This case-based presentation by UCSF Chief of Pediatric Urology Laurence S. Baskin, MD, provides clarity on which conditions are emergencies that need specialty care. Baskin discusses common urologic issues – including incontinence, urinary tract infections, hypospadias and circumcision complications – as well as useful imaging tests and optimal timing of treatments.
A guide to treating your child's constipation, wetting, and urinary tract infection is included for reference. we're going to talk about pediatric urology, which is obviously my passion and we're going to talk about emergencies and kind of when to refer. And I welcome questions. I think everybody knows our team. Uh mike cassandra. Oh uh and Hillary coffin myself. All of us work out of the East Bay and Hillary and I also at Mission Bay as well as our outreach and Moran and Modesto and walnut Creek. And we have a bunch of nurse practitioners who are awesome and also very helpful to our practice and uh angie previously bethany and Lucille. I'd like to do this. My kind of case based learning. We're going to try to do some zoom pulling for fun. I guess the diagnosis and our goals are to determine. Is this a pediatric urologic emergency and the need for referral? So let's go ahead and basically jump right in. Here's our first case. Uh This is a newborn with a hard painless testes I brought up the pole and each of the poll questions are exactly the same. Uh, is this a pediatric urologic emergency? Um, and should you refer this to uh, to our team and if you can go ahead and um, uh, click away, then we'll kind of see where reward. We'll do this for a number of different cases. All right. So, I think the polls going and why the poll is going, I am going to talk a little bit about what the diagnosis is here, which is of course neonatal torshavn. Now, I think as we all know, neonatal torches the spectrum. And this can happen either sometime in utero or right before little babies born. And the unfortunate thing here is that we never really get to catch this to the time when we can do something about it. In other words, the salvage rate of neonatal torshavn is less than really 1% and everybody pretty much has the right answer there. The issue with neonatal torshavn is that it's typically painless. There is no acute changes. In other words, when you're seeing this baby, he's completely healthy, you touch the testicle. It's a hard, painless mass. And what's happened is that the distortion has occurred uh either many days or even many weeks before we get a chance to see the patient. The focus and therefore me comes on the focus and it really is the health of the contra lateral tests. And we know if one test use twist in neonatal torshavn from about 0 to 6 months of age. There's a reasonable chance that the other one could twist and obviously if you lose both testes that suboptimal and pretty much of a crisis if you lose one and the other ones, pecs, test the chance of a normal life, normal testosterone or more fertility is basically close to 100%. So our focus in neonatal Torsten is really continental or Capex. E uh it's not as emergent, for example, as um adolescent portion. Because in a newborn period, our preference is not to operate in the 1st 24 to 48 hours of life. And preferably even to wait a few weeks if it's safe because of the increased risk of anesthesia. Could this hard, painless mass be a tumor? And the answer is that's extremely rare and that tumor wouldn't go away and torso ultimately would. So again, you need a torch in. Very hard to salvage definitely a referral. And then we make the decision where we're going to operate immediately, which would be unusual. Or within a week or two when the baby's physiology is healthy. Unlike adolescent or ship. Uh huh. Yeah. All right. What about a young child who presents with scrotal pain and the age range I'm thinking of here is 2-8 years and these symptoms tend to be self limiting. So I'm going to relaunch the pole if I can. There it is. Um, is this a pediatric urologic emergency? And do we need to refer to a pediatric urologist? So, what we're kind of seeing here and I know it's a little bit hard is the classic blue dot sign. And this is not torching of the tests. As I think you all know, this is tor shin of the appendix testis. The appendix testis of course, is a malaria in remnant little structure that comes off the testes that essentially melts away, melts away and um allows uh, what would have formed the uterus if there wasn't uh, malaria inhibiting substance hormone. Um, the pain is typically slight. In fact, I think most of the time that portion of the appendix testis occurs uh is and here's our poll results. Everybody's I think on with this one uh typically I think occurs and we don't actually know that it's happening because the child might be a little bit irritable, but then that goes away on occasion. However, you can get a reactive hydro seal, it can be quite painful. And the key here is really to diagnose and confirm that this is torching the appendix testis and that it's non operative and we can do that with a good physical exam and occasionally ultrasound. So torching of the appendix testis occurs approximately age two years to eight years. It's torching of that malaria and remnant this is earlier in my career when I operated on this patient because I didn't um couldn't make the proper diagnosis and didn't have ultrasound to rule it out. So you can see the normal testes, the normal epidemics. And here's that little appendix that basically in across and twisted. And uh this is typically self limiting. Okay, here's a very uh slightly different scenario. You've got a baby, you've got an inaugural mass uh and pain. And is this a pediatric uh urologic emergency? And the answer is, let's get rid of the poll here, definitely. This is actually torch in of the appendix testis. And um this is more typically when you would see that followed, you would think of a hernia. So that would be your most common diagnosis. But we know patients with undescended testes have an increased incidence of hernia and portion and in this case that was torched in of an undescended testes. So that would be, especially if there's pain involved, that Charles often won't be eating. That would be an immediate referral basically to the emergency room or a phone call where we get that kid went right away to try to fix this in the hopes of um saving the tests, but also in the hopes of making sure that there's no bow, which can also be quite severe group. All right. This is what we is more common and I think everybody's quite familiar with this and this is torshavn of uh, the actual testicle in an adolescent. And um, there's a lot of focus on the physical examination here, I think. But the history is, I think this is important. Almost all these kids who are teenagers are nauseated, uh and or have vomited, um, teenagers who are in Hungary. That in itself is a sign that they're sick. Physical examinations important, but without actually palpate in the testes. If you see a high writing tests in this case, the left testicle is supposed to be lower than the right or if it's quite swollen, that's really Torsten until proven otherwise. I'm going to share the results of the poll. Was basically shows yes. This is absolutely 100% of pediatric urology emergency. 100% referral. We have our E. R. Is really tuned into this where if a patient if you call us instead of patient the er with testicular pain, you know and you suspect torso and they will actually call us before before they arrive. We'll notify the operating room and our goal. And we've been pretty good at this. The last fears as I get them to the your within an hour, we typically have eight hours from the time this occurs. I think the unfortunate thing about Torshavn is that our patients who are a little more stoic have the worst outcomes because if they wait a day or so or they wake up in the middle of night and wait till morning, it can often be often be too late. Here's our example of what we find in the operating room on a patient who presented late. Obviously the left testicle is not in great shape. Our focus here again is on the healthy testes, so we bring that out, we pecs that down and these kids actually will do super well with really no long term issues. Um, I have not not been an advocate to put a fake test is in for these patients. Parents often asset as well as the patient with one test is the scrotum seems to fill up and made you just fine. Okay, So um we've covered kind of pain in the testes, which can be certainly painful for the patient. There's some certainly morbidity involved that they use the testicle, but if it's just one and we fix the other one down, I think the chance of them having a long healthy life, fertility, um Normal puberty and sexual functions quite good. All right. What about undescended testes? That's one of the most common things we see. When should we refer? When should we do imaging? Um And the bottom line is we know that the testes descends typically at the second trimester beginning in the third trimester. Um But with patients who are born with undescended testes, that would be about 3% of newborn males. But by three months of age that test that tests that was undescended, two thirds of those will become descended. Therefore, our general recommendation for a undescended testes that is palpable is not to refer till after six months of age because we want to give kind of nature to take its course If it's non palpable, I think the general consensus now which is not It doesn't need to be written in stone, but a little early referral at 3-4 months of age so we can get them on the schedule at six months of age I think is better because our outcomes are better than earlier. We go for the inter abdominal chest user. The non palpable testes test the start up near the kidney, they send down into the scrotum 3%. As I mentioned, newborns have an undescended testes drops to 1% at six months of age. We also have a small minority, about 1% where the test is is not really understand. It is just went to the wrong spot. The so called ectopic testis which is treated in the same way as an undescended testes. What are the indications for surgery? Um For unilateral undescended testes, fertility is not particularly an issue. Although I would tell the families we want to try to protect the fertility potential of that abnormal testes by bringing it down as early as possible. The good testes will typically take care of business. We want to decrease cancer risk back to baseline. So that's another reason to get it down. We want to reduce the risk of trauma which seems to be higher for an undescended testes as well as torso. And I showed you a picture of a tourist on the Senate tests. And finally if you're a male it's nice to be normal and have your tests in the right spot. So summarizing six months of days for referral 3-4 months if it's not palpable. Here's some data on fertility. If you do an early or Capex e you can see that the germ cells look good there stich um Looks good. There's light excels. This is what it's supposed to be. And I would just compare that if you wait till age 48 10 or a teenager you can see the germ cells have. There's a lot less of them a number. And also there's a lot of fibrosis. So early orchid Ipek see the better for fertility potential. And that's certainly german with bilateral disease. Which fertility could certainly be an issue. When do we image for undescended testes? And the answer is never I think concept when we have an exception. But what do I mean by that? When you send a patient in and they get a sonogram and we find the testes in the wrong spot, we fix it. If we don't find the tests we still have to look because ultrasound is not perfect and we can often miss an inter abdominal testes so it doesn't really change our management. We really base it on physical examination. Also if you image and the testes is in the inguinal canal but it's very mobile. It might get confused as a retractable testes which is indeed a normal testes and just needs to be followed of course like in anything in medicine, there are exceptions. So I reserve imaging for patients with an increase BME and here's an example of an M. R. On a patient with an undescended testes and the MRI shows the testes you can see with the yellow arrow in the inguinal canal. That's important for me to know because of its abdominal. I would do laparoscopy England. We we do it open and um it's just impossible to do a good physical exam here and feel the test. So 2 to 3 times a year I will do M. R. For understanding tests and patients with an increased BMI lot of semantics would understand the testes. And as a reminder I think we all know this. A retractable testes is a normal testes and a sending testes is a true understanding testes. An ascending testes was most likely attests that was previously down or retractable. But as the patient grew and now moved into a spot where it's clearly undescended. And this is an explanation at least for me is why sometimes see kids who are four or five whose testes was down during the 1st 34 years well documented on your exams. And then all of a sudden it becomes undescended. Well it's not that we miss an undescended testes. This kid just grew so fast that the testes couldn't keep up with them. Hence, treatment of an ascending testes is like an understanding testes and an important part of our kind of well check exams. Um what's our goal? Just like this little guy we want. The test seems to be in the right spot so they stay healthy. Okay, let's talk a little bit about circumcision. Um and circumcision issues. Here's a whole smattering of pictures and the bottom line is if you look at this, you would say circumcision is dangerous. But if remember that two million kids a year approximately are being circumcised, United States. If we have Less than 1% complication rate, that's still going to be the occasional child. So what are the complications of what do we need to worry about? I think a or when you look at this picture, this is a child who is going to give you the classic history from the parents when they're three or four. That when he pees, the urinary stream will basically be deflected upward and he'll need to push his penis between his legs to get the urinary stream into the toilet. And he has middle cyanosis, which is a super well known complication of anybody who's been circumcised. What's the treatment? Well, me autonomy, which is an operation. Is there a prevention? Theoretically everybody who circumcised if if they were to dab a little bit of Vaseline or maybe ky jelly on the latest to prevent any irritation from the penis in the urine in the diaper that would prevent it. But the bottom line, since this is so rare to begin with, it seems like kind of overkill to prevent it. But it's certainly a real problem and we certainly take care of it. And kids who are uncircumcised don't get it because the force can protect them. You hate us. Then we have kind of our regular issues from Asus which is not responsive to steroid cream or circumcision where the penis kind of retracts back and you get kind of a sick of tricks or scarring a neonatal circumcision that separated and you end up with skin bridges that can typically be taken care of the office at age 3-4 with some Emily cream and just clipping these little bridges. Too much skin, more severe complications when using like a gamco clamp for example, which I'll show a picture of in a sec. Uh the penal shaft skin was circumcised and not the foreskin, fortunate this is super rare. Other examples of issues where too aggressive with the gamco clamp and you have basically fish july created from crush injuries. And finally, this is not a circumcision injury, but a patient has a congenital fistula. So circumcision uh in my experience, everybody's super get it at super safe. But on rare, rare occasion we do see some issues. And I guess I would characterize those by the acute issues of bleeding which was taken care of by pressure. Uh that doesn't go away. That's reason to referral. Give us a call. Uh the other reason to call us, if God forbid there is an amputation. Our experience with that is that is typically a little bit of the glands and that can be put back on and the kids actually do great. So if that unfortunate thing uh comes to anybody's attention, you want to save the body part, put it on ice and send them to us asap everything else. Well, infection is super rare. Typically just taken care of with antibiotics and local care call if there's any issues but that usually is self limiting. And then the other things if there's problems that I would call more chronic like skin skin issues, too much skin, too little skin skin bridges from Asus. Those are electoral referrals that are typically hopefully we can take care of those in the office. Okay. What about hip asparagus? Um Hip asparagus is one of uh my favorite things to take care of because I think we can do a great job with it. It's still pretty common. We don't really understand the ideology occurs about one and 250 newborn males and possibly environmental influence can affect it. I think the key points I want to make make here is like when to refer and when do we just leave it alone and not worry about it because not all hyperspeed Ius needs to be fixed. Um And I think the best way to describe that is to better characterize what hipaa speediest is. Um which is not just an abnormal location of the regional status um but often associated with abnormal foreskin development and penal curvature. Um We don't do anything until six months of age, but I like to see the patients you know pretty early at a month to two months because I think they're worried about it. I think counseling is good to kind of relieve anxiety for the families um that there's really nothing wrong with their kid for regular standard high pasta ideas which I'll talk about. We don't need a work up, we don't need an ultrasound. And m are we know that this is just localized to the penis. And embry logically, we know that the penis kind of forms later in gestation after kind of all the other important stuff. So this is some of the hippo space we see and I would kind of classify this as the form free stuff, hip asparagus or such a minor defect that we don't recommend anything be done. And that's when you see like, you know what we think is two openings and the family says, yeah, he's got two openings. But if we look carefully, the the arrow, the white arrow is actually where the urethra is a black arrow is kind of a blinding pit. And unless this patient's having some other procedure or whatever, we would not recommend this being fixed is really of no consequence. The child can avoid normally normal sexual function, etcetera. So glandular hypothesis piteous. Um in my mind is something that we can follow with no clinical ramifications. Here's another what we call form fruits of hip asparagus and these are patients with a normal yuri throughout. But they have an asymmetric for skip. And the problem here, as you guys know is that the devices we use for circumcision, the gamco clamp, the plaster bell and the bogen clamp. They only work if you have a symmetric foreskin. So these are patients whose family wish to circumcision. And my take on this would be I would I would not recommend to try a neonatal circumcision without a circumferential force. And unless you're a super expert, I think it's a bit tricky. And we would do a formal circumcision at six months of age or a year or two of age in the operating room to avoid having any issues. So that would be one kind of uh referral. If the family was not interested in a circumcision. Fine. I think this kid will do just fine without the need for any surgery. Mhm. Here's a more standard hip asparagus. Um These are a little more mild because the opening is not quite where it's supposed to be. Um It's actually this is kind of normal development and you can imagine arrested development somewhere down here. Uh This is more severe hypoxia radius as the opening moves further approximately. And um these are patients who I think definitely need surgical reconstruction again at six months of age and even more severe hip asparagus. And when we see patients like this, I like to call it kind of varsity or severe hip asparagus. And what I mean by that is that the head of the penis may be smaller than normal. The force can maybe fused there maybe pedal scrotal transposition. And these are patients that in 2020 were starting to work up and look for genomic causes. And they, they basically fall in the category of a disorder of sex development. And we're finding very specific genes like five alpha reductase based or these jeans I've never heard of until the last few years and are five a one Wilms tumor gene, which we've heard of for Wilms tumor but also causes a typical genitalia. And some of these genes. When we make these diagnosis of these gender defects, it's important because they have ramifications for other issues. So varsity hip asparagus, that's the real deal. We do a work up in conjunction with our endocrine and genetics team were doing genomics now and finding some interesting things and these patients typically will need what I would call a two stage repair um, to get their penis, uh, you know, functional and working. So that brings us to a typical genitalia and I think we'll relaunch our poll here. I'm curious to see what people think about this. But these are patients who we used to call intersects or we used to call ambiguous genitalia. I don't know if a typical genitalia is a better term, but that's what we're using in 2020. And the most common diagnosis we see here, which is an emergency type diagnosis um is a congenital hyperplasia. I'm watching everybody vote here. I think I'll go a little bit longer. Um And everybody remembers this pathway which I know you've memorized and is near and dear to my heart. But in general dinner hyperplasia can be life threatening. And I think the key there is if you have a patient with high pasta tedious or atypical genitalia and you don't palpate go nads, then immediately you have to start thinking, is this a child who was very realized from an enzymatic defect and is genetically um X. X. And um this would be examples of congenital adrenal hyperplasia up here in the top row. Um And it can be so severe of course that it kind of looks just like a normal penis but more commonly it looks like C. And D. Where you have clitoral visualization. But no palpable go nance. We also of course have patients with other unusual uh causes of sort of sex development. This is five alpha reductase androgen insensitivity, Mexico Natalie's genesis. Uh This is a genomic defect, high pasta tedious. This is over testicular syndrome. And I think that take home message here is and all of you agreed is that I'm going to share the pole. Here we go. Everybody agreed 100% that these should be referred. And the question is timing. Um And if you don't suspect in general, you know, hyperplasia and that's been ruled out by you palpate tests and then it can be controlled. You know, hyperplasia. I don't think it's an emergency. We have our multidisciplinary clinic at Oakland as well as at Mission Bay with our big team. And genomics have played a big part in this to help with diagnosis and to sort these patients out who I think overall can do quite well. Other examples of disorders of sex development would be classical. Extra fee, you know, rare stuff. But obviously this is going to get referred right away because of the severity of the abdominal wall defect. These are a little tricky because you have to determine the sex. Khloe. Co anomalies are a little more straightforward because they're always females, but they need to diverting colostomy. So these are emergencies that we're all familiar with and on a much more it needs to be set. Okay, let's focus on some of the more common stuff in the last part of the lecture. And this is a two day old uh prenatal diagnosis hiding necrosis. Sometimes we get to see those studies. Sometimes we just get a written report post natally. This patient, the left kidney is perfectly normal, but the right kidney, the black area is basically the hydro necrosis. And let's relax the poll to see what everybody's thinking here in terms of referral. Is this a pediatric urologic emergency? And does this patient need referral? And uh, the answer is if its unilateral, it's unilateral most of the time, this is not an emergency. Okay, so people are voting. Let's just talk a little bit about the differential diagnosis of prenatal hydro necrosis and some of the factors. And one of the key points is that as the baby is born and in a few days after birth, the baby's changing the physiology for mom to themselves. So for you, an ultrasound on day one of life in a healthy baby, they're essentially, they kind of look like they're physiologically dehydrated, they're kind of adjusting. And so what happens practically, as we underestimate the level of height and a throw sis. So if you're interested on day one, as normal as possible and on day three weeks or four weeks could actually be abnormal enough. That would be concerned about it. So, our philosophy and stuff for certain circumstances. We try to avoid doing the ultrasound on day one or two of life, which is inconvenient because in the hospital it's nice to get it done, but at least way today to of life, if possible. And I think we do we get a little more accurate assessment of the height and atrocious. So what's in our differential you? Re grow pelvic junction type obstruction where you have a blockage up here, you're a troll testicle type obstruction, where the blocks is down where the ureter meets the bladder. Physical, you read or reflux or backwash of urine. All of these are kind of detectable on prenatal studies, but we can't confirm the diagnosis to do the post natal study. We also have blockages from your uterus seal, which is like a bubble in the bladder the year. That goes to the wrong spot. And what's super important is we don't want to miss posterior urethral valves, which often affects both kidneys and that is an emergency that we'd want to see, you know, kind of right away. Um, so I'm going to share the pole. I think we have kind of what I would expect. These patients should be referred. But it's really a question of timing. And that was suggested here by the variable response. Okay so I'm gonna go over each one of these specifically for you P. J. Obstruction or you read or pelvic junction obstruction if it's severe and we grade this kind of one through three. So if it's a great for like this uh these patients are almost always at some point going to get surgery, they need to be referred. Not on day one of life. I think day week of life for two weeks of life is fine. We used to be aggressive with prophylactic antibiotics but not so much anymore. Especially for this. Do they have symptoms? I guess it's possible. But typically we don't see babies where the symptoms or if they do we we say it's colic and we'll let you guys deal with it. I think it's unusual for them to have symptoms and the ones that are old enough to talk to us. Even with big dilated kid, you seem to be okay. The key point here is that the great for hydro necrosis. Yeah that's a problem. But the grades one and two that's a variation of normal. And we don't need to do anything there. We don't need to do a V. C. G. We don't need to do antibiotics. We basically need to kind of sign off and say have a great life. So we don't want to overreact to the minimal grades and high. Gonna throw sis. What about mega your orders? Where the blockage is here? Um back in the day, way back in the day when I was a fellow, we would operate on a lot of these patients. Um But now we know actually, even if the order is super dilated. If there's no reflux, no back loss of urine. So we do do a V. C. G. When the order is super big to rule out reflux. If it's basically non obstructive mega ureter with big your order. If we follow them over time the ureter thins down without surgery. So this is typically a non operative disease. And contrast that to vesicular reader reflux where the BCG so is massive reflux. That's a problem and that we treat with antibiotics. Mhm. Everybody is familiar with multi system this plastic kidneys. So as long as the other kidney and again it's like torture and we want to focus on the good kidney as long as the other kidneys in great shape. And in fact if we document the other kidney um undergoes competitor hypertrophy uh then we don't need to do anything. What about posterior throw valves? That's an issue if we suspect that. And we often do prenatal because the bladder is thickened and abnormal. And here is the recipe for example where the bladder itself you can see is very abnormal. And here's the posterior urethra which is quite dilated. These kids as we know are at risk for renal insufficiency. Ut continents and very abnormal bladder function. It's not really a valve, it's more of a membrane. And the idea is to respect that membrane. But once you respect it, everything doesn't go back to normal. And these kids typically, we need a lifelong follow up. We see approximately a third of them who are quite severe. The other third actually are pretty mild and I think a third are so severe. They die in utero. So it's quite a spectrum and this would be an immediate referral. So it kind of summarized in hydro necrosis. Um for you p. J. obstruction or if we're worried about that we do a sonogram. If it's super severe we do a nuclear medicine study. The so called Mag three follow up is usually 3 to 4 weeks. Even for bilaterals for mega your eaters we do a V. C. G. To rule out severe reflux. Follow 3-4 weeks multi systems plastic kidneys, ultrasounds. All we need for 46 weeks. The reader is still Follow up 1-2 weeks at topic. Your order 1-2 weeks valves less than one week. Okay. And finally I'd like to touch a little bit on uh one of the most common things that we see and that would be urinary tract infections, uh daytime incontinence and constipation. And you can see I lumped those all into one category and the reason I did that because I think we treat them all the same and right up front. Although I don't recommend an ultrasound for these. If you get a normal ultrasound, if you get an ultrasound it's going to be normal. I would contrast that the patients who are more severe like high grade reflux occurs who present with infection and their case the ultrasound is going to be abnormal. So we typically start for these patients with a good physical exam. Obviously this are you know, super severe abnormalities in the back. But sometimes it can be more subtle spinal dimple. You definitely don't want to miss neurasthenic causes of all of this. We then do a voiding diary and we can estimate bladder capacity. We rule out constipation kind of make the assumption that almost everybody is constipated. Why is constipation issue? Because the fecal mass will press them on the back of the bladder and give them mixed messages. Mhm. Some kids require super aggressive uh care here. Clean out enemas. And um we think we can pretty much take care of this with voiding diaries and rarely have to do invasive Euro dynamics. A shout out to our nurse practitioner team. Um We spent a lot of time putting this uh hand out together which is available on our website. Uh Eight pages of beautiful color guide treating your child with constipation, wedding and urinary tract infections. And the families are finding this super helpful and telehealth has actually been super effective for the treatment of this too. Right? Um We didn't cover a lot of stuff because we can't cover everything in an hour and just want to remind you about cancer, trauma, spina, bifida stones, obstructed vaginas. Those are I think pretty straightforward and obvious that we could help out with that. Um, I would like to shout out to our team a little video. Mhm. And do not hesitate to contest that. Contact us. I hope I got all the right numbers up here. Um, we're a Mission Bay in Oakland as well as all of our outreach places. Shoot me an email if you have any questions, Uh, glad to talk to you with you guys any time and thanks for your attention. Mm.