Urgent Issues In Pediatric Urology - Medicine.yale.edu
Urgent Issues in Pediatric UrologyAdam B Hittelman, M.D., Ph.D.Yale School of MedicineDepartments of Urology and PediatricsPediatric Urology6/5/2019SLIDE 0
No disclosure I do not have any significant financial interest or other relationshipwith the manufacturers of any products or providers of services Iintend to discuss.SLIDE 1
Urgent/emergent urologic issues Common calls from the ED/pediatrician’s office Billy presents with testicular painSwollen scrotum/Erythema“pain when I pee”HematuriaTrauma Differential Diagnosis Management strategiesSLIDE 2
Call Us: Share our phone numbers -AH 203-645-9662 Pediatric Urology Scheduling 203-785-3588Fax 203-737-8035 Y-ACCESS888-YNHH-BED (888-964-4233)SLIDE 3
Acute Scrotum Symptoms:– Scrotal pain, swelling, erythema, nauseas/vomiting Evaluation includes: onset/severity of pain; orientation of testis Wide differential diagnosisHydroceleIncarcerated hernia Torsion of testisAppendage torsion Testis tumorEpididymitisEpididymal cystEpididymal tumorParatesticulartumorVaricoceleHSPIdiopathic edemaHemangiomaFuniculitisPatent processusSLIDE 4
Epididymo-orchitis Pain Erythema/Swelling Differential Testicular torsion Abscess Torsion of appendage Elevate testicle “Prehn sign” Urine sterile, unlikely infectious Ultrasound Rule out abscessSLIDE 5
13-y/o with right testicular pain and swelling Increased in pain over 2 days withassociated scrotal swelling anderythemaSLIDE 6
Torsion of Appendix Testis or Epididymis Painful Blue dot sign Crescendo pain Distinguish from epididymitis/torsion Urine analysis Consider ultrasound Antibiotics not necessary No Surgery NSAIDS Warm Soaks Scrotal supportSLIDE 7
13-y/o with right testicular pain and swellingLeft -DopplerRight -DopplerDoppler: Right no flowSLIDE 8
Testicular torsion– “Swirl”SLIDE 9
Testicular torsion PainSwellingAbnormal testicular lieAssociated nausea and vomiting Injury dependent on Degree of rotation of the cord Duration Manual detorsion- “open book”*25% other direction Increased risk of contralateral torsion “bell-clapper” deformityUrgent trans-scrotal US andUrology Consultation Intermittent torsion Torsion/detorsionS L I D E 10
Testicular torsion Extravaginal (neonatal) vs. Intravaginal (adolescent) Intrauterine and Neonatal– Extravaginal (including tunica vaginalis)– 1:7500 newborns– Main cause of monorchidism Age 12- 18 y.o.– Intravaginal (within tunica vaginalis)– Bell clapper deformity– Estimated lifetime incidence1/4000 males 25 yearsA. IntravaginalB. ExtravaginalS L I D E 11
Neonatal torsion Prenatal torsion– Minimal to no discomfort– Hard, fixed, often discolored scrotal mass Postnatal torsionUrgent Scrotal Ultrasoundand UrologyConsult Considerable tendernessand swellingof a previously normaltestis Pre- Post- natal distinction not always appreciatedS L I D E 12
Neonatal Torsion Prenatal to 1st month of life (3rd month) Etiology unclear Rare event– 10% all torsions– 10-22% neonatal torsion are bilateral Risk contralateral torsion up to 3-4 months old(? up to 6th months) Surgical intervention or parents check diaper when babyin distressS L I D E 13
Left scrotal swelling 3-y/o with painless left scrotal swelling Does not fluctuate in size Developed after– Congenital– Infection– Trauma– Increased over timeNon-communicating hydroceleConservative managementS L I D E 14
3-y/o with scrotal swellingFluctuates in sizeIncreased when bearing down; Reduces when sleepingRisk of developing a herniaS L I D E 15
Hydrocele of the cordScrotal swellingDistinct from testicleCommunicating vs. Non-communicatingRule out inguinal herniaS L I D E 16
Inguinal herniaUrgent referral for: IncarcerationPain, swelling, Erythema, Nausea/VomitingS L I D E 17
Back to the AnatomyS L I D E 18
Hernia repair-Internal viewDiagnostic laparoscopyLeft internal ring- patentClosed ring-post repairS L I D E 19
Undescended testicles at higher risk forherniaS L I D E 20
Right abdominal testicleLeftRightLaparoscopic orchiopexy1- vs 2- stageS L I D E 21
Trauma- Testicular ruptureLacrosse ball . No cup .Left ecchymosisTesticular ruptureTunica vaginalis flapS L I D E 22
Groin/testicular pain Unilateral vs. bilateral– Specific/distinct vs. diffuse Acute vs. chronic Intermittent– Torsion-detorsion ? Testicular pain– Bladder spasms Pain at tip of penis Abnormal voiding? Associated constipation?– Distal stoneS L I D E 23
Left ureterovesical junction stone Flank pain- radiating to groin Hematuria Nausea/vomitingS L I D E 24
Kidney stone Kidney stones oftenasymptomatic Pain with obstruction–distention– Hydronephrosis– HydroureterConservative management– Tamsulosin/alpha blockerUreteral stent placementCystoscopy and lithotripsy/stone extractionS L I D E 25
Penis problemsOuch!S L I D E 26
Circumcision injuryMogen clamp***Release foreskinadhesionsS L I D E 27
Plastibell circumcisionPenile injuryPlastibell too largeFall off 4-8 daysProximal migrationSkin LossUrethrocutaneous fistulaRing cutterS L I D E 28
Balanitis / Balanoposthitis (1.5%) uncircumcised 0-15 yrsMost common candidaCan be bacterialTopical antibiotics (metronidazole cream or bacitracin) andantifungals (clotrimazole cream)? Tear glans adhesions– inflammatory response, not infectionS L I D E 29
ParaphimosisConstriction from phimotic bandEdemaTreatment --- Grip of death reduce shaft edema and re-advance skinS L I D E 30
Foreskin problemsCut the bottom of the zipper .S L I D E 31
Penile fractureDuring intercourse“Pop” sound, de-tumescence and painConservative management vs. surgicalinterventionErectile dysfunctionPenile CurvatureUrethral involvementBlood at meatusInability to urinateRetrograde urethrogram vs. cystoscopyImagingPenile US- tunical defectsMRIS L I D E 32
Ureteropelvic junction obstructionSymptomaticStudying in college .Antenatal imagingTrauma Incidental More susceptible to injuryS L I D E 33
Intermittent ureteropelvic junctionobstruction Intermittent pain “Beer drinkers syndrome” Nausea vomiting “Cyclic vomiting syndrome” Obtain ultrasound while symptomaticAsymptomaticLeft flank painS L I D E 34
Ureteropelvic junction obstruction More susceptible to minor traumaLeft ureteropelvic junction obstructionRenal pelvic ruptureS L I D E 35
Peds Urology Team Angela Arlen MDIsrael Franco MDTherese Gardere APRNAdam Hittelman MD PhDSarah Lambert MDKaitlyn Murphy APRNRobert Weiss MDS L I D E 36
Questions?Adam B Hittelman MD, PhDAdam.Hittelman@yale.eduOffice 203-737-8076Cell203-645-9662Pediatric Urology NHH-BED (888-964-4233)S L I D E 37
What are the concerns? Worsening hydronephrosis Renal compromise Infections Chronic renal failure . Hypertension .Transplant S L I D E 38
Conservative management–Tamsulosin/alpha blocker Ureteral stent placement Cystoscopy and lithotripsy/stone extraction. S L I D E 26 Penis problems . Robert Weiss MD. . Adam B Hittelman MD, PhD. Adam.Hittelman@yale.edu Office 203-737-8076 Cell 203-645-9662 Pediatric Urology Scheduling 203-785-3588. Fax . 203-737-8035 Y-ACCESS 888-YNHH .
Urology training The Urology Department is also well-known for its educational activities, training a growing number of medical students and urology residents. The resident training programme was established by Ministry of Health and the Croatian Board of Urology. Currentl
Robotic-Assisted Laparoscopic Surgery (RALS) in Pediatric Urology. Sherry S. Ross, MD. Associate Professor of Urology and Pediatrics. Department of Urology. Division of Pediatric Uro
General Urology Isuru Jayaratna, MD General Urology, Urologic Oncology Steven A. Kaplan, MD Men’s Health, Benign Prostate Disease Reza Mehrazin, MD Urologic Oncology, Robotic Surgery Jay A. Motola, MD Male and Female Urology Craig F. Nobert, MD Urologic Oncology, General Urology Sovrin M. Shah, MD, FPMRS
and leading UCLA Urology's Division of Female Urology, Reconstructive Surgery and Urodynamics, helped to define the field through numerous innovations that would become the standard of care worldwide. "On the urology side, female pelvic medicine really started here at UCLA," says Dr. Nitti, who was trained by Dr. Raz as a UCLA Urology fellow.
Communication Skills Learning Tools for the Pediatric Clerkship 37 Pediatric History Taking Approach to the Pediatric Patient 38-39 Explanation of Pediatric H&Ps/Pediatric Database 40-43 Example H&Ps (older child and infant) 44-52 Pediatric Physical Examination Benchmarks for Pediatric Physical Examination 53 54-65
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