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
• 20-30% NON-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
1.
PROVIDERS SHOULD OBTAIN GESTATIONAL HISTORY AT INITIAL EVALUATION
OF BOYS SUSPECTED OF CRYPTOCHIDISM
DESCENT
• TRANSADOMINAL – 1 ST 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
Bae158 Korea 43
La Scala159 Switzerland
64
<23%
Marchetti160
25%
Stec126 USA
USA
Italy
172
122
40
274
41
4
204
3
150
5
4.4
2.8
45%
5
No Information
2.2
NI
30%
14%
3.8
2.3
7%
32%
34%

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
• URETEROPELVIC JUNCTION OBSTRUCTION
• VESICOURETERAL REFLUX
• VESICOURETERAL OBSTRUCTION
40-80%
10-30%
10-20%
5-10 %
•
• MULTICYSTIC DYSPLASTIC KIDNEY
• DUPLEX KIDNEY
POSTERIOR URETHRAL VALVES
4-6%
2-7%
1-2%
• OTHER – URETHRAL ATRESIA, UROGENITAL SINUS, PRUNE BELLY SYNDROME

ANTENATAL HYDRONEPHROSIS

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
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•
•
•

ANTENATAL HYDRONEPHROSIS

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