Chapters Transcript Video Urology for Primary Care- UTIs, reflux, and testicles Bethany Sean, I got married. You also know me as Bethany Galaris. I respond to both. They're both me. Um, I am a nurse practitioner. I've been in neurology for about 8 years now, um, here at UCSF at Benioff Children's Hospitals. Um, Jessica has joined our team about a year ago, um, coming from the, um, transitional care unit, and then we also have another new Nurse practitioner who's gonna pop into the screen with me really quick. I'm close, this is a parna, um, so if you see our names on Paperwork and things like that. Now you can put a face to the name. We don't have any disclosures. For this presentation. Um, the learning objectives, um, by the end of this talk, we hope that you have a really clear understanding of UTIs versus concern for reflux, and when to do what tests, um, when not to do what tests, and how we tend to think about these things. Um, we want you to be able to clearly differentiate between undescended testicles and retractile testicles, and know what testing needs to be done and what doesn't need to be done, as well as, um, Recognize like postoperative emergencies and post-operative care. Um, we'll talk a little bit about some cultural considerations for circumcisions and give an update on how our department is handling elective circumcisions at this moment. UTIs, when to worry, um. When it comes to urinary tract infections, what we have found is that if a patient has had one, the parents are worried about it all the time. They're always worried that they'll get another. Any foul smelling pee, any dark urine, anything like that, parents want to check. To understand the sentiment, because the experience of UTIs is pretty extreme, um, and very, very painful, and we want to avoid pain in our patients. Um, signs and symptoms, you guys are the primary care experts on this. Um, you know, infants and young children, younger than potty potty training age can have kind of non-specific symptoms, and unexplained fever without cough, runny nose. They're the only ones sick in the household. They could have fever, vomiting, abdominal pain, um, they could cry when they pee, they could pee less than normal, they could have blood in their pee more than normal. It could be anything like that, or it could be we don't know what's wrong, and we happen to check their pee and found a bacteria present. Older children tend to present with dysuria, maybe hematuria, urgency and frequency is very common, um, flank pain, foul smelling urine, and then new onset incontinence in a potty trained child. UTIs are one of the things where we love. Them because we can test for them, right? We want an answer. So, um, very commonly if someone came in with these concerns, I imagine anyone would do a UA, urinalysis, and then a urine culture of anything on the urinalysis came back positive. Um, we are always balancing. Use of antibiotics versus patient symptoms. Um, you know, the textbook always says we don't want to treat a UTI until we have a young culture and sensitivities, so that we know what antibiotics to use. That's really hard when you have a crying kid in front of you. And so there are some antibiotics that we tend to lean on and use, um, presuming we have a positive culture, and if the culture comes back negative, we obviously stop those. Um, in neurology, we consider a positive culture, uh, greater than 100 colony forming units of avoided specimen. Or greater than 50,000 colony farming units of a um Catheterized has been. Um, differentiating between lower and upper urinary tract infections can sometimes be possible based on symptoms and sometimes not. Um, all febrile UTIs should be considered to involve the upper tract. Um, this matters because we want to avoid multiple UTI's to the upper tract, which would be, um, pyelonephritis, which could cause renal scarring. Um, bagged specimens are highly unreliable, and in fact, when we find out that urine culture was done with a bag specimen, we almost don't consider it, um, at all. We, we really don't recommend bag specimens. Ideally we could do the gold standard is a straight catheter, a sterile straight catheter, or um a midstream clean catch. Now, I think one thing that's really important to know in the updates is the American Academy of Pediatrics recommends against routine urinalysis for asymptomatic patients. This means for child coming in for a well visit, we don't recommend that we just do a urine dip, um unless there are concerns. Um, this often leads to overtreatment, and overuse of antibiotics. So the way I describe it to parents is When a patient comes in and um you know, we do a routine we just check and let's say the test comes back positive for whatever reason, there's a lot of bacteria there. But my patient in front of me is perfectly healthy, not having any symptoms, not feeling anything, not concerned about anything. Do I take care of the lab slip or do I take care of the patient? And I always want to take care of my patient. So if I were to get an Asymptomatic urine culture that came back positive, I would actually probably flush with water, increase um fluid intake, increase voiding habits, maybe address constipation, and then retest in a couple weeks, um, as long as they remain asymptomatic. I do a lot of education on symptoms and when to re-seek care. Ultrasound. So, in a child less than 2 years of age, we tend to do an ultrasound with the first UTI, um, in a child over 2 years of age, um, we hold off on that, uh, mostly because they're potty training, usually potty training or explored potty training or have control over their um bowels and bladder, and so we look at some of the more habit forming things. Um, with the first febrile UTI, we will do an ultrasound. Um, we'll do a VCUG with recurrent febrile UTIs or an abnormal finding on ultrasound like hydronephrosis. Um, VCUGs are obviously how we determine is urine going backwards from the bladder up to the kidneys. Um, this is very important because if there's bacteria in the bladder and it goes backwards up to the kidneys, then the bacteria is in the kidneys and can cause kidney scarring with with repeat infections. Um. And so we want to know that if And It involves using a catheter and laying still in the hospital. And so discussion with the family and considering the best way do we presume it's positive because they've had multiple every UTI has been febrile, and they've had multiple positive urine cultures, or do we um do the test and have the experience, and then have data to go off of, and those are conversations we have regularly with our families. Um, DMSA is, uh, something we would do if we were worried about scarring, um, in a patient that might be slightly older and has had lots and lots of febrile UTIs. Um, on the screen, I, I'm not gonna read this to you, but here's the definition of vesicoureteral reflex, and as well as how we grade it and how we look at it. Um, in babies less than 2, it's often con it could be congenital, but it can also be acquired. So in kids that are potty training that like to hold their pee for really, really long periods of time, holds in their poop, this typically could lead to grade 1 or 2, reflex. And the treatment for that actually is not necessarily antibiotics and prophylaxis, it's more working on the habits, making the poop really soft, making sure they're drinking enough water, and not holding their pee, um. And, uh, you know, reducing the risk through through those habit changes. Um, With the previous slide defined the diagnosis and um we can also see if they have any type of hydronephrosis on ultrasound that would make us curious to know if there's reflux going on. Um, it can come from a, a poor connection in the ureter vesicle junction, um, or the increased blood pressure which I just discussed. Management. So in newborns, infants, especially if we have prenatal hydronephrosis, those babies are put on amoxicillin, um, usually until um until about 2 months of age, and then we switch them over to Bactrim. We can also use Keflex or nitrofurantoin depending on age and other factors, other risk factors. Um, Again, repeating, low grade reflex can be managed with habit habit changes. There are cases that obviously need surgical interventions, um, for higher grade reflux and open ureteral reimplant where you Essentially very, very low, take out the kinked part and um make the flow better, um. Redo the connection points, um, can resolve this, as well as Dflex, which is putting in a bulking agent into the ureter so that P doesn't go backwards as much. Um, both of those are very effective interventions. Um, we typically hold off on doing surgery and get over to until there's well managed bow and bladder habits and under 2. And congenital um reflex, that's not considered. Complications of reflux can be impaired renal growth, renal scarring, hypertension, chronic kidney disease. We I have this case. So 7 month old male referred for two recurrent febrile UTI's with the normal renal ultrasound. He is uncircumcised. After the first UTI we'd recommend treating the fimosis, the most common cause of UTI in um Young boys and teaching the parents for skincare. Um, Because it was recurrent, they had a VCUG and um was found to have grade 2 reflex on the left, grade 1 on the right, so they're started on antibiotic prophylaxis, followed up with a repeat ultrasound in 6 months and then yearly, and that has remained normal. So we'd continue the antibiotic prophylaxis until the child is very good at potty training, and then we would um trial them off of it, and Um, do a lot of education on signs and symptoms of infection, and if they remain infection free off of it, we don't need to repeat the VCUG. Another case, a six year old female patient. Um, referred for history of recurrent febrile UTIs. She had no UTIs in infancy, and they didn't start until she was potty trained. With a normal ultrasound, um. She was started on prophylaxis and we got a VCUG which showed grade 2 reflex on the left side. She had signs and symptoms of bowel and bladder dysfunction with the KUB with moderate stool burden. She family admits that she doesn't like to stop what she's doing to go poop or pee, and is often constipated. She was started on um BBD protocol, which is MiraLax timed voids and increasing fluids, and she's remained infection-free for about a year. We stopped the prophylaxis, um, and she hasn't had any more UTIs. These are kind of the The classic cases that we see. So next, I'm gonna mute myself and Jessica is going to um speak on the next topic. OK. Hi, everybody. I'm Jessica. I am one of the new nurse practitioners to the urology practice. Um, I used to work inpatient in the transitional care unit, like Bethany said. Um, today I'm gonna talk about um testicles and differentiating between retractile versus undescended. Um, This is just kind of a picture um depicting how the testicles kind of distend into the scrotum during um gestation, sometimes after birth, testicles are still kind of on that path to descending. Um, they develop in the abdomen and then they follow the path as seen here down into the scrotum. Um, some of the risk factors for undescended testicles include prematurity. Um, babies that are small for gestational age, and twins are all found to have a higher incidence of undescended testicles. Um, so we get lots of referrals for these young babies with concerns for, um, undescended testicles. We also get some in the school-aged boys. There is um a small risk of something called ascending testicles where they were descended and they are now um no longer able to be palpated in the scrotum. That can happen when boys go through rapid growth spurts and The testicles kind of don't, don't um keep up with the height increase. Um, so the definition of an undescended testicle is a testicle that is not able to be brought down into the scrotum. During a physical exam, um, all testicles move, they move in response to cold and stress. A really stressful place for little kids is a doctor's office. So a lot of times when they're in our office or in the pediatrician's office, um, they can like to hide and make the exam a little bit difficult. Um, In some boys, especially in toddler age, um, baby boys, they have an overactive muscle that makes them look like they're undescended testicles, and but then they're able to be brought down into the scrotum during exam. This is called a retractile testy, and it does not require surgical intervention. Um, so, like we said, retractile testicles or testes that are found outside of the chro the scrotum due to an active chromosteric reflex, um, but they're able to be brought into the scrotum. If they're able to be brought into the scrotum, and then it's not truly an undescended testicle and it doesn't require surgical intervention. Um, So we kind of tell, we get referrals a lot for undescended testicles versus retractile testicles. Um, if we're able to bring the testicle into the scrotum during our exam, then often our guidance for families is to just continue with the yearly well child checks at the pediatrician's office. Um, we tell families if the pediatrician's having a hard Time palpating in the office because the patient's scared and crying and cold. Um, a good place to check is at home during diaper changes or in a warm bath. If parents are able to confidently feel or palpate both testicles in the scrotum, then we don't need to see them back, but we are always happy to, you know, follow patients annually if there's a concern that the testicle has become ascended. Um, diagnosis, physical exam is gold standard, ultrasound is not helpful. We don't use that to guide us in deciding between surgery or um or not. Um, testicles, like I said, they move up and down, so often during an ultrasound where they're scared and cold, the testicles will move up out of the scrotum, but again, if they're able to be brought down to the scrotum during exam, um, then it's not truly an undescended testicle. Um, treatment. So we usually watch, um, when we get referrals for baby boys under 1 year of age and there's an undescended testicle, we usually just follow them closely. The testicles can descend usually by around 8 months of age, they'll if they're gonna descend, they'll have already descended. Um, and so sometimes you can kind of follow them, uh, going down that path from the abdomen into the scrotum, but if they haven't descended on their own by one year of age, then we would recommend surgery to the family. It's a same day surgery. The patients do go under general anesthesia. It's generally a pretty well tolerated surgery postoperatively, we just, um, pain is managed really well with Tylenol and Motrin. It's about 2 to 3 days of rest post-op, um, but then no strenuous activity for 2 weeks. Um, most parents tell us that they weren't able to keep their child calm cause they were just feeling so great after the surgery. Um, Yeah, that's you. All right, all right. I'm gonna jump back in here, um. And talk a little bit about postoperative care after neurologic surgeries. So, This is broad, um, I'm not talking about each specific surgery. There's gonna be nuance here. Kidney surgery is, um, obviously a different recovery than an orchiopexy and things like that. But in general, the postoperative care for urologic surgery, um, has limited activity for 2 weeks, and pain is usually managed quite well with Tylenol and Motrin. Um, parents alternating that for the 1st 3 days and then using it as needed. Um, like Jessica said, most parents come back to us surprised saying that, um, They they couldn't keep their kids still. The kid was feeling so good and wanted to go back to playing right away. Um, we encourage bathing, usually on day 2 after surgery. The incision care, um, bandages, if they're present, should be removed as instructed. Oftentimes bandages are not. Um, present, uh, we use a lot of Vaseline and um teach parents how to put Vaseline in the diaper and protect the surgical site that way. However, um, very often, if there is a dressing, we do want it to come off. Um, as they come off, there can be a little bit of bleeding, which often scares families. They're told that it happens, but when you see it in real life, it's, it's much scarier. Um, once the bandage is off, leaving it open to air, letting things dry out, and then covering it with Vaseline is the plan. If there's any active bleeding, the way we define active bleeding is like drops of blood coming off of the surgical site. Bleeding that doesn't stop for 5 minutes, bleeding that fills up the di pur, any bleeding that's active, um, we need to know about it immediately, or they need to go to the um urgent care or the ER or somewhere that can take, take a look at them. Um, when we order surgeries, we often tell families that the private parts are a very high blood flow area. High blood flow areas tend to bruise, they tend to swell a lot. Um, and it will, it may look worse than I expected. The best tip we have for this is rather than comparing diaper change to diaper change or moment to moment, comparing, you know, week to week and see that the swelling goes down over time, the bruising will go down over time. Um we love reviewing pictures on my chart, um, so encouraging families to send us photos for review is another thing that we like to do. Um, on a slightly different note, circumcision. So, Circumcision requests for circumcisions is one of the most common um referrals we get, and on the um screen is the policy statement from the American Academy of Pediatrics, um, which encourages basically families to make the right decision for them. The hard place we are is that our surgery block times, the amount of surgery time that we have, is so full of Non-elective surgeries or surgeries that have to happen, there's not a lot of space for elective circumcisions. Now, we're hoping this changes. We have a new attending starting with us at the end of the month, um, And we are actively working on finding a way to write this equity issue, um. We, um, however, when a patient is currently referred to us for an elective circumcision, um, first off, we wait until they're at least 8 months of age, um, before anyone would do that procedure, partially because it is done under general anesthesia, and the risks of anesthesia decrease, um, slightly after 6 months, but we wait till 8. Um, but as of right now, we are unable to offer lots of elective circumcisions. Um, this is, we will very much say this is not how we want it, this is not how we're going to continue going. We are working on a solution, and um it's, it's really hard to balance the the surgeries that have to happen and the surgeries that are chosen to happen for very, very good reasons, family reasons, religious reasons, and ethnic traditions are very good reasons. Um, so keep posted on us, we'll, uh, on us about that. We will try and update you as that changes and um evolves. Um, it will not be forever. It is, however, a current issue. That is what we have as a prepared presentation. I do imagine there will be a lot of questions um on these topics or on other topics, which we are more than happy to answer, um. And so I'm gonna I do have a lot of questions, so let's let me um Let me pull up my side with the QR code so people can view that while we go through questions. One moment. OK, there's a QR code. It should be correct. If it's not, let me know. Um, And then you'll get it in the email too if you don't want to scan it. OK, let me pull up the questions here and I will read them to you all. First question, can you comment on circumcision recommendation for neonates with documented reflux? Uh, yeah, if, um, they're still within the, um, The newborn window. Age and wait to do a newborn circumcision and the family wants it, it is safe to do it. Reflex doesn't mean the family has to do a circumcision, um, taking care of the foreskin. Um, reduces the risk of more bacteria going in, but if they want one, please give it to them. Um, there's no reason to wait because of reflux, and, um, I could see the argument, we don't have a formal opinion on this, but I could see the argument that because they're prone to infections or their infections, are prone to going up into their kidneys that maybe reducing the one risk for the main risk for UTIs and boys would be a good idea. Thank you. As question says, in the first case for for skin care, what do you discuss and what age do you routinely start for skincare? Um, So, for skin care is gently retracting the foreskin. Actually, I'm gonna back up even further. Every boy is born with a penis and a foreskin that has a tight homotic ring at the end of the foreskin. Phomotic ring might sound familiar because a super tight homotic ring is called thymosis. Some boys have a short foreskin, so that when they get little baby erections, the penis pops right through that homotic ring and stretches it out, and there's nothing to worry about. Those are the lucky families, those are the ones that um Never have to think about foreskin care at all, cause the way the body is designed has a short foreskin and it's just popping out, easy to clean, stays nice and open. Other boys have a slightly longer foreskin, so when they get little baby erections, The penis doesn't quite make it through that ring. What happens in that case is that the kids are peeing into their own foreskin, and there's a buildup of dead skin cells underneath, and Over time, if there's no change to the tightness of that ring, it can cause ballooning, it can cause irritation, it can cause a buildup of smegma, and it can cause pain. So I do encourage families to gently open up the foreskin, and I mean gently, and we don't need things to go all the way back past the glands, just enough so that if they're in the bath, water can flow into that area and clean it out. Um I, in healthy skin, in skin that isn't scarred, isn't dry, um, isn't cracked, I wouldn't use any steroid cream or medication on this. If there is um cracking of the skin or dry skin, I would start with a steroid cream as well, teaching families that the cream moisturizes the skin. The treatment is actually stretching the skin. So if you just put the cream on, nothing's gonna change, um, but stretching the skin, um, Just just enough so that water can clean it out, kind of helps prevent future problems and is routine for skin care. Thank you. I'm gonna jump around a little bit. There's some more cir uh circumcision questions and we'll try and stay on the same topic. Why do you do circumcisions under general anesthesia? Because we don't do newborn circumcisions. So, um, outside the newborn period, um, We Uh, put kids to sleep because expecting them to, to stay still. It is the um pediatric urology. Uh, uh, recommendations. I can't think of the body right now, I'm having a pregnant brain moment, but um. It is the recommendations that circumcisions done outside the newborn period are done under general anesthesia for the patient experience. Thank you. Most rafts look asymmetric. How do I tell if there's a penile torsion, especially in an uncircumcised baby with foreskin that does not retract, so that I can't actually see the medias. OK, so most median rhas. Which is the vein from the bottom of the penis, kind of curve up around. Like that, and we all want everyone to be perfectly symmetric. We all want the line to go straight up the middle, we know where all the blood vessels are, we know how everything looks, um. But Um, sorry, I'm missing the second half of that question. Um, OK, so it, it was, it says most rats with asymmetric. How do I tell if there's a penile torsion, especially in uncircumcised baby with foreskin that does not retract, so I can't actually see the medius. Yeah. OK. Sorry, I moved it. That's right. I just um needed to refresh myself. Penile torsion is when the penis itself is slightly rotated. Um, so the way you can see that is the meatus isn't perfectly vertical, it might be off to the side degrees. Um, what I would say is, is teach the family for skin care and, and over time, um, assess it. Um, most penile torsions don't need intervention, they don't need surgery, um, and some, some do if they're above 30 degrees from abnorm from normal. Um, but within a small range, there's, it's, there's not much to do, no one's perfectly symmetric. Thank you. Please comment on the incidence of UTIs in circumcised or uncircumcised males, like actual numbers beyond the comment that it doubles the incidence. Um I don't think I made a comment that it doubles the incidence, but I'm gonna have to get back to you with actual numbers and um Maria, can you make a note that I need to get back to them on that? Yeah, no problem. I have a newborn with a mild unilateral hydronephrosis and was advised to apply 2.5 hydrocortisone twice daily since they chose not to circumcise until 4 to 6 weeks when they saw urology. And I think they're just asking if this might be correct advice. Yes. Yeah, it makes perfect sense. And applying cream is only part of the process, right? So applying the cream makes the foreskin nice and healthy. We love a healthy foreskin cause it's stretchy, it's thin, so it's not painful when it stretches, and I would love it if the parents were to gently kind of open up that um that area. Um, I think this is a great proactive intervention. Um, if you didn't do it, I wouldn't think that was wrong either. Um, but basically who told you this was trying to make sure we prevent, um, a UTI because of type foreskin. Next question asked. For a while recently, I have received many referrals for penile torsion. Is this being overdiagnosed or is this a real condition that needs to be managed? Um, We, it's, it's hard to say because what if, what if all of them are going to you? Um, but I would say that in general we don't worry very much about penile torsion, um, especially if the penis is straight, um, the patient isn't having any negative effects like UTIs or any issues with the urinary system. Um, and the torsion is less than 30 degrees. We are always happy to look at them. If it's disfiguring, if the penis is very twisted or curved, um, then we do surgery on those patients, um. So it's hard to give you a blanket answer if it's being overdiagnosed or used, um, but It is a nice one because you can look at the meatus and see, um, curvature of the median refa is one that is often confused for penile torsion, and um the curvature of the media refe isn't anything that we worry about or interfere with. Along those same lines, what do we do if a boy's penis always curved to the same side when they urinate? Um, It's a great question. So, penile curvature, so, um, The only way to tell if a penis is straight, the medical way to tell is when they have an erection. Um, So, We can do that artificially in the operating room to check, um, parents after kids get out of the bath can check. Um. If the penis, there are a lot of boys who will have a straight penis, but be a righty or a lefty. And they just kind of lean to the right or lean to the left. The example I give moms for this is the same way that women have different sized breasts. No one's like, Sometimes the breast on the right is a little bit bigger, sometimes the breast on the left is a little bit bigger, and no one really worries about that. So, um, if it's only noticed when he pees, um, It might be worth checking is the foreskin is the pea bouncing off the foreskin, um, is It aiming issue, is there curvature when he has an erection. I'd have more questions to kind of figure those things out, um. Before I could tell you if I'm worried about it or not. Thank you. Going back to foreskin, what age do you advise the parents to try to stretch the foreskin? How often and is it just in the bath, which I think you kind of covered. Yeah, I, I tend to think we should do it earlier rather than later, mostly because it looks really scary to parents. It's very, it, it just looks really scary. It's not something a lot of people are familiar with, um, you know, a generation ago. A lot of dads were kind of routinely circumcised in the United States, and now we're asking parents if they want that. And so, um, because there's a bit of a culture shift and circumcisions um aren't just Done because a boy was born, which is how it used to be, um. Then there's some confusion on how to care for the foreskin. And so I do think that, you know, starting 8 weeks after birth and teaching the parents how to gently care for it. Makes it easier to do. Now there's nothing magic at eight weeks about the foreskin. If you wait longer, if the parents are really nervous about it, that's all fine. But um because it's something that a lot of people aren't very familiar with, and it does look scary the first couple times you do it, I think starting on the earlier side can be helpful. That question asking in case scrotum is very small or barely formed, testicles are palpable but very close to pubic bone. What is the intervention or the best intervention? Yeah, um, for that one I use our, our one Mississippi rule or one California rule, um, It If the testicles are small and in the scrotum and stay in the scrotum for one Mississippi, for one California 1 2nd, without you holding them, then I am really not too worried. I might note it and don't make sure I check at every physical. Um, if you can pull them to the scrotum and they bounce right out, I would like, I would like to see them in neurology, um, just to make sure that they're they're not spending most of their time up in the abdomen. Um, I do think one of the reasons, it's it's good to understand, one of the reasons we don't worry about retractile testicles is because typically they're only retractile when you're looking. So when a kid's sleeping, when a kid's relaxed, when a diaper is on, the testicles are typically down, um. If the size is really, really small, I might say like, oh, are they retractile or are they like not spending their time down in the scrotum? I might want to investigate a little bit further. Thank you. At what age should ultrasound be done when there is hydronephrosis or prenatal on prenatal ultrasound? Great question. Um, When there's hydronephrosis on prenatal ultrasound, we like to get, get an ultrasound on day one or two of life, and then again at 6 weeks of life. Reason being is there's fluid shifts that are happening in the 1st 6 weeks of life that can give us a false positive of hydronephrosis, just because fluids moving around, um, in a specific way until about 64 to 6 weeks. Um, so I'll do 6 weeks for Prenatal hydronephrosis. What is your first line and second line of antibiotic choice for UTI to be started while we wait for culture results? Who feel like you're poking a bear with that one, like, well, why don't you wait for the culture results? Um, we love, we love, love, love basing treatment on culture and sensitivity, um. If I, the patient is in a lot of pain, if I'm highly convinced it is a positive UTI, whether it's based on symptoms or um history or whatever, I would, one, look at previous urine cultures and see what the bacteria was sensitive to and consider using that antibiotic. Um, if there are no previous urine cultures, um, we tend to use Bactrim or Keflex. Um, depending on the age, uh, like if they're very young, it would be amoxicillin, um, but Bactrim or Keflex. What's the preferred steroid cream for homosis? We use Triamcinolone 0.1% ointment. Um, sometimes insurance doesn't cover that from the pediatrician though. They will cover hydrocortisone 2.5% cream. So, um, being aware of that is helpful. They, I don't know why they cover it from the specialist, but not the pediatrician. But um that's what we use, and then sometimes we'll use betamethasone as well. Yeah. And someone's asking on this along the same lines, what's the duration to apply hydrocortisone or any steroid cream for renosis. Yeah, um. 6 to 8 weeks, and then a check-in, and then another 6 to 8 weeks if there's no improvement. The check-in is usually a time where the provider can get the foreskin to go back. Um, in a way the parents aren't able to because it is really scary to push back foreskin. It looks scary, it looks like it's gonna hurt the kid. I dream of one day having a video for you guys of like foreskins that look like they're not going to open, that we just gently push the foreskin back and the kid is sitting there smiling and totally fine because it looks really scary. So, um, We typically do, you know, 2 months, a check-in to make sure the actual retracting of the foreskin, the actual treatment for fimosis is happening, and then another 2 months, um. To to help it resolve. Along the same lines, they are asking if you have a handout or a video for for skincare, but it doesn't sound like you do. We're working on it actually. It's on our, it's on our 20,252,020, it's on our next year's goals of to have all the handouts fixed all all available on our website, um, that is definitely a need that we have, yeah. That's great to hear. OK, switching to bedwetting, I usually cancel families not to worry about bedwetting until it becomes socially upsetting. Is there an age that you think we should intervene or is it OK to let things happen on their own? I love this question. Um, Yes, so bedwetting, wedding when you are sleeping, nocturnal and your recess, all of those things is a huge social issue. The way I, I start talking about it when I talk to families about it is actually, it's one of the oldest medical diagnoseses that we have. They found some like papyrus scrolls from 1550 BC that tried to cure bedwetting, and we can follow this diagnosis through different civilizations throughout history that have tried. Different interventions, some of them funnier than others. Um, when I give my bedwetting talk, I have a great slide on it. I can share all that. So what that means is this isn't a modern day problem. This is part of the human experience. Some bodies have just always wet the bed. Now, if one parent wet the bed, there's a 40% chance the kid will. If both parents wet the bed, there's a 70% chance the kid will. Um, sometimes neither parent wet the bed and the kid still wets the bed. That's just how their genetic makeup happens, um, because in the theory is there's delayed release of um DDAVP in the body, um, which is why those kids don't concentrate their urine when they're sleeping, and um. But So what, what age? The the treatment for bedwetting has to do with constipation management, voiding on a schedule, and drinking enough water during the day. The age to treat bedwetting is the age when the child is willing to do those things. So here's when it becomes a problem. When we say like age 8, it's abnormal to wet the bed. But the 8 year old doesn't care enough to stop playing to go to the bathroom when it's time. Then what happens is we get this really big disconnect between the choices we make during the day and the effect they the cause and effect, the effect they have when you're sleeping at night. And the interventions, the BBD protocols that we have, which start with all those things I just said, pooping, peeing, and drinking, and then move on to our bed wetting alarm instructions, which are slightly different than the package instructions and move along, you know, down a pathway. They only work if we can get the baseline, the foundation, really well done. And so, We're happy to treat bed wetting at any age when the kid is really, really interested. Now, every kid says they want bed wetting to stop. Don't get me wrong. I wish I had that magic wand where I could just say like, and it stops. But interested enough to walk away from something fun, from a video game, from recess, from, you know, whatever they're doing, to go to the bathroom when the timer goes off, when it's time, not when they feel the urge. That's when the bed wetting interventions are successful. So, um, we do feel like the age of bed wetting in in our experience has kind of increased post COVID with um maybe we don't know why, but my guess is maybe some decreased delayed gratification and things like that, less understanding of cause and effect. I, I, I don't know anything about that, but Um, so it's, it comes down to truly just knowing, knowing your patience, you're having your parents even honest, like, is your kid gonna tell the truth about how much water they're drinking at school? are they gonna take their medicine every day without you having to remind them and nag them, you know, that that's when we're successful, um. So I sort of answered your question. I, I wish I could give you an exact number, but that's how it works. Follow up about the uh specifical there I have somebody asking if you recommend a specific alarm, what are your bed wetting alarm instructions? Can you share them? Is that in our incontinence booklet that we have for urology or is that not? It's actually not. It should be though. We should update that. Um, we don't have a specific, um, Alarm that we recommend. We do recommend an alarm that vibrates and makes noise. So here's the difference in instructions that work and the instructions in the package, OK? Instructions that work. Um, we have zero expectation of the bed wetting alarm waking the child up. And that's really, really hard, because what happens is the kid goes to sleep, you know, they start to pee, the alarm goes off, the entire house wakes up, and that child is in their deepest stage of sleep and does not respond. They don't wake up. Everyone else, the whole neighborhood's awake, the whole whatever, but the the kid sleeps right through it. So understanding that we do not expect the bed wetting alarm to wake the child up, we expect it to wake a parent up who then wakes the child up. And that's a that is a key difference to make it more effective. Now, what we need is the child to be fully brought out of their deepest stage of sleep, which is when accidents tend to happen. And so in order to do that, we have a couple different, they can splash water on their face, they can do 10 squats, they can do a math problem, they can be told to like code word that they have to remember in the morning. Something that proves, OK, I started to pee, I was fully woken up. I didn't um sleep through it, even though I slept walked to the toilet and finished peeing. I got cleaned up, went back to bed. That would be a successful night with the bed wetting alarm if they remembered that in the morning. Um, we would never start a bed wetting alarm without Bowel cleanouts, daily bowel medicine. voiding on a schedule and drinking sufficient water all day long. You'll be shocked at how many of our patients don't really drink water until lunchtime, and then again until after school, um, and so they kind of shift their water drinking until the afternoon. Um, and so then they're thirsty, they're actually like needing water and their bodies are craving water before they go to sleep and You know, then they go to bed. So that's, that's kind of how we use the bed wetting alarm was we after that we only use it after the foundation is really well established. We talk a lot about how um It is supposed to wake up a parent. I do actually have a worksheet on this that I can get to Maria. Um, yeah, we can share it when we share the slides and the survey link, that would be very beneficial. Uh, what do you think about the doctor that recommends the mop method and regular enemas for bedwetting? Yeah, Stephen Hodges, we think he's great. Um, and if, uh, family wants to do enemas, then that is a great intervention. Um, Doctor Stephen Hodges has a website and a lot of his information is on there. He also has a book which just came out with a New edition called It's No Accident. Um, And his treatment plan, again very similar to ours, we use Miralax and bowel clean out, sometimes we use Xlax. He likes to use enemas, um, and he'll do a daily enema for a month, and then an enema every other day, and an enema every third day in addition to these other interventions of drinking and and peeing, and It's if the family is OK with using animals, we think it's a great intervention, um. I have less patient, I have some patients that like enemas and more like Miralax. The last question I have right now is do we recommend all uncircumcised males where we can't retract foreskin enough to see media start uh try, yeah, ointment and parents gently retract at age 2 months. I wouldn't necessarily start cream um at that point, but I would work on teaching um over the course of the first year of well child visits because it's scary to pull the foreskin back. The cream doesn't fix the problem. Pulling the foreskin back fixes the problem. So, um, I really only use the cream if the skin is really dry and cracked, if it's painful to the patient, but, you know, less than 8 weeks, um, That I would still work on overcoming the fear that comes with routine for skin care. Thank you. That was a marathon of questions. That was amazing, great job. Oh, someone's saying peanut. Do you see that? Yeah, peanut to a TikTok diagnosis. That's why you're seeing so many. You know it's so funny is I go on Reddit regularly just to see what, you know, like parent groups are saying, and I think it'd be really great if we were to collectively as a medical community figure out a great way to respond to some of these trends. Yeah. Yeah. Thank you so much, Bethany and Jessica, for your time today and presenting to us. Thank you all for attending. You will get the uh their slides, um, and then the extra handout that Bethany was talking about, we'll email those out to all of you and then look out in your emails for our future webinars once we get them scheduled. We appreciate all you taking the time to Uh, join us today and we hope you have a good rest of your week. We'll see you all later. Thank you all. Created by
