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.

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 ?

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

UNDESCENDED TESTIS CONGENITAL UNDESCENDED TESTIS ACQUIRED UNDESCENDED TESTIS

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

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

UNDESCENDED TESTIS POSITION

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

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

UNDESCENDED TESTIS ACQUIRED ASCENDED FROM AN INTRASCROTAL TO AN EXTRASCROTAL POSITION PEAK AGE OF INCIDENCE – 5-10 YEARS OF AGE ENTRAPPED ACQUIRED AFTER PRIOR INGUINAL SURGERY HERNIORRAPHY HYDROCELECTOMY ORCHIOPEXY

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

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.

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

UNDESCENDED TESTIS AMERICAN UROLOGICAL ASSOCIATION GUIDELINES PROVIDERS SHOULD OBTAIN GESTATIONAL HISTORY AT INITIAL EVALUATION OF BOYS SUSPECTED OF CRYPTOCHIDISM DESCENT TRANSADOMINAL – 1ST TRIMESTER INGUINOSCROTAL - 25-30 WEEKS GESTATION PRIMARY CARE PROVIDERS SHOULD PALPATE TESTES FOR QUALITY AND POSITION AT EACH REMOMMENDED WELL-CHILD VISIT.

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

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

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

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 122 204 5 2.8 30% 32% Bae158 Korea 43 64 3 4.4 45% 14% La Scala159 Switzerland 150 5 3.8 <23% Marchetti160 Italy 40 41 No Information 2.3 34% 25% Stec126 USA 172 274 4 2.2 NI 7%

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.

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.

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

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

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

antenatal hydronephrosis PREVALENCE - ~1-5% DIFFERENTIAL DIAGNOSIS TRANSIENT HYDRONEPHROSIS 40-80% URETEROPELVIC JUNCTION OBSTRUCTION 10-30% VESICOURETERAL REFLUX 10-20% VESICOURETERAL OBSTRUCTION 5-10 % MULTICYSTIC DYSPLASTIC KIDNEY 4-6% DUPLEX KIDNEY 2-7% POSTERIOR URETHRAL VALVES 1-2% OTHER – URETHRAL ATRESIA, UROGENITAL SINUS, PRUNE BELLY SYNDROME

antenatal hydronephrosis Anterioposterior diameter of renal pelvis

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

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

ANTENATAL HYDRONEPHROSIS SOCIETY OF FETAL UROLOGY GRADING SYSTEM FOR HYDRONEPHROSIS

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

ANTENATAL HYDRONEPHROSIS

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

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

antenatal hydronephrosis Postnatal evaluation and treatment

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

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