Urology

Question 1

Phimosis
- Inability to retract foreskin

• Physiologic phimosis (most common)
  
  • Parents should be advised to cleanse the uncircumcised penis without retraction.
  • Most foreskins are easily retracted by 4 years of age (80-90% of uncircumcised boys will have retractile foreskins by 3yo, and 99% will have fully retractile foreskins by adolescence) . Physiologic phimosis is quite common up to age 5-6 yo and is often present in older children as well.
• Pathologic phimosis is the inability to retract the foreskin because of distal scarring.
  
  • Tx is gentle retraction, topical steroid
• Complication: Posthitis, which is preputial inflammation and cellulitis. If it progresses to the glans, it is called balanitis.
  
  • In most cases, treat balanitis with topical and/or oral antibiotics and steroid cream with local hygiene.
• Tx if evidence of obstruction exists: Requires opening the preputial ostium (foreskin’s distal opening) with a hemostat.

Answer 1

Phimosis
- Inability to retract foreskin

• Physiologic phimosis (most common)
  
  • Parents should be advised to cleanse the uncircumcised penis without retraction.
  • Most foreskins are easily retracted by 4 years of age (80-90% of uncircumcised boys will have retractile foreskins by 3yo, and 99% will have fully retractile foreskins by adolescence) . Physiologic phimosis is quite common up to age 5-6 yo and is often present in older children as well.
• Pathologic phimosis is the inability to retract the foreskin because of distal scarring.
  
  • Tx is gentle retraction, topical steroid
• Complication: Posthitis, which is preputial inflammation and cellulitis. If it progresses to the glans, it is called balanitis.
  
  • In most cases, treat balanitis with topical and/or oral antibiotics and steroid cream with local hygiene.
• Tx if evidence of obstruction exists: Requires opening the preputial ostium (foreskin’s distal opening) with a hemostat.

Question 2

Paraphimosis

• Retracted foreskin cannot be reduced.
• Tx:
  
  • Emergency that necessitates immediate urology referral to prevent ischemia/necrosis.

Answer 2

Paraphimosis

• Retracted foreskin cannot be reduced.
• Tx:
  
  • Emergency that necessitates immediate urology referral to prevent ischemia/necrosis.

Question 3

Balanitis
- Pt: Erythema and inflammation of glans penis only.

• Tx:
  
  • Conservative tx includes mild soap, keeping the glans areas clean and dry. Sitz baths may help with itching and skin tenderness
  • Tx underlying cause: Antifungal creams. Bacterial infection.

Answer 3

Balanitis
- Pt: Erythema and inflammation of glans penis only.

• Tx:
  
  • Conservative tx includes mild soap, keeping the glans areas clean and dry. Sitz baths may help with itching and skin tenderness
  • Tx underlying cause: Antifungal creams. Bacterial infection.

Question 4

Hypospadias
- Hypospadias occurs most commonly as an isolated malformation, and no imaging to look at the upper GU system is required.

• Management
  
  • Circumcision should be avoided until 6-12 months because the foreskin is used for repair and the risk for anesthesia at this age is similar to older children.
  • Perform surgery before 2 years of age.
• For proximal hypospadias (penoscrotal, scrotal, perineal) associated with cryptorchidism or ambiguous genitalia, a more extensive evaluation should be performed; evaluate for intersex condition.
  
  • Bilateral cryptorchidism warrants screening for salt-wasting forms of CAH

Answer 4

Hypospadias
- Hypospadias occurs most commonly as an isolated malformation, and no imaging to look at the upper GU system is required.

• Management
  
  • Circumcision should be avoided until 6-12 months because the foreskin is used for repair and the risk for anesthesia at this age is similar to older children.
  • Perform surgery before 2 years of age.
• For proximal hypospadias (penoscrotal, scrotal, perineal) associated with cryptorchidism or ambiguous genitalia, a more extensive evaluation should be performed; evaluate for intersex condition.
  
  • Bilateral cryptorchidism warrants screening for salt-wasting forms of CAH

Question 5

Meatal Stenosis

• Frequently overdiagnosed. Visual inspection is not satisfactory. You must observe the voiding process. Look for evidence of straining and assess the strength and angle of the urinary stream.
• Tx: Ventral meatotomy

Answer 5

Meatal Stenosis

• Frequently overdiagnosed. Visual inspection is not satisfactory. You must observe the voiding process. Look for evidence of straining and assess the strength and angle of the urinary stream.
• Tx: Ventral meatotomy

Question 6

Microphallus / Micropenis

• Central causes:
  
  • ______
  • ____ syndrome
  • _____
• Definition
  
  • For a term infant, a stretched phallic length of

Answer 6

Microphallus / Micropenis

• Central causes:
  
  • Panhypopituitarism
  • Kallman syndrome
  • Prader-Willi
• Definition
  
  • For a term infant, a stretched phallic length of <2.5cm meets the definition for micropenis. Normal stretched length is 2.5-3.5cm.
• Management: Babies with micropenis should undergo evaluation in the immediate newborn period to detect and treat potentially life-threatening conditions. If genital ambiguity is present, the neonate should be evaluated for disorders of sexual differentiation and monitored to prevent any potentially associated adrenal crisis. For neonates with micropenis without other genital ambiguity, monitoring for hypoglycemia and evaluation for other pituitary hormone deficiencies should occur.
• Tx: Early tx with testosterone is beneficial in some boys.

Question 7

Priapism

• Painful, unremitting erection in which the ____ is rigid but the glans and ____ are flaccid.
• RF: ______ is the most common cause of priapism. Priapism is sometimes the presenting symptom of sickle cell disease
• Tx: In patients with sickle cell disease, hydration, pain control, oxygen, transfusion. Other therapies include corporal aspiration and irrigation with phenylephrine and caudal anesthesia. If the priapism does not respond in 24-48 hours, perform surgery with cavernoglandular shunting.

Answer 7

Priapism

• Painful, unremitting erection in which the corpora cavernosa is rigid but the glans and corporus spongiosum are flaccid.
• RF: Sickle cell disease is the most common cause of priapism. Priapism is sometimes the presenting symptom of sickle cell disease
• Tx: In patients with sickle cell disease, hydration, pain control, oxygen, transfusion. Other therapies include corporal aspiration and irrigation with phenylephrine and caudal anesthesia. If the priapism does not respond in 24-48 hours, perform surgery with cavernoglandular shunting.

Question 8

Polyuria

• Definition: 24-hour urine output >2L/m2/day or anytime >3L/day
• In children >2yo, the expected bladder capacity in mL = (age in years + 2) x 30

Work-up of polyuria

• Initial work-up: Serum glucose, plasma sodium, plasma osmolality, urine osmolality
• Low plasma sodium (<137) + low urine osmolality (<50% plasma osmolality) = water overload from primary polydipsia
• High plasma sodium (>142) with urine osmolality less than plasma osmolality = DI (central or nephrogenic)

Answer 8

Polyuria

• Definition: 24-hour urine output >2L/m2/day or anytime >3L/day
• In children >2yo, the expected bladder capacity in mL = (age in years + 2) x 30

Work-up of polyuria

• Initial work-up: Serum glucose, plasma sodium, plasma osmolality, urine osmolality
• Low plasma sodium (<137) + low urine osmolality (<50% plasma osmolality) = water overload from primary polydipsia
• High plasma sodium (>142) with urine osmolality less than plasma osmolality = DI (central or nephrogenic)

Question 9

Enuresis (bedwetting) is diagnosed in children >_____ years old who void in bed or their clothes >2x/week for 3 consecutive months

Answer 9

Enuresis (bedwetting) is diagnosed in children >5 years old who void in bed or their clothes >2x/week for 3 consecutive months

Question 10

Evaluation after 5yo
- Underlying causes should be considered but are rare (<25% of cases); especially consider in secondary enuresis: UTI, diabetes, chronic renal failure, constipation, hyperthyroidism, OSA, psychological stressors, seizure disorders, sickle cell disease

• Rule out infection with urinalysis and urine culture
• _______ must be performed on all children with daytime incontinence.
• For sensory defect or detrusor instability, try timed voiding and anticholinergics as initial therapies.
• Giggling incontinence is also treated with anticholinergics and stress incontinence with perineal exercises and alpha-adrenergic agonists.
• If presents later in childhood, typically presents with recurrent UTIs, diurnal enuresis in pts >5yo or secondary diurnal enuresis, pain with voiding, voiding dysfunction, or an abnormal urinary stream. VCUG is specific for the diagnosis.
• Primary daytime and nocturnal enuresis in the setting of poor linear growth and proteinuria is concerning for ______
• Psychological factors are more often implicated in _____ enuresis.

Answer 10

Evaluation after 5yo
- Underlying causes should be considered but are rare (<25% of cases); especially consider in secondary enuresis: UTI, diabetes, chronic renal failure, constipation, hyperthyroidism, OSA, psychological stressors, seizure disorders, sickle cell disease

• Rule out infection with urinalysis and urine culture
• Ultrasound of the kidneys and bladder must be performed on all children with daytime incontinence.
• For sensory defect or detrusor instability, try timed voiding and anticholinergics as initial therapies.
• Giggling incontinence is also treated with anticholinergics and stress incontinence with perineal exercises and alpha-adrenergic agonists.
• If presents later in childhood, typically presents with recurrent UTIs, diurnal enuresis in pts >5yo or secondary diurnal enuresis, pain with voiding, voiding dysfunction, or an abnormal urinary stream. VCUG is specific for the diagnosis.
• Primary daytime and nocturnal enuresis in the setting of poor linear growth and proteinuria is concerning for chronic kidney disease.
• Psychological factors are more often implicated in secondary enuresis.

Question 11

NOCTURNAL ENURESIS
- Occurs in 10% of 5 year olds and spontaneously resolves at a rate of about 15% per year.

• RF
  
  • Note the importance of a detailed___
  • Nocturnal enuresis factors: Defective sleep arousal, delayed maturation of the cortical mechanisms that allow voluntary control of the micturition reflex, reduced ADH at night, constipation, UTI, and genetic factors.
• Causes:
  
  • ____ can cause nocturnal enuresis.
• Dx:
  
  • Urinalysis and culture to rule out infection.
  • Imaging studies (an ultrasound and a VCUG) are not routinely recommended unless a child >10 years has continued enuresis.
• Management
  
  • Limit fluid intake before bedtime, empty bladder before going to sleep, void again at night (before parents go to bed), and establish a consistent bedtime routine.
  • “Potty alarms,” which work fairly well in younger children
    
    • If daytime urgency and frequency are also a problem, then use ___ in the daytime and ____ at night.

Answer 11

NOCTURNAL ENURESIS
- Occurs in 10% of 5 year olds and spontaneously resolves at a rate of about 15% per year.

• RF
  
  • If one parent had nocturnal enuresis, there is a 40% risk to the child of having the condition, this increases to 70% if both parents had nocturnal enuresis as children. Note the importance of a detailed family hx
  • Nocturnal enuresis factors: Defective sleep arousal, delayed maturation of the cortical mechanisms that allow voluntary control of the micturition reflex, reduced ADH at night, constipation, UTI, and genetic factors.
• Causes:
  
  • Ask if the pt snores. Obstructive apnea can cause nocturnal enuresis.
• Dx:
  
  • Urinalysis and culture to rule out infection.
  • Imaging studies (an ultrasound and a VCUG) are not routinely recommended unless a child >10 years has continued enuresis.
• Management
  
  • Limit fluid intake before bedtime, empty bladder before going to sleep, void again at night (before parents go to bed), and establish a consistent bedtime routine.
  • “Potty alarms,” which work fairly well in younger children
  • Medications are effective for older children: Desmopressin acetate (DDAVP), oxybutynin, and imipramine (rarely used now due to potential life-threatening side effects when overdosed).
    
    • If daytime urgency and frequency are also a problem, then use oxybutynin in the daytime and desmopressin at night.
      
      • Oxybutynin is used in children with a small-capacity bladder or a hyperactive bladder when 1st line medication treatment with desmopressin has failed.
      • Intranasal desmopressin has had FDA approval revoked for nocturnal enuresis because of safety issues (ie cases of fatal hyponatremia).

Question 12

Testicular mass

- Evaluation of a testicular mass should always begin with ___

Answer 12

Testicular mass

- Evaluation of a testicular mass should always begin with US

Question 13

Indirect inguinal hernia

• Dx: Manual reduction of an inguinal hernia should be attempted at the time of diagnosis by gentle applying upward and lateral pressure
  
  • After successful manual reduction, a non urgent but timely referral to pediatric surgeon is warranted.
  • If reduction is not successful, the hernia is defined as incarcerated

Answer 13

Indirect inguinal hernia

• Dx: Manual reduction of an inguinal hernia should be attempted at the time of diagnosis by gentle applying upward and lateral pressure
  
  • After successful manual reduction, a non urgent but timely referral to pediatric surgeon is warranted.
  • If reduction is not successful, the hernia is defined as incarcerated

Question 14

Hydrocele

• Dx: Clinical. Supported by transillumination of scrotum which confirms the fluid-filled mass
  
  • Hydrocele and hernias will transilluminate when light placed behind mass while other masses will not.
• Tx:
  
  • Observation as most resolve on their own
  • Repair indicated for: Hydroceles that last past ______ year of age require surgical repair.

Answer 14

Hydrocele

• Dx: Clinical. Supported by transillumination of scrotum which confirms the fluid-filled mass
  
  • Hydrocele and hernias will transilluminate when light placed behind mass while other masses will not.
• Tx:
  
  • Observation as most resolve on their own, usually before patient’s 1st birthday.
  • Repair indicated for: Hydroceles that last past 1 year of age require surgical repair.

Question 15

Varicocele

• Congenital dilation of ____ venous plexus and _____ vein
• Pt:
  
  • Almost exclusively on ___ side (85-95%).
  • Most pts are asymptomatic
  • Asymmetry of scrotal size with painless scrotal masses as “________”
• Tx: Controversial
  
  • No treatment when _____
  • Indications for surgical repair: _____, abnormal ___, ____, and ____.
    
    • Perform surgery at 1st sign of ___.
  • Unilateral R varicoceles are very rare and are often due to underlying pathology, such as ___ or ____.
  • Isolated R sided varicocele should raise concern for ____ as should a varicocele in a child <10 yo.

Answer 15

Varicocele

• Congenital dilation of pampiniform venous plexus and testicular vein
• Pt:
  
  • Almost exclusively on left side (85-95%).
  • Most pts are asymptomatic
  • Asymmetry of scrotal size with painless scrotal masses as “bag of worms”
• Tx: Controversial
  
  • No treatment when asymptomatic
  • Indications for surgical repair: Significant loss of testicular volume (L side 2-3mL less volume than R side), abnormal semen analysis, very large varicoceles, and pain/discomfort.
    
    • Perform surgery at 1st sign of reduced testicular growth. Follow with semen analysis
  • Unilateral R varicoceles are very rare and are often due to underlying pathology, such as IVC obstruction from a clot or tumor.
  • Isolated R sided varicocele should raise concern for abd/retroperitoneal mass as should a varicocele in a child <10 yo.

Question 16

Spermatocele

• Cyst of epididymis attached to the ____ of the testis in sexually mature boys
• Tx:______

Answer 16

Spermatocele

• Cyst of epididymis attached to the upper pole of the testis in sexually mature boys
• Tx: Does not usually require tx and is usually discovered incidentally on exam.

Question 17

Cryptorchidism (Undescended testes)
- Path: Testes typically begin to descend through inguinal canal into the scrotum around ____ weeks gestation.

• RF: Maternal diabetes and obesity, prematurity, SGA, low birth weight
• Def: Failure of 1 or both testes to descend from abdomen into the scrotum by ___ months of age
• Dx: Physical exam
  
  • Distinguish from: Retractile testis is one that has descended into the scrotum but can move in and out of the scrotum. Can be misdiagnosed as undescended testicle (unlike undescended, can be brought down into scrotum). Retractile testes are able to be pulled down to the bottom of the scrotum and are due to a hyperactive cremasteric reflex. The best way to perform the exam is to have the pt sit in a cross-legged position. Almost all retractile testes eventually end up in the scrotum, so no further management is required.
• Tx:
  
  • Observation of undescended testis appropriate. After ____mo, referral to surgical specialist indicated.
  • Reasons for referral of a child with cryptorchidism:
    
    • Bilateral undescended testes at birth
    • Unilateral undescended testis with hypospadias
    • Suspected disorder of sexual development
    • Failure of a unilateral undescended testis to descend by 4mo of age (adjusted for prematurity)
    • Acquired undescended testes should be referred
  • Orchiopexy should be completed between 6-18mo to optimize fertility potential and testicular growth. Surgery decreases risk of torsion and testicular cancer (but malignancy risk is higher than in pts wo hx of cryptorchidism)
• Complications: inguinal hernia, testicular torsion, reduced fertility, testicular cancer, testicular trauma
  
  • Malignancy - increased duration of suprascrotal location of the testis increase the degree of germ cell dysfunction, esp seminoma, so prompt orchiopexy improves outcomes
  • Leydig cells are preserved, so ____ is not affected.

Answer 17

Cryptorchidism (Undescended testes)
- Path: Testes typically begin to descend through inguinal canal into the scrotum around 28 weeks gestation.

• RF: Maternal diabetes and obesity, prematurity, SGA, low birth weight
• Def: Failure of 1 or both testes to descend from abdomen into the scrotum by 6 months of age
• Dx: Physical exam
  
  • Distinguish from: Retractile testis is one that has descended into the scrotum but can move in and out of the scrotum. Can be misdiagnosed as undescended testicle (unlike undescended, can be brought down into scrotum). Retractile testes are able to be pulled down to the bottom of the scrotum and are due to a hyperactive cremasteric reflex. The best way to perform the exam is to have the pt sit in a cross-legged position. Almost all retractile testes eventually end up in the scrotum, so no further management is required.
• Tx:
  
  • Observation of undescended testis appropriate until 6mo. After 6mo, referral to surgical specialist indicated.
  • Reasons for referral of a child with cryptorchidism:
    
    • Bilateral undescended testes at birth
    • Unilateral undescended testis with hypospadias
    • Suspected disorder of sexual development
    • Failure of a unilateral undescended testis to descend by 4mo of age (adjusted for prematurity)
    • Acquired undescended testes should be referred
  • Orchiopexy should be completed between 6-18mo to optimize fertility potential and testicular growth. Surgery decreases risk of torsion and testicular cancer (but malignancy risk is higher than in pts wo hx of cryptorchidism)
• Complications: inguinal hernia, testicular torsion, reduced fertility, testicular cancer, testicular trauma
  
  • Malignancy - increased duration of suprascrotal location of the testis increase the degree of germ cell dysfunction, esp seminoma, so prompt orchiopexy improves outcomes
  • Leydig cells are preserved, so virilization is not affected.

Question 18

Testicular torsion

• Exam
  
  • ____ testicular lie
  • ____ cremasteric reflex
  • Elevation of testicles ___
• Dx:
  
  • If the diagnosis of testicular torsion can be confirmed with history and physical exam, urology should be consulted emergently. There is no need for imaging.
  • Imaging: If torsion is not obvious, perform scrotal Doppler ultrasound to see decreased blood flow/perfusion.
• It is essential that a testicular exam be completed in any male w abdominal pain, bc testicular torsion can manifest solely w abdominal pain in some patients.
• Tx:
  
  • Surgical exploration, detorsion, reduction, and _____ fixation - remember the contralateral testicle is at future risk
  • With torsion, testicles typically twist medially so you must twist ______ for detorsion, 180 degrees at a time. Repeat as needed, may take up to 4 tries because torsion can have rotations up to 720. Successful detorsion is made evident by immediate pain relief.

Answer 18

Testicular torsion

• Exam
  
  • Horizontal testicular lie
  • Absent cremasteric reflex
  • Elevation of testicles does not improve pain
• Dx:
  
  • If the diagnosis of testicular torsion can be confirmed with history and physical exam, urology should be consulted emergently. There is no need for imaging.
  • Imaging: If torsion is not obvious, perform scrotal Doppler ultrasound to see decreased blood flow/perfusion.
• It is essential that a testicular exam be completed in any male w abdominal pain, bc testicular torsion can manifest solely w abdominal pain in some patients.
• Tx:
  
  • Surgical exploration, detorsion, reduction, and BILATERAL fixation - remember the contralateral testicle is at future risk
  • With torsion, testicles typically twist medially so you must twist laterally for detorsion, 180 degrees at a time. Repeat as needed, may take up to 4 tries because torsion can have rotations up to 720. Successful detorsion is made evident by immediate pain relief.

Question 19

Neonatal testicular torsion

• Torsion of the entire spermatic cord and testis outside the tunica vaginalis (extravaginal torsion)
• Occurs only neonatally or prenatally.
• Pt: Painless, swollen, discolored hemiscrotum
• Dx: Clinical
• Tx: Testicular salvage is usually attempted but rarely successful. At time of surgery, some recommend that contralateral testis be fixed as a precautionary measure even though the risk of bilateral disease is much less than intravaginal torsion

Answer 19

Neonatal testicular torsion

• Torsion of the entire spermatic cord and testis outside the tunica vaginalis (extravaginal torsion)
• Occurs only neonatally or prenatally.
• Pt: Painless, swollen, discolored hemiscrotum
• Dx: Clinical
• Tx: Testicular salvage is usually attempted but rarely successful. At time of surgery, some recommend that contralateral testis be fixed as a precautionary measure even though the risk of bilateral disease is much less than intravaginal torsion

Question 20

Testicular appendage torsion
- Path: Torsions of the appendix testis and the appendix epididymis

• Pt
  
  • Early-stage exam can show a palpable tender nodule on the top portion of the testicle with blue discoloration - the blue dot sign.
  • Gradual onset of pain at the upper poles of the testis with progressive inflammation and swelling
• Dx: Consider scrotal color-flow Doppler ultrasound to distinguish from torsion of spermatic cord, which is an emergency. Color doppler US and radionuclide scans are normal.
• Tx: Torsion of the appendix testis normally resolves spontaneously in several days (less than 1 week).

Answer 20

Testicular appendage torsion
- Path: Torsions of the appendix testis and the appendix epididymis

• Pt
  
  • Early-stage exam can show a palpable tender nodule on the top portion of the testicle with blue discoloration - the blue dot sign.
  • Gradual onset of pain at the upper poles of the testis with progressive inflammation and swelling
• Dx: Consider scrotal color-flow Doppler ultrasound to distinguish from torsion of spermatic cord, which is an emergency. Color doppler US and radionuclide scans are normal.
• Tx: Torsion of the appendix testis normally resolves spontaneously in several days (less than 1 week).

Question 21

Orchitis
- Acute reactive inflammation of the testicle in response to infection.

• Path:
  
  • Viruses
  • May occur due to an extension of epididymitis
• More common in adolescents who are both postpubertal and sexually active
• Pt:
  
  • Sudden onset of testicular pain and swelling are the presenting symptoms. Accompanied by fever, nausea, fatigue.
    
    • If caused by mumps, the orchitis presents 4-7 days after parotitis
• Dx: Ultrasound to exclude testicular torsion, urinalysis and culture, and urethral cultures in sexually active patients. Doppler US will typically demonstrate testicular enlargement and hypervascularity
  
  • UA will typically reveal pyuria +/- bacteriuria
• Tx:
  
  • Supportive, including bedrest, ice packs, and scrotal elevation with tight-fitting underwear. NSAIDs for comfort, and antibiotic therapy if etiology is bacterial.
  • As per epididymitis, IM _____ and ___

Answer 21

Orchitis
- Acute reactive inflammation of the testicle in response to infection.

• Path:
  
  • Viruses
  • May occur due to an extension of epididymitis
• More common in adolescents who are both postpubertal and sexually active
• Pt:
  
  • Sudden onset of testicular pain and swelling are the presenting symptoms. Accompanied by fever, nausea, fatigue.
    
    • If caused by mumps, the orchitis presents 4-7 days after parotitis
• Dx: Ultrasound to exclude testicular torsion, urinalysis and culture, and urethral cultures in sexually active patients. Doppler US will typically demonstrate testicular enlargement and hypervascularity
  
  • UA will typically reveal pyuria +/- bacteriuria
• Tx:
  
  • Supportive, including bedrest, ice packs, and scrotal elevation with tight-fitting underwear. NSAIDs for comfort, and antibiotic therapy if etiology is bacterial.
  • As per epididymitis, IM Ceftriaxone and doxycycline (if STI)

Question 22

Acute epididymitis

• Epidemiology:
  
  • Prepubertal (less than __yo) - most commonly arises from a postviral phenomenon
  • After puberty, infection is usually sexually transmitted and fairly common
    
    • Age <35: sexually transmitted (chlamydia, gonorrhea)
• Pt:
  
  • Subacute unilateral testicular pain, erythema, and edema.
  • Typically in setting of fever, dysuria
• Exam:
  
  • _____ cremasteric reflex (distinguish from testicular torsion), and the testicle remains in the ______ orientation
  • Should have _____ with elevation of testicle of the testicle (_____ sign)
• Dx:
  
  • Usually by physical examination.
  • Doppler ultrasound can be used if needed, which will show ______ blood flow to the affected epididymis and increased size.
  • Evaluation confirms 1 of the following
    
    • Gram-stained smear of urethral exudate or intraurethral swab with >5 PMNs/oil-immersion field is consistent with epididymitis.
    • UA/urine culture will typically reveal positive leuk esterase on 1st void urine or >10 WBC/hpf pyuria +/- bacteriuria.
    • Intraurethral exudate or a NAAT (either swab or 1st void urine) for C trachomatis and N gonorrhoeae
• Tx:
  
  • Tx offending bacteria. Response within 48 hours is expected.
    
    • Children <14 years old: Antibiotic treatment for underlying enteric organism
    • Sexually active adult <35 years old
      
      • Empiric abx, pending lab results: IM __ and __
  • Treat all sexual partners.

Answer 22

Acute epididymitis

• Epidemiology:
  
  • Prepubertal (<14yo) - most commonly arises from a postviral phenomenon
  • After puberty, infection is usually sexually transmitted and fairly common
    
    • Age <35: sexually transmitted (chlamydia, gonorrhea)
• Pt:
  
  • Subacute unilateral testicular pain, erythema, and edema.
  • Typically in setting of fever, dysuria
• Exam:
  
  • Normal cremasteric reflex (distinguish from testicular torsion), and the testicle remains in the normal vertical orientation
  • Should have relief of pain with elevation of testicle of the testicle (Phren’s sign)
• Dx:
  
  • Usually by physical examination.
  • Doppler ultrasound can be used if needed, which will show increased blood flow to the affected epididymis and increased size.
  • Evaluation confirms 1 of the following
    
    • Gram-stained smear of urethral exudate or intraurethral swab with >5 PMNs/oil-immersion field is consistent with epididymitis.
    • UA/urine culture will typically reveal positive leuk esterase on 1st void urine or >10 WBC/hpf pyuria +/- bacteriuria.
    • Intraurethral exudate or a NAAT (either swab or 1st void urine) for C trachomatis and N gonorrhoeae
• Tx:
  
  • Tx offending bacteria. Response within 48 hours is expected.
    
    • Children <14 years old: Antibiotic treatment for underlying enteric organism
    • Sexually active adult <35 years old
      
      • Empiric abx, pending lab results: IM Ceftriaxone 250mg in 1 dose and oral doxycycline 100mg BID for 10-14 days (if STI).
  • Treat all sexual partners.