Surgery II 6.6 Dr.

Yrastorza
PEDIATRIC UROLOGY March 2, 2015
OUTLINE PREVALENCE
I. Scrotal Mass
Most often involves the LEFT TESTICLE
II. Abdominal Mass
III. Anatomic Abnormality of the External Genitalia Age: most often in males younger than 30 years; most aged 12-18
IV. Urinary Incontinence years
Dilemma at the ER Adolescent patient presenting with acute
REFERENCES testicular pain
1. Recording o Differentials: epididymitis, epididymorchitis, or torsion
2. 2015B trans o Torsion requires surgical intervention immediately while the other
two are managed medically
**Note: The lecturer said that he will just be getting questions from his lecture only.

PERINATAL TORSION OF THE SPERMATIC CORD

INTRODUCTION
The following are the common presentation in the pediatric age group
1 Occurs in the prenatal or in the immediate postnatal period
o Scrotal mass Prenatal (inside the womb) findings:
o Abdominal mass o Hard, non-tender testis fixed to the overlying scrotal skin at birth
o Any anatomic abnormality in the external genitalia (ie. Ambiguous o Scrotal skin discolored by the underlying hemorrhagic necrosis
genitalia, small penis, hypospadia, empty scrotum) o Mostly EXTRAVAGINAL (torsion of the cord and its tunics)
1
o Any problem in urination (ie. Urinary incontinence) (vaginal referring to processus vaginalis )

SCROTAL MASS
Table 1. List of different conditions presenting with a painful or painless
scrotal mass.
PAINFUL PAINLESS
Testicular Torsion Hydrocoele
Torsion of the appendix testis Inguinal Hernia (NOT incarcerated)
Epididymitis Varicocele
Trauma: ruptured
Spermatocele Figure 1. Prenatal torsion of the spermatic cord (mostly extravaginal)
testis/hematocoele
Inguinal Hernia (incarcerated) Testicular Tumor INTRAVAGINAL TORSION
Orchitis (i.e. Mumps Orchitis) Henoch-Schonlein Purpura Due to inappropriately high attachment of tunica vaginalis
Idiopathic Scrotal Edema Free rotation of spermatic cord within the tunica vaginalis, within the
If painful, usually it is due to inflammatory process or obstruction. inguinal canal usually 1 Bell clapper deformity
For painless, think about malignant conditions or hernia, etc.1
CAUSES
ABDOMINAL MASS Undescended testicle
Important to differentiate between cystic and solid1 Sexual arousal and/or activity
Cystic more common; most commonly due to hydronephrosis1 Trauma
o Hydronephrosis Exercise
Causes (any obstruction from the ureters up to the urethra)
Active cremasteric reflex
Uretero-Pelvic Junction Obstruction most common1
Cold weather
Other causes: Posterior urethral valves, Ureteroceles,
Congenital anomaly BELL CLAPPER DEFORMITY
Ectopic ureters, Neurogenic Bladder, Vesicoureteral
Reflux(VCUR)
CLINICAL HISTORY
o Multicystic kidney
o Polycystic kidney Sudden severe pain in one testicle (first manifestation)
o Duplication of collecting system o Compared to orchitis & epididymitis which presents as GRADUAL
pain and swelling of the scrotum1
Solid
o Mesoblastic Nephroma most common benign solid kidney tumor Followed by: swelling, reddening of the scrotal skin, lower abdominal
pain (which follows path of spermatic cord), nausea and vomiting
o Neuroblastoma
o Wilms Tumor
PHYSICAL EXAMINATION
Enlarged, hard and tender testicle
SCROTAL MASS
o Frequently elevated in position (low-lying testis in orchitis)
TESTICULAR TORSION 1
o Horizontal lie (normally testes should be in a vertical plane )
True urologic emergency
Scrotal erythema and edema
Testicular necrosis and atrophy due to strangulation of blood supply
Ipsilateral loss of the cremasteric reflex
Usually the coiling is INWARD1
(-) Prehn sign NO relief of pain upon elevation of scrotum
o LEFT TESTICLE TORSION CLOCKWISE
o In contrast, in inflammatory conditions like epididymitis, there is
o RIGHT TESTICLE TORSION COUNTERCLOCKWISE
(+) Prehn sign relief of pain upon elevation of the scrotum1
Delay of diagnosis can result in loss of the testicle
Fever (uncommon)
Most frequent cause of testicle loss in adolescent males
Torsion may be EXTRAVAGINAL (during perinatal period; rare; torsion
of cord including tunics encasing it) or INTRAVAGINAL (more common
in incidence; torsion of testicle only within tunica vaginalis)

Group 16 | John, Lucy, Heidi, Becca, Claud. LAST TRANS OF GROUP SEXY!!! Page 1 of 6
 SURGERY II 6.6
TESTICULAR TORSION SALVAGE RATE
Table 2. Duration of ischemia and corresponding salvage rate. The earlier
the intervention, less duration of ischemia, the higher salvage rate.
DURATION OF ISCHEMIA (in hrs) SALVAGE RATE
0-6 85-97%
6-12 55-85%
12-24 20-80%
>24 <10%
GOLDEN PERIOD (usually 6-8 hours) If you are able to do surgery within
6-8 hours, you have a higher rate of saving the testes1 Otherwise,
unsalvageable already and orchiectomy must be performed.
DIAGNOSIS
COLOR DOPPLER ULTRASOUND
Adjunctive diagnostic modality of choice
There is decrease to absent blood flow to testis (as compared to
orchitis or epididymitis which has increased blood flow d/t inflamm.)
Assessment of anatomy (presence of hydrocele, swollen epididymis)
Sensitivity = 88.9%; Specificity = 98.8%
1% rate of false positive results (Baker and associates, 2000)
RADIONUCLIDE IMAGING
Originally the study of choice for acute scrotum
Limited because it allows only an assessment of testicular blood flow
Positive predictive value = 75%; Sensitivity = 90%; Specificity = 89%
A false impression of blood flow may result from hyperaemia of the
scrotal wall Levy and associates, 1983)
Nuclear Scintigraphy
o A photon deficient area in the ipsilateral hemiscrotum is almost
pathognomonic for torsion
o Requires 1-2 hours
TREATMENT
Note: you can do manual detorting of the torsion Outward rotation
(torsion of spermatic cord is usually inward) 2
ORCHIOPEXY
Done if testis is still viable
Evaluate testis for viability: (+) return of color and arterial bleeding
after incision of tunica albuginea
o Perform detorsion, and observe the pinking up phenomenon
2
(representing the return of blood flow to the testicle)
Remove necrotic testis
o If you keep necrotic tissue, particularly the testis, within the
scrotum, this will stimulate production of antibodies to the normal
testicular antigen. This will eat up the contralateral testis. 2
o Always explain that there is always a possibility of the procedure
being converted to an orchiectomy.2
Fix viable gonads to scrotal wall with sutures
o Release the torsion and suture the testes into the scrotum to
prevent twisting1
o How do we fix it? Usually theres a three-point fixation: lateral,
medial, and the inferior portion of the testis. Then you fix it to the
wall of the Dartos cavity.2
Perform also on contralateral testicle
1
o To prevent torsion to the other side
o Predisposition to torsion is bilateral in 50% of cases
o 5-30% of contralateral testes that are not fixed subsequently
undergo torsion
ORCHIECTOMY
Done if the testes are not salvageable anymore1
Group 16 | John, Lucy, Heidi, Becca, Claud. LAST TRANS OF GROUP SEXY!!!
TORSION OF THE APPENDIX
Common cause of acute scrotum at age 7-12 y/o
Small, painful, firm paratesticular nodule at superior pole of the testis.
BLUE-DOT SIGN - infarcted appendage seen through the scrotal skin.
Treated with conservative measures include rest, testicular elevation,
and analgesics.
EPIDIDYMITIS
Gradual onset of pain an indolent process, in contrast to acute onset
of torsion of spermatic cord
Fever in 40%, dysuria in 50%, pyuria in 50% of patients
Rare clinical diagnosis in the pediatric age group.
A past history of the following increase likelihood of epididymitis:
o Urinary tract infections
o Urethritis
o Urethral discharge
o Sexual activity
o Urethral catheterization
o Urinary tract surgery
Physical signs: localized swollen and tender epididymis, or a massively
swollen hemiscrotum, (+) Cremasteric reflex
Confirm that torsion of testis does not exist
o Scrotal Doppler ultrasound findings increased arterial flow
Treatment: antibiotics against gram (-), anti-inflammatory drugs
ORCHITIS
Can present with severe epididymitis, associated with testes atrophy
o Insufficient treatment may result in loss of testes, cause infertility
Usually viral, common in children with mumps.
(+) Prehn sign pain relief upon lifting testes
Do ultrasound as well
TESTICULAR TRAUMA
Most occur by blunt trauma. Penetrating trauma requires surgery
Do Early exploration (<72 hours).
Suspect urethral injury if with voiding symptoms
TESTIS TUMOR
Gradual scrotal/testicular enlargement, Rarely with pain
Presentation is rarely acute
HYDROCOELE
Associated with patent processus vaginalis (normally closes at birth)
Fluid passes through patent processus vaginalis Painless swelling
Scrotal contents can be visualized with transillumination (flashlight or
penlight under the scrotum)
Types
a) Communicating hydrocoeles
o more common in pediatric patients
o Hydrocoele appears with increased abdominal pressure (ie.
Crying, standing, straining)
o Disappears on lying down
b) Non-communicating hydrocoeles
o More common in adult patients
o Processus vaginalis closes after some time
o Fluid collection is permanent
Neonatal hydrocele: 50% of newborns. Most close by age 1
Reducible scrotal mass indicates communicating hydrocoele. Non-
reducible indicates non-communicating hydrocoele.
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 SURGERY II 6.6

HERNIA POSTERIOR URETHRAL VALVE (PUV)

Large opening of the processus vaginalis which may allow abdominal
contents to enter scrotal sac.
Reducible scrotal mass indicates indirect hernia. Non-reducible scrotal
mass indicates incarcerated/strangulated hernia. Hernial mass is also (-)
transillumination.
Treatment: Herniectomy (semi emergency) for both indirect and
communicating hernias. Closure of the processus vaginalis near the
internal ring may be done through an inguinal incision.
Figure 2. Anomalies of the inguinal canal and scrotum that may result from
anomalous closure of the processus vaginalis.
ABDOMINAL MASSES IN CHILDREN
Infants
o 50 to 75 % of palpable masses are of urinary tract origin
o Mostly hydronephrosis and multicystic kidney
Diagnosis
o Ultrasonography - initial exam of choice; check location & density
(differentiate if cystic or solid)
Location
o Retroperitoneal most are renal in origin
o Anterior Abdominal Masses primarily GI in origin
Density
o Cystic masses are evaluated with IVP (Intravenous Pyelogram) and
VCUG if indicated; usually hydronephrosis or multicystic kidney
o Solid masses are evaluated by IVP for CT Scan and are usually
mesoblastic nephroma or neuroblastoma.
CYSTIC
MULTICYSTIC DYSPLASTIC KIDNEY
Bunch of grapes on ultrasound;
May be unilateral/bilateral. Has no functioning renal tissue & has
atretic ureter
Tends to involute through childhood
Higher rate of contralateral renal anomalies ureteropelvic junction
obstruction (UPJO), vesicoureteral reflux (VUR)
Slight but definite risk of Wilms tumor
Differentiate from hydronephrosis by performing ultrasound then renal
scan. If no function, MCDK. If (+) function, hydronephrosis.
Nephrectomy if symptomatic
HYDRONEPHROSIS
Leading cause of abdominal masses in newborn & infant
Ultrasononography - mainstay in workup
Antenatal Hydronephrosis can be detected in 0.5-1% of antenatal UTZ Treatment
Antenatal Surgery urinary diversion
Causes of Hydronephrosis
o Posterior Urethral Valves
o Ureterocele
o Ectopic ureter
o Neurogenic bladder
o UPJ (Ureto-pelvic junction) obstruction most common!
o Vesicoureteral reflux (VCUR)
Group 16 | John, Lucy, Heidi, Becca, Claud. LAST TRANS OF GROUP SEXY!!!
Remnant valves in the urethra causing obstruction
There are 3 types. No need to know how to differentiate these for now.
Presents with renal failure, reflux, bladder dysfunction, UTI, straining
on urination, and urinary retention.
Imaging
o Voiding Cystourethrogram (VCUG): imaging of choice for
diagnosis; check for associated reflux
o IVP or UTZ: for upper tracts
o Radioisotope renal scan: assess renal function
Treatment
o Transurethral incision: take out the valves (PUV ablation)
o Manage secondary problems
o Cutaneous Vesicostomy if:
Creatinine is significantly elevated
Infection cannot be controlled
Urethra will not accept endoscope
Follow-up is very important
o Up to 1/3 develop chronic renal insufficiency. If there is still no
improvement after several weeks, do cutaneous pyelostomy or
ureterostom.
URETEROCELE
Cystic dilation of the terminal ureter
Persistence of Chwalle's membrane between ureteric bud and
urogenital sinus
ECTOPIC URETEROCELE
Ureter not ending up in the bladder
Can empty anywhere into
o For males: Wolfian (mesonephric) duct, prostate, seminal vesical,
posterior urethra
o For females: epoophoron, Gartner's duct, vagina, cervix
Can cause obstruction of kidney, hydronephrosis, UTI, incontinence in
girls
NEUROGENIC BLADDER
Neuromuscular dysfunction of the lower urinary tract
International Continence Society Classification
o Detrusor: normal, hyperreflexic, hyporeflexic
o Striated Sphincter: normal, hyperactive, incompetent
o Sensation: normal, hypersensitive, hyposensitive
URETEROPELVIC JUNCTION (UPJ) OBSTRUCTION
Primary: due to adynamic segment in ureter (normally has peristalsis),
stenosis, or a crossing vessel impinging on the UPJ
Secondary: stone or stricture in UPJ
Presentation: Flank pain, hematuria, UTI
Diagnostics
o Initial screening study: KUB Ultrasound (check for
hydronephrosis)
o Do CT scan with contrast which is more sensitive and specific. If CT
scan is inconclusive, do retrograde pyelogram.
o Diuretic renogram is a quantitative assessment of degree of
obstruction.
o 1/3 kidneys deteriorate and/or develop complications which
require surgery
o Observe if no significant UPJO. Pyeloplasty, if pain, infection, or
affecting function of the kidney
o Take out the adynamic segment and the dilated part of the pelvis
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 SURGERY II 6.6

Figure 3. Pyeloplasty. The common type of pyeloplasty is dismembered
pyeloplasty. Cut and remove diseased segment, then one part is spatulated
laterally (not medial, because the vessels are there) so the lumen will enlarge.
Once its spatulated, you anastomose to the wider lumen of the pelvis. You
should also place a stent, the double J stent (ureteral indwelling stent) to
facilitate healing of the anastomoses. This can be done laparoscopically or
2 ANATOMIC ABNORMALITIES of THE EXTERNAL GENETALIA
via an open technique.
VESICOURETERAL REFLUX (VUR)
Most commonly presents as UTI
o 40 to 50% of children with documented UTI
o Single documented UTI in children warrants radiologic exam
Diagnostics: Do VCUG, IVP/UTZ, Radionuclide imaging
PRIMARY VUR
o A congenital, abnormal retrograde flow of urine from bladder to
ureter with or without involvement of the kidney
o Results from inadequate length of submucosal ureteric tunnel
o Risk factors for primary VUR: short intramural ureter segment,
lateral ureteral orifice.
o Presentation
Newborns with abnormal sonograms
UTI (most common)
Asymptomatic sibling
Older toilet-trained children with voiding dysfunction
SECONDARY VUR
o Due to functional or mechanical bladder outlet obstruction: PUV,
neuropathic bladder
GRADING
TREATMENT
Primary goal: prevent infection
Mild to severe: antibiotic prophylaxis and surveillance
Persistent VUR, Persistent infection: surgical (ureteroneocystostomy)
Surgical: Goal is to lengthen ureter within the bladder
o Politano-Leadbetter Technique
o Cohen cross-trigonal technique, bilateral reimplant
o Laparoscopic Reimplantation
o Endoscopic treatment of reflux: place bulking agent to narrow
lumen and prevent regurgitation
Bulking Agents (Polytetrafluoroethylene (Teflon), Bovine
Collagen, Polydimethylsiloxane (Macroplastique),
Detranomer microspheres (Deflux)
AMBIGUOUS GENITALIA
Pseudohermaphroditism (Male or Female), True hermaphroditism
Mixed gonadal dysgenesis
EVALUATION OF INTERSEX PROBLEM REQUIRED FOR:
Male-appearing genitalia with micropenis, moderate/severe
hypospadias, bilateral cryptorchidism, or two mild defects (e.g. mild
hypospadias and unilateral cryporchidism)
Female appearing genitalia with posterior labial fusion, clitoromegaly,
or a labial or inguinal mass.
EVALUATION IS A MEDICAL AND PSYCHOLOGICAL EMERGENCY
Diagnose CAH before an adrenal crisis
Designate correct gender
Correct problems early for correct body image and gender identity
Provide genetic counseling for the future
Identification of children at higher risk for gonadal tumor
PENILE SIZE
Term newborn: at least 1.9 cm long
Normal pediatric age group: 3.5cm +/- 0.7cm (stretched)
Reference point is the symphysis pubis

MICROPENIS
Normal formed penis at least 2.5 SD < mean size for age
Penile length pubic symphysis to tip of glans
Stretched length used because of correlation with erectile length

WEBBED PENIS
Scrotal skin extend into ventrum of penis
Abnormality of the attachment between the penis and the scrotum
Figure 4. Grades of Reflux. Higher grade = more severe reflux
CONCEALED PENIS
Table 3. International Classification of Vesicoureteral Reflux Normally developed penis camouflaged by suprapubic fat pad
SPONTANEOUS Congenital; inelasticity of Dartos fascia
GRADE DESCRIPTION
CESSATION RATES
I Into the nondilated ureter 85% HYPOSPADIAS
II Into the pelvis and calyces without dilation 65% 1:300 boys
Mild - moderate ureter, renal pelvis, and Due to the arrest of the development/migration of urethra. The worst
III calyx dilatation with minimal blunting of the 55% would be that the urethral opening is in the scrotal area.
fornices Components
Moderate ureteral tortuosity and dilatation o Ventral bend of penis (chordee)
IV 33%
of the pelvis and calyces o Proximal ventral urethral meatus
Gross dilatation of the ureter, pelvis and 0% o Deficient foreskin ventrally
V calcyces; loss of papillary impressions; and (surgery Vast majority not associated with other endocrinopathy or GU anomaly.
ureteral tortuosity recommended) o We should ask if the mothers took any drugs during the pregnancy,
which could have lead to arrest in development.

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 SURGERY II 6.6

TREATMENT
Hormonal (hCG, GnRH)
o Conflicting reports
o Best response in 3-5 years old with bilateral maldescended testes
o Overall success rate at best is 25%
o Close surveillance recommended: may re-ascend!
o Not done if hernia present
Surgical (orchiopexy) Perform by 6 months to 1 year of age

Figure 7. Ochiopexy. Formation of a Dartos pouch. Create a sub-Dartos

Figure 5. Anatomically descriptive levels of hypospadias within the three pouch, free the testicle and spermatic cord, and bring it down. The
major categories, based on the level of the meatus following orthoplasty. If environment that the testis needs should be cooler than the body
you have a proximal urethral meatus, you expect the distal parts to have temperature. Thats why some have a certain degree of infertility.
fibrosis. The fibrosis leads to contraction, causing the ventral bending.
FUTURE FERTILITY
TREATMENT/ SURGICAL REPAIR Unilateral cryptochordism: 89%
Usually at 1 year of age General population: 93%
Flaps tubularized foreskin flaps, local skin Not significantly decreased
Grafts bladder mucosal, buccal mucosal, skin grafts Paternity rate:
o Bilateral cryptorchidism: 65%
TESTIS NOT IN SCROTUM o General population: 93%
Retractile Vanishing testes because of a hyperactive creamasteric
muscle TESTICULAR CANCER RISK
Maldescended Incompletely descended (cryptorchidism), out of 10% of testicular neoplasms arise from cryptorchid testis
normal pathway of descent (Ectopic) 10x more frequent than in normal testes
Absent agenesis Approximately 1% life time risk
The higher the testicle, the greater the risk.
CRYPTOCHORDISM 4x greater for abdominal testes than for inguinal
o If intra-abdominal in location, theres no way to monitor the
testicle. So if you bring it down, you will be able to palpate it or
have an ultrasound on a yearly basis.
Risk even for contralateral descended testis
Seminoma most common tumor
Orchidopexy probably doesn't reduce risk but allows surveillance

Figure 6. Undescended Left Testes URINARY INCONTINENCE

Repeated involuntary micrutition or wetting
Etiology is unknown, possibly due to testosterone deficiency
Incidence: (Glorer, 1964) 21% in premature infants (< 2500g), 2.7% in PEDIATRIC CAUSES OF URINARY INCONTINENCE
newborn, 0.8% at 8 months of age, 0.8 % in adults Structural
The more premature the baby is, the greater the chance of having o Ureteral duplication with ectopia
congenital anomalies in their sex organs o Extrophy-epispadias complex
Multiple Possible Sites o Posterior urethral valves
o Emergent at external ring: 70% o Urethral duplication
o Intracanalicular: 20% o Vesical fistula
o Intra-abdominal: 5% Neurogenic
o Absent: 5% o Myelodysplasia
Why fix it? o Sacral agenesis
o Histologic changes present by 1 year old o Spine trauma
o Allows surveillance for malignancy o Cerebral palsy
o Less prone to trauma Enuresis
o May enhance fertility potential o No evidence of urologic or neurogenic cause
o Fix associated hernia 20- 50% of the time o Maturational delay in urinary control
o Cosmesis
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 SURGERY II 6.6

COMPLETE BLADDER CONTROL

75% by age 3
90% by age 5
Unless there are other symptoms that indicate an organic cause, work-
up of a child less than 5 years old is NOT warranted
Work-up if:
o Daytime & night-time wetting
o History of UTI
o Dysfunctional voiding pattern
o Continuous wetting
o Significant physical signs ( neurologic)

Little boy made wee-wee on daddys back

-END-
GOODLUCK 2016B! STUDY HARD, STUDY SMART!

TEST YOURSELF!
1. 18-year-old male at the ER complained of left scrotal pain. He denied
history of trauma or sexual intercourse. PE revealed erythematous,
swollen, and tender left hemiscrotum. Prehn's sign is negative. The
diagnostic modality of choice would be:
a. KUB X-ray
b. CT urogram
c. Scrotal doppler ultrasound
d. DMSA scan

2. High flow color doppler showed increase in blood flow.

a. Normal testes
b. Testicular torsion
c. Epididymorchitis
d. Atrophic testicles

3. An 8 year old boy with recurrent UTI consulted at the OPD with low
grade fever, dysuria and poor appetite. PE findings are normal. The best
imaging modality is:
a. IVP
b. CT Urogram
c. MRI
d. VCUR

4. A 6y/o boy with a history of recurrent UTI underwent voiding

cystourethrography. Results revealed spinning top deformity. Your
impression will be?
a. Vesicoureteral reflux
b. Posterior urethral valve
c. Bladder exstrophy
d. Neurogenic bladder

Answers: C, C, D, B

Edited by: MJ Ng
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