Urology Part I

Stay Current is a multimedia publication designed to keep healthcare professionals up to date with standards of care and new emerging ideas. This chapter is created and edited by Todd Ponsky, Sophia Abdulhai, Abdulruf Lamoshi, and Rajavendra Rao and is recorded and produced at Akron Children's Hospital in Akron, Ohio. This is Todd Ponsky with State Current and Pediatric Surgery, and today we're gonna be talking about pediatric urology. Uh, we've decided to break this up into a few sessions. Today we're gonna be mostly talking about external genitalia, and this is gonna be an overview for pediatric surgeons to get an idea about all the things that we probably should know about external genitalia as it relates to pediatric urology. And with us today we have a great friend of mine, Dr. Patricio Gargoya, and Patricio is the senior associate consultant in pediatric urology at the Mayo Clinic Rochester. He's associate professor of urology at the Mayo Medical School, and he is really truly a superstar pediatric urologist. So Patricio, thanks for joining us. Oh, thanks so much for the invitation and the great introduction. It's my pleasure to be here. Patricio, we met, I think we met a year ago now at the Mexican Congress of Pediatric Surgery. Is that right? Is that where we met? That's correct, yeah, absolutely. So thanks for agreeing to do this, and we'll just get right on into it. So I was just at the um at the AAP meeting and like always there's a lot of protesters out there having trouble with uh the fact that we do circumcisions. So this is clearly a very controversial topic. Tell me your thoughts and, and what does the literature say? Do we need to be doing this? When do we do it? How do we do it? What does it say? Yeah, absolutely. No, yeah, I think you hit the nail on the head. This is a very controversial topic as, as you know, we're one of the few industrialized countries that routinely circumcises our newborns, so certainly, um, you know, we, we have some controversies that have to deal with that, especially since again our rate of circumcision is pretty high. And the way I like to break down circumcisions when a parent comes to me and say we're, you know, we're expecting a boy, you know, doctor, what do you think we should do? You know, what, what does the evidence show, um, regarding circumcisions, I basically break it down into several things and I say, look, circumcisions can be broken down into 3 main areas, and that's the risk of urinary tract infections. The risk of sexually transmitted diseases and the risk of penile cancer, I mean those are the main three things that people should worry about. So if we break these individually, the UTI, the urinary tract infection risk is, is very low overall. We're talking about 3/41% in the first year of life. So even the risk of UTIs are. Much lower than a lot of people think. Now granted, in kids that are uncircumcised, that that equals out to about 1 in 100 children will have a urinary tract infection at some point versus a circumcised child, those chances go up to 1 in 1000. So clearly a lot more common to have a urinary tract infection, but again, the numbers are pretty small. Now if we kind of shift a little bit to, you know, sexually transmitted diseases, there's kind of three main subsets of STDs and circumcision, and that's, you know, which in which one of these has a decreased risk in a circumcised child and which is there no change, so decreased risks for sexually transmitted diseases in circumcised males we see in for HIV. Uh, we see it for syphilis and we see it for gonococcus, um, and we also see it for HPV and HSV-2, so there's decreased risks in all of those, and really the only STD that does not have a change in risk is chlamydia. And all of these studies have come out of Africa, and there's actually been several very interesting studies out of Africa that show that again the STD transmission risk is significantly lower. One of these came out of Kenya and I think they had close to 3000 people and basically they were randomized to either circumcision or control, and they were followed up. At three month intervals 136, 1218, and 24, and they showed that the rate of protection for HIV was exceedingly high. It was about a 53% less chance of getting HIV in the circumcised cohort, and it was actually so significant they stopped the trial early. The second trial in Uganda looked at almost 5000 males again randomized search versus control, and they looked at the same thing HIV transmission and percent protection and it was also about the same. So 50, only 50% of men that were circumcised became infected when compared to the control group, and that was also. Um, stopped early. So again, very significant decreased risks for STDs and you know, again some for UTIs and the last one's penile cancer. Penile cancer is exceedingly, exceedingly rare. We really don't see it even in countries that do routinely circumcise their newborns. So when you kind of put all those things together, and this is where, you know, we've gotten to the AAP policy statement that you were mention. You know, they have basically said that this data, all of this data, the one I've talked about and other data, and that their exact statement is these data are not sufficient to recommend routine neonatal circumcision. According to the AAP, even though the data is very strong for certain things, they do not routinely recommend it, and they go on to say to make an informed choice, parents of all male infants should be given accurate and unbiased information. And be provided the opportunity to discuss this decision. So again, they're a little bit neutral as as their recommendation, you know, again this is a very strong cultural thing and that's what I usually tend to tell parents. Look, I mean these are the risks, these are the benefits of going one way or another, um, you know, and in many cases it's a cultural thing is the father circumcised or the other brother's circumcised, and most, most families will choose to have kind of all boys in the family appear the same. I agree with that that those were interesting numbers and some of them pretty astounding actually, but I think a lot of it just really comes down to the cultural part of it. Patricio, tell me how do you usually do your circumcision and then I wanna talk about some of the pitfalls that can happen when doing a cirque. Absolutely, so you know I think. Doing a circumcision falls into two broad areas for me and that's whether or not you're gonna do a circumcision in the office versus a circumcision in the operating room. Now I realize some people just do not do office circumcisions, and that's perfectly, perfectly fine. My routine and what I recommend, uh, for other surgeons to do is that, you know, have a definitive cut off for your office circumcisions that you feel comfortable with whatever that number may be. My personal number is I will do a newborn circ in the office under local if the child is either 3 months of age or younger or weighs less than 13 pounds. Totally random. I've no data to support that. That's just how I was trained, um, and I honestly that has worked very well for me that the two main concerns being that if you're going to restrain the child. Any way either use a papoose board or anything else that when they get a little bigger it's going to be a little harder to do that. And the second is obviously the older the child, the higher the bleeding risk. So I'm setting you up for some controversial stuff here you know that you said you like to do it in the office, but if you don't, that's perfectly fine. Do you believe that? Do you think that if a newborn, a 1 month old baby Has a circumcision that it's OK for a surgeon to take that child under general anesthesia for a circumcision? No, I actually don't. And as you know, again you're very well aware of this. There's some literature now suggesting that exposing sort of our younger children to elective cases such as a circumcision, you know, is not particularly recommended from an anesthetic safety point of view. Um, and what I meant more was that if in your practice you feel comfortable with doing these neonatal circus in the office, and a lot of people don't, um, this, this is my practice, I, I personally feel that if you don't do them that there's really no reason to not refer that child to somebody who does do them. So I think that's a great point. I, I want to highlight that because. Um, this is often done more by the urologists at a lot of hospitals, and if you're consulted to do a circumcision in a newborn and you're not going to do it at the bedside in the nursery or in your office, then you should probably refer it to someone who would. Yes, absolutely agreed. OK, we might get some, some debate about that in our in our discussion board after this, but I, I agree with that. So. Sorry, so I cut you off. So, so let's say you're doing the, the in office, uh, procedure, right? So you know I, I think you, you need to know and and have fairly set in your mind what you know what the materials are you're gonna need and I, you know, we can certainly provide for the audience a little bit of a of a list of what I personally do but again I think you need some basic things. One is, you know, what are you're gonna use for an anesthetic agent? Two is what are you gonna use for your restraining device? And 3. What are you going to use for your actual circumcision tool of choice, um, you know, I personally use a papoose board. Um, there's a lot of literature now that suggests that the absolute best method of analgesia is a dorsal penile nerve block combined with a ring block. So I personally like to use 0.25% bupfecaine obviously without epinephrine. Um, for my newborn circumcisions, um, some people will put Ela before, uh, which I think is, is perfectly fine. Uh, I don't tend to do that necessarily, and, and the babies seem to be very comfortable as long as you give the block a little bit of a chance to set, um, and, and, you know, then the question is, well, what do you use for your tool? There's basically 3 tools that most people that do these neonatal circumcisions will utilize, and that is either a Mogan clamp. A Gomco clamp or a lastael device, those are kind of the, the main three devices to use, um, I will say that. Subjectively speaking, I feel that the Plastael device has a little bit more, um, postoperative and post-procedure complications associated with it. Again, that's just from a subjective point of view. I know there has been some literature randomizing children to GMO and Plastael showing no difference, uh, but I, I. tend to ask most parents when I do see a post circumcision problem what device was used. I would say the vast majority of them utilize plastic bottleneck branded. That's a totally biased question and a biased answer. But, but I prefer to use the Gomco device. I think it does very well. And I'll say that the Mogan clamp, which I know a lot of people use and a lot of people use very efficiently and very well, the only time I've ever seen a major injury from a circumcision like Glands amputation has been when the Mogan clamp has been used. Again, people use what they're comfortable with, and I think that's perfectly fine. Um, but, but again, the main issue that I've seen has been with the MOGgan, and I have seen 2 to 3 glands avulsions, which of course is a catastrophic injury. So before we get into the technique, um, talk to me. Can you take us through the key points of a dorsal penile block? Yeah, absolutely. So, um, so the, the main nerves run if you're kind of facing the penis, they run at about 2 o'clock to about 11 o'clock. So you need to be able to numb the nerves right at that location. And what I tend to do is I kind of feel for the pubic symphysis and go a little bit below that when I put the needle in. I try to use a small needle, you know, a 25 gauge, you. Need anything very big and I do initially just, you know, go in right around the area where the pubic symphysis kind of dips down and do my initial infiltration there again this is a weight-based 0.25% bupcaine, so you know, 1 cc per kilo, and I do about half of the block there and then proceed with a ring block just directly, directly around the base of the penis. How deep do you go with the needle? So I use the shorter 25 gauge needles. I pretty much hub it to the skin, and I would say that's probably about 1.5 centimeters perhaps. So I go fairly deep again as long as you don't hit anything vascular, I think you're perfectly safe to do that. OK, and then you do a ring block, correct? OK. If someone was to use a MOgan clamp, how does it happen that they would do an amputation, a gland amputation? Is, is it that they would have a small gland that would fit through the opening? Yeah, so if anybody's not familiar with a Mogen clamp, you know, basically it's, it's a slit, it's a metal slit, and what you do is you grab the foreskin and you pull it through that slit, and again, hopefully the gland stays behind underneath the slit, so you really just have foreskin exposed up, and that's what's cut. Um, yeah, and that's exactly right. It's exactly what you said. When people force the skin up through that slit, if the glands are smaller, or if the practitioner doesn't pay close attention, you can pull the glands up. And so when you go to cut that foreskin off, that's exactly what happens. The glands gets right in that wedge and just gets gets amputated off. And when people do the bedside plastels and they tie the rope around. Do they usually just let the skin fall off, or do they cut the skin off in the office? Yeah, I've seen it both ways, honestly. I think a lot of the OBs like to either just take a little bit of the skin off or just leave it on to kind of necros on its own. And then I've seen people cut it, and I don't particularly feel that there's a better way or a less way. I would think it's a little less gross to have a, you know, no dead skin there on your newborn baby. But, but, you know, again, it's practitioner, practitioner dependent. So I do think that the Gomco is probably the, the most commonly preferred method. Can you tell us the, the pearls and pitfalls of using the Gomco? Yeah, absolutely. I think that the main thing is to be able to size the bell, you know, you, you have to, the Gomco basically has. Four components and so it has a bell which is what's gonna fit over the glands um and that has to fit fairly well. The bell sizes are in in centimeters so it's they have a 1.1, a 1.3, a 1.45, and a 1.6, and those are the main sizes. There's some others, uh, and again that's based on the centimeter, uh, width of the gland. So if you were newer to gumco clamps and haven't gotten used to. Uh, measuring and kind of knowing which bell size to use, you can just use a simple ruler, and a lot of people do that and measure and then call for whatever clamp they want. Most of the time, I would say 75% of the time, it's going to be a 1.3. Um, and the other only important component is you have to make sure that the bell is matched with the rest of the device, because if you have a mismatched bell that happened to get sterilized and put in a pan. Say a 1.3 bell with a 1.45 base, you'd run the risk that that bell will pull straight up, and that will also expose the glands, and I have seen some glands injuries when you go to cut this foreskin off after you kind of set the gomko because it wasn't recognized that the belt size was too small or too large for the rest of the device. So I would say that's pitfall and technique point number one. The the other thing which gets done very frequently and I think is a source of error, and this can happen with, you know, the plasttael or the Gomko clamp, and that's that people don't take down the profucial adhesions all the way down. So you really have to make sure that when you're, when you bring the skin down, whether you like to do a dorsal slit or just basically pull the skin straight back, you just have to make sure that you see that ridge underneath the corona. You should see all around. You should see a little ridge, a little divot. Uh, to tell you that the adhesions are all the way down. If you don't do that, you're going to leave some skin behind and it's going to be asymmetric. So that's a second point that's fairly important. And then a third point that's very important is if you do a dorsal slit, you have to make sure that when you bring the skin through the hole of the base of the Gomko device that you have the inner and the outer prepus up. I've seen it numerous times where people will either pull the inner prepus only or the outer prepus only, and then it becomes very messy if you don't kind of know what you're looking at, and people can get very confused and It can be a little nerve-wracking if you don't know where you are. So I think those are the main three points. The last thing is again that the belle of the Gomko is what's crushing the skin. That's your hemostatic agent. So I tend to leave it on for at least a few minutes, at least 5 minutes for the older kids. And another important pearl is when you remove the bell, you just want to yank the bell off the glands of the penis because that can actually separate your skin edges that you worked hard to crush together. So you really want to force the skin off the bell rather than pull the bell off the skin. Couple of questions, points, um, and this is great because I think that a lot of the listeners are new into practice and are going to be doing a lot of these that they may not have done in their training. So the amount of tissue to pull up is always a stressor. You don't want to do too much or too little. What pearls do you have to know exactly the right amount to pull up? Yep, I would say that with the Gomko it's hard to pull too much skin up because as soon as you put that bell on the glands of the penis, you can't really pull skin much past that. I mean, you have to try really hard to do it. So what I tend to do is once the bell is on, the skin is brought up, and I, I personally like to put the bell on and then put a little sterile safety pin through both edges of my dorsal slit because one of the more difficult parts of doing a Gomko circumcision is pulling the skin, the foreskin through the little hole at the base of the Gomko device. And if you have that little safety pin in there that kind of snugs the. Skin around your bell, you grab that safety pin through the hole, pull on the safety pin, and that'll actually bring the skin up. So it's a little easier than kind of going all the way circumferentially to try to get that skin up. I want to make sure I understand this because it sounds like a good trick. So you make your dorsal slit, you put a safety pin through the two edges of your dorsal slit, so you're on just on one, just on the dorsal surface. You have this through the foreskin, and then you pull that. Safety and up through the hole of the garden hole correct, but you just have to make sure obviously you put the bell on the glands first so you do your dorsal slit, take your adhesions down, put the bell on the glands, and then skewer like you said, both edges of your dorsal slit so they will basically snug around that bell. And then you put the bell through the hole on the base of the Gomke device and then you pull the safety pin through the hole, and that'll bring the entire foreskin up and you won't have to struggle trying to get the foreskin all around. So it is a really nice trick. One trick that a colleague of mine taught me early on was to look and see where the scrotal skin is, and if you're pulling any scrotal skin up to the base of the penis, you've gone too far. So. Uh, pulled down until there's no scrotal skin pulling up onto the penis. That was a nice trick he showed me, and that's maybe using other things other than just the, uh, gumko. Yeah, and I think that's, I think that's a great point, and I actually always, and I teach my residents and fellows to always look underneath the bell for two reasons. One, exactly like you said, you want to make sure that you see shaft skin and that you're not on top of the scrotum. And 2, you want to make sure that you didn't accidentally twist the foreskin. So you want to make sure that that median rafa, that line that goes up and down the penis, is pretty much in the center where it should be, because if it's twisted, then you know that you twisted the skin as you brought it up, which, which can happen very easily. So those are two tricks to do before you actually crank the clamp down. I like that. And then do you leave it on for a few minutes after you've made your cut? Yeah, so the older kids, I try to really time it and do, you know, close to 5 minutes. We're talking about the kids that are closer to 3 months or 13 pounds. The younger kids, the newborns especially, 1 or 2 minutes is perfectly plenty of time. That's great. Before we move on, anything that we didn't talk about, how do you dress it? Breast bacitracin? Do you use, uh, do you use Dermabond? Yeah, so that's a great question. I, you know, I personally have been using Dermabond. I know that's not particularly cost conscious, but since a lot of our patients live from a little bit farther away, it gives me a little bit of peace of mind from a hemostasis point of view to do that. And the only thing because people are so ingrained and have, I mean this is, I'm talking about parents are so ingrained to think, oh, you know, circumcision, you have to put a bunch of Vaseline on it. Again, most of the listeners probably know that Vaseline actually dissolves Dermabond, so I tell parents, make sure you do not put Vaseline on it, uh, because they're kind of used to doing that. Um, again, if it's a little bloodier and this kind of goes to more like, you know, what should you have in your tray for any potential problems you may encounter, one of them is obviously gonna be bleeding. So if it's a little bloodier, I will wrap it. I won't Dermabond it. I'll just put a little telfa or something a little bit compressive, and then Tegaderm the penis to the baby's, um, abdomen. But I think the two things to just have available in case there is bleeding, one is just small caliber stitch, maybe like a 60 chromic or a 60 fast absorbing plane in case you have a little pumper or a little bleeder that you just can't get under control with pressure. They just put a little figure of 8 stitch on the skin. And number 2 is just some epinephrine. So if, you know, worst comes to worst, you can put a little 10 to 1000 diluted epinephrine just as a as a topical agent to try to get any of that oozing to decrease. I love that. So you have that in your trays when you're doing this in the office? Yes, absolutely. OK, that's great advice. In the operating room, do you do the same thing or is there anything different? I mean, in the operating room, you know, again I use stitches and, you know, everybody has their own particular way of doing this. I'll say that, you know, some of my mentors, who of course I have immense respect for, tend to use some suture that sticks around for quite a bit. I would say that if you're going to use any sort of Vicryl stitch, you should do more of a subcuticular closure because Vicryl does tend to leave some pie crusting and the skin doesn't tend to look as nice. I tend to use, depending on the size of the kid, either 60 or 500 fast absorbing plain gut. Which you know, again, a lot of the plastic surgeons use in the face and it heals very, very nicely, um, and I personally just interrupted circumferentially all the way around. I do quadrant stitches and then kind of fill in the gaps. I know some people have described doing quadrant stitches and Dermabond. Um, again, I don't think there's a right answer. It's whatever works for you. The only thing I would say is that, you know, the less using suture that is that goes away quicker will definitely leave a nicer cosmetic appearance. That's great and uh I, I actually. Um, I have tried every method. Um, I've never used the Mogan, but I've done everything else. I actually will use the plasta bell in the operating room. It's really actually a freehand, which is how I was taught, but it's a, uh, one of my colleagues showed me a trick. I use the plastic belt and I just actually cut it off right then, so I use it almost as like a, yeah, it's like a little cookie cutter. It cuts off a perfect circle. I cut, take off the plaster bell and throw a bunch of stitches the way you described, and then I actually do also now since uh. Uh, I used to always put bacitracin, but now I use Dermabond. I did, I found it interesting, your trick about taping the penis to the abdominal wall with a Tegaderm. I never thought about that. So lots of tricks, lots of ways of doing this, exactly, yep for sure well this was, this was a good, uh, summary, but I wanna talk about some things that potentially could go wrong so tell me about issues that you see and how and how we can avoid and manage these. I mean, we talked about bleeding briefly. I mean, you know, obviously surgeons can handle bleeding. There's lots of different ways to do that. There shouldn't be anything too excessive unless the child has, you know, some kind of coagulopathy that's been previously not diagnosed, which I've seen once, and that can be a little bit, a little bit of a mess, you know, the main things are sort of, you know, the, the postoperative things that happen with circumcisions, not particularly secondary to any sort of technique, but these are just kind of the things that happen. And you know the, the most common ones are meatal stenosis um and uh penile skin bridges and sort of secondary fimosis so we can talk about those separately. I, I will say one sort of extra thing is that I've had, you know, children either seen by a pediatric neurologist or general practitioner, pediatric surgeon that have certain. Odd, not necessarily straightforward conditions of their foreskin where a circumcision was attempted, um, and obviously I mean again if you just see something that you're not familiar with, I would advise people to not proceed with a circumcision. There's certain conditions such as congenital mega prep use, a couple others that if you proceed with a circumcision not knowing and not recognizing these things, you can get in a little bit of trouble. So obviously one is, you know, doing the right thing for the right patient, of course, um. But as far as other, you know, postoperative problems we can take those kind of one at a time so. There's a difference between post circumcision, what I call physiologic adhesions, meaning adhesions where the perpetual skin just kind of happens to ride up onto the glands. Tend to see that a lot with kind of chubbier babies, you know, that fat pad kind of pushes that skin forward and, and the skin kind of adheres back to the to the underside of the glands, and the difference between. That type of adhesion and a skin bridge where the skin is actually fused with the glands and now you have a little bridge of skin there that you have to deal with and the way to differentiate that is that a physiologic adhesion you will see a distinct line. There will be a distinct line where the adhesion occurs to the glands. Um, and those honestly don't really need any treatment. As the baby grows, the fat fat goes away, and the, and the penis grows, those tend to lice on their own and certainly no need to lice them in the office. In fact, I encourage people not to lice them because you can end up having a raw surface and turning a physiologic adhesion into a bridge. I want to just say it again because I think that's a very common thing that patients come to you and they'll have it done either. Uh, by a moil or they'll have it done by someone else and they come to you as another opinion because they have adhesions and there's been a lot of debate in the literature and I, I, uh. I agree with you. I don't touch them, so, OK. Absolutely, and I think, you know, again it's just you can turn a problem that's not a problem into a problem, and you know I warn parents, look, you're going to see a collection of smegma underneath the skin. They look like little white little dots, and you know, don't worry about it. That's the way those adhesions will lice on their own. So but yeah, absolutely don't touch them. Great, great. Now. And what about the skin bridges? Yeah, so the bridges again, you will see no line. There will be an area of skin that kind of rise up in the glands. You will not see a line. Usually you tend to see two little holes on each side of the bridge. And again, this is not necessarily a problem that occurred during the circumcision. I think it happens to all of us, but those do need to be dealt with because eventually, you know, they will not lice on their own. And as the child grows and gets erections and the penis grows, they can tether the penis fairly significantly. Um, personally, and again this may be an area of controversy as well, as I take care of these in the office. Most of them you can take care of the office. I just put some Emla cream on there, put a Tegaderm, let it sit for about 30 to 40 minutes, um, and then just get a little hemostat, uh, you know, underneath the bridge, clamp the bridge, and just divide it with a fine scissor. Now some bridges are very thick, some bridges are very long, you know, in that case, the Emla cream won't get behind the bridge. So when you put that clamp in between the gland, skin, and the bridge, patients will feel that. Um, so obviously if the bridge is too thick or too extensive, some of them go all the way around the sub coronal margin. Well then, yeah, of course that's the kind of child that's going to need to go to the operating room, be put. Under uh and then go ahead and lice it, but I, I tell you if I can avoid a general anesthetic in a child, I, I, I'm absolutely all in. I think in general this is probably a statement I should watch what I say, but I do think that, uh, the pediatric urologists are, are oftentimes better than pediatric surgeons at doing these things in the office like you said, if, if there's something that could be dealt with by someone in the office and, and you're not comfortable, send it to a urologist to do it. The big question that people come in before we get to medial stenosis. Uh, a very common problem I, I get in the, in my clinic are parents coming to bring a child who had a circumcision done and they say looks like it wasn't done, uh, can we, can you redo it? Right? Absolutely. No, we see that. I mean, I'm sure you all see that all the time. We see it all the time, and I think in those cases you have to take a little bit of a step back and, and really ask, is the foreskin redundant or is there a fat pad displacing the skin distally, right? So what I always do is when I, and, and that's usually what it is, you know, you get these kind of babies, they're a little chubbier, they have that fat pad. Underneath their penis and that fat pad pushes the skin forward and yeah, the penises can look either uncircumcised or they can look like there's a lot of redundant foreskin and in that case I just in front of the parents I just kind of push that fat pad down. If the penis looks circumcised and looks fine when you do that, I mean there's no need to do anything. That baby will start walking around. They'll lose that fat pad, and that penis will, you know, pop out on its own. In cases where you look at the penis or do that maneuver where you push the fat pad down and the penis still looks uncircumcised, I mean, I give parents the option, you know, I say I personally in my career have never seen an adolescent come in complaining of too much foreskin, and I suspect that a lot of these cases where we think there's too much foreskin, as soon as they hit puberty. It's going to be perfectly fine and things are going to stretch out, but it's hard to predict that. And you know some parents are very adamant about, you know, having the penis look circumcised. And again, when there's not a condition of the fat pad being too prominent, well yeah, I mean in those cases if the parents understand the potential risks of anesthesia. You know, that's when you kind of say, OK, well I think a reduced circumcision is fairly reasonable, but I really tell parents, look, if it looks circumcised, even if it looks like it has a little bit of redundant skin, as soon as that penis grows, I suspect that would go away and I'll tell you that in my practice I maybe do about 1 to 2 redo circumcisions a year and that was, you know, here in Minnesota and also down in Texas where our volume was, you know, we had a lot more kids we took care of, so I think most, most of these cases. Probably are fine by themselves, but this is a, it's a very subjective area, you know, and I know that a lot of people feel very strongly about taking these kids and redoing their circu. I, I don't. I think a lot of them get better on their own. So I, I can't remember ever having done one, maybe once at the most, and I always wondered if I was accurate in what I told parents because I have not followed them into adolescence, and I always was under the impression that as they grow it would return to normal if the person did a reasonable circumcision, so. I don't know if anyone's ever really looked at that, but I'm glad to hear you say that that you've seen that you've never seen someone come to your office with a complaint after. No, I never have, and I used to have a, you know, a senior mentor who's been in practice 30 plus years and said, you know, I've I've never done a redo circumcision in an adolescent, probably because these children grow and their penises grow and the skin stretches, and we don't need to do anything. Yeah, all right, talk to me about meatal stenosis. Absolutely. So this is kind of another one of these, you know, diagnoses which can be a little tricky. I, I think a lot of these meatuses can look subjectively small, and I, I think people can certainly talk themselves into doing something when they see that. And again, meatal stenosis is a condition exclusively seen in circumcised boys. The tip of the meatus rubs, you know, against the diaper, against the underwear, and, and, you know, that causes, we think, an inflammatory reaction at the edge of the meatus, and that causes a little web sort of on the at the 6 o'clock position in the meatus. Again, you know, I get these referrals for rule out meatal stenosis, and the kid is urinating perfectly fine, doesn't have to push, maybe has a little bit narrower, narrower caliber stream than one of their brothers or, or something, but, but they're having no symptoms, and in that case I don't do anything. I think the cases of meal stenosis that need an intervention is where the parents will tell you, Doctor, this child, when he urinates, shoots straight up towards the ceiling. Some parents will say it's so bad that they have to sit to pee and it kind of push their penis way down because it shoots straight up, but what's going on is that the urine is hitting that little 6 o'clock web, deviating straight up, and then you get the stream that is completely deviated upwards, um. If I don't hear that in the history, I don't do anything about, you know, again a subjectively small meatus because I think a lot of these meatuses look small and back to what we discussed before, I've never seen an adolescent with meatal stenosis, and I think as a lot of these kids grow, maybe those, you know, subjectively narrow meatuses become totally normal meatus, um. When I do see meatal stenosis again, it depends on the child, but you know, you're going to see this a lot, you know, between the 3 and 6 year old range. Again, I personally do these in the office. I put Ela on the tip of the penis, let it sit for a little while, then I use just a straight hemostat. I kind of crush that little 6 o'clock web and use a fine little scissor to incise it. I personally don't use any sutures, although I know people that like to put a fine suture at 3 and 6 o'clock. I'm not aware of any data that shows that that has less of a recurrence rate. Um, and unless the child is, you know, very nervous or has some kind of learning disability that may make it difficult for them to understand what you're doing, um, they do great. I have the parents show them their phone or their iPad, you know, and, and they almost never know I'm doing anything. I, I, I, I think a key for that if you are going to do it in the office, hide the instruments, make sure. They don't see a pair of scissors and a big shiny hemostat clamp, so I kind of put the instruments, hide them under a paper towel, you know, remove the Tegaderm where the where the endless kind of sitting, and I just say, Well, I'm going to, you know, clean things up. You're going to feel me kind of cleaning things up here. They're watching their phone, watching their iPad, and then I go ahead with the medianomy. It takes about less than 10 seconds. They don't know what's going on, and they do fantastic. Yeah, that's great. You're just a brute, man. No, but I, I do think that's great and, and the fact that you can do these things in the office is something that we should really be listening to. I do wanna ask you, Patricio, so before we, you had alluded to this earlier, conditions when we should be sending these to you, uh, hypospadius, we should be sending these to you, correct? And, and, um. Uh, uh, the micro penis kids, um, I also usually send those to you guys as well. Um, how, how do you just out of curiosity, how do you deal with the micro penis kids that need a circumcision? Yeah, I mean, again, if, if it's a true micro penis, um, you know, honestly, I have a lot of those kids see endocrinology because, um, you know, as, as urologists we're certainly not going to be able to do much for them. Um, the actual, the, the, the clinical definition of a micro penis is you have to have a stretched penile length of greater than 2.5 standard deviations below the normal mean. So again, and the means are by age, right? So just as an example, the mean stretch penile length for a 6 month to 12 month old when most parents tend to be concerned about this is about 4 centimeters. So again, anything greater than 2.5 standard deviations, and this has been published, there are actual tables. of stretched penile length in centimeters means for a newborn all the way to adult and you know you can get those. I think there's one from 1999, I believe the author is Bin Abbas, B I N A B B A S, that has a nice stretched penile length. That's great and we'll try to put any, any articles you mentioned, we'll try to put links to those on PubMed for people. We obviously can't provide the article, but we can give you the link. Uh, to the abstract, so buried penises though, if we see one of these kids and, and, um, you know, have, I think these can be tricky because you don't want to take off too much skin in these kids. They really can. And again, I just, I tell people don't be a hero with these things, you know, one of the highest areas of litigation are circumcisions that are done and then there's a problem afterwards if you really see something. It just doesn't look right, whether it's a hypospadius, it's a penile torsion where the penis is kind of turned off to one side, if there's a big web between the penis and the scrotum, so-called penis scrotal webbing, or if there's a buried, a true buried penis, not a penis that you can kind of push out if you push on the baby's fat pad, and I tell people that the main way to recognize that, and again I can provide a picture for you guys, is that. The penis will look like a little pyramid. It doesn't look kind of like a little structure that's coming out of the body. It looks like a little short squat pyramid, and those are the true buried penis or the other conditions called congenital mega prep use tends to occur mostly in Hispanic patients. Those are the cases you just really do not want to even attempt a circumcision because, like you said, you can take the entire shaft's skin off, and I've seen patients that have needed. You know, skin grafting, very complex reconstructive surgery if it doesn't look quite right or quite like what you're used to just refer him to a pediatric neurologist, save yourself the hassle. It's just, it's not worth it. OK, that's great. That was a great summary of circumcision, uh, probably the most common thing that we see of all the things we're gonna talk about here. So I, I think that was really helpful. Let me move on to a new topic. Talk to me about, um, fimosis. How do these patients usually present and how do you usually treat them? So again, you know, just you said it, we see this very, very commonly in the office, you know, a practitioner will see a child, they think the foreskin should be retracted, it's not, and then, you know what, what is the issue, so. My main approach to fimosis is, of course, you know, when you do your physical exam you have to rule out uh between what I call again physiologic fimosis and and pathologic fimosis and I kind of run through those separately. So physiologic fimosis is again what you would see in a newborn baby, um, you know, the sort of the adhesions that you would take down when you do a newborn circumcision, um. Um and the skin looks supple, it looks soft, and a child has never had a problem with their penis, you know, if, if the child comes in and the parents say, oh, you know, doctor, this, you know, my child has had. You know, 32 episodes of balanitis and they've got terrible infections and they get, you know, terrible yeast infections, and that's the time when if the skin is tight, if you cannot retract the foreskin, you may want to institute some treatment for that, and I'll go over what that is here in a second, but But you know, even though the AAP has published guidelines as to when the foreskin should retract based on age, I don't really go on those because I've seen 5, 6-year-old kids, 7, 8-year-old kids where the foreskin doesn't retract at all. But again, they've had zero problems. The skin is supple, it's soft. It doesn't look. Diseased or scarred and in those cases I, I don't do anything, you know, um, and then I've seen younger kids where you know the foreskin shouldn't be retracted at this age but they are having a lot of infections, a lot of, you know, ballooning of the foreskin with urination where I think management is, is, is indicated and again for these sort of cases of fimosis where you're just gonna treat them mostly for balaitis, you don't see anything in the skin that's abnormal or concerning. You know, I personally treat them with betamethasone ointment, 0.1% 3 times a day for 2 to 3 months. You know, some people do 0.05 2 times a day for a few weeks. I honestly think that that dose is too low and that time period is too low to actually see an effect. Um, you know, the literature shows that if you, if you use it for about 3 months, greater than 50% of those children are going to have retractile foreskins at that time. So that's kind of my first line of, of therapy, especially in, in patients if they're Hispanic and they don't necessarily want a circumcision anyway. I think that's a really good, uh, you know, bridge before you decide to, to go ahead and perform a circumcision. Now the main Two pathologic fimoses where there actually is a legitimate problem that you are going to need to do something about. One of them is what's called secondary fimosis, when you tend to see that a lot after a circumcision. And basically what happens is the cicatrix contracts and you get this sort of very hard stenotic ring and the penis completely buries down. Again, this is more common in the younger babies, newborn circumcision, just with a bad scar reaction. And in those cases again, betamethasone ointment tends to do the trick, 0.1% 3 times a day for 2 to 3 months. Greater than 50% of children with secondary fimosis will do great with that therapy and won't need anything else. But the other really important cause of pathologic fimosis, which I don't think pediatric surgeons see much of, well, pediatric urologists we don't see much of either, but I always kind of warn my trainees. To look for uh is what's called bellonitis erotica obliterans or BXO. BXO will not respond to steroids, you know, there is some literature that suggests that it may, um. It may Respond to topical chemotherapeutic agents 5-fluorouracil, etc. but, but it tends to be a tough agent, and you don't want to miss it because it will actually spread onto the glands and into the urethra. It can cause some fairly significant urethral strictures. And the way to look at that is if you have a child that you're concerned for fimosis or gets referred for fimosis, you look at the skin, the skin will be white like paper. The very, very tip will be super white. It usually tends to be a little scaly and a little hard. If you see that at the tip of the prep use with fimosis, and again most of these kids you will not be able to retract the foreskin, that's BXO until proven otherwise. And in those cases I don't mess around with any steroids. I just tell the parents, look, you can see it right at the penis. It's very, very obvious. The parents will be able to see it right away. And in those cases I just go straight to circumcision. What is paraphymosis? So paraphymosis, we see when children that are uncircumcised have their foreskin retracted for whatever reason. They either do it themselves or it gets done during a catheterization or a procedure, and then the foreskin isn't brought back over the head of the penis. Paymosis can become a medical emergency. You can get a lot of swelling and entrapment of the glands. You can get A vascular compromise to the glands and usually these patients will be, again, they're all uncircumcised, they will present with a lot of pain and redness and swelling to the foreskin and most of the time if you get to the point where there is swelling there, it's very difficult to reduce that foreskin. So again, you know, we get this phone call from the from the emergency room not too infrequently and I'm sure you know if you if you don't happen to have urology coverage at your institution, you will likely get this call as well. So the, the main things to do is one is you need pain control. Whether you do that through some Emla cream or a penile block, EmL tends to be perfectly fine because you're going to need to manipulate that foreskin, and again, it can be very tender, so pain control is very important. Sometimes you need to do a little bit of conscious sedation to reduce that foreskin. If you happen to be a little bit far away or you get a phone call from an ER that's a few hours away, what I tell them to do is to wrap the penis in a bandage soaked with D50. Um, what that does, is it's an osmotic. It tends to take a lot of the fluid out of the foreskin. It decreases the swelling, and it makes your manual reduction a lot easier. Once you get to your manual reduction, the trick is that you're gonna have your thumbs on the glands and your fingers on the shaft skin. You're gonna pinch the shaft skin in between your fingers and push the, the glands back into the foreskin. That tends to work, I would say 9 out of 10, especially if you've done the good pain control and the D50 to decrease the swelling. Um, I personally have never had to do a dorsal slit for a paraphymosis, although I know people have done them. Um, so again it's just a matter of quick diagnosis and quick intervention if they happen to be a little bit farther away, the main thing is to go ahead and get that wrap with D50 and that that helps quite a bit. Talk to me about, uh, penile trauma. What do you usually see and how do you treat these? So you know there's there's sort of penile trauma. I like to break up into two basic categories, and that's trauma of the shaft, whether it's just the skin or the subcutaneous tissues in the skin and actually trauma to the urethra. I mean, urethral trauma is a totally topic in and of itself. I'll mention just a few things that I think are important to just keep in mind at the end. But, but you know, there's, there's been actually several papers that have shown that the main cause of penile trauma is from zipper injuries, which is not, not a big. Big surprise and and the main thing to do if that happens to come is to really cut the zipper off the pants and and cut the bridge on the actual zipper itself rather than trying to manipulate the zipper either closed or open. So if you get a nice uh bolt cutter from the operating room, cut the bridge on the actual zipper, that's the part right underneath the little handle, um, that will usually separate the device completely and you can just separate the zipper. Um, the second most common thing that I think we see is, you know, injuries from, from toilet seats falling on penises. So we tend to see a lot of toilet seats getting dropped on penis. You see some crush injuries of the penis. They look fairly terrible when you look at them. The glands can have a big hematoma. It can almost look necrotic in some cases, as long as the child is voiding. Um, and not having any gross hematuria, there's really no need to do much else as far as the diagnostic workup. It's mostly just, um, conservative management. But that tends to be the second thing. If there is gross hematuria, I would get a urologist involved because then, you know, now you're talking about a potential urethral injury. And lastly, we see, you know, we see all kinds of weird avulsions of the skin, you know, kids getting caught up on fences and these sort of things. Most of these, I would say the vast majority of these can be. Repaired fairly easily whether in the ER under conscious sedation or in the OR, but the main thing to, to just make sure is that, that, that the, the tunica, the, the buck's fascia of the penis, kind of the harder part of the penis underneath the, the dartos fascia isn't broken into or violated into because if you have a, uh, Buck's fascia injury, you know, that requires a little bit more work again, it's nothing too. Complicated, but, but that's the sort of thing that should be taken to the operating and to make sure you get the stitches there because you can't lead to long term issues with scarring, you know, potential potency issues down the line. Again, rare, but things that that should definitely watch out for. But, but I would say those are the main three categories and just lastly, the urethral injuries, of course, and you know you all know this from your adult trauma training and your pediatric trauma training. Gross visible blood at the me anus or gross hematuria after trauma, especially any kind of pelvic fracture, you know, lower abdominal injury or a good mechanism, requires a full evaluation of the urinary tract from the urethra all the way up to the kidneys to make sure there's no kidney lacerations. Uter problems, bladder, or of course some kind of urethral injury. And again just like in the adult world, if you see gross immature of the meatus in a trauma patient, the main thing we say is please do not instrument that child because if there is a urethral injury, you can create a much bigger problem if you don't have the right person putting the catheter in. So you have to rule out a urethral problem if you see gross blood in a trauma patient at the urethral level, and you would proceed with a retrograde urethrogram. Yeah, exactly. We do a retrograde urethrogram at that point, OK. Um, Patricia, one thing that I have had, uh, little to no experience with are, are kids with hypospadius. Um, tell me how, uh, they usually present to you and how do you, uh, work these kids up. So you know, again, most of these kids are diagnosed at birth. Now and again, very, very rarely we'll get a call from a neonatal nursery or a pediatrician's office that says, oh, we were doing the circumcision and we happened to find a, you know, a mild hypospadius, and I'll talk about that here in a in a bit, but you know, again, most of the. Honest to goodness hypospadius where you can see very clearly that there's a problem or diagnosis of birth, and it's a fairly high incidence, which is, you know, about 1 in 150. We don't really know what the etiology of these hypospadiuses are likely multifactorial, uh, you know, whether it's exposure. You know, some children with in that have had in vitro fertilization have a higher propensity of hypospadius. So again, not too sure about what the etiology is, but the main problem is that the urethral folds just don't fuse in the midline. So you have kind of an open urethra or your urethral plate, and then you have the meatus where the urine comes out anywhere along, you know, the shaft from the sort of distal area underneath where the glands is all the way down to the perineum, um. And the associated problem with hypospadius tends to be ventral penile curvature or it's sometimes called core D. And so when you look at these hypospadius patients, you kind of have to assess those two things. One is what's, where is the meatus? What's the location of the meatus? Obviously the more proximal the meatus is, the more complex the procedure to fix that is going to be. And second is, what is the degree of curvature of the penis, and that is also going to determine a little bit of our intraoperative algorithm as to how we're going to repair this, um. You know, again, hypospadius is very obvious. We talked earlier about not circumcising a penis that shows any kind of abnormality. No one would miss a hypospadius. That's obvious. Back to the condition where, you know, they find this on a nursery and they get very concerned because they think we're going to utilize the foreskin to do a reconstruction. We don't utilize the foreskin to do a reconstruction for mild hypospadius almost ever, if ever. So if I ever get that phone call, I say finish the circumcision, you know, don't leave the skin kind of hanging there, just get it done, because again, these are hypospadiuses that the foreskin probably looked completely normal and they only happened to find that the meatus wasn't at the tip when they reduced the foreskin down and took the adhesions down. That means it's going to be a very distal mild hypospadius, and we just do not use the foreskin for those reconstructions. That's a foreskin key piece of information because that can happen to us, you know, we go, oh, absolutely, yeah, yeah, we get that phone call all the time and actually I see patients in my office refer for hypospadias that have had just a dorsal slit and then people have aborted the circumcision. Because they're under the impression that we utilize that foreskin and you know yes we did 20 years ago very commonly but now with the the current techniques, the surgical techniques for distal hypothesis, we almost never do um. But if you happen to get called again, if you don't have urology covered, you get called to the nursery for hypospadius, you know, as long as the baby's voiding, it's not really an issue. The only other thing to really consider is whether or not the hypospadius actually isn't a hypospadius, but represents some sort of disorder of sexual differentiation. I mean, that's what you really have to watch out for. And the key to that is whether or not there's a palpable, you know, two palpable gonads in the scrotum. So if you can feel two testicles and there's a hypospadius, the chances that that's a patient with DSD is almost zero. If there's an undescended gonad, especially if it's a non-palpable gonad and a hypospadius, that child needs a full DSD workup because you may be dealing with one of, again, just a multitude of different DSD patients, you know, have likely been covered in the podcast elsewhere, um, but undescended gonad. Hypospadius equals DSD workup. Certainly if there's bilateral non palpable gonads in a hypospadius, then your number one thought should be that it could be a congenital adrenal hyperplasia baby. And again, that baby needs a full DD workup, but that's kind of the basic approach to. The spadius, you know, the surgical techniques to fix it very extensive, a whole another hour in and of itself, um, but again, most of these kids are going to end up seeing a pediatric urologist anyway. So tell me, which do all patients with hypospadius need surgical repair? Yeah, that's a great question, and again this goes back to some of the, you know, slightly more controversial areas we've touched upon. You know, the main two reasons to fix a hypospadius are one is cosmetic, right? You want the penis to look fairly normal, and the second is functional. You want a child to be able to urinate standing up like the rest of his friends that don't have hypospadius, and you obviously want them when they're having sexual activity, to have an emission, you know, at the distal tip of their penis and not have any fertility issues from that. And that really tends to be a problem only for the proximal hypospadius, meaning the functionality aspect of it, you know, patients that have a midshaft hypospadius, a distal hypospadius, could they urinate normally standing up, and would they have any fertility problems? Probably they'd be fine on both of those issues. But cosmetically, you know, a lot of people get these fixed, which I think is perfectly legitimate. You know, when you get into a little bit of a controversy is when you get these very mild variants of Hypospadius. One is what's called the mega meatus variant where the meatus is kind of big, you know, some of them you kind of see a little urethral pit and then a little tiny meatus right below that. You know, a lot of those where you're just really doing it for cosmetic reasons. I don't know what the answer is honestly. Again, it just makes me think because of the literature we have available regarding the exposure of the anesthesia to to young brains about, you know, whether these very mild cosmetic only hypospadiasis should be done when these child, when these children are young, or if we should just. Be waiting to do them electively when they're older if it even bothers them, you know, I've had patients that come in, they have super mild hypospadius and the mom says, Oh yeah, dad has that, and you know he's never had it fixed, or, you know, Uncle John has that, and it's not an issue. It's more when you get into the bad curvature hypospadius, proximal meatus, yeah, those you really need to take care of because those children are going to have functional problems in the future. So Patricia, we're this is certainly not in the Scope of this podcast, but can you tell us in very brief the essence of the elements of repair of a hypospadius? Yeah, absolutely. I mean, the, the, the basic two things are the urethroplasty, meaning bringing the urethro meatus to the tip, and the, the phaloplasty, or kind of straightening out the penis from any curvature that might be there. A lot of these patients with hypospadius will have what's called the dorsal hooded prepus, um, and you can deal with that in one of two ways. There's some people that do a hypospadius repair with propal reconstruction. Destruction where they'll actually fix the curvature, fix the urethra, and then reconstruct the foreskin so the penis looks like an uncircumcised penis. And again that's, you know, mostly for cultural reasons, um, or they'll go ahead and do a circumcision and just remove that dorsal hooded prepus because it does look a little bit different. But that those are the basic two tenets are just the urethroplasty where you're gonna tubularize that urethra you're gonna cover it with a second layer, usually some kind of pedicled flap to protect against any fistulization, and you're gonna do your corporaplasty where you're gonna straighten out the penis. The vast majority of the time once you kind of bring all the skin off the shaft of the penis, what's called penis degloving, the cordi most of the time tends to go away. Sometimes the cordi is significant enough that we need to do some other maneuvers to kind of straighten it out, but those are the two basic tenets of hypospaia surgery. That was great. That's a great summary. Um, what is epispadius, right? So Epispadius is actually the total opposite of hypospadius. So instead of having a. urethromeatus on the on the ventral surface of the penis. You actually have a urethromeatus on the dorsal aspect of the meatus, and you know, it's extremely rare. It's, you know, less than 1 in 50,000 live births, but again, it's a defect of the dorsal urethra, and again this is not a mild thing or a subtle thing, you know, once you see it, you will know there's something abnormal there. The main issue with these babies is that they basically represent a Spectrum along the bladder atrophy and epispadius spectrum, and they can have a lot of the associated problems that atrophy babies have, the main ones being urinary incontinence, a pubic diastasis, and vesicoureteral reflux. So again, if you see epispadius, that's the kind of baby that's going to end up going through the doorstep of some pediatric urologist. But again, it's just good to know that those are some of the associated things that epispadius can have. So, um. If we're going to do a circumcision and see that, how do we handle that situation? Yeah, in those cases I would not proceed with a circumcision. Most of these penises don't look normal. I mean, you will know that there's something not quite right. I have seen a few cases where the episphus only becomes noticeable once you reduce the foreskin, but again, once you reduce the foreskin, you will know there's something wrong there. OK, great. We had talked briefly about micro penis before. You said you'll send that to an endocrinologist. Just anything else that we need to know about that, or is that pretty no, again, the main thing is just to keep in mind that a true diagnosis of micro penis is an objective measured diagnosis. You know, we have a lot of kids that come in that are on the chubbier side. Parents are concerned about quote unquote micro penis, and you know, again it's a pubic fat pad issue. Once you push that down, the penis becomes exposed and clearly there's not an issue with length. True micro. Penises, they're just extraordinarily small and again, most of the time these children will have small testes, they'll have other issues, but again, if for a true diagnosis of micro penis to exist, there's very strict guidelines for it which I mentioned earlier um and those patients should be referred to endocrinology. There's nothing as urologists that we can do because it tends to be a hormonal deficiency issue. A little bit of rapid fire here penile portion. Yeah, so again, penile torture is just a twisted penis, and you know, again, most of the time this is very obvious. If the baby is uncircumcised, the way to kind of tell is that the rafa won't be at its normal 6 o'clock location. It'll tend to twirl around the penis and then you, you just have to keep in mind that it may be a penile torsion. Now if you happen to do a circumcision and you happen Notice penile torsion. Not the end of the world at all. We don't tend to fix these unless the torsion's close to 90 degrees to one side or the other. So and it's certainly we're not going to use that foreskin for anything in the repair. But again, if the torsion's significant or the parents are concerned, they should come see us. OK, isolated core D. So again, Cordy's just that ventral penile curvature. The penis kind of hooks down most of the time associated with some degree of hypospadius, but we do see it without hypospadius. And in those instances, again, if the baby was going to have a circumcision anyway, that's probably the A child that would benefit from an operative in OR circumcision so we can actually take those skin adhesions down all the way down to the base of the penis at the peniscrotal junction, release all that kind of cordy tissue there and straighten the penis out. That's great. OK, peo scrotal webbing. So I talked about that a little bit before in the do not circumcise category, and those are again just, you know, the the penile shaft just has a web to the scrotum. It is very obvious it is not subtle. um, so again, just the idea that if the penis does not look normal, don't proceed with the circumcision in a penis scrotal webbing case, you know, we do tend to use some flaps sometimes for the foreskin. I personally don't, but I know some people that do, so in those cases better to refer. OK, totally shifting gears here to round out the audio chapter here. I wanna talk about females and uh very common thing that we see is labial adhesions. So how do you approach these? Yeah, again, you know, these are just interesting because people become very concerned about them, you know, practitioners become very freaked out about it. Parents don't like how they look, and again this is basically just fusion of the labia minora in the midline. You can kind of have a, you know, anywhere from a little bit of adhesions all the way to just complete fusion where you don't see anything. Doesn't tend to happen very often. The incidence is at the high end, about 2% in the first two years of life. Um, don't see it in newborns. It's kind of thought that the maternal estrogen is protective. So again, we see it in kids that are a little bit closer to toddler years. The only real issue with labial adhesions is because the labia minora are closed, you can have some post-void dribbling, kind of pooling of urine in the vagina that can lead to a lot of skin breakdown or yeast infections just again because of the moisture. It is thought that these things can contribute to UTIs. So again, if I see isolated labial adhesions, much like the meatal stenosis we discussed earlier, without any symptoms whatsoever, I don't treat them. Uh, you know, I look for those things that I mentioned, and that's post-void dribbling or incontinence, skin breakdown, or recurrent urinary tract infections. If that's happening, then I, I do think it merits treatment, and there's kind of two schools of thought for initial treatment. I personally don't know of any literature that shows that one is better than the other, and the first is, you know, estrogen cream or Premarin cream. Most people use that BID for about 6 weeks. People don't like to use it for a very long time because obviously it can actually lead to pubic hair development, which is a problem in a 2 year old, um, but so that's kind of the school of, you know, thought number one and the other one is again to, to use, uh, betamethasone ointment much like you did for fimosis, and some people do that. I tend to use betamethasone only because it makes me feel better about not putting estrogens on a, a prepubertal child. In my experience they've worked quite well, you know, again, if they don't work. They recur and the child is having, you know, actual symptoms, you know, then we do tend to take them to the operating room for, you know, a formal lysis of adhesions, although I've only had to do that, I think, once in my career. So it's pretty rare that we have to go to that degree of aggressiveness with these. So that's, that's new to me. I've always used the estrogen cream, but the steroid cream works, works pretty good too, it sounds like. OK, it works really, really well. Well, I'll switch to that then. I agree with you. It sounds like that's a Better way to start first and then maybe if that doesn't work, then maybe try the estrogen cream. Yep, OK, absolutely. I wanted to talk to you about the rest of some other female external genitalia issues that we do see. In fact, one of these I saw very recently. Let's talk about a girl has abdominal pain. She's 13. She's had abdominal pain for a couple of months, and they get a CAT scan, and she's got hydrometro culpos. How do you manage that patient? Yeah, no, those, that's a great question, and I think, you know, this kind of falls. I like to think about that problem along with a couple other problems that I think can present very similarly, especially in young babies. They can look almost identical, and that's sort of the bulge between the labia in a baby and, you know, in this case in an adolescent, but the, but the idea of some sort of bulge in between the labia and the midline. And kind of the the different things that that can be and so you know one of them is like you said is an imperfect hymen right? so you have an imperfect hymen. You will tend to have a bulge in between, um, you know, the labia minora and the introitis, and this tends to be again just retained vaginal secretions, and the treatment for this is an incision, you know, again, in your patient's case you had a CT scan which kind of confirmed this big fluid filled vagina, and then the diagnosis becomes fairly straightforward and then just again opening the hymen will usually do the trick if that's the case. Of course there's a lot of mullerian duct anomalies that can give you, um, you know, hydrocopos which. Obviously need to be differentiated out, but in the in the younger kids this tends to be an imperforated hymen. I don't know what it ended up being in your patient, right? I mean you have to look for that bulge, and if there's not, then it could be vaginal genesis or other problems. So all right, so what else can cause a bulge in between? Yeah, so the, the, the main other things to keep in mind, and again these are the more common things besides imperforated hymen is you can have a what's called a pro I'm going to just kind of name these and then we'll kind of go over each of them, you know, by itself, but. You can have what's called a prolapsed urethrocele, which again this is a bladder problem, and the second one is a paraurethral or pervaginal cysts. These can look like these sort of midline bulges. And the last one, which is a little bit easier to differentiate, not really a bulge, more of a mass, is vaginal rhabdomyosarcoma. Uh, so again, I think those are the three main things besides imperforate hymen to keep in the diagnosis of these, these midline bulges. So let's take one of each of these at a time. So a prolapsed urethrocele tends to be smooth. It, it's mucosa covered. It looks a lot like an imperforate hymen. Um, again, it usually protrudes from the urethra but is distinct from the vagina. So that's kind of the way to tell them if you really spread the labia majora part, you should be able to tell that the vagina is, is not where this is coming from. Prolapsed urethrocele, babies tend to have other issues. Again with prenatal diagnoses, most of these babies will have some sort of hydronephrosis diagnosed prenatally, and then you happen to see this bulge, and then you have to worry about a prolapsed urethrocele. But if you think it's a urethrocele, the main two things to get are a renal bladder. Ultrasound, which will almost always pick it up and a voiding cystourethrogram, but again at that point you're probably involving your pediatric urology colleagues and the treatment for those prolapsed urethroceles is fairly extensive and I won't get into that. But again it's just important to differentiate that that's coming from the urethra, not the vagina. The second is these perurethral or perivaginal cysts, um, you know, you can have either a Gardner's Gardner's duct cyst or Skene's gland cyst, um, you know, again, when you do your physical exam, these tend to be a midline bulge. They tend to be present a lot at birth and then just sort of resolve once the maternal estrogens are gone. They don't tend to cause any sort of either urethra or vaginal obstruction. But again, most of these will spontaneously regress, and you will see patency of the urethra and the vagina. I think that's what's key. If you see patency of the urethra and vagina, you can suspect that it's going to be one of those two, either perivaginal, paraurethral cysts, and like I said, they tend to resolve on their own unless they get infected. There's no need to really mess with them. Um, and again, the last one was vaginal rhabdomyosarcoma, which, you know, doesn't look that much like a, like a single bulge but more like, you know, a quote unquote bunch of grapes which were all kind of taught in residency in medical school, um, and again the treatment for that is, is fairly extensive. I won't get into that, but then you really have to, you know, involve your oncology colleagues and either your pediatric urologist or your. Pediatric surgeon, depending on your institution's preference for how these are managed, right, and I, I think that's great. That was a great review of of those and the back to the hydrometric call posts, I think the best thing to do is a good exam under anesthesia to see if there is the bulge and then if not, maybe get an MRI or further imaging to see if there's a Mullerian duct anomaly, um, so. Well, that was great. I think, uh, obviously we, this was a bit of a cursory review of pediatric urology from an external genitalia standpoint, a lot of crossover between what we do and what you do, but certainly what I learned here are are when to send to your urologist and uh what, what things to look for for all of these different uh. Situations and I, I think this was a fantastic review for me. So I, uh, really wanna thank you, Patricio. You are always a great fund of knowledge for this stuff and you've been a great, um, colleague for me to bounce ideas off of when I have a difficult situation. So, um, hopefully we'll be able to work with you again on, on, uh, part two and three of pediatric urology. Oh yeah, thank you guys so much for having me. It was my absolute pleasure. We hope you enjoyed this episode of Stay Current in Pediatric Surgery. You can listen, watch, or read all content by downloading the Stay Current and Surgery app. Send questions or comments to us at statecurrent podcast@gmail.com. We'll see.