1. PEDIATRIC UROLOGY CLAUDE REITELMAN, M.D.
Pediatric Specialty Care: The Most Frequent Reasons for Calling an Expert - Part II
PEDIATRIC UROLOGY
CLAUDE REITELMAN, M.D.

2. PEDIATRIC UROLOGY TOPICS UNDESCENDED TESTIS
IS THERE A ROLE FOR ULTRASONOGRAPHY ?
URINARY TRACT INFECTIONS/REFLUX
WHEN SOULD ANTIBIOTICS BE PRESCRIBED ?
ANTENATAL HYDRONEPHROSIS
WHAT AND WHEN DHOULD POSTNATAL IMAGING BE OBTAINED ?

3. UNDESCENDED TESTIS DESCENDED TESTIS
SCORER – 4 CM BELOW THE PUBIC CREST IN FULL TERM MALES
2.5 CM BELOW THE PUBIC CREST IN PRETERM MALES

4. UNDESCENDED TESTIS CONGENITAL UNDESCENDED TESTIS
ACQUIRED UNDESCENDED TESTIS

5. UNDESCENDED TESTIS RETRACTILE TESTIS
INITIALLY EXTRASCROTAL, BUT CAN BE MANUALLY REPLACED IN STABLE, DEPENDENT SCROTAL POSITION AND REMAIN THERE WITHOUT TENSION AT LEAST TEMPORARILY
MAY BE AT INCREASED RISK FOR TESTICULAR ASCENT AND SHOULD BE CHECKED ANNUALLY

6. UNDESCENCED TESTIS CONGENITAL PRESCROTAL SUPERFICIAL INGUINAL POUCH
EXTERNAL RING
CANALICULAR
ECTOPIC
ABDOMINAL

7. UNDESCENDED TESTIS POSITION

8. UNDESCENDED TESTIS PALPABLE VERSUS NON-PALPABLE TESTIS 70-80% PALPABLE
~30% INGUINAL-SCROTAL
~50% INTRA-ABDOMINAL
~20% ABSENT OR VANISHED

9. UNDESCENDED TESTIS PHYSCIAL EXAMINATION
SIZE OF THE HEMISCROTUM RELATIVE TO CONTRALATERAL NORMAL SCROTUM
POSITION OF THE TESTIS RELATIVE TO THE PUBIC TUBERCLE
SIZE OF TESTIS RELATIVE TO CONTRALATERAL NORMAL TESTIS
CONSISTENCY OF TESTIS
LENGTH OF IPSILATERAL SPERMATIC CORD
RETRACTIBILITY

10. UNDESCENDED TESTIS ACQUIRED ASCENDED
FROM AN INTRASCROTAL TO AN EXTRASCROTAL POSITION
PEAK AGE OF INCIDENCE – YEARS OF AGE
ENTRAPPED
ACQUIRED AFTER PRIOR INGUINAL SURGERY
HERNIORRAPHY
HYDROCELECTOMY
ORCHIOPEXY

11. UNDESCENDED TESTIS PREVALENCE PRETERM MALES - ~30% FULL TERMS - ~3%
ONE YEAR OLD MALES – 1%
ACQUIRED AFTER ONE YEAR OF AGE - ~1%
OTHER FACTORS THAT AFFECT PREVALENCE
BIRTH WEIGHT
GENETICS

12. UNDESCENDED TESTIS PHYSICAL EXAMINATION
“LET YOUR FINGERS DO THE WALKING”
STANDING ON THE RESPECTIVE SIDE OF THE PATIENT, USE THE INDEX AND MIDDLE FINGERS OF OPPOSITE HAND OF THE EXAMINER TO WALK DOWN THE INGUINAL CANAL AND TRAPPED THE TESTIS BETWEEN THESE FINGERS AND THE THUMB AND THE INDEX FINGER OF THE OPPOSITE HAND.

13. UNDESCENDED TESTIS PHYSCIAL EXAMINATION POSITION OF TESTIS
RETRACTABILITY OF TESTIS
SIZE AND CONSISTENCY OF TESTIS
LENGTH OF SPERMATIC CORD
PRESENCE OF HERNIA/HYDROCELE
SIZE OF CONTRALATERAL TESTIS

14. UNDESCENDED TESTIS AMERICAN UROLOGICAL ASSOCIATION GUIDELINES
PROVIDERS SHOULD OBTAIN GESTATIONAL HISTORY AT INITIAL EVALUATION OF BOYS SUSPECTED OF CRYPTOCHIDISM
DESCENT
TRANSADOMINAL – 1ST TRIMESTER
INGUINOSCROTAL WEEKS GESTATION
PRIMARY CARE PROVIDERS SHOULD PALPATE TESTES FOR QUALITY AND POSITION AT EACH REMOMMENDED WELL-CHILD VISIT.

15. UNDESCENDED TESTIS AMERICAN UROLOGICAL ASSOCIATION GUIDELINES
IN THE ABSENCE OF SPONTANEOUS TESTICULAR DESCENT BY SIX MONTHS SPECIALIST SHOULD PERFROM SURGERY WITHIN THE NEXT YEAR.
100% OF MALES WHO EXPERIENCE SPONTANEOUS DESCENT DO SO BEFORE SIX MONTHS OF AGE.
FAILURE OF MATURATION OF GERM CELLS AT BOTH THREE MONTHS AND FIVE YEARS OF AGE
3 MONTHS – FETAL GONOCYETES TRANSFORM INTO ADULT DARK (AD) SPERMATOGONIA
5 YEARS – AD SPEMATOGONIA BECOME PRIMARY SPERMTOCYTES

16. UNDESCENDED TESTIS AMERICAN UROLOGICAL ASSOCIATION GUIDELINES
PROVIDERES SHOULD REFER INFANTS 6 MONTH OF AGE WITH CRYPTOCHIDISM TO A SURGICAL SPECIALIST
LOW PROBABILITY OF SPONTANEOUS DESCENT
PROBABLE CONTINUED DAMAGE TO TESTIS
POOR GROWTH – GERM CELL AND LEYDIG CELL LOSS
DECREASED FERTILITY INDEX (SGONIA/T)
TESTICULAR FIBROSIS

17. UNDESCENDED TESTIS
AMERICAN UROLOGICAL ASSOCIATION GUIDELINES PROVIDERS SHOULD REFER BOYS WITH NEWLY DIAGNOSED (ACQUIRED) CRYPTORCHIDISM AFTER SIX MONTHS OF AGE TO SURGICAL SPECIALIST PREVALENCE PEAKS AT 8 YEARS OF AGE HISTORY OF HYPOSPADIAS HISTORY OF RETRACTILE TESTIS

18. UNDESCENDED TESTIS
AMERICAN UROLOGICAL ASSOCIATION GUIDELINES IN BOYS WITH RETRACTILE TESTIS, PROVIDERS SHOULD ASSESS THE POSITION OF THE TESTES AT LEAST ANNUALLY TO MONITOR FOR ASCENT.
Outcomes of follow-up from the referred cohorts with retractile testes
Author Location Patients Testes Mean F/U 9YRS) RESOL UNDES
Agarwal157 USA % 32%
Bae158 Korea % 14%
La Scala159 Switzerland <23%
Marchetti160 Italy No Information % 25%
Stec126 USA NI 7%

19. UNDESCENDED TESTIS AMERICAN UROLOGICAL ASSOCIATION GUIDELINES
PROVIDERS SHOULD NOT USE HORMONAL THERAPY TO INDUCE TESTICULAR DESCDNT AS EVIDENCE SHOWS LOW RESPONSE RATES AND LACK OF EVIDENCE OF LONG-TERM EFFICACY.

20. UNDESCENDED TESTIS AMERICAN UROLOGICAL ASSOCIATION GUIDELINES
PROVIDERES SHOULD NOT PERFORM ULTRASONOGRAPHY (US) OR OTHER IMAGING MODLITIES IN THE EVALUATION OF BOYS WITH CRYPTORCHIDISM PRIOR TO REFERRAL, AS THESE STUDIES RARELY ASSIST IN DECISION MAKING.
SENSITIVITY 45%
SPECIFICITY 78%
TYPICALLY, ULTRASOUND DOESN’T DETECT INTRA-ABDOMINAL TESTIS.

21. UNDESCENDED TESTIS AMERICAN UROLOGICAL ASSOCIATION GUIDELINES
PROVIDERS MUST IMMEDIATELY CONSULT A SPECIALIST FOR ALL PHENOTYPIC MALE NEWBORNS WITH BILATERAL, NON-PALPABLE TESTIS FOR EVALUATION OF A POSSIBLE DISORDER OF SEX DEVELOPMENT (DSD).
20-30% OF PATIENTS WITH CRYPTORCHIDISM HAVE BILATERAL UNDESCENDED TESTIS.
??? CONGENITAL ADRENAL HYPERPLASIA
17-HYDROXYPROGERSTRONE LH
FSH T
ANDROSTENEDIONE

22. undescended testis AMERICAN UROLOGICAL ASSOCIATION GUIDELINES
PROVIDERS SHOULD ASSESS THE POSSSIBILITY OF A DISORDER OF SEX DEVELOPMENT (DSD) WHEN THERE IS INCREASING SEVERITY OF HYPOSPADIAS WITH CRYPTORCHIDISM

23. UNDESCENDED TESTIS ULTRASONOGRAPHY POSSIBLE INDICATIONS FOR SPECIALIST
NON PALPABLE
OBESE MALE – MAY AUGMENT PHYSICAL EXAMINATION
IMPAIRED MALE IN WHOM FERTILITY IS NOT AN ISSUE AND IN WHOM IT IS FELT THAT SURGERY SHOULD BE AVOIDED
MALE WITH PRIOR INGUINAL SURGERY – MAY AUGMENT PHYSICAL EXAMINATION

24. antenatal hydronephrosis
PREVALENCE - ~1-5%
DIFFERENTIAL DIAGNOSIS
TRANSIENT HYDRONEPHROSIS %
URETEROPELVIC JUNCTION OBSTRUCTION 10-30%
VESICOURETERAL REFLUX %
VESICOURETERAL OBSTRUCTION %
MULTICYSTIC DYSPLASTIC KIDNEY %
DUPLEX KIDNEY %
POSTERIOR URETHRAL VALVES %
OTHER – URETHRAL ATRESIA, UROGENITAL SINUS, PRUNE BELLY SYNDROME

25. antenatal hydronephrosis Anterioposterior diameter of renal pelvis

26. antenatal hydronephrosis
DEFINITION
ANTEROPOSTERIOR DIAMETER
SECOND TRIMESTER >4 MM
THIRD TRIMESTER > 7MM

27. ANTENATAL HYDRONEPHROSIS
POSTNATAL EVALUATION
REPEAT ULTRASOUND DURING FIRST WEEK OF LIFE OR BEFORE DISCHARGE FROM HOSPITAL
SEVERITY OF HYDRONEPHROSIS SHOULD BE ASSESSED BY THE SOCIETY OF FETAL UROLOGY GRADING SYSTEM

28. ANTENATAL HYDRONEPHROSIS
SOCIETY OF FETAL UROLOGY GRADING SYSTEM FOR HYDRONEPHROSIS

29. ANTENATAL HYDRONEPHROSIS
POSTNATAL EVALUATION
NORMAL ULTRASOUND SHOULD BE REPEATED IN 4 -6 WEEKS
IF NORMAL, NO FURTHER FOLLOW UP NECESSARY
IF ABNORMAL, SHOULD BE FOLLOWED BY SEQUENTIAL ULTRASOUNDS UNTIL RESOLUTION OR PROGRESSION OF FINDINGS
HIGH RISK – APD 10 MM AND SFU GRADE 3-4

30. ANTENATAL HYDRONEPHROSIS

31. antenatal hydronephrosis Classification of by Anteroposterior diameter
APD, mm
Second Trimester
Third Trimester
Mid
<7
<9
Moderate
7<10
10-15
Severe
>10
>15

32. antenatal hydronephrosis
RISK OF POSTNATAL HYDRONEPHROSIS
MILD 11.9%
MODERATE 45.1%
SEVERE 88.3%

33. antenatal hydronephrosis Postnatal evaluation and treatment

34. urinary tract infections/reflux
AMERICAN ACADEMY OF PEDIATRICS GUIDELINES
FEBRILE INFANTS WITH UTIS SHOULD UNDERGO RENAL AND BLADDER ULTRASONOGRAPHY
VCUG SHOULD NOT BE PERFORMED ROUNTINELY AFTER THE FIRST FEBRILE UTI: VCU IS INDICATED IF RBUS REVEALS HYDRONEPHROSIS, SCARRING OR OTHER FINDINGS THAT WOULD SUGGEST EITHER HIGH-GRADE VUR OR OBSTRUCTIVE UROPATHY, AS WELL AS IN OTHER ATYPICAL OR COMPLEX CLINICAL CIRCUMSTANCES

35. URINARY TRACT INFECTIONS/REFLUX
RIVUR STUDY
AMONG CHILDREN WITH VESICOURETERAL REFLUX AFTER URIARY TRACT INFECTION, ANTIMICROBIAL PROPHYLAXIS WAS ASSOCIATED WITH A SUBSTANTIALLY RECUDED RISK OF RECURRENCE BUT NOT OF RENAL SCARRING.
PATIENTS WITH BLADDER AND BOWEL FUNCTION SPECIFICALLY BENEFITTED BY PROPHYLACTIC ANTIBIOTICS