PEDIATRIC UROLOGY CLAUDE REITELMAN, M.D. PEDIATRIC SPECIALTY CARE: THE MOST FREQUENT REASONS FOR...

PEDIATRIC UROLOGY

CLAUDE REITELMAN, M.D.

PEDIATRIC SPECIALTY CARE: THE MOST FREQUENT REASONS FOR CALLING AN

EXPERT - PART II

PEDIATRIC UROLOGY• TOPICS

• UNDESCENDED TESTIS

• IS THERE A ROLE FOR ULTRASONOGRAPHY ?

• URINARY TRACT INFECTIONS/REFLUX

• WHEN SOULD ANTIBIOTICS BE PRESCRIBED ?

• ANTENATAL HYDRONEPHROSIS

• WHAT AND WHEN DHOULD POSTNATAL IMAGING BE OBTAINED ?

UNDESCENDED TESTIS• DESCENDED TESTIS

• SCORER – 4 CM BELOW THE PUBIC CREST IN FULL TERM MALES

2.5 CM BELOW THE PUBIC CREST IN PRETERM MALES

UNDESCENDED TESTIS• CONGENITAL UNDESCENDED TESTIS

• ACQUIRED UNDESCENDED TESTIS

UNDESCENDED TESTIS• RETRACTILE TESTIS

• INITIALLY EXTRASCROTAL, BUT CAN BE MANUALLY REPLACED IN STABLE, DEPENDENT SCROTAL POSITION AND REMAIN THERE WITHOUT TENSION AT LEAST TEMPORARILY

• MAY BE AT INCREASED RISK FOR TESTICULAR ASCENT AND SHOULD BE CHECKED ANNUALLY

UNDESCENCED TESTIS• CONGENITAL

• PRESCROTAL

• SUPERFICIAL INGUINAL POUCH

• EXTERNAL RING

• CANALICULAR

• ECTOPIC

• ABDOMINAL

UNDESCENDED TESTISPOSITION

UNDESCENDED TESTIS• PALPABLE VERSUS NON-PALPABLE TESTIS

• 70-80% PALPABLE

• 20-30% NON-PALPABLE

• ~30% INGUINAL-SCROTAL

• ~50% INTRA-ABDOMINAL

• ~20% ABSENT OR VANISHED

UNDESCENDED TESTIS• PHYSCIAL EXAMINATION

• SIZE OF THE HEMISCROTUM RELATIVE TO CONTRALATERAL NORMAL SCROTUM

• POSITION OF THE TESTIS RELATIVE TO THE PUBIC TUBERCLE

• SIZE OF TESTIS RELATIVE TO CONTRALATERAL NORMAL TESTIS

• CONSISTENCY OF TESTIS

• LENGTH OF IPSILATERAL SPERMATIC CORD

• RETRACTIBILITY

UNDESCENDED TESTIS• ACQUIRED

• ASCENDED

• FROM AN INTRASCROTAL TO AN EXTRASCROTAL POSITION

• PEAK AGE OF INCIDENCE – 5-10 YEARS OF AGE

• ENTRAPPED

• ACQUIRED AFTER PRIOR INGUINAL SURGERY

• HERNIORRAPHY

• HYDROCELECTOMY

• ORCHIOPEXY

UNDESCENDED TESTIS• PREVALENCE

• PRETERM MALES - ~30%

• FULL TERMS - ~3%

• ONE YEAR OLD MALES – 1%

• ACQUIRED AFTER ONE YEAR OF AGE - ~1%

• OTHER FACTORS THAT AFFECT PREVALENCE

• BIRTH WEIGHT

• GENETICS

UNDESCENDED TESTIS• PHYSICAL EXAMINATION

• “LET YOUR FINGERS DO THE WALKING”

STANDING ON THE RESPECTIVE SIDE OF THE PATIENT, USE THE INDEX AND MIDDLE FINGERS OF OPPOSITE HAND OF THE EXAMINER TO WALK DOWN THE INGUINAL CANAL AND TRAPPED THE TESTIS BETWEEN THESE FINGERS AND THE THUMB AND THE INDEX FINGER OF THE OPPOSITE HAND.

UNDESCENDED TESTIS• PHYSCIAL EXAMINATION

• POSITION OF TESTIS

• RETRACTABILITY OF TESTIS

• SIZE AND CONSISTENCY OF TESTIS

• LENGTH OF SPERMATIC CORD

• PRESENCE OF HERNIA/HYDROCELE

• SIZE OF CONTRALATERAL TESTIS

UNDESCENDED TESTIS• AMERICAN UROLOGICAL ASSOCIATION GUIDELINES

1. PROVIDERS SHOULD OBTAIN GESTATIONAL HISTORY AT INITIAL EVALUATION OF BOYS SUSPECTED OF CRYPTOCHIDISM

DESCENT

• TRANSADOMINAL – 1ST TRIMESTER

• INGUINOSCROTAL - 25-30 WEEKS GESTATION

• PRIMARY CARE PROVIDERS SHOULD PALPATE TESTES FOR QUALITY AND POSITION AT EACH REMOMMENDED WELL-CHILD VISIT.


IN THE ABSENCE OF SPONTANEOUS TESTICULAR DESCENT BY SIX MONTHS SPECIALIST SHOULD PERFROM SURGERY WITHIN THE NEXT YEAR.

• 100% OF MALES WHO EXPERIENCE SPONTANEOUS DESCENT DO SO BEFORE SIX MONTHS OF AGE.

• FAILURE OF MATURATION OF GERM CELLS AT BOTH THREE MONTHS AND FIVE YEARS OF AGE

• 3 MONTHS – FETAL GONOCYETES TRANSFORM INTO ADULT DARK (AD) SPERMATOGONIA

• 5 YEARS – AD SPEMATOGONIA BECOME PRIMARY SPERMTOCYTES


PROVIDERES SHOULD REFER INFANTS 6 MONTH OF AGE WITH CRYPTOCHIDISM TO A SURGICAL SPECIALIST

• LOW PROBABILITY OF SPONTANEOUS DESCENT

• PROBABLE CONTINUED DAMAGE TO TESTIS

• POOR GROWTH – GERM CELL AND LEYDIG CELL LOSS

DECREASED FERTILITY INDEX (SGONIA/T)

TESTICULAR FIBROSIS

UNDESCENDED TESTISAMERICAN UROLOGICAL ASSOCIATION GUIDELINES

PROVIDERS SHOULD REFER BOYS WITH NEWLY DIAGNOSED (ACQUIRED) CRYPTORCHIDISM AFTER SIX MONTHS OF AGE TO SURGICAL SPECIALIST

PREVALENCE PEAKS AT 8 YEARS OF AGE

HISTORY OF HYPOSPADIAS

HISTORY OF RETRACTILE TESTIS

UNDESCENDED TESTISAMERICAN UROLOGICAL ASSOCIATION GUIDELINES

IN BOYS WITH RETRACTILE TESTIS, PROVIDERS SHOULD ASSESS THE POSITION OF THE TESTES AT LEAST ANNUALLY TO MONITOR FOR ASCENT.

Outcomes of follow-up from the referred cohorts with retractile testes

Author Location Patients Testes Mean F/U 9YRS) RESOL UNDES

Agarwal157 USA 122 204 5 2.8 30% 32%Bae158 Korea 43 64 3 4.4 45% 14%La Scala159 Switzerland 150 5 3.8

<23%Marchetti160 Italy 40 41 No Information 2.3 34%

25%Stec126 USA 172 274 4 2.2 NI 7%


PROVIDERS SHOULD NOT USE HORMONAL THERAPY TO INDUCE TESTICULAR DESCDNT AS EVIDENCE SHOWS LOW RESPONSE RATES AND LACK OF EVIDENCE OF LONG-TERM EFFICACY.


PROVIDERES SHOULD NOT PERFORM ULTRASONOGRAPHY (US) OR OTHER IMAGING MODLITIES IN THE EVALUATION OF BOYS WITH CRYPTORCHIDISM PRIOR TO REFERRAL, AS THESE STUDIES RARELY ASSIST IN DECISION MAKING.

SENSITIVITY 45%

SPECIFICITY 78%

TYPICALLY, ULTRASOUND DOESN’T DETECT INTRA-ABDOMINAL TESTIS.


PROVIDERS MUST IMMEDIATELY CONSULT A SPECIALIST FOR ALL PHENOTYPIC MALE NEWBORNS WITH BILATERAL, NON-PALPABLE TESTIS FOR EVALUATION OF A POSSIBLE DISORDER OF SEX DEVELOPMENT (DSD).

• 20-30% OF PATIENTS WITH CRYPTORCHIDISM HAVE BILATERAL UNDESCENDED TESTIS.

• ??? CONGENITAL ADRENAL HYPERPLASIA

17-HYDROXYPROGERSTRONE

LH

FSH

T

ANDROSTENEDIONE


PROVIDERS SHOULD ASSESS THE POSSSIBILITY OF A DISORDER OF SEX DEVELOPMENT (DSD) WHEN THERE IS INCREASING SEVERITY OF HYPOSPADIAS WITH CRYPTORCHIDISM

UNDESCENDED TESTIS• ULTRASONOGRAPHY

• POSSIBLE INDICATIONS FOR SPECIALIST

• NON PALPABLE

• OBESE MALE – MAY AUGMENT PHYSICAL EXAMINATION

• IMPAIRED MALE IN WHOM FERTILITY IS NOT AN ISSUE AND IN WHOM IT IS FELT THAT SURGERY SHOULD BE AVOIDED

• MALE WITH PRIOR INGUINAL SURGERY – MAY AUGMENT PHYSICAL EXAMINATION

ANTENATAL HYDRONEPHROSIS• PREVALENCE - ~1-5%

• DIFFERENTIAL DIAGNOSIS

• TRANSIENT HYDRONEPHROSIS 40-80%

• URETEROPELVIC JUNCTION OBSTRUCTION 10-30%

• VESICOURETERAL REFLUX 10-20%

• VESICOURETERAL OBSTRUCTION 5-10 %

• MULTICYSTIC DYSPLASTIC KIDNEY 4-6%

• DUPLEX KIDNEY 2-7%

• POSTERIOR URETHRAL VALVES 1-2%

• OTHER – URETHRAL ATRESIA, UROGENITAL SINUS, PRUNE BELLY SYNDROME

ANTENATAL HYDRONEPHROSIS

ANTERIOPOSTERIOR DIAMETER OF RENAL PELVIS

ANTENATAL HYDRONEPHROSIS• DEFINITION

• ANTEROPOSTERIOR DIAMETER

• SECOND TRIMESTER >4 MM

• THIRD TRIMESTER > 7MM

ANTENATAL HYDRONEPHROSIS• POSTNATAL EVALUATION

• REPEAT ULTRASOUND DURING FIRST WEEK OF LIFE OR BEFORE DISCHARGE FROM HOSPITAL

• SEVERITY OF HYDRONEPHROSIS SHOULD BE ASSESSED BY THE SOCIETY OF FETAL UROLOGY GRADING SYSTEM


SOCIETY OF FETAL UROLOGY GRADING SYSTEM FOR HYDRONEPHROSIS

ANTENATAL HYDRONEPHROSIS• POSTNATAL EVALUATION

• NORMAL ULTRASOUND SHOULD BE REPEATED IN 4 -6 WEEKS

• IF NORMAL, NO FURTHER FOLLOW UP NECESSARY

• IF ABNORMAL, SHOULD BE FOLLOWED BY SEQUENTIAL ULTRASOUNDS UNTIL RESOLUTION OR PROGRESSION OF FINDINGS

• HIGH RISK – APD 10 MM AND SFU GRADE 3-4


CLASSIFICATION OF BY ANTEROPOSTERIOR DIAMETER

APD, mm

Second Trimester Third Trimester

Mid <7 <9

Moderate 7<10 10-15

Severe >10 >15


• RISK OF POSTNATAL HYDRONEPHROSIS

• MILD 11.9%

• MODERATE 45.1%

• SEVERE 88.3%


POSTNATAL EVALUATION AND TREATMENT

URINARY TRACT INFECTIONS/REFLUX• AMERICAN ACADEMY OF PEDIATRICS GUIDELINES

• FEBRILE INFANTS WITH UTIS SHOULD UNDERGO RENAL AND BLADDER ULTRASONOGRAPHY

• VCUG SHOULD NOT BE PERFORMED ROUNTINELY AFTER THE FIRST FEBRILE UTI: VCU IS INDICATED IF RBUS REVEALS HYDRONEPHROSIS, SCARRING OR OTHER FINDINGS THAT WOULD SUGGEST EITHER HIGH-GRADE VUR OR OBSTRUCTIVE UROPATHY, AS WELL AS IN OTHER ATYPICAL OR COMPLEX CLINICAL CIRCUMSTANCES

URINARY TRACT INFECTIONS/REFLUX• RIVUR STUDY

• AMONG CHILDREN WITH VESICOURETERAL REFLUX AFTER URIARY TRACT INFECTION, ANTIMICROBIAL PROPHYLAXIS WAS ASSOCIATED WITH A SUBSTANTIALLY RECUDED RISK OF RECURRENCE BUT NOT OF RENAL SCARRING.

• PATIENTS WITH BLADDER AND BOWEL FUNCTION SPECIFICALLY BENEFITTED BY PROPHYLACTIC ANTIBIOTICS

PEDIATRIC UROLOGY CLAUDE REITELMAN, M.D. PEDIATRIC SPECIALTY CARE: THE MOST FREQUENT REASONS FOR...

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