had no or low grade fever. He is uncircumcised and is not toilet trained. - According to his mother, a bag was used to collect the urine, the most recent was E. Coli \>100K cfu/ml. - A renal US was recently performed demonstrating normal appearing kidney parenchyma with left pelviectasis, no hydroureter and a normal bladder. What is your next step? A. Obtain VCUG B. Repeat renal US in 6 mo C. Recommend circumcision D. Observe (TEST QUESTION)
A. Obtain VCUG B. Repeat renal US in 6 mo C. Recommend circumcision **D. Observe**
42
What are two big anomalies of GU tract that may predispose to UTIs?
- Obstructive defects in urinary tract - Vesicuoureteral reflux
43
What do the obstructive defects predisposing to UTIs include?
- UPJ (ureto-pelvic junction) - UVJ (ureto-vesicular junction) - Posterior urethral valves - Ureterocele
44
What is seen here?
UPJ Obstruction
45
What is seen here?
**UPJ Obstruction** - Point 0: administer tracer - Tracer taken up in first few min (determine differential function of each kidney) - Look to see how well kidney drains function (here, relatively fast with downward sloping curve for one kidney, but accumulates in other kidney)
46
What are indications for correcting a UPJ obstruction?
- Infections - Loss of renal function - Pain
47
What are surgical corrections of UPJ obstruction?
**Pyeloplasty** - Open: flank, dorsal or subcostal **incision** - Laparoscopic/Robotic: transperitoneal or retroperitoneal
48
What is seen here?
UVJ Obstruction
49
What are indications for correcting a UVJ obstruction?
- UTI - Loss of renal functi - Pain
50
What are surgical corrections of UVJ obstruction?
Ureteral reimplant: may need tapering
51
Describe posterior urethral valves - Potential consequences - Prognosis
**Obstructing leaflets in the prostatic urethra** - Occurs only in males - Traditional cause of renal failure, but rare - Now most commonly identified prenatally and treated immediately after birth (sometimes occurs in young infant or older child)
52
Presentation of posterior urethral valves varies based on age. What does prenatal presentation look like?
- Hydronephrosis - Dilated bladder - "Key hole" sign: dilated posterior urethra - Oligohydramnios
53
What is seen here?
"Key Hole" Sign on fetal ultrasound (posterior urethral valves)
54
What is treatment/intervention for posterior urethral valves when caught prenatally?
Fetal intervention: vesicoamniotic shunting
55
Presentation of posterior urethral valves varies based on age. What does presentation at birth look like?
Varies depending on renal damage and degree of oligohydramnios - Septic shock - Pulmonary failur - Renal failure - Asymptomatic
56
Presentation of posterior urethral valves varies based on age. What does presentation as a child look like?
- UTI - Incontinence - Enuresis - Renal Failure
57
What does management of posterior urethral valves diagnosed at birth involve?
- Resuscitation - Antibiotics - Renal us - Placement of Foley or feeding tube - Await negative urine culture - VCUG - Nadir creatinine - Transurethral ablation (TUR) - Vesicostomy (exteriorize bladder to skin)
58
What is seen here?
VCUG provides definitive diagnosis (right) - Dilated posterior urethra - Notched area classic for valves
59
What are other clinical problems with posterior urethral valves?
- Renal Failure / Renal Dysplasia - Vesicoureteral reflux - Incontinence/Enuresis * High volume dilute urine * Poor bladder compliance
60
What is seen here?
Ureterocele (another obstructive defect)
61
What is treatment for ureterocele?
Individualized - Incision of ureterocele - Upper pole nephrectomy - Lower pole reimplant - Ureteroureterostomy
62
What is seen here?
Vesicoureteral reflux
63
Describe the grading of vesicoureteral reflux
Grade I-V - Grade I: urine just into ureter - Grade V: significant distance with blown out renal calyces
64
What are proposed causes of VUR?
- Abnormal anatomy or ureterovesicular junction? * 5:1 ratio of tunnel length:ureteral diameter * Adequate intramural length * Anatomy of the ureterovesical musculature Superficial trigone: formed by ureteral muscle * Deep trigone: formed by Waldeyer’s sheath
65
What are causes/classes of primary reflux?
**Congenital** - Inadequate tunnel length - Deficiency of trigone muscle complex - Associated with complete ureteral duplication, ureteral ectopia, ureterocele **Familial/genetic** - 1/3 of siblings of index case will have VUR
66
What are causes/classes of secondary reflux?
**Functional** - Neurogenic bladder - Non-neurogenic neurogenic bladder - Voiding and elimination dysfunction **Anatomic** - Posterior urethral valves - Eagle Barrett (Prune Belly) Syndrome
67
Management of VUR is aimed at what? - What does treatment/mgmt entail
Avoiding renal damage - Antibiotic prophylaxis with periodic VCUG and upper tract imaging - Surgery - Observation off prophylaxis
68
Controversies with VCUG and other components of VUR management?
- VCUG as a diagnostic test is painful, uncomfortable - While reflux can lead to renal scarring, the risk is undefined and is thought to be decreasing - Long term antibiotic prophylaxis leads to resistance - VUR must be managed on a case by case basis with parents involved in the management decisions.

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