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Pediatrics > Pediatric Urology > Flashcards

Pediatric Urology Flashcards

1
Q

What is the normal appearance of male genitalia at birth?

A

Foreskin tightly adherent to glans
Deep rugae and testes bilaterally

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2
Q

When does foreskin develop?

A

Beginning at 12 weeks gestation
Covers entire glans by 18-20 weeks

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3
Q

What are abnormal findings for neonatal male genitalia?

A

Shallow rugae: preterm infant
Empty scrotum: cryptorchidism

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4
Q

When does puberty normally occur in boys?

A

9-14 ys, avg 11.5 yrs

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5
Q

What is an early and later sign of male puberty?

A

early: increase in testicular size and volume
later: pubic hair development and increase in penile length

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6
Q

What happens in male development at the end of puberty?

A

Sperm in urine and nocturnal emissions aka male menarche

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7
Q

When does penile enlargement occur?

A

Tanner stages 2-5
mean length at 1 year: 3.75 cm
by late childhood: slow increase to 4.84 cm
by late puberty: sharp increase to 9.5 cm

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8
Q

what is circumcision?

A

surgical removal of foreskin

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9
Q

the US is unique in that it is the only country that does what related to circumcision?

A

Most male infants circumcised for non-religious purposes

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10
Q

What does circumcision in the US vary according to?

A

Geographic area
Socioeconomic status
Religious affiliation
Insurance coverage
Hospital type
Racial/ethnic group
Father’s circumcision status
Opinions of others
Desire for conformity of son’s appearance
Easier to keep clean

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11
Q

When is circumcision usually done? What is the preferred timeline?

A

Male child between 1 and 10 days
Infant 24 years old (to allow for ID of health issues)

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12
Q

What are contraindications to circumcision?

A

Unstable or significantly premature infants
Infants
Penile abnormalities ie hypospadias with foreskin abnormalities, chordee/curvature of penis, concealed penis/buried or large suprapubic fat pad
bleeding disorders: not full CI (procedure with clinicians experienced in circumcision)

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13
Q

benefits of circumcision

A

easier genital hygiene
lower UTIs
decreased invasive penile cancer
decreased viral STDs (no decrease in gonorrhea/chlamydia)
decreased cervical cancer in female partners

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14
Q

what is phimosis

A

narrowing of opening of foreskin so it can not be retracted

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15
Q

what is paraphimosis

A

foreskin stuck behind glans of penis

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16
Q

what is balanoposthitis

A

inflammation of glans penis and foreskin

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17
Q

risks of circumcision

A

procedure related risks
improper skin removal
bleeding
infection
pain
glans injury
development of epidermal inclusion cysts
adhesions and scarring
skin bridges

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18
Q

how is a circumcision performed?

A

local anesthesia by nerve block (dorsal or circumferential) with 1% lidocaine without epi or 4% lidocaine

Mogen clamp: occasional amputation of glans
Plastibell: clamp stays in place
Gomco: clamp removed at end of procedure

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19
Q

what is post circumcision care for circumcision?

A

barrier ointment: petroleum or vaseline with diaper changes to glans and part of diaper where glans would hit
shaft skin not forcibly retracted
if skin of shaft lays on glans, gently retract
for 2 weeks until skin healed

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20
Q

What is a normal uncircumcised penis appearance?

A

extends 1 cm beyond glans

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21
Q

What is the relationship between foreskin retraction and age?

A

Can’t retract (incomplete) at birth (50%) can’t be retracted to see urethral meatus
Retractability increases yearly
By age 1: 50% have retractile foreskins
90% by age 3
92% by age 6 to 7
99% @ adolescence

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22
Q

At birth, most boys have —— phimosis, meaning what?

A

Physiologic: inner surface of foreskin developmentally fused to glans penis

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23
Q

What is sometimes seen under foreskin as pearls?

A

smegma

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24
Q

foreskin care and hygiene

A

routine (as rest of body)
wash penis with non-irritant soap
frequent diaper changes
may gently retract foreskin with diaper changes and bathing to clean and dry underneath, replace after cleansing

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25
Q

what could happen if retraction is forced?

A

Bleeding
Fibrosis
Pathologic phimosis

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26
Q

What can phimosis lead to?

A

Recurrent UTIs
Paraphimosis
Recurrent balanoposthitis

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27
Q

What generally causes secondary non-retractability of foreskin?

A

Chronic nonspecific inflammatory process
Repeated infection cause scarring and stricture
Forcible premature retraction of foreskin, causing scarring and adhesions
Balanitis xerotica obliterans (a chronic dermatitis)

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28
Q

Signs and symptoms of phimosis

A

irritation
bleeding
dysuria
painful erection
recurrent balanoposthitis
chronic urinary retention with ballooning

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29
Q

treatment of phimosis

A

topical steroid (betamethasone .05% MC) BID x 6 wks
routine stretching exercises
creams from tip of prepuce and down to junction with glans BID
Surgery: circumcision or dorsal slit surgery

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30
Q

advantages of creams for phimosis

A

less invasive
avoids risks of surgery
preputioplasty: stretches foreskin without removing it
much more cost effective
prevent emotional problems for boys who undergo circumcision at later age

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31
Q

What is paraphimosis?

A

Urologic emergency
Foreskin retracted and not replaced and becomes trapped behind corona
During cleaning or during catheterization, sexual activity, or trauma
Impairment of lymphatic and venous flow and venous engorgement of glans with swelling
Arterial flow ultimately becomes compromised (hours to days)

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32
Q

Presentation of paraphimosis on physical exam?

A

Collar of swollen foreskin at coronal sulcus
Ischemia and necrosis of glans (can result)
Edema/tenderness of flans
Swelling of foreskin
Constricting band of tissue proximal to glans and flaccid shaft

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33
Q

S/s of paraphimosis

A

pain
swelling
irritability
dysuria

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34
Q

treatment of paraphimosis

A

urology consult
goal to replace to normal position
if early, manual replacement
manual compression with penile block, sedation, or anesthesia to decrease edema and allow reduction
dorsal slit, multiple punctures in glans or foreskin

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35
Q

what is balanoposthitis

A

erythema and edema of prepuce that produces purulent discharge from preputial orifice
inflammation and edema of glans penis and foreskin

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36
Q

what is balanitis?

A

inflammation of the glans penis only

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37
Q

causes of balanoposthitis

A

infection
bacterial: normal flora, STDs for older adolescents
fungal: candida albicans
viral: HPV

trauma
irritation from soaps or detergents, poor hygiene

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38
Q

signs and symptoms of balanoposthitis

A

preputial, glans penis, meatus, or shaft
swelling
tenderness
erythema
exudate
foul odor
scarring between glans and prepuce
lymphadenopathy

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39
Q

treatment of balanoposthitis

A

sitz baths, avoid irritants

nonspecific: topical antibiotic ointment such as bacitracin/mupirocin
irritant: avoidance of precipitating factors, topical low-potency corticosteroid cream bid for 3-5 says
candidal infection: topical antifungals, nystatin, clotrimazole, or fluconazole
bacterial: topical antibiotics, if severe, oral antibiotics for GAS (amoxicillin)

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40
Q

what is the most common penile abnormality

A

hypospadias

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41
Q

what is hypospadias

A

urethral folds fail to completely or partially close
urethral meatus opens on ventral surface of penis often on distal shaft or proximal point along shaft or scrotum or perineum

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42
Q

what can hypospadias do?

A

interfere with ability to urinate and sexual function

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43
Q

treatment of hyospadias?

A

severity of the deformity and position of meatus on undershaft influences surgical decisions
sent to urologist for surgical repair, usually 6-12 months

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44
Q

what is epispadias?

A

urethral meatus located dorsally
can interfere with urination and sexual function
meatus formed on dorsum along glans/shaft

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45
Q

proximal deformity of epispadias may be associated with what?

A

urinary incontinence because of involvement of bladder neck area with distortion of normal architecture of pubic bones

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46
Q

treatment of epispadias

A

surgical correction by urologist

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47
Q

what is the mc congenital abnormality of GU tract

A

cryptorchidism

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48
Q

what is cryptorchidism

A

hidden testis not in scrotum
can be absent, undescended, ascending, ectopic
retractile d/t overactive cremasteric reflex

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49
Q

what usually happens with cryptorchidism?

A

generally spontaneously descend by 4-6 months, very rare after 6 months

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50
Q

where is cryptorchidism MC?

A

left testicle

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51
Q

what are types of cryptorchidism?

A

abnormal descent: 1) abdominal 2) inguinal 3) suprascrotal: 4) suprapubic 5) femoral 6) perineal

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52
Q

indications for referral of cryptorchidism

A

phenotypically male newborn infants with bilateral nonpalpable testis
unilateral non-palpable testis with hypospadias
suspected disorder of sexual development
congenital palpable undescended testis in infant (ideally between 4-12 months of age)
ascending testis in boys beyond infancy
palpable tissue in scrotum thought to be atrophic testes
difficulty differentiating between undescended, retractile, or ectopic (ideally between 4 and 12 months of age)

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53
Q

work up for cryptorchidism

A

initial lab evaluation
karyotype if absent or non palpable
US of pelvic structures looking for gonads and uterus
adrenal hormones and metabolites to evaluate CAH: hydroxyprogesterone, testosterone, cortisol, DHEA
LH, FSH, Mullerian inhibiting substance

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54
Q

treatment of cryptorchidism

A

hormonal therapy used as adjunct
surgery mainstay –> orchiopexy
retractile/ascending testes treated with orchiopexy within 6 months

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55
Q

what are hormone treatments for cryptorchidism?

A

hCG

hastens descent of test
greater success with lower positioning of testis

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55
Q

drawbacks of hormone therapy for cryptorchidism

A

can retract after discontinuation of hCG
can hasten puberty
can cause testicular damage and sterility
long-term studies lacking

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55
Q

complications of cryptorchidism

A

increased risk for developing testicular cancer
infertility
testicular torsion
decreased sexual function
testicular cellular damage increases with each passing year, probably not reversible after age 4 or 5

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56
Q

what causes ambiguous genitalia

A

Developing tissue doesn’t respond to hormones
Gonads don’t form appropriately and function to secrete hormones

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57
Q

What is disorder of sex development?

A

discrepancy between external genitalia and gonadal/chromosomal sex
genitals that do not appear typically male or femal or appearance discordance with chromosomes

58
Q

What is the MCC of DSD (disorder of sex development)?

A

Congenital adrenal hyperplasia

59
Q

What does congenital adrenal hyperplasia cause in addition to abnormal sex hormones?

A

severe electrolyte and mineralcorticoid imbalances

60
Q

when are external genitalia sexually differentiated

A

around 9th week

61
Q

initial male external genital development is complete when? What about female?

A

around 12-16 weeks
12 weeks

62
Q

phenotypic female ambiguous genitalia appearance

A

enlarged clitoris
fused labial folds
palpable gonads

63
Q

phenotypic male ambiguous genitalia appearance

A

bifid scrotum
severe hypospadias
micropenis
cryptorchidism

64
Q

initial work up of ambiguous genitalia

A

expedited evaluation of sex chromosomes – karyotype
assessment of gonadal function after birth: FSH, LH, testosterone, dihydrotestosterone, AMH
adrenal steroids: 17-hydroxyprogesterone
baseline electrolytes
ACTH, hCG if indicated
gender assignment and surgery following counseling

65
Q

treatment of ambiguous genitalia

A

stabilization of medical and pyschosocial needs including CAH (most life threatening)
multidisciplinary therapeutic plan

66
Q

what are ongoing medical concerns in ambiguous genitalia patients?

A

potential for malignancy in gonadal tissue
effects of altered levels of sex steroid exposure
decreased bone mineral density
psychosocial concerns

67
Q

what is a hydrocele

A

peritoneal fluid between layers of tunic vaginalis

68
Q

types of hydrocele

A

communicating: patent processus vaginalis with flow into tunica vaginalis, increases over course of day or with straining
noncommunicating: processus vaginalis closed, fluid trapped, not reducible and does not change in size/shape with crying/straining

69
Q

presentation of hydrocele

A

cystic scrotal mass
common
asymptomatic with some scrotal swelling/bulge: communicating may enlarge throughout day or with valsalva, noncommunicating does not enlarge

70
Q

diagnosis of hydrocele

A

scrotal transillumination, scrotal US

71
Q

tx of hydrocele

A

supportive until 1-2 years of age
surgery if not resolved by 1-2 or symptomatic or compromise skin integrity

72
Q

hernia

A

protrusion of organ or tissue through abnormal opening in wall

73
Q

who more commonly gets hernias

A

premature newborns >newborns
male > female
MC in boys and children <10 months

74
Q

what is an indirect hernia? Direct?

A

indirect: patent inguinal canal/processus vaginalis
direct: external inguinal ring only rare in kids

75
Q

presentation of inguinal hernia

A

intermittent bulge in groin
noted at times of increased intrabdominal pressure (straining or crying)
painless inguinal swelling
may retract when cold, active, frightened, agitated
can be reduced

76
Q

what are s/s/pe of incarcerated hernia

A

cannot be reduced by manipulation
intestinal obstruction
pain
vomiting

PE: firm, discrete inguinal mass palpated in groin
mass tender and surrounded by erythema and edema

77
Q

what is strangulated hernia?

A

vascular compromise of contents of incarcerated hernia
may see gangrene of testis/ovary/bowel loop

78
Q

treatment of inguinal hernia

A

reapir on diagnosis to prevent incarceration (increases with time)
laporoscopic surgery
if open processus vaginalis, be aware of risk of contralateral hernia

79
Q

diagnosis of testicular torsion

A

doppler US DO NOT DELAY

80
Q

treatment of testicular torsion

A

urgent urological consult and surgery
orchiopexy if viable
orchiectomy if not viable

81
Q

prognosis of untreated testicular torsion

A

100% viability within 4-6 hrs
after 12 hrs 20% viability
after 24 hrs 0%

82
Q

when would you attempt manual detorsion and how?

A

If pts present before scrotal swelling (surgery still done if successful)
testis twisted clockwise/counterclockwise
if successful rapid return of blood flow and pain relief

83
Q

what is acute epididymitis

A

acute inflammation of epididymis

84
Q

who mc gets acute epididymitis

A

late adolescents, may occur in younger boys without sexual activity

85
Q

mc causes of acute epididymitis

A

sexual activity
heavy physical exertion
direct trauma
structural GU abnormalities

sexually active: chlamydia (MC), gonorrhea, E. Coli, viruses
not sexually active: mycoplasma, enteroviruses, adnoviruses

86
Q

signs/symptoms of acute epididymitis

A

acute/subacute onset of pain/swelling isolated to epididymis
possible history of frequency, dysuria, urethral discharge

87
Q

physical exam of acute epididymitis

A

scrotum red
scrotal edema
possible inflammatory nodule
normal cremasteric reflex
pain relief with elevation of testis —> Phren sign

88
Q

work up for acute epididymitis

A

UA/urine culture
diagnosis with findings consistent and gram stained and smear culture of urethral exudates
or intraurethral swab specimen
OR nucleic acid amplification tests for N. gonorrhea and C. trachomatis
AND urine culture/first void urine for leukocytes
syphilis and HIV testing

89
Q

imaging of acute epididymitis

A

doppler US with increased blood flow to affected epididymis

90
Q

treatment of acute epididymitis

A

abx
scrotal support
bed rest
should improve in 3 days

91
Q

if suspected STD what abx should be given for acute epididymitis

A

ceftriazons IM once + doxycycline PO BID 7 days

92
Q

if enteric organisms what abx should be given for acute epididymitis

A

levofloxacin 500 mg PO QD 10 days

93
Q

if suspected UTI, what abx should be given for acute epididymitis

A

cefdinir or bactrim

94
Q

signs and symptoms of vulvovaginitis

A

vulvar pruritis
vulvar burning
vulvar soreness
vulvar irritation
dysuria
discharge that is white, thick, adherent to vaginal sidewalls, clumpy

95
Q

PE of vulvovaginitis

A

erythema of vulva and vaginal mucosa
vulvar edema with or without discharge

96
Q

risk factors for vulvovaginitis

A

diaper use
broad-spectrum antibiotic use
immunosuppression
adolescents with certain contraceptive devices
poor hygiene
bubble baths, shampoo, soaps
choice of clothing

97
Q

diagnosis of vulvovaginitis

A

most clinical in pediatric office
can swab vaginal sidewall and discharge: assess vaginal pH (normal 4-4.5), elevated in BV
perform microscopy: wet mount test

98
Q

treatment of candidal vaginitis

A

fluconazole

99
Q

treatment of bacterial vaginosis

A

metronidazole, clindamycin

100
Q

what can be used for uncomplicated vulvovaginitis or young children not able to swallow pill?

A

clotrimazole, miconazole
topical nystatin 12 and under

101
Q

patient education for vulvovaginitis

A

wear cotton underwear
avoid tights
frequent diaper changes
daily warm bath as follows: allow child to soak in clean water, use soap to wash regions other than the genital area right before exiting bath, gently pat dry
no bubble baths
front to back wiping
avoid letting child sit in wet swimsuits

102
Q

what causes labial adhesions

A

fusion of adjacent mucosal surfaces of the labia minora via thin and transparent or thick and fibrous layer
likely due to chronic irritation and inflammation

103
Q

who is most prone to labial adhesions and why?

A

prepubertal girls in first 5 years of life
rise in endogenous estrogen levels prepubertal –> decrease in labial adhesions, improved hygiene

104
Q

symptoms of labial adhesions

A

often asymptomatic
minute spotting d/t partial dehisce
uncommonly, vaginal pain, pain with ambulation or urination
UTI
urinary retention
altered urinary stream

105
Q

diagnosis of labial adhesions

A

visual inspection
labia majora stretched apart with membrane at midline

106
Q

management of uncomplicated labial adhesions

A

if no accompanying symptoms, not treated
inform parents and reassure
educate on potential symptoms

107
Q

management of complicated labial adhesions

A

if pain on urination or ambulation, altered stream, retention, or hx of UTI
first line tx: topical estrogen bid x 2 weeks
after separated labia, topical lubricant for 30 days

108
Q

what should be done if labial separation doesn’t occur within 8 weeks or if can’t tolerate estrogen?

A

manual separation
topical anesthetic, firm traction
daily lubrication for several months
rarely, thick adhesions will need surgical lysis by urologist or gynecologist

109
Q

penile adhesions

A

tiny areas of fusion between foreskin and corona most resolve with time

110
Q

tx of penile adhesions

A

gentle retraction followed by application of petroleum jelly or abx for one week to prevent new adhesions
if not effective, low potency steroid
prevent via education to retract and clean skin covering glans

111
Q

what is a penile skin bridge?

A

foreskin adheres higher up on glans results in dense adhesions

112
Q

what can penile skin bridge cause?

A

tethering of penis, visually displeasing

113
Q

treatment of penile skin bridge

A

refer to pediatric urologist for lysis via scalpel
can be done in office or OR

114
Q

who more commonly gets UTIs?

A

girls >6 months
uncircumcised boys <3 months

115
Q

MCC of UTIs

A

E. Coli
Klebsiella
Proteus
occasionally enterococcus or staphylococci

116
Q

risks for UTI

A

dysfunctional voiding
constipation
neurogenic bladder
poor hygiene
structural abnormalitiesc

117
Q

complications of uti

A

renal parenchymal scarring
HTN
renal disease
renal failure later in life
pyelonephritis

118
Q

s/s of UTI in newborns/infants

A

fever
hypothermia
jaundice
poor feeding
irritability
vomiting
FTT
sepsis

119
Q

s/s of UTI in preschool

A

abdominal/flank pain
vomiting
fever
urinary frequency
dysuria
urgency
enuresis

120
Q

s/s of uti in school aged children

A

frequency, dysuria, urgency
+fever, N/V, flank pain if pyelo
CVA tenderness rare in young children may be seen in school-aged

121
Q

how can a urinalysis/culture be collected if not toilet trained?

A

suprapubic aspiration
transurethral bladder catheterization
clean catch voided urine: through bladder stimulation or bag specimen

122
Q

techniques for UA/urine culture

A

females: labia spread apart and perineum cleansed 2-3 times iwth non-foaming antiseptic
males: meatus cleansed and foreskin retracted

123
Q

what is required for diagnosis of UTI?

A

urine culture with growth of >100,000 from clean-voided sample or 50,000 from catheter both single pathogen

124
Q

goals of UTI tx

A

elimination of infection and prevention of urosepsis
relief of symptoms
prevent recurrence and long term complications
acutely manage via antimicrobial therapy

125
Q

when would you hospitalize UTI?

A

age less than 2 months
clinical urosepsis
immunocompromised patient
vomiting or inability to tolerate oral meds
lack of adequate outpatient f/u
treatment failure

126
Q

uti treatment

A

third gen cephalosporin (cefdinir, cefpodoxime, ceftriaxone, cefotaxime)
cipro for pseudomonas

10 days in febrile children
3-5 days for immune-competent children without fever

127
Q

clinical response to treatment in uti

A

improves within 24-48 hrs
if worsens or fails to respond, broadening antimicrobial
repeat urine culture

128
Q

indications for RBUS (renal US)

A

children younger than 2 yrs old with first febrile UTI
children at any age with recurrent UTI
children of any age with a UTI who have family hx of renal or urologic disease, poor growth, or hypertension
children who do not respond as expected to approp antimicrobial therpay

129
Q

VCUG indications

A

children at any age with 2+ febrile UTIs OR
children of anyage with first febrile UTI AND
any anomalies on renal US or combo of temp of 102.2 and pathogen other than e. coli or poor growth or hypertension

130
Q

what is vesicoureteral reflux

A

retrograde passage of urine from bladder into upper urinary tract
predisposes to acute pyelonephritis
predisposes to recurrent UTI –> scarring, hypertension, end stage rneal disease

131
Q

diagnosis of VUR

A

post or pre-natal: finding of hydronephrosis on prenatal US
postnatal VCUG
renal function with UA to detect proteinuria, serum cr

132
Q

grades of VUR

A

grade 1: reflux into ureter
grade 2: into kidneys
grade 3: into kidneys, dilation of ureter
grade 4: into kidneys, dilation of ureter, and mild blunting of renal calyces
grade 5: into kidneys, dilation of ureter, and moderate to severe blunting of renal calyces

133
Q

management of grade 1-2 VUR

A

watchful waiting d/t spontaneous resolution, can give daily abx in children not potty-trained

134
Q

management of grade 3-5 VUR

A

abx prophylaxis daily on assumption that continuous use results in sterile urine and wont cause renal scarring
surgery to correct anatomy by pediatric urologist for 4-5 and stage 3 with no compliance or breathrough infections

135
Q

what is enuresis

A

voiding on bed or on clothes at least twice per week for at least 3 consecutive months in child at least 5 years of age

136
Q

types of enuresis

A

diurnal wetting in daytime
nocturnal passage of urine during nighttime
monosymptomatic: no daytime symptoms
polysymptomatic: urgency, frequency, dribbling, or daytime enuresis

137
Q

what can be related to enuresis

A

hereditary
delayed speech and walking

138
Q

what can cause polyuria that exceeds bladder capacity —> monosymptomatic nocturnal enuresis

A

decreased ADH at night
apnea
anatomic abnormlaities
constipation
lesions of spinal cord –> neurogenic bladder
diurnal when urine held until last minute –> UTIs

139
Q

PE of enuresis

A

most often normal

140
Q

labs for enuresis

A

UA
urine culture
US if daytime symptoms or initial positive studies
voiding cystourethrogram

141
Q

treatment of enuresis

A

treat constipation or UTIs first
if both day and night, tx day first
underlying cause
NE: minimize fluid intake, wake to urinate before parents go to bed
encourage to go often during day, no shame or blame, positive reinforcement
alarm therapy, CBT
DDAVP

142
Q

what is alarm therapy?

A

alarms throughout night, every time alarm sounds child gets up to void
continue x 3 mos

143
Q

moa of DDAVP

A

tx monosymptomatic
NE due to antidiuretic activity
may take 2-3 mo

Pediatrics (12 decks)

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