Urology Part I
With Dr. Patricio Gargollo · hosted by Dr. Todd Ponsky · StayCurrentMD
Cued at 25:38 · stops at 26:23 · press play
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
UTI risk in the first year of life is 3-4% overall, with uncircumcised boys having 1/100 risk versus circumcised boys 1/1000 risk
Circumcision decreases risk of HIV, syphilis, gonococcus, HPV, and HSV-2, but does not change chlamydia risk
Circumcision provides 53% protection against HIV transmission in randomized trials from Kenya and Uganda, with both trials stopped early due to significant benefit
Office circumcision should be limited to infants 3 months or younger or weighing less than 13 pounds to minimize restraint difficulty and bleeding risk
Exposing young children to elective general anesthesia such as for circumcision is not recommended from an anesthetic safety standpoint
The best analgesia for circumcision is a dorsal penile nerve block combined with a ring block using 0.25% bupivacaine without epinephrine
The Gomco clamp is preferred over Plastibell (subjectively more complications) and Mogen clamp (risk of glans amputation)
Glans amputation during circumcision has been seen 2-3 times with Mogen clamp when small glans is pulled through the slit
Complete preputial adhesion takedown is essential—you must see the ridge under the corona all the way around to avoid asymmetric skin removal
When using Gomco, leave the bell on for at least 5 minutes for older infants (closer to 3 months/13 pounds) and 1-2 minutes for newborns
When removing the Gomco bell, force the skin off the bell rather than pulling the bell off the skin to avoid separating crushed edges
A safety pin through both edges of the dorsal slit helps pull foreskin through the Gomco base hole more easily
Before clamping, check underneath the bell to ensure shaft skin (not scrotal skin) is visible and the median raphe is centered to avoid twisting
Vaseline dissolves Dermabond, so parents must be instructed not to apply Vaseline after Dermabond circumcision
Office circumcision tray should include 6-0 chromic or fast-absorbing plain suture for bleeding and 1:1000 epinephrine for topical hemostasis
For OR circumcision, 6-0 or 5-0 fast-absorbing plain gut (used by plastic surgeons on face) heals nicely; Vicryl causes pie-crusting unless subcuticular
Physiologic post-circumcision adhesions (distinct line visible, common in chubby babies) do not need treatment and will lyse spontaneously as the child grows
Lysing physiologic adhesions in the office can turn a non-problem into a problem by creating a raw surface that forms a true skin bridge
True skin bridges (no line, two holes on each side) require treatment because they tether the penis and do not resolve spontaneously
Most skin bridges can be lysed in office with EMLA cream for 30-40 minutes, hemostat placement, and fine scissor division
Redundant foreskin appearance after circumcision is usually due to suprapubic fat pad displacing skin distally; if penis looks circumcised when fat pad is pushed down, no revision is needed
Dr. Gargollo has never seen an adolescent complain of too much foreskin after circumcision, suggesting most cases resolve with puberty
Dr. Gargollo performs only 1-2 redo circumcisions per year despite high volume, indicating most redundant skin resolves spontaneously
Meatal stenosis is a condition exclusively seen in circumcised boys, caused by meatal inflammation from rubbing against diaper/underwear creating a 6 o'clock web
Meatal stenosis requires intervention only when urine stream deviates straight upward or child must sit to void, not for subjectively narrow meatus alone
Dr. Gargollo has never seen an adolescent with meatal stenosis, suggesting many subjectively narrow meatuses normalize with growth
Office meatotomy can be performed with EMLA cream, straight hemostat crush of 6 o'clock web, and fine scissors; sutures at 3 and 6 o'clock have no proven benefit for reducing recurrence
Micropenis is defined as stretched penile length greater than 2.5 standard deviations below the mean for age; mean is 4 cm at 6-12 months
Hypospadias, buried penis, penile-scrotal webbing, penile torsion, and congenital megaprepuce are contraindications to routine circumcision and should be referred to pediatric urology
A buried penis appears as a short squat pyramid rather than a protruding structure; attempting circumcision can result in complete shaft skin loss requiring skin grafting
Physiologic phimosis (soft, supple foreskin without symptoms) requires no treatment regardless of age, even in 5-8 year olds
First-line treatment for symptomatic phimosis is betamethasone 0.1% three times daily for 2-3 months, with >50% success rate
Secondary phimosis (post-circumcision cicatrix causing stenotic ring) responds to betamethasone 0.1% TID for 2-3 months in >50% of cases
Balanitis xerotica obliterans (BXO) presents with white paper-like, scaly, hard skin at prepuce tip and does not respond to steroids; requires circumcision to prevent urethral stricture
Paraphimosis management includes pain control, D50-soaked bandage wrap to reduce edema, and manual reduction with thumbs on glans pushing back through foreskin
Dr. Gargollo has never had to perform a dorsal slit for paraphimosis, as manual reduction with proper pain control and D50 wrap is successful
The main cause of penile trauma is zipper injuries; treatment is cutting the zipper bridge with bolt cutters rather than manipulating the zipper
Toilet seat crush injuries to penis can be managed conservatively if child is voiding without gross hematuria; glands hematoma may look necrotic but resolves
Buck's fascia violation in penile trauma requires OR repair to prevent long-term scarring and potency issues
Gross blood at urethral meatus or gross hematuria after trauma mandates full urinary tract evaluation and retrograde urethrogram before catheterization
Hypospadias incidence is approximately 1 in 150 live births, likely multifactorial etiology including in vitro fertilization exposure
Hypospadias assessment requires evaluation of meatus location and degree of ventral curvature (chordee); more proximal meatus and greater curvature indicate more complex repair
For distal hypospadias discovered during circumcision, the circumcision can be completed because foreskin is not used in modern distal hypospadias repairs
Non-palpable gonad with hypospadias requires full disorder of sexual differentiation (DSD) workup; bilateral non-palpable gonads suggests congenital adrenal hyperplasia
Very mild hypospadias variants (megameatus, distal) raise controversy about timing of repair given anesthesia exposure concerns in young children
Hypospadias repair involves urethroplasty (tubularizing urethra with second-layer coverage) and phalloplasty (straightening chordee, often resolved by degloving alone)
Epispadias (dorsal urethral defect) is extremely rare (<1/50,000) and represents the bladder exstrophy-epispadias spectrum with associated incontinence, pubic diastasis, and vesicoureteral reflux
Penile torsion (twisted median raphe) requires surgical correction only if rotation is ≥90 degrees
Labial adhesions occur in approximately 2% of girls in the first 2 years of life, not in newborns due to protective maternal estrogen
Labial adhesions require treatment only for symptoms: post-void dribbling, skin breakdown, or recurrent UTIs; asymptomatic adhesions should not be treated
First-line treatment for symptomatic labial adhesions is betamethasone ointment BID for 6 weeks, preferred over estrogen cream to avoid pubic hair development in prepubertal girls
Surgical lysis of labial adhesions is rarely needed; Dr. Gargollo has performed it only once in his career
Differential diagnosis for midline genital bulge includes imperforate hymen, prolapsed urethrocele, paraurethral/perivaginal cysts, and vaginal rhabdomyosarcoma
Prolapsed urethrocele is distinct from vagina on exam, associated with prenatal hydronephrosis, and requires renal bladder ultrasound and VCUG
Paraurethral and perivaginal cysts (Gardner's duct, Skene's gland) present at birth, spontaneously regress with loss of maternal estrogen, and show patent urethra and vagina on exam
Vaginal rhabdomyosarcoma appears as a 'bunch of grapes' mass rather than a single bulge and requires oncology involvement
The AAP states that data are not sufficient to recommend routine neonatal circumcision, and parents should be given accurate, unbiased information