Peds Genito-Urology

Toilet Training

Urinary Tract Disorders

Urinary Tract Infection

• Etiology:
  • usually from ascending bacteria – E. coli most common (80%)
    
  • viruses or fungi less common
• Risk factors:
  • -female
    
  • -urinary tract anomalies
    
  • -bowel and bladder dysfunction (chronic constipation)
    
  • -vesicoureteral reflux
    
  • -sexual activity
    
  • -bladder catheterization
    
  • -hx of UTI
    
  • -lack of circumcision
• Presentation in younger children:
  • may be non-specific – fever without any clear source, vomiting, irritability, poor appetite
• Presentation in older children:
  • dysuria, frequency, urgency
    
  • ABD/suprapubic pain
    
  • back/flank pain
    
  • new-onset urinary incontinence
• Diagnosis:
  • if potty trained
    • – UA clean-voided specimen 
  • if NOT potty trained
    • – catheterized specimen recommended
      
    • – suprapubic aspiration if catheterization is not feasible
  • Clinical suspicion
    • obtain UA and culture
  • Suspected UTI
    • obtain C&S helps direct treatment
• UA findings:
  • significant bacteriuria with (usually) pyuria
    
  • + leukocyte esterase (produced by WBC breakdown)
    
  • + nitrite (produced by gram-negative rods)
• Management:
  • duration 3-10 days
  • guided by local resistance patterns
  • Cephalosporin
    
  • Amoxicillin
    
  • Augmentin
    
  • Bactrim
• Follow up imaging:
  • renal bladder US (RBUS) (1st line)
    
  • voiding cystourethrogram (VCUG)
  • renal scintigraphy
• RBUS indicated for:
  • <2 y/o with first febrile UTI
    
  • children of any age with recurrent UTI
    
  • children with a UTI and FH of renal or urologic disease, poor growth, or HTN
    
  • children who do not respond to appropriate abx therapy
• Voiding cystourethrogram (VCUG):
  
  • test of choice to detect vesicoureteral reflux (VUR)
  • children of any age with >=2 febrile UTIs
    
  • children of any age with 1st febrile UTI and: any anomaly on RBUS or temp >102.2 and pathogen other than E. coli or poor growth or HTN

Hematuria

Proteinuria

Vesicoureteral reflux (VUR)

• Etiology:
  • retrograde flow of urine from the bladder into the upper urinary tract, usually due to inadequate closure of the ureterovesical junction (UVJ)
• Presentation:
  • hydronephrosis
    
  • postnatal febrile UTI
• Risks:
  • recurrent infections
    
  • scarring and damage to the kidney
• Diagnosis:
  • voiding cystourethrogram (VCUG)
    • invasive test
    • a catheter placed, contrast injected
      
    • under fluoroscopy, movement of contrast and anatomy watched while patient voids
• Management:
  • controversial
  • watchful waiting vs. low dose prophylactic abx vs. surgical correction
    
  • aggressive screening (UA) in febrile/symptomatic patients
  • many cases will resolve spontaneously

Kidney Disorders

Horseshoe kidney

• Etiology:
  • the most common type of renal fusion
  • a fusion of one pole of each kidney (usually at the lower pole)
• Cause:
  • abnormal migration of kidneys
• Presentation:
  • usually asymptomatic
    
  • may have pain
  • hematuria
• Associated:
  • 1/3-1/2 will have another urological or genital abnormality (VUR, hypospadias, undescended testes)
    
  • maybe associated with other genetic disorders
• Risk:
  • Wilms tumor – most common renal malignancy in kids
• Diagnosis:
  • US
  • VCUG (if UTI)
  • serum creatinine
  • if creatinine is normal and no hydronephrosis – no further evaluation
  • if creatinine is elevated or hydronephrosis is present – require additional renal scans
• Management:
  • not usually required – excellent prognosis
  • horseshoe kidney and VUR – prophylactic abx

Pyelonephritis

Penile Disorders

Circumcision

• Types:
  • Gomco
    
  • Plastibell
• Decreases rates of:
  • UTI, penile cancer, penile inflammation/dermatoses, and some STIs
• Benefits:
  • greater in individuals with congenital uropathy
• Risks:
  • uncommon
    
  • inadequate skin removal, bleeding, infection, urethral complications
• Contraindications:
  • unstable infant
    
  • congenital penile anomalies (hypospadias, chordee)
• American Academy of Pediatrics recommendation on circumcision:
  • benefits outweigh risks, but benefits are not great enough to recommend routine circumcision for all newborn boys
    
  • the final decision left to parents to make in the context of their religious, ethical, and cultural beliefs

Uncircumcised Penis

• Patient education:
  • -avoid forcible retraction at any age
    
  • -stop retraction if met with any resistance
    
  • -return foreskin to the natural position after cleaning
• Cleaning foreskin:
  • no special care required – clean with mild soap and water, return to natural position after cleaning

Phimosis

• Path:
  • inability to retract the foreskin
• Types:
  • Physiologic phimosis
  • Pathologic phimosis

Physiologic phimosis

• Path:
  • normal state where foreskin adheres to glans – decreases naturally with age
• Management:
  • no treatment necessary

Pathologic phimosis

• Path:
  • non-retractable foreskin due to scarring/fibrosis that occurs secondary to infection or inflammation, early forcible retraction
• Presentation:
  • -secondary non-retractability after having had a fully retractable foreskin
    
  • -painful erections
    
  • -irritation or bleeding
    
  • -dysuria and/or urinary retention
    
  • -recurrent infections (balanitis, UTI)
• Management:
  • stretching exercises (gently pulling back foreskin QID)
    
  • topical corticosteroid
    
  • circumcision

Paraphimosis

• Path:
  • retracted foreskin in an uncircumcised male that can not be returned to a natural position
  • entrapment –> impaired venous flow –> engorgement –> arterial compromise
  • urologic emergency
• Causes:
  • -forcible retraction of partially phimotic skin by a caretaker
    
  • -infection or inflammation
    
  • -genitourinary procedures
    
  • -sexual activity, penile trauma (not as common)
• Presentation:
  • swelling of the penis
    
  • penile pain
  • preverbal infant – irritability
• Physical Exam:
  • -edema and tenderness of the glans
    
  • -tender swelling of the distal retracted foreskin (constricting band)
    
  • -color change (blue/black) if ischemia is present
• Management:
  • -pain control
    
  • -timely, manual reduction in office or ED
    
  • -surgical intervention by urology

Epispadias

• Path:
  • a congenital anomaly with abnormal dorsal displacement of the urethral opening
• Associated with:
  • bladder exstrophy

Hypospadias

• Path:
  • a congenital anomaly that results in an abnormal ventral displacement of the urethral opening
• Opening located:
  • glans, shaft, scrotum, perineum
• Presentation:
  • -abnormal foreskin
    
  • -a second opening, with one false opening
    
  • -abnormal penile curvature (chordee)
• Associated with:
  • chordee
    • abnormal penile curvature
• Diagnosis:
  • during newborn exam
• Management:
  • refer to urology
    
  • surgery usually performed around 6 months of age
  • circumcision should NOT be performed during the newborn period

Testicle Disorders

Cryptorchidism

• Etiology:
  • most common GU congenital abnormality
  • hidden or absent testis
    
  • a testis that is not within the scrotum and does not spontaneously descend into the scrotum by 4 months of age
• Cause:
  • cause of absent testis – agenesis or atrophy
  • cause of undescended testes – stopped short along normal descent
  • cause of retractile testes – overactive cremasteric reflex pulls testes back inside
• Presentation:
  • absent testicle unilaterally or bilaterally with flat, underdeveloped scrotum
• Most common location for undescended testis
  • suprascrotal
• Risk:
  • -testicular torsion (10x more common)
    
  • -subfertility (risk improves if corrected before 1 year of age)
    
  • -testicular cancer
• Diagnosis:
  • US – if nonpalpable
• Management:
  • Most cases resolve spontaneously
  • Most cases will spontaneously descend by 3-4 months – monitor closely at wellness exams (if not occurring spontaneously, refer to urology)
  • refer to urology (spontaneous descent rare after 6 months of age)
    
  • surgery recommended as soon after 6 months as possible (orchiopexy)
  • orchiopexy – testicle is brought down and attached into the scrotum – allows for improved testicular growth and fertility potential

Hernia

Hydrocele

Testicular torsion

• Etiology:
  • torsion (twisting) of the spermatic cord due to a poorly anchored testicle
  • Emergent condition due to risk of vascular compromise
  • peak incidences of testicular torsion
    • -neonatal period
    • -during puberty (12-18)
• Presentation:
  • -abrupt onset of severe testicular or scrotal pain
    
  • -pain usually constant
    
  • -N/V
• Physical Exam:
  • -edematous, indurated, erythematous scrotum
    
  • -affected testis tender, swollen, and slightly elevated
    
  • -absent cremasteric reflex
    
  • -negative Prehn’s sign
• Diagnosis:
  • confirmatory test – doppler ultrasound
• Management:
  • immediate consult with a urologist
    
  • surgical detorsion and fixation (orchiopexy) of both testes
• Prognosis:
  • depends on duration and completeness of torsion
    
  • (detorsion within 4-6 hours = 100% viable, after 12 hours = 20% viable, after 24 hours = 0% viable)

Enuresis

Congenital GU deformities