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Pediatrics Exam 4 > Pediatric Urology > Flashcards

Pediatric Urology Flashcards

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1
Q

Normal Penile Development and Hygiene

A

● At birth, the foreskin adheres to the glans of the penis
○ Physiological phimosis
■ Nearly all will resolves with time
● Hygiene
○ Gentle washing
○ If retractable, wash the glans (remember to reduce)
○ Never forcibly retract a foreskin that isn’t retractable

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2
Q

Benefits of male circumcision

A

●↓ risk of UTIs (absolute risk is really low)
●↓ penile cancer (again, what’s the absolute risk?)
●↓ cervical cancer in female partners
●↓ penile inflammation & retractile disorders
● ↓ sexually transmitted diseases including HIV
● Hygiene: Easier

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3
Q

Risks to Male Circumcision

A

● Surgical risks (minor and infrequent with good technique and pain management)
● Diminished sexual sensation…
○ Permanent externalization of the glans penis results in desensitization due to keratinization of the glans that buries nerve endings deep into the glans
○ A systematic review of 36 studies showed
circumcision was NOT associated with decreased sexual arousal, sensitivity, or satisfaction

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4
Q

Medical indications for circumcision

A

○ Phimosis – inability to retract the prepuce
○ Paraphimosis – prepuce trapped behind
the corona of the glans penis
○ Balanitis – inflammation of the glan
○ Posthitis – inflammation of the prepuce
○ Balanoposthitis – inflammation of both
the glans and prepuce

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5
Q

Four common ways to collect urine from a child:

A

A. Midstream clean catch
B. “Clean voided” bag for collection
C. Straight catheterization
D. Suprapubic bladder aspiration

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6
Q

“Clean voided” bag for collection

A

● Noninvasive
● Properly clean, rinse, & dry perineum before applying
● Bag must be immediately removed after urine voided
● Should NOT be used for culture → high rate of false positives
○ DO NOT administer antibiotics on the basis of a urinalysis from a clean voided bag urine specimen

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7
Q

Straight Catheterization

A

● “In-&-Out”
○ Useful for culture & sensitivity
○ Post void residual

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8
Q

Suprapubic Bladder Aspiration

A

● Reserved for males difficult to catheterize
○ Usually limited to infants younger than 6 months
1. Immobilize the child
■ Do not attempt if the child has voided within the last
hour

  1. Palpate & percuss the limits of the bladder above the
    pubic symphysis
    ■ The bladder sticks out high above the pubis in a young
    child when it is full
    ■ May occlude the urethra in boys by holding the penis &
    in girls by inserting a finger in the rectum to exert
    pressure
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9
Q

“The Quick-Wee Method”

A

Suprapubic Cutaneous Stimulation
● A gauze pad soaked in cold fluid placed on the suprapubic region
○ Contamination rate with Quick-Wee was 27%
■ Standard clean-catch, it was 46% (not significant)
● Parents (and clinicians) were more satisfied with the kinder, gentler, and faster
method

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10
Q

The prevalence of UTI in children <2 years presenting with fever is
approximately ____

A

7%

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11
Q

Risk Factors for UTI in children

A

● Vesicoureteral Reflux
○ Most common urologic anomaly in children
● Urinary Obstruction
● Voiding Dysfunction
● Uncircumsized
● Sexually active

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12
Q

Urinary Tract Infection imaging for kids

A

○ Renal ultrasonography (RUS) & voiding cystourethrogram (VCUG)
■ Girls < 3 years of age, 1st UTI
■ Boys of any age, 1st UTI
■ Children of any age with a febrile UTI
■ Children with recurrent UTI & no previous imaging

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13
Q

Treatment for UTI in children

A

● Urine culture and sensitivity
● Antibiotics
■ Trimethoprim-sulfamethoxazole (Septra®, Bactrim®)
■ Cefixime (Suprax®)
■ Cephalexin (Keflex®)

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14
Q

Recommended duration of antibiotics for UTI in kids

A

■ 5-7 days for simple UTI
■ 7-14 days for febrile UTI at ages 2-24 months
■ 10-14 days for severe UTI (pyelonephritis)

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15
Q

When are IV antibiotics indicated for UTI

A

■ Infants < 3 months old
■ Inability to tolerate oral treatment
■ Poor response to oral treatment
■ Severe illness with vomiting & dehydration

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16
Q

When is surgical treatment recommended for UTIs

A

○ Vesicoureteral Reflux
■ Mild cases are likely to resolve over time
○ Circumcision
○ Meatal Stenosis
■ Meatotomy
○ Urethral Stricture
■ Dilatation or urethroplasty

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17
Q

Complications of UTI in Kids

A

● Hypertension, renal scarring, and end-stage renal dysfunction
● Recommended initiation of antibiotics

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18
Q

Hypospadias

A

Congenital urethral meatus on ventral surface of penis, scrotum, or perineum

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19
Q

Hypospadias most often occurs where on the penis?

A

(50%)
● Anterior/Glanular – meatus is on the inferior surface of
the glans penis
● Coronal – meatus is in the balanopenile furrow

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20
Q

Epispadias

A

Congenital urethral meatus on dorsal surface of penis or near the pubic bone

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21
Q

Hypospadias/Epispadias diagnosis

A

● Clinical assessment
● Nearly all will also present with curvature of
the penis
● Do not circumcise

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22
Q

Treatment of Hypospadias/Epispadias

A

● Minor cases – meatus is located up toward the tip of the glans
○ May not require surgical repair – observation
● Surgical correction
○ Distal and proximal penile
○ Between 6 months – 2 years old

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23
Q

Hypospadias/Epispadias
Treatment Goals

A
  1. Create a straight penis by repairing any curvature (orthoplasty)
  2. Create a urethra with its meatus at the tip of the penis (urethroplasty)
  3. Re-form the glans into a more natural conical configuration (glansplasty)
  4. Achieve cosmetically acceptable penile skin coverage
  5. Create a normal-appearing scrotum
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24
Q

What will Forcible Retraction of a phimosis cause in kids?

A

● Can tear the foreskin from the head of the penis & leave an open wound
○ Risk for infection – Balanoposthitis
○ Adhesions – Healing surfaces can form adhesions between the foreskin & the
glans (permanent problems with retraction)
○ Phimosis – Small tears in the foreskin can heal to form non-elastic scar tissue
○ Paraphimosis – Foreskin can get “stuck” behind the head of the penis

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25
Physiologic Phimosis treatment
● Let it be – Almost all resolve with time ● If pathologic, conservative treatment with corticosteroid ointment or cream (0.05%-0.1%) twice daily for 20-30 days ● Circumcision
26
Paraphimosis is Typically seen in one of the following populations
○ Children whose foreskins have been forcefully retracted ○ Children who forget to reduce their foreskin after voiding or bathing ○ Adolescents following vigorous sexual activity
27
Paraphimosis treatment
● Urological Emergency ● Reduction ○ Anesthesia (dorsal penile block or “ring” block) ○ Manual reduction ■ Circumferentially compress the foreskin and hold for 2-10 minutes to reduce the edematous fluid
28
Hydrocele
Fluid collection within the tunica vaginalis of the scrotum or along the spermatic cord
29
Etiology of a hydrocele
● In children, most hydroceles are communicating type ○ Patency of the processus vaginalis allows peritoneal fluid into the scrotum, esp. with Valsalva maneuvers ○ Clinical hydroceles evident in only 6% beyond the newborn period (12-18 months)
30
Hydrocele Diagnosis
● Soft, non-tender fullness within the scrotum ○ The testis is generally palpable along the posterior aspect of the scrotum ● Transillumination reveals a homogenous glow, without internal shadows
31
Treatment for Hydrocele
● Observe ○ Communicable hydrocele under 12-18 months old ● Hydrocelectomy ○ Inguinal approach – ligation of the processus vaginalis high within the internal inguinal ring
32
Varicocele
Dilatation of the pampiniform venous plexus and internal spermatic vein
33
Etiology of Varicocele
● Unknown ● Varicoceles are much more common (~80-90%) in the left testicle than in the right because of several anatomic factors
34
Varicocele diagnosis
● History ○ Usually asymptomatic, may report scrotal pain or heaviness ● Physical Exam – Primary method of detection ○ Enlarged, potentially visible, veins in the scrotum – “Bag of Worms” ■ Grade 1 – Palpable only with Valsalva ■ Grade 2 – Palpable without Valsalva ■ Grade 3 – Visible externally with or without Valsalva
35
Varicocele imaging
● High-resolution color-flow Doppler ultrasonography
36
Treatment of Varicocele
● Surgical Ligation ○ Occlusion of the varicosity
37
Testicular Torsion
Twisting of the testicle/spermatic cord restricting blood to the testicle Emergent condition
38
Etiology of Testicular Torsion
● 90% related to “bell-clapper deformity” ● Left > Right ● Usually related to sports/physical activity, but can be spontaneous ● Fixation of the epididymal-testicular complex posteriorly, effectively prevents twisting of the spermatic cord
39
Testicular Torsion presentation
● Sudden onset of severe unilateral pain ● Significantly swollen and erythematous scrotum ● 1⁄3 may have nausea, vomiting, and GI upset ● Affected testicle WILL BE higher ● Negative prehn's sign ● Refer to ER - this is an emergency!!
40
Testicular Torsion treatment
● Surgical detorsion – restore blood flow ● Ischemia within 4 hours after torsion & is almost certain after 24 hours ● Salvage rates after detorsion ○ 90% if within 6 hours ○ 50% if within 12 hours (25%) ○ < 10% if after 24 hours
41
Most common solid malignancy affecting males aged 15-35 yo
Testicular Cancer
42
Diagnosis of Testicular Cancer
● Painless mass is typical ● Some may have dull ache and/or present with pain (mass effect)
43
Imaging for Testicular cancer
● Ultrasound ○ Scrotal US showing hypoechoic mass is diagnostic of testicular cancer
44
Treatment of Testicular Cancer
● Radical inguinal orchiectomy ○ Subsequent histology confirms diagnosis ● “Pure” seminoma – very sensitive to radiation
45
Cryptorchidism
(Undescended Testis)
46
Most common congenital abnormality affecting genitalia in newborn males
Cryptorchidism (Undescended Testis)
47
Etiology of Cryptorchidism (Undescended Testis)
● Congenital cryptorchidism ○ Undescended testis – testis deviates/stops along path of normal descent during fetal development ○ Absent/vanishing testis due to in utero or perinatal spermatic cord torsion/vascular accident ● Acquired cryptorchidism ○ Ascending testis – retracted by spermatic cord that remains short during somatic growth
48
Diagnosis of Cryptorchidism (Undescended Testis)
● If the testilce is palpable, physical exam is usually sufficient for diagnosis ○ Ultrasound for non-palpable
49
Treatment of Cryptorchidism (Undescended Testis)
● Clinical management depends on location and presence of testes ○ Must determine if the gonads are palpable or nonpalpable (~70% are palpable) ● Surgery is routinely used for treatment of undescended testis (Orchiopexy) ○ Refer to urology if undescended testis persists or presents at age > 6 months (corrected for gestational age)
50
A newborn with _____ is potentially a genetic female (46 XX) with Congenital Adrenal Hyperplasia (CAH) until proven otherwise
a male phallus and bilateral non palpable gonads
51
_____ becomes gonads based on chromosomal sex
Genital ridge
52
Precursors of external genitalia are
urogenital tubercle, swelling, and folds
53
Precursors of internal genitalia are ___
genital ridge, sex ducts, and germ cells
54
Dihydrotestosterone causes
■ Urogenital tubercle → glans penis ■ Urogenital swelling → scrotum ■ Urogenital folds → penile shaft
55
Absence of Dihydrotestosterone causes
■ Urogenital tubercle → clitoris ■ Urogenital swelling → labia minora ■ Urogenital folds → labia majora
56
Ambiguous Genitalia Disorders of Sex Development (DSD)
DSD are congenital conditions in which development of chromosomal, gonadal, or anatomic sex, is atypical ● In infants, DSD typically manifest a ○ Congenital ambiguous genitalia ○ Malformed genitalia ○ Discordant genotypic and phenotypic sex
57
DSD can be classified as...
● 46, XX DSD = Virilized female (female develops characteristics associated with male hormones/androgens) ○ Disorders of androgen excess ● 46, XY DSD = Undervirilized male ○ Disorders of androgen action or synthesis
58
DSD can be classified with chromosome abnormalities including:
● Klinefelter syndrome (47, XXY) ○ Male phenotype, (typically) ● Turner syndrome (45, XO) ○ Female phenotype (typically)
59
Management of Ambiguous Genitalia Disorders of Sex Development (DSD)
● Stabilize infants with suspected Congenital Adrenal Hyperplasia or hypopituitarism presenting with adrenal crisis ● Multidisciplinary team, along with parents, involved with all gender assignment and treatment decisions ● Goals ○ Sex-appropriate appearance ○ Stable gender identity ○ Good sexual and reproductive function (if possible) ● Surgery ○ Masculinizing surgery ○ Feminizing surgery
60
Most common renal tumor of childhood
Wilms Tumor
61
Diagnosis of Wilms Tumor
Suspected clinically based on – ○ Abdominal mass in previously healthy child ○ Physical anomalies & /or developmental delay characteristic of Wilms tumor predisposition syndromes ■ Denys-Drash syndrome ■ Perlman syndrome ■ “WAGR” syndrome ● Abdominal ultrasound used to detect or evaluate renal mass ● Biopsy confirms diagnosis
62
Denys-Drash syndrome
Congenital nephropathy, disorders of sexual development in affected males, and Wilms tumor
63
Perlman syndrome
Overgrowth of different parts of the body (head, liver, kidneys)
64
“WAGR” syndrome
Wilms tumor, aniridia, genital anomalies, retardation
65
Treatment of Wilms Tumor
● Protocols use a combination of nephrectomy and/or chemotherapy, with or without radiation therapy for most patients ● Five-year overall survival rates approach 90 percent

Pediatrics Exam 4 (7 decks)

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