Common Pediatric Urology Problems CDR Lisa Cartwright Pediatric

Common Pediatric Urology Problems CDR Lisa Cartwright Pediatric Urology WRAMC/NNMC

Common Issues Foreskin n Hypospadias n Varicocele n Hernia/hydrocele n Cryptorchidism n Acute Scrotum n Hydronephrosis n Nocturnal enuresis n

Foreskin Elective circumcision n Smegma n Normal prepuce n Preputial adhesions vs. adherence n Phimosis n Paraphimosis n

Elective Circumcision n < 2 months and < 10 lbs. n n Clinic procedure Local anesthetic ASAP referral to allow timely completion >2 months or >10 lbs. n n n Main OR General anesthesia Defer until 12 months Preop eval and schedule OR Option for general urolgoy

Webbed penis

Webbed Penis Defer neonatal circ n Refer at 6 months n Repair at 6 -18 months n

Preputial Adherence vs. Adhesion / Skin Bridge

Circumcision Skin Bridge Possible steroid trial n Clinic vs. OR lysis n

Phimosis vs. Paraphimosis

Phimosis n n Routine referral May give trial of steroid cream n n Kenalog 0. 1% BID Trial up to 6 weeks Paraphimosis n n Trial of reduction Urgent referral if unable to reduce

Paraphimosis n n Trial of reduction Urgent referral if unable to reduce

Trapped penis

Trapped penis Post circ phimosis n Possible trial of steroid cream n Likely OR for revision n

“Penile Mass” Mobile along shaft n Whitish discoloration n Possible thick white “discharge” n

“Penile Mass”

Smegma Normal physiology n No intervention necessary n Will resolve spontaneously with time n

Normal Prepuce n Intact prepuce (uncircumcised) n n n Do not forcibly retract In the range of normal to not retract until puberty Retract only to point of ease for hygine n Wipe away smegma

Hypospadias n Investigation n n ? Of intersex (concomitant UDT) Perineal hypospadias Defer circumcision n Referral n n n 3 months for initial eval OR at 6 -18 months

Hypospadias

Varicocele n Indications for repair n n n Referral n n Symptoms Testicular hypotrophy At diagnosis Annual f/u through puberty if not corrected n Follow for evidence of hypotrophy / testicular size differential

Inguinal Hernia Reducible inguinal bulge n < 1 yo has increased risk of incarceration n Routine referral at diagnosis n Provide family hernia precautions n n Emergent eval for pain with bulge that does not reduce

Congenital Hydrocele n n n Transilluminates No need for US if testis palpable May resolve spontaneously up to 2 yo n n Communicating hydrocele = hernia n n n Refer for persistence >2 yo Hx of waxing/waning size Refer at diagnosis Abdominoscrotal hydrocele n Refer at diagnosis as may progress

Cryptorchidism n Incidence n n 30% premature 3. 4% term infant 0. 7 -0. 8% 1 yo Rare spontaneous descent at > 3 mo

Cryptorchidism

Cryptorchidism and US US 44% accurate in UDT n Rarely alters management n Not routinely recommended n

Bilateral non-palpable Testes n DDX n n n Anorchia Intersex condition Eval n n Karyotype US n n Eval for muellerian structures T vs HCG stim

Cryptorchidism Referral Refer at 3 mo n OR at 6 -12 months n Refer at diagnosis if associated inguinal hernia n

Retractile Testicle n PE n n n Ascending testis n n n Able to be brought into scrotum without tension May spontaneously retract into groin Likely true undescended testis that is relatively low May have prior documentation of scrotal testis Annual f/u until puberty n n Refer if unable to bring into scotum without tension at rest Further eval at home in rest in tub

Acute Scrotum Pain n Erythema n Edema n

Acute Scrotum n DDX n n Eval n n n Testicular torsion = SURGICAL EMERGENCY Torsion appendix testis Epididymitis PE UA Urgent urology evaluation US with urology input Greatest diagnostic delay is typically in presentation to primary care for initial evaluation

Testicular Torsion

Antenatal Hydronephrosis Vesicoureteral Reflux n Ureteropelvic junction obstruction n Ureterovesical junction obstruction n Posterior urethral valves n Ureterocele n

Antenatal ABX Imaging Timing DDX OR Mild hydro No RUS ? VCUG 2 -3 mo UPJO UVJO VUR Unlikely moderate / severe hydro Yes RUS VCUG 1 -2 mo UPJO UVJO VUR Mild PUV Unlikely Severe unilateral hydro Yes RUS VCUG MAG 3 1 mo UPJO UVJO VUR Unusual PUV Possible Severe B hydro Yes RUS VCUG < 1 week PUV VUR B UPJO B UVJO Probable Intravesical cystic Yes RUS VCUG < 1 month ureterocele Likely

VCUG for Antenatal Hydro n 20 -30% VUR if any antenatal hydronephrosis n n 23% VUR with negative postnatal sono All degrees of antenatal hydro need to be evaluated for 95% identification threshold of gr III VUR

VCUG vs. RNC

VUR Grading

VCUG vs. Nuclear Cystogram n VCUG n n n Classic grading Anatomy Male urethra n n n Indications n n One study with dx of VUR Initial study for male UTI or hydro Nuclear cystogram n n Higher sensitivity No anatomy No urethral evaluation Less radiation Indications n n n Sibling screening Female screening VUR f/u

Monosymptomatic Nocturnal Enuresis n n No daytime symptoms Familial Rarely is the only symptom of organic disease Investigation not indicated (poor yield) n n Consider RUS in pubertal children Treatment n n n Alarm - 66% success (Houts, 1994) DDAVP (10 -40 ucg) - 50% success (Moffatt, 1993) Imipramine (1. 5 mg/kg) - 43% success (Houts, 1994) Oxybutinin - poor results Propantheline - poor results Tolteridine - poor results

Nephrology Evaluation Proteinuria n Microhematuria n n n UA with micro x 3 separated by 2 -3 weeks Random urine calcium to creatinine ratio