A specialist in bowel and bladder dysfunction, Bethany Geleris, PNP, MSN, offers a refresher on what’s anatomically and functionally normal in foreskins, testicle retraction and voiding control, then provides steps to appropriate management of such conditions as phimosis, undescended testicles and incontinence. Her how-to pointers include taking a useful history; distinguishing undescended testicles from retractile ones; and talking to parents about sensitive issues, including circumcision and urinary control delays. Find out why she says, “Good poopers make good pee-ers!”
So I'm going to introduce our speakers. We have Dr Michael D. Sandra, who is one of our pediatric neurologist and his expertise is in surgery for urinary disorders for Children. And then we have Bethany galleries. Sorry? Um She is one of our nurse practitioners in neurology and she specializes in caring for patients with bowel and bladder dysfunction which can cause incontinence and urinary tract infection, diarrhea and constipation. So I'm going to hand this over to them. Um Oh and one more thing. Please fill out your evaluations at the end so you can get credit. Um You'll find there will be a link that um comes up at the end of our lecture and also you'll get an email um tomorrow if you did not fill it out you only have to fill it out once but you cannot get credit unless you fill out the form. So please don't forget to do that. Okay so I'm gonna stop sharing and let Bethenny and dr december take over. Thanks. Hello everybody. Um In true presentation fashion the microphone isn't working on my computer today. So I have this lovely black straw microphone. So if you ever can't hear me, wave chat me, let me know but I'm Bethany on the screen you'll see my dog Ollie. Unfortunately I didn't get dr cassandra's dogs but he also has two adorable dogs. And today we are going to talk about urology for the primary care provider. So a lot about the foreskin. We're gonna talk about testicles and then we're gonna talk about Bell bladder dysfunction which includes incontinence, urgency frequency. You frequent U. T. I. S. And different things like that to get started. I actually fortunate enough to have a video for you guys this morning shared with permission from the parents. And this is a patient I saw today. We can't see the video yet. That's me. I'm watching it. You have to switch over let me switch over the screen. Yeah and I meant to say there will be a lot of photos in this presentation. So if you are in a Starbucks or something you should probably hide your screen because there are a lot of penises and testicles in this presentation. So in this patient was referred to me for concerned about time. Asus and the family had been given steroid cream which they used twice a day for um three months before I saw them again. And um. Mhm. And the family had never pulled back the foreskin. They had tried they moved it a little bit. Mom was concerned that there was some redness to the tip which I think you saw in the video and what it really happened was mom didn't know how to pull back the foreskin and it looks really scary. But what I wanted to point out is the baby was perfectly fine the whole time he was actually breastfeeding while I was doing that. Um So he was comfortable. He didn't seems like painful. It looks painful. It looks scary because it's not something that most people do regularly but that's a perfectly healthy normal foreskin. Mom is able to pull it back um regularly in the bath, clean it with water and then always of course return it forward when she's done what we're talking about today's, you know, nemesis, the inability to retract the foreskin covering the head of the penis. There's normal physiologic nemesis which is where it's a little bit tight in a newborn and then there's pathologic and I have a lot of pictures of what would be pathologic physiologic nemesis is normal. It usually resolves around A. G. But it can continue um foreskin adhesions which is where the foreskin is a little bit stuck to the glands is also normal and separation occurs over time we treat it if there's a problem if it's hurting patients if they're getting infections, if they can't clean it it's itchy or ballooning with peeing, it's definitely should be treated well treated families concerned about it. But most of the time it just kind of resolves as um Children have directions that kind of stretch out. The demotic bring this would be a normal kind of physiologic nemesis that we can treat. We can use the steroid cream or over time it will stretch out. Pathologic nemesis, as the name implies, does not resolve without surgical intervention. It's when it often happens when the skin has been pulled back and it's cracked and dry and kind of like eczema itchy skin that heals thicker and scars over, over and over again to the point where it can't be pulled back at all. So, if you look in these pictures, you can see this skin is like white scar tissue and that's not gonna stretch, scar tissue is not gonna stretch. So this would be a patient that would have needed a circumcision. Again, this is some pretty thick scarring when this patient peas. I imagine there's probably a lot of ballooning because the urine gets trapped under the foreskin and then leaks out later. Uh the treatment is retracting the skin twice a day. We use triumphs alone alone steroid cream that you can also use data, methadone or hydrocortisone 2.5. Um physiologic nemesis doesn't often require circumcision. Um Family has chosen not to circumcise up to this point. We respect that decision that they made, urge them to just care for the skin. And my analogy is in the same way that you have to continuously brush your teeth and care for your teeth. You have to continuously care for this part of your body and and take care of it and cleaning pathologic nemesis, curious circumcision. Now, a lot of pediatricians are having conversations like, well, should should everyone just get circumcised. Should no one get circumcised? It is a hot topic with a lot of emotion behind it um benefits are huge reduction in risk of penile cancer. However, the risk of penile cancer in regards to the poor skin, it's kind of only present if it's never clean. So the risk isn't really there. If you're able to retract the foreskin and clean the penis and that's later in life. It's not a risk for young Children or infants. Um It can be a reduction in the risk of U. T. I. During infancy. You've reduced instance of vallon itis or prostatitis such as infections of the clans and elimination of nemesis obviously because there is no formal agreeing to be tight. Don't we do a circumcision, newborn circumcision will not be done if there's a family history of bleeding disorder tedious, you don't want to do a circumcision because we need that for skin for the reconstruction. A buried penis is um It's difficult because the penis can sometimes stick out and then later be buried their babies being wait, they get a little chub and the penis is kind of stuck on the inside. Um And so you cut like if there's a circumcision done and open cut, that skin will heal to whatever it's constantly touching. So if the penis is really buried on the inside then it's healing and penises can get a little bit trapped on the inside and in the um situation of Cordy, we don't want to do a newborn circumcision. There are some pictures of hipAA spade Ius. So you can see that the is below the tip of the penis. Um Glandular hipAA radius and this shows various degrees of hipAA radius. Oftentimes in mild is still high pasta ideas. Um We don't recommend uh hipAA stadio surgery because the hole is so close to the tip that it functions normally. It doesn't affect paternity. Um and it's not really something people are, people will see or be concerned with. Kids will be able to pee normally. So it's not really a problem. And that's something like this picture right now, pretty bending as a people, a picture of a buried penis and why you wouldn't really want to do a newborn circumcision on this Because if you cut off the skin then where's the peanut? You kind of have to dig out the penis surgery. The pearls. This is often referred to me under the concern of cysts or tumors. And it's a normal natural build up of dead skin cells. It can be itchy. It can be worrisome because it grows and then one day white stuff pops out. Also often confuse with a fungal infection because it is kind of like a cottage cheese discharge. But it is just a build up of dead skin cells from a foreskin where there's either adhesion. So the skin can be pulled all the way back and the dead skin cells can't be washed out or the family isn't regularly washing out. We've gone over this slide terrifying. Most verify moses is when the thematic ring gets stuck behind the glands as you can see here. So the skin was pulled back, it got stuck and now there's all this swelling in both the glands and the foreskin. It's a medical emergency, patients need to come to the emergency room for reduction where the treatment is basically squeezed pain control and then squeeze the, pull the skin forward quickly as we can. Um and it's preventable by always returning the foreskin forward after cleaning or after retracting recently because I've seen an influx of patients who have said like, oh, we just didn't know we always wanted to get circumcised, but no one ever talked to us about it. And so, um, something to be aware of is, you know, our office doesn't do newborn circumcisions. There are practices in the community and, but there's an age limit and a weight limit for them to be done in the office after that period of time we wait until they're closer to eight months and 98 or nine months of age because it has to be done under anesthesia, it becomes surgery, it becomes a bigger deal. And um, insurance insurance decides if they pay for it most of the time they do and I have had instances where they said no and I don't understand why. Um, so it's a little challenging because the family wanted it and insurance said they wouldn't pay for it. It's quite expensive to pay for out of pocket. Um, and a lot of cultures have different timelines for circumcisions, some cultures say two years old, some cultures say seven years old. And so being aware that if it's something the family might want in the future, it's worth having the conversation. Is it okay to do now? Um Is there any reason to wait because medically speaking, there is no reason to wait if it is something that they want and it's safer to do it as a newborn than it is to wait and do it under anesthesia later for the post op care for patients that didn't get the newborn circumcision, the, you know, slide pretty much outlines everything. It's not a deep cut, it's, you know, just cutting off some skin, but it is a really private area with high blood flow so it gets a lot of swelling. You do wanna manage pain with Tylenol Motrin and keep it covered with Vaseline a off before. And one thing I always say to families, like we tend to use creams and lotions, like we're just like, you know, covering the area when it comes to this, I say, like dig your fingers and spread it all the way around, create a barrier so that the cut isn't rubbing in the diaper because the cut, rubbing against the diaper causes friction, which causes a little bit of bleeding, which really is scary. Um The sutures used for circumcision dissolve naturally, so you don't have to get them taken out, they fall out over six weeks and um they're usually depending on the age, but they're usually back to normal in a day or two. This looks ugly after circumcision, There's a lot of blood flow there, it's swollen, it gets purple e it gets a little bruised, um It looks scary. I let families know that that's normal abnormal bleeding, as if it's actively bleeding, drops of blood are coming off of the penis. We definitely want to know about that, that's not normal. And, you know, it could be a sign of a bleeding disorder or something else that should be looked into if like we went over before with the berry penis. It's always possible that skin from this part of the penis heals to this part and causes adhesions, that we would need to try and break up while they're nice and thin before they get thick informed and would need a revision later care of the uncircumcised penis, There's not really any special care needed in infancy and, you know, kind of gently opening up the skin so water can flow in in the back and kind of cleaning house, teaching Children to pull it back gently over time and keep it clean as they potty train and start showering on their own and do all those things. It's good pickles, retract tile versus undescended balls, The testicles that don't go down into the scrotum. Um the overactive hysteric reflex makes the testicles seem like it's not going down into the scrotum but really it's just bouncing up and down really quickly because as we know, testicles will move up and down in response to cold and stress. So what do we do with little kids? Right? We put them in a cold doctor's office, make them get naked, make them scared and cry. And then we're like, oh the testicles are missing trying to calm the kids down gently, pulling the testicle down. If you can't feel it, trying to feel, I'm pulling it down. Um If it stays in the scrotum for the California test or the Mississippi test for that many, you know, second syllables. Um Then forever concerned, we're more than happy to check and feel and you don't need to worry about it. The big takeaways that ultrasounds really aren't helpful in determining the difference between undescended and retracted testicles. With ultrasounds, we squirt cold jelly right on the testicles. Even if they're not retractable, that's enough to make them shoot on up away from the cold to try and protect themselves. So you don't need to be ordering ultrasounds on these patients. Um diagnosis is based on physics exam, but retractable testicles are not dangerous. There's no higher instance of of cancer pathology. It's a normal part of childhood and as the testicular volume increases, the cremaster muscle will relax and the testicles will stay in the score no more descended testicles is when the test develops in the abdomen and doesn't migrate down to the scrotum. Um For birth diagnosed based on physical exam treatment is surgical correction. It's anarchy a Pepsi and there's like a hernia there because there's a hole that it went, it didn't go through the canal and so that will be repaired at the same time. Surgery is a same day procedure usually done around one year of age and um, it is done under general anesthesia. There are often two incisions. It could be one and then if the testicle has never been felt before, there could also be an incision in the belly button where the camera was put in to look and find it. Um, there's always a chance that if the testicle is really high up, it could be a two part procedure done six months apart. Um, down as you can let the blood flow re re um, but the book reestablished and then bringing the rest of the way down, freeze rest for two or three days. This has done an older child, seven or eight year old's parents often say they walk like a cowboy for several days and no sports spirit strenuous activity for about two weeks, no bikes, no monkey bars, Nothing that could hit them in that area. Here's my uh, fancy little history of incontinence, it's clearly been a problem for a long time because as early as 15 50 Bc, there were treatments for it. Um, and the treatments are varying. I do have to say my favorite one is that as in the 19 seventies in Nigeria frogs were the child's penis so that when the child started to pee, it woke up the frog who croaked which then woke up the child. So they could be outside. Which I think it's just using your resources very interesting. His accident, the accident leaking urine, There's a neuro genic or functional incontinence um functional incontinence also development. Normally kids babies stop pooping overnight when they're sleeping again. Nocturnal bowel control and then they gain daytime bowel control. Then they gain daytime p control. Which is when most parents start potty training, then they gain nighttime control. But a lot of times that doesn't happen. And um it is a really really high stress burden on families. It often is referred to as the great family secrets and people are have a lot of shame around this. Um There is a lot of concern like what did I do wrong and most likely nothing and there is a genetic component and there's things that we can is work on poop it now. I know because I read the referrals and I recognize a lot of names, the families say that they're not constipated and I believe that I believe that their child poops every day, but I also know that pooping and peeing are really closely related to each other. So even in a perfect poop history, we still are probably going to work on the pooping because good poopers make good peers, Here's why this rectum muscle kind of becomes the bully of the G. U. Area. What happens gets stretched out really easily. Its job is to hold on to poop. That's what it's supposed to do. It holds on to it and it is a good soldier and it will not let it go. But over time it stretches out because it's totally under poop and you can poop every day. But this muscle has gotten stretched out, it's bigger than it should be, but you're emptying and every day you're pooping. But if this muscle is really big then it can squish the structures around it. And that's oftentimes when we that's the relationship between pooping and peeing and you can't see it because I mean we could do an X ray look for it but you can't see it in the daily habits because you can poop every day. This all this brown stuff could empty. But this muscle is still all stretched out. And so what we're trying to do with our treatment is we're trying to shrink this muscle down and then teach the bladder to squeeze an empty feeling The Bristol Stool chart is a fun um conversation, especially if the kids like you know 10. But They tell me they have type four poop every day. I'm still gonna be concerned with their pooping um on the screen. You'll see some questions for history that we ask. Um Is it only happening when you're playing Nintendo that rule out that there's probably not something bigger going on that well to pee before and after playing um are holding their p for long periods of time, then they're also holding the poop their muscles, those muscles are all connected. The muscles of are they drinking at all during the day? It's really hard. Our schools, kids have limited access to water bottles, They have limited access to the bathroom. They're not necessarily encouraged to go to the bathroom, It's more tolerated. And even in the best situation, a lot of maturity to say, I'm gonna leave my friends, I'm gonna leave this what? By myself, exam some of the things we're looking at, looking, noticing um federal dimples, it would make my concern greater that this is not just functional, that there could be a neural um neurasthenic component. Not it is a great way to make it really complicated, but oftentimes, you know, there's urgency, there's frequency, there's trial tries to pee, but their muscles on their perennial are so great that it's really hard to get the P out when they're sitting, peeing is a relaxing activity. But kids who want to be quickly become power peters and they push their pee out and that teaches their muscles to squeeze and then it makes it kind of harder to pee if that's the case. Um We offer biofeedback, which is a great, great way to teach um Children to relax those muscles? Underactive bladder? Little urge to avoid. Um No but times avoiding reminders would be really helpful with that giggle and then vaginal avoiding is really interesting because kids are peeing perfectly. But the way their anatomy is the hearing is traveling along the skin and re flexing up into the vagina. It's not dangerous. It's not causing any problems but when they stand up then you know move around it falls into the underwear. So it seems like they had an accident. They didn't really here for that is very simple of them like a cowboy cowgirl on the toilet. So put their feet really really wide. If they're in pants they might need to take one ft all the way out of the pan if they're young and we don't trust them to do that. Then just turn them around on the toilet and have them sit backwards facing the tank. And that will push the knees open and the urine will go straight into the water instead of along the scale. The thing is the initial treatment for all of these concerns including oftentimes um you know frequent U. T. I. S. And Children over the over the age of two who were previously healthy um Syria with negative urine cultures. All of these treatments would be the same. We talked a lot about you know causes of date of incontinence slide reviews. A lot of, I already talked about Children will always say parents will always say their child is not constipated and I believe that they poop every day. And I know that pooping is a big, big reason. Having a p problem indicates that there is a problem. More details on how we use them. You relax our new booklets, we just rewrote them. And so there's a lot of information in those and I know that Tabatha is going to distribute all of those. I like me relax, relax is my first choice. Um because it's a very safe medication. It is processed with a body like food is it just kind of goes through your tube. Um 99, of it is not absorbed in the body. It doesn't go through your liver kidneys. However, it's not drinking enough water. It just doesn't work. It's an osmotic laxative meaning it pulls liquid into the poop. But if there's no liquid you can take it every day. It just doesn't do anything. So that's a really big teaching point for families that they need the liquid with this medication. If for some reason there is an ideological view against me relax because one person in one study said something about um neurologic concerns that has been um well studied did not validate it at all. Um here are some other options for things that we can use. I typically recommend me relax because it works best. But here are other options. Um The next step is the most is the easiest most important thing to say. And the hardest thing to do, pee every two hours now, it sounds so easy and I talk about it all day long and I am a nurse practitioner and I don't see that often four hours. So we're asking kids to go almost twice as often as normal. There's some type of external reminder, some alarm, some adult telling them to go. So it shouldn't be that you need to feel like you need to pee every two hours. You need to go to the toilet and try and pee every two hours. Now we know you sit on the toilet a little bit will come out, especially if you're hitting your water bowls, which is the next step increasing water intake. And there's a nice chart in our booklets on how much water for how much, what age should be the goal. You always want to be concerned that if, you know cute onset accidents, especially overnight waking the child up, make sure we're not missing diabetes or infection. Um, if we do all this and there's no improvement. There are medications that can be used for overactive bladder as well accidents is a huge area of concern. What's wrong. Why aren't they killing it? What's going on? And oftentimes it's for a long, long periods of time and you kind of train your bladder not time. That's not exactly scientific, but it's the way I say it to the families, it's well received that way. But if you have a big old fecal mass pushing against the bladder? It's also fishing against the spine. And so that I believe has an effect on the sensation for the child that's vaginal avoiding already. And it's happening in an uncircumcised boy. It's likely ballooning of urine under the foreskin and pulling. No, you recommended all of this. You did a bowel program ongoing. Made me relax time avoiding increasing water intake. And they're still having daytime incontinent. See how it's going because it's hard to do. It's really, really hard to do. Um, we repeat cleanups. Cleanups on a one time thing. The holidays are coming up. Everybody is about to get constipated. It's winter. No one, it's dark at five o'clock. Kids aren't outside playing as much it's cold, they don't want to drink as much. Those are all things to consider. We're about to eat foods, richer foods, more foods. Winter vacation schedules are all thrown out? Clean outs are something that are ongoing care. It's not just a one time thing. And then we can also, What, what's happening? You do clean out later? How often are you actually able to go to the bathroom if you go every two hours? Are you staying dry? Are you having an accident at 90 minutes? What's what's going on and avoiding diary is really helpful. Um, and kind of figuring out what what to do next or what's truly happening in the home. Um, definitely consider a renal and bladder ultrasound. If the first step didn't help and then I want to see them. I want to know what's going on and and help the patient Our internal injuries. This is very common. The most interesting thing about nocturnal in your thesis is that it's highly genetic. So if one parent went to bed, there's a 40% chance the child will, both parents went to bed. There's a 70% chance the child will. And what's super interesting is that they tend to stop at the exact same age. The parents stopped, but I find it interesting, but that's a nice observation. Um There's three main reasons for how this happens. There's not really seeing vice President or and Children are avoiding in their deepest stage of sleep as well as the water dysfunction from the daytime, which we already talked about the treatments the same. We start with this with nighttime wedding. I really, really encouraged families to push their liquid earlier in the day and make sure they're drinking enough. Now this isn't exactly scientific. So, I know I'm talking to a group of um providers, but the way it explained is your kidneys have to build your blood, your kidney's don't make your p if you're holding it all day long and not giving your kidneys the food they need, which is water, then they're gonna filter your blood and work really hard when the muscles around them relax. So what we wanna do is we want to have you pee a lot during the day and drink a lot during the day. So your kidneys to filter through your blood. So they're not making as much P and a frequently during the day kind of training the body to work really hard and then help your kidneys relax at night, will help you know, solve this. Now we know that's not how the body works. Um and I say this to patients, I say this isn't scientific, but here's how I want you to think about it. And um that peeing frequently and drinking a lot, starting first thing in the morning and they stopped drinking at a certain time. It doesn't work. But they do say that if you're drinking all day long, you're not quite as thirsty at night. So what happens, what I see happening is that kids don't want to drink water at school or they forget or they have like a little bit, they get home from school and they're so thirsty, their body needing liquid. And so then they're drinking all their water from you know, three o'clock till nine o'clock and then they have to pee all night. Um So we're trying to shift that to start, you know drinking at seven a.m. And all day long 19 morning will never get better before day time's up. You have to follow the natural progression nature uses, which I went over in the beginning, which is 19 pooping daytime pooping nighttime peeing a champagne night on. Um And so it's the same progression. If we bladder dysfunction stuff and child not getting better, then we get to move on to the bed, wetting alarm instructions that come in the package, There's zero expectation that child up. We know the child is having an accident in the deepest stage of sleep, waking up from a deep stage of sleep is really, really hard. However, we'll wake everyone else in the house up. So I encourage a parent to sleep with the child if we're getting to the bedwetting one, encouraged a parent to sleep in a room near a child and when the alarm goes off, wake the child up, make sure they're awake. Give them a math problem, give them something to remember, you do something so that the child's brain can associate the feeling of fullness with needing to actually wake up. Um It only is a successful night if the child remembers waking up in the middle of the night, if they stuff and they don't remember it then they weren't drawn out of that deep stage of sleep and they were just kind of going through that like twilighting motion, wanna keep making sure they wake it up. Treatment takes takes a while and it takes a high commitment. So I encourage families not to do this until the child has demonstrated their commitment by peeing every two hours by initiating, taking their medicine every day. Um And by showing kind of that maturity that they really want this to stop because this is disruptive to the family, to the whole basically the whole house because the alarms are really loud. Um So it only works with a lot of buy in things that don't work waking up at random intervals over the night. Um It's a big stress around the family logically I get it. It makes sense. It just doesn't fix any issue like it just doesn't work. Um And that's for example when you know mom's like oh yeah before I go to bed at 11 I just wake kids up and then I wake up at three, make sure they go pee. Um It's already had an accident by the time they're woken up or like or they still have an accident. The other thing that does not work is fluid restriction, saying don't drink after six o'clock or seven o'clock just doesn't work. So it's not kind. So don't do it. Federated alarm. Do we recommend we recommend one that vibrates and makes noise because the noise wakes other people up the vibrational people by the child with the noise makes Pick your favourite one on the Amazon, there's no present. Um D D. A. V. P. Is a great vacation medication but it's not a cure to bed wedding. I wish it was because it makes my job a lot easier But uh it's can work really well for like camp. However it puts your bladder and urinary retention. So encourage kids not to drink anything after they take it. So they should go pee take the medication and then not drink anything more because it puts their bladder and retention for about eight hours. For some people. It works for a couple of weeks and then stops for some people. It never works. And then there are actually cases where they take it and it cures the bed wedding and they're all better. Um That's less common. Much much more rare. And placed in my experience, the child is waking up multiple times during the night and having a lot of p we definitely want to be suspicious of diabetes and diabetes. Um pooping and peeing are related. Unfortunately, the treatment plan is kind of the same. Um Initial plan don't get better until daytime. The shoes do during questioning. You don't want to manage it. Parents aren't buying in. I'm here. I want to help. I like helping this. It's such a win when families finally get it because it is such a burden to families. Here are some takeaways from the talk. Um You know when treating nemesis when trying to loosen up the skin. Just applying cream doesn't really solve it. But rather stretching it. Like I showed you in that video. Um retractable testicles are normal. If in doubt we should we can examine them. We're more than happy to ultrasounds aren't helpful and pooping and peeing are related to each other. So most of the time functional incontinence is due to stool retention. Poor avoiding habits and not drinking enough water. Thank you Bethany. So if you have any questions go ahead and put them in the Q. And A. And then we can go over them. Um um Just another reminder that please fill out your hand dr Sandra. Do you have anything else to you? If you have other questions that are not on what I talked about today but other urologic questions are also happy. Yeah. Yes. So please feel free to do that in the chat. And again this is our last lecture of the year. We'll be back in the new year and we thank you everybody for joining us this year for all of our lectures. No questions. Nobody. Oh yes. Let me see. Seems to be one. I can grab it. Okay how would you be or africa bladders during the day after constipation has been treated. Yeah. So if if we've done you know multiple clean outs and they're drinking a lot of water then use medication. Um I would use oxy button in um their face flushing feeling warm but the side effects go away after using it for I just let families know that but it helps relax the bladder wall. And also encourage families that we are starting um digital can or oxytocin which is the same medication um to make sure they're peeing on a schedule because it works by relaxing the bladder and so they might not feel anything great. Thank you. That's me. Oh dr also it's called urinary urgency frequency syndrome which is usually young boys get it um You know 12 years old and uh it goes away by itself. So if there are some kids find peeing every 15 minutes during the day but sleeping okay at night then we just wait and usually goes away in a few months. But if it doesn't then what that means that we can use convergex um to help with that. Thank you. Any other questions like it doesn't have to be related to this topic. Can be any of your neurological questions that you might have. Okay here's another one. Does treatment regimens for vaginal adhesions fall under the urology of birla as well. Would you treat it the same as famous sis it's um yes we definitely see that. So um but you can try treating it yourself first. So if the adhesions are super tight and causing urinary problems like urinary dribbling or urine getting stuck or they're getting U. T. I. S. Then you can treat it if they're not if it's not super tight symptoms you can just watch it because eventually open up on their own sort of like your question like physiological you don't really need to treat it unless it's causing a problem. But if it is causing a problem you can use primer and print just regular adult dose 0.625 and then you do it twice a day. The parent would just apply it gently spread the labia apart and then usually after a few weeks it opens up on its own. You could also use steroid cream like we do for fibrosis try and alone. Um But usually we start with the primary and if you and if you do that uh and it's not working well we'd be happy to see the patient and we can be a little bit more aggressive trying to open up. Sometimes rarely you have to do surgery if the cream is not working and they're still having trouble. Thank you any more questions from anybody. Give it another minute to see if there's anybody else. And yes like Stephanie said we will distribute their updated booklet. If you've not received in your office. We can bring it to you in physical form. We also have them in spanish as well. Um But we also can send it to you. We'll send it to you as a pdf when we um send you your thank you and perhaps with your um credits. So please feel free to reach out to us if you don't receive it or reach out to your physician leads on and we'll make sure we get those out to you. Especially if you like them a physical copy of them. Okay well it looks like there's no more questions. So I'm just gonna say thank you to um dr cassandra and to Bethany for taking your time out to do this. Talk for us and thank you to all the attendees. We want to wish you guys a happy holidays and feel free to contact us if you have any questions. Oh, is there another question? Oh yes, yes, we'll make sure we get you those. Oh, one more quick question. Is that okay? Is it harder to treat famous is if you wait until puberty than if you treat it in the newborn? Uh that's a tough one. So anything is harder than puberty right, when it comes to a teenager penis. So normally if they have just physiologic nemesis as a newborn, it's not gonna cause a problem when they become a teenager because you know, we're treating it with steroid cream, they're gonna have their natural steroids when they reach puberty, a lot of testosterone and that softens up the skin, as Bethany said that you get more erections and it's kind of stretches things. So if it's just physiologic nemesis and a baby can assume that they're not going to have to moses as a teenager, if it's tight from Asus and you're worried like the pictures Stephanie showed up the scar and scarring type tissue then you can assume that's gonna be a problem when they're teenagers, so then it's definitely better to take care of it when they're babies. Either with the steroid cream or with surgery. Obviously surgery and a baby. It's a lot easier to do a circumcision recovered wise than a teenager. Um And with the same set of risk, the same risk of complications. So if it is definitely been scarred and it's not responding to the story cream and it is better to keep the circumcision younger. Thank you doctor. Okay well there's no more questions. Thank you again. Happy holidays everybody and we'll see you in the new year.