Urology - Surgical Topics for the PCP

Hey, everybody. Good morning. Uh, my name is, for those of you that don't know me, I'm Nick de Blasio. I am general pediatrician in, uh, the PPC here at Cincinnati Children's. And want, just wanted to welcome everyone to the Cincinnati Children's Live Event for Urology today. Um, it's based on the community support tools, uh, which are on the website and will also be sent out later on, kind of at the conclusion of this. I just wanted to review the format just a little bit uh before we get started. So we have, um, again, we have 4 great speakers, 5 great speakers today talking about 4 different topics, and each topic will take about 8 to 10 minutes to kind of present through. I did want to go ahead and just kind of introduce the division directors who will introduce their faculty. Uh, so we have, uh, Doctor Tia from surgery and Doctor Reddy from, uh, urology. So I will turn it over to them to just kind of say a couple words about their divisions and then introduce the faculty who will be speaking. And then once we, there are introductions, then they'll come back to me and I will introduce the individual speakers. Good morning. Um, thank you very much, Doctor De Blasio, for this opportunity for the Division of Urology and Pediatric Surgery to present. Um, good morning to all of the people from around the world that have logged in today. We appreciate you joining us live and engaging with us in this discussion of some of the common conditions that we encounter and that affect the, uh, genitorary system of children. The topics that we're gonna be speaking about were selected by the Community Pediatric Partners, and it's a true pleasure for my colleagues, Doctor Minovich, Doctor Defour, Doctor Stein, and then from the Division of Pediatric Surgery, Doctor Garrison, Doctor Teo, to be here this morning to share, uh, some of our knowledge and, uh, discuss any questions that you might have with us. Um, a bit about our divisions, you know, ever since Doctor Sheldon and Doctor Waxman first established our division 25 years ago, we have grown, we've added new faculty who are experts in various aspects of pediatric urological care. For the last 10 years, our division has been recognized for its excellence in care delivery, and we've been ranked amongst the top 5 programs in the country. The mission of our division is to provide the highest level of care for children with genitourinary conditions and to embody the concept of Cura personalis, which is care of the whole person. And to achieve these goals, we've built a phenomenal team of faculty, nurses, advanced practice providers, and professionals from other disciplines to ensure that we can really deliver on that mission. In providing this level of care, you know, we go above and beyond to be available to our patients and to that end, we have clinics in every single location, uh, that Cincinnati Children's Hospital has, and we also provide after-hours and weekend clinics. There's no question that COVID-19 has impacted every single one of us, and it has made us pause, and, uh, the slower pace has allowed us to review and reflect upon our delivery of care. And I want to assure you that we remain committed to providing the safest level of care to all of the children that come to Children's Hospital. We've also used this time to enhance the model that we use to deliver care, and part of that has been Ensuring that every single touch point of our interaction with patients, their families, and our team members has been looked at and again made as safe as possible. We also have options for telehealth and, uh, with all of our providers, uh, both our nurse advanced nurse practitioners and our faculty. And given some of the delicate conditions that we do deal with, we understand that, uh, due to the inability to do a physical examination, not every single condition is amenable to a telehealth visit, but certainly for our post-operative visits and follow-up visits, we do allow that to happen. So we wanna make sure that you and your colleagues know that we are available for our patients and enable them to have the visit, uh, from the safety of their home. We also strongly believe in educational partnerships and to that end, we have an annual pediatric urology workshop that we put on for our pediatric colleagues, and this, uh, discusses topics that are germane to you and are forwarded by you actually to our team to present. Um, we have, uh, you know, made ourselves available to you through our priority link numbers and also you can always email us. We have a dedicated email, it's peeds urology@ CCHMC.org. And, um, you know, we are just privileged to be able to partner with you and make sure that, uh, ultimately our goal is to provide seamless communication pathways so that together, We, the division of Urology and all of our community pediatricians and colleagues from around the world can ensure that all of our patients receive timely, patient-focused, family-centered, and culturally competent care. So thank you for this opportunity to speak to you, and on behalf of my colleagues, thank you for logging in and being part of this, and I look forward to a successful, um, program today. So I'll turn it back to Doctor Tiao. Thanks, Doctor Eddie. Uh, I also, too would like to thank the audience for joining us this morning. Uh, for those in the local community, those on international setting, it's a privilege to have you join us here today. Um, I also want to thank Dr. Eddie for inviting us from a pediatric surgery, um, group to, to join this, this symposium as the primary focus of this presentation, these presentations are urologic issues. But the pediatric surgery group here, it's Children's also will work with our urology colleagues in a variety of settings. And then for some of the topics today here to the undescended testicle, we do provide that service. But I do want to thank Pramode for including us in this presentation. Um, that we will be having separate presentations that are more pediatric surgery focused, uh, and other venues including the Global cast, uh, national event that's going to be taking place later on, uh, in, in, in, in August. Um, the pediatric surgery division at, at, at the Cincinnati Children's has also been long-standing and has expanded significantly over the last years. Um, we've had a new faculty. Doctor Garrison is a representative of that next generation. We have 5 young faculty who have joined us, all who um have areas of expertise, but beyond general pediatric surgery. But in today's presentation, we're focusing more on the, the broader, more common topic of the, uh, a descended testicle. Our, our group too, like Pramod had uh referenced, uh, all went through this COVID challenge that all of us in the community has experienced. Um, we too have looked at a variety of different care delivery components to the process and similar to all the divisions of surgery at the Children's have telehealthcare, uh, um, options available for all family members in the effort to make it a little bit easier for families in this, um, these trying times. Uh, just as Pramod mentioned, our educational focus, uh, remains, uh, one of our, our high priorities. Uh, we'll be working with the community to address some of the issues that, uh, that are arising that are more ped surgery, um, centric, including bariatric and pive care, uh, in, in future, uh, uh, um, iterations of this process. Uh, beyond that, I'm going to defer to the group here as I think we've taken enough, uh, enough, enough time introducing the divisions here. Uh, again, it's a privilege for us to all be here, um, sharing this, uh, venue for educational purposes. Uh, we do have, uh, contact information that's already available for pediatric surgery. Our email is pediatricsurgery. At CCHMC.org. And then we have both the priority link construct that has been longstanding. Uh, we are working on some new, new mechanisms for, for our community to reach out to us directly to, to improve the efficiency of that. We'll be discussing that in other venues. And with that, I'll turn it back over to Doctor De Blasio. All right, thank you guys very much. Um, so just to kind of jump right in, we're gonna start off with, uh, Doctor Minovich who is gonna be talking about foreskin issues and penile adhesions. So Doctor Minovich, you're on. Thank you, Nick. Um, I would like to spend the next few minutes discussing what sometimes feel like the most commonly discussed topic in pediatric urologist's office. It's care of baby penis. There is a lot of confusing or conflicting information about how to take care of uh uncircumcised babies. At birth, the foreskin covers the head of the penis and in most boys cannot be retracted even partially. That's what we call a physiological thymosis. And we need to remember that it is absolutely normal in uncircumcised babies and toddlers. It will start to separate from the tip of the penis naturally between 2 and 6 years of age, though it might happen later. Gentle external cleaning during diaper changes, and external washing with soap and water during bath time. are all that's necessary. There is no need to use cotton swabs or special cleansers. Please leave the foreskin alone until it begins to retract on its own. Let nature take its course. Improper care can actually lead to a child needing a circumcision later in life. This often happens if a parent is instructed to retract a child's foreskin forcefully before it is ready to be retracted. Don't be alarmed by whitish discharge coming from underneath the foreskin. This is not pus, but infant's magma and it's completely normal. Parents just need gently wipe these white pearls away during a bath or diaper change. The foreskin can usually be retracted in about 50% in 3 year old boy. And almost 90% of 5 to 7 year olds. Once the foreskin can retract easily on its own, parents or the child should be instructed gently pull back the foreskin, clean underneath it with the soap and water, rinse and dry the area, and what's very important, then put the foreskin back in place. Failing to put foreskin back in place can lead to uh paraphymosis. We usually recommend the referral to us to pediatric neurologist for any uncircumcised child who has suspected discomfort while urinating or, or foreskin fills with urine and balloons out during urination. The child who develops well-documented urinary tract infections or balanitis has persistent penal adhesions or penal inclusional cysts. Has history of paraphhymosis or develops pathological hymosis, which is inability to retract foreskin in older children with visible scarring of foreskin or painful erection in a teenager. In older children with persistent physiological fimosis, a topical steroid ointment may be used to help soften the foreskin and make retraction easier. We usually use Kenalog 0.5% Kenalog cream. The ointment is massaged into the area around the glands and foreskin twice a day for 4 weeks. Circumcision still might be advised due to failure of steroid ointment, development of pathological fimosis, paraphymosis, recurrent urinary tract infections, or severe balaitis. Let's talk about circum circumcised babies. Circumcision is fairly common for newborn boys in the United States. For some families, circumcision is a religious ritual, but for most, it is a matter of family tradition or personal hygiene. The use of circumcision for medical or health reason is an issue that continues to be debated. There is some evidence to That circumcision has health benefits, including a decreased risk of urinary tract infections. We do know that uncircumcised male infants appear to be an increased risk of UTIs, especially in the 1st 6 to 12 months of life. There is potential protection against penile cancer and even a reduced risk of cervical cancer in female sex partners. And although cancer of the penis is rare, it is much less common in circumcised men. And neonatal circumcision, again, neonatal circumcision is highly protective against penile cancer later on in life. And the most controversial potential benefits, there is a reduced risk of sexually transmitted infections. Some studies suggest that circumcised men might have a low risk of certain sexually transmitted infections, including HIV. Still, the most important part is safe sexual practices, proper personal hygiene, and HPV prevention. That remains essential. After newborn circumcision, the penis is usually wrapped in a gauze. It is important to remove the bandage after 48 hours or any time if it's too tight or baby having any problems urinating. After that, gentle cleaning during diaper changes are all that's necessary. It is normal for the tip of the penis to look red and appear to have a crusty white or yellow coating. We get those phone calls all the time. Please do not instruct parents to wipe it off. It's just normal process of healing. Once the penis is healed, usually after 7 to 10 days, parents should wash it with soap and water during daily bath and pull the foreskin back routinely to prevent penal adhesions. Please call us for any postoperative difficulties with urination, bleeding, or increase in swelling. As you can imagine, we see a lot of patients with foreskin problems after neonatal circumcision. And ideally, sufficient amount of foreskin is removed during neonatal circumcision, but as we know, sometimes it's a little bit difficult. If not enough of foreskin is removed, the child might have redundant crepus. When the skin is too long, covering the penis completely or partially when it is not erect. The redundant skin can also be uneven with the extra skin on one side versus the other. This may lead to problems later on including a buildup of smegma, inclusion of cysts, melaitis, or penile adhesions. Penile adhesions occur when the penile shaft attached to the head of the penis. Circumcision revision may be necessary if significant redundant foreskin, penal adhesions, episode of bellonitis, or pathological fimosis present in the previously circumcised boy. As you know, it is an outpatient procedure under general anesthetic. Again, it is normal in postoperative period for the tip of the penis to look red and appear to have a crusty white or yellow coating. Daily baths starting usually 3 to 5 days after circumcision, revision, and regular local antibiotic ointment are all that's necessary for postoperative care. Uh, that's all all I have today for this, uh, very important topic, and again, thank you very much for bringing us together for this important, uh, discussion. Yeah, thank you, thank you very much. So no questions, um, popped up. I did have one, if you have a, a kid who comes in with, um, who's been circumcised and has penile adhesions, um. And we're not able to kind of reduce them in the office, do you recommend using just like the Kenalog as well for those, or what would your recommendation be? Can you repeat the beginning of the question? Uh, I, I couldn't hear you very well in the beginning. Sure. So if, if you have a kid coming in for, you know, in the first couple of months of life that had a circumcision and has had penile adhesions, do you recommend that we try and kind of like light adhesions in the office, and if not, if they're too thick, you recommend that we use, uh, like a Kenalog cream as well, OK. Uh, if I, if I understood you correctly, you're asking about circumcised baby who has persistent penal adhesions. Yes, yes. You see those parents all the time. Personally, I do not recommend to pull foreskin back forcefully in the office because usually, uh, it's creating more problem down the road and uh frequently parents are not very happy. So what I usually recommend is gentle pulling down foreskin. As much as long as baby is not reacting. And yes, I think trial of Kenalog cream for one month would be very useful in that particular scenario. OK. Thank you. All right, looks like no other questions. So, next up, we're gonna have um Doctor Defour is gonna be talking about UTI stones. Hi, thanks for allowing us to talk today. Actually, I'm gonna talk about kidney stones. We're gonna move from the bottom of the urinary tract up to the top of the, of the urinary tract. And so for pediatricians, uh, kidney stones, uh, probably when I was in training 20 years ago, 25 years ago were a very rare occurrence in children. Uh, often, uh, you might see one every now and then in your office and, and that was probably the same for pediatric neurologists. And the last, um, Uh, a couple of decades though, the incidence and prevalence of kidney stones in children has increased quite dramatically. And there's several sort of putative theories for that. But, um, uh, it seems to be something that we're seeing often, uh, in, in our practice almost on a daily uh. And definitely a weekly basis. In fact, about 33 to 4 years ago, we started a kidney stone center in children here at Cincinnati Children's, that's a multidisciplinary clinic with nephrology, urology, genetics, uh, uh, and partnered with the emergency department and, uh, we have a, a nutritionist in our clinic. So, um, again, it's something that's become, uh, definitely much more of a public health concern over the last, uh, several years. So, um, in children, there can often be a chronic underlying condition that predisposes them to form, uh, kidney stones as opposed to adults. So in children, we often do a full metabolic workup, uh, to, um, try to identify the etiology of the kidney stones. Uh, and then recommend more precise, um, uh, treatment, uh, uh, to prevent recurrence. Uh, now, stones can be asymptomatic, especially when they're in the kidney and not obstructing the ureter. Um, and so, uh, uh, on occasion, they're found incidentally, uh, when abdominal imaging is done for some other, uh, purpose. The classic sort of symptoms for kidney stone pain, um, in a child who's verbal and able to give, uh, sort of, uh, a more precise history, uh, say, say your adolescent patient would be renal colic, which is sort of flank pain, um, which is intermittent and spasmodic. And happens um towards the, the back over the kidney. It can radiate uh into the abdomen, down to the groin on the ipsilateral side as the stone passes down the ureterra and hits the ureter vesicle junction. That would be the most likely place for the stone to get stuck. Typically, a stone under around 3 to 4 millimeters has a high likelihood of spontaneous passage. Uh, and so, in, uh, initially, if a patient is not, um, extremely ill or in having acute kidney injury or, uh, febrile or have an associated urinary tract infection, we often will try medical expulsive therapy, uh, which is uh aggressive hydration and the use of an alpha-blocker, uh, off-label called Flomax, uh, which if the child can't swallow the capsule can be opened up and, and, uh, sprinkle it into, uh, applesauce or, um, yogurt. So on our practice support tool, um, we've listed some red flags for managing, uh, children with kidney stones. Uh, obviously, unmanageable pain, intractable nausea, vomiting, or like I said before, fever associated with, uh, suspicion for urinary tract infection would be, um, uh, uh, red flags that we would need to, um, Uh, know about sooner rather than later. Uh, on the second page of our, uh, tool, we've divided the algorithm into, uh, whether patients have a known history of kidney stones. And so if a patient, uh, has a history of stones and has been treated and diagnosed before and maybe even be followed on our, uh, by our service, typically, Um, the initial assessment would be just to assess your pain level and like I said before, UTI symptoms. If the pain is not manageable or if they have any of the red flags, then the patient should be referred, uh, promptly to the emergency department. If the pain seems to be manageable and they're otherwise not too ill, um we have uh 24/7 access. Um uh during the day, we have a stone Center nurse coordinator and uh we have a, uh a dedicated phone line uh and it's uh 803 Rock, R O CK and that's area code 513. Uh, we're very proud of that number. Um If it's at night or on the weekend, of course, uh, through Priority Link, a urologist is always available to discuss the disposition of the patient. If a patient has no previous history of kidney stones and, uh, the symptoms are sort of classic for renal colic and or they have gross or microscopic hematuria, the initial study of choice would be a renal and bladder ultrasound. And that's usually available, um, at least at the main base Children's Hospital. Um, Uh, night and day. And, uh, during the day, most of the children's satellites, uh, have ultrasound, uh, capability. And if they can't, uh, perform the study as an add-on, then they might be referred down to the base hospital or to the ED. If the ultrasound shows kidney stones, um, and there's no other red flags and the patient is, uh, able to managed on over the counter analgesics, uh, like Tylenol or ibuprofen, and they're not vomiting, Then, um, you can always call the, the kidney stone Center. Again, that's 513-803-ROCK to discuss disposition and we can usually see the patient uh quite promptly even the next day in the office. If the patient has any of those red flags, then they would be referred to the emergency department. And one caveat to that is if they are vomiting and appear dehydrated, then we would highly recommend avoiding NSAIDs, uh, in particular, um, uh, Toradol, um, to avoid acute kidney injury. So, um, after the patient, uh, has their stone episode stabilized and or they, um, are now asymptomatic, uh, then the patient can follow up in the stone center and then they'll see nephrology and neurology and undergo a thorough evaluation like I mentioned before to see why they formed the stone. And then if a metabolic uh etiology is identified, then the patient can be prescribed, uh, specific therapy, pharmacotherapy. Sometimes specific dietary interventions are performed. Sometimes it's as simple as drinking more water and, um, avoiding added table salt. And the reason, uh, that's important as, as you, as you know, the way the kidney gets rid of calcium is to, um, or excuse me, gets rid of sodium is to excrete more calcium in the urine. So it's actually more the dietary sodium that's the culprit in many children and not the dietary calcium. So we don't typically restrict uh dietary calcium like cheese or um milk. But um all of our patients get general advice on increasing hydration. And decreasing added table salt to the diet. And as far as hydration is concerned, it depends obviously on the patient's age and weight. But in general, if the patient's urine is clear, then they're drinking enough water. If it's yellow or dark yellow, then um they're typically um not drinking enough, and that's when the stones are going to, or the calcium salts are gonna precipitate in the urine, clump together and form new stones. So again, um, uh, on the, on the tool, the red flags would be unmanageable pain, intractable nausea, vomiting, or fever, and, uh, signs of infection. And if any of those are present, then, uh, prompt evaluation by our service and the emergency department is appropriate. If the patient is otherwise stable and not too ill, then you can always call us to get a disposition and we can see the patient quite promptly, uh, in our office. And Doctor de Blasio, I think that's all I had. Um, happy to take any questions. Sounds good. Is everyone able to hear me? I had to switch over to my phone. Can everyone hear me OK? OK. OK, great, good. So I did have, uh, one question here, and I think this may be more for Doctor Minovich, um, specifically thoughts on antibiotic ointment after circumcision. Are you talking about neonatal circumcision or circumcision revision? Uh, it is, uh, so the question is why antibiotic ointment after circumcision? This is not the standard in newborns, is the question I have. Well, first of all, for the first couple of days, the baby will have some bandage on it, so it's probably not practical to put antibiotic ointment around the penis. Uh, plus the risk of infection is very, very small after neonatal circumcision. So definitely, I would recommend antibiotic ointment if there is any redness or any signs of local infections. Otherwise, most time it's not necessary. Um, at least for the first couple of days. After, uh, circumcision revision, I personally do recommend antibiotic, uh, applying to the penis with every diaper change after 3 days. Most of, uh, uh, me and most of my partners, we use a Dermabond, the biological glue which provides very, very good sealing dressing around the penis, and again, Uh, there is some data to suggest that antibiotic ointment might kind of dissolve that glue within the first couple of days. That is why I recommend not to put it for first couple of days. Got it, got it. Thank you. Thank you. So now we're gonna turn over to uh Doctor Stein talking about uh UTIs. All right, thank you. I appreciate it. Um, I appreciate the opportunity to present our community practice support tool on urinary tract infection. I'm gonna provide a brief overview of it and obviously, I'm open to answering any questions about this or if you want to discuss any particular topic in any more detail. Um, UTIs are, one of the more common problems evaluated by primary care physicians, and among the most pro Common problems evaluated by us as urologists, uh, up to 3.5% of children develop a UTI annually in the United States. Uh, UTIs have a significant burden on our healthcare system. They account for greater than 1.1 million office visits and greater than 13,000 inpatient hospitalizations per year. Um, these estimates are from several years ago and they're likely more today. Um, with regard to assessment of, uh, urinary tract infection, the most important component is the presence, duration, and severity of fever. Um, a fever is the most reliable indicator, um, to differentiate between upper UTI or pyelonephritis and lower UTI or cystitis. An upper UTI can present with high fevers, lethargy, emesis, and flank pain, while a lower urinary tract infection can present with urinary frequency, urgency, dysuria, incontinence, foul smelling urine, gross hematuria, and sometimes suprapubic pain. Uh, these signs and symptoms can obviously vary depending on age and developmental status. I'm always to, uh, patients and families, as well as, um, healthcare providers that the character of the urine is not a great indicator of urinary tract infection. Um, it can often depend on their diet as well as their hydration in terms of whether it's cloudy or has any debris in it. So I always encourage patients and families to increase their oral intake of fluids and reevaluate their urine for any improvement. Um, as we'll discuss shortly, um, it's important to determine the presence of fevers because a febrile UTI is going to be managed much differently than an afebrile urinary tract infection. Um, I've included a fairly comprehensive list of risk factors for UTI on our community practice support tool. I won't discuss them all in detail. Um, however, I wanted to touch on circumcision, um, as Doctor Minovich did recently. Um, I'm commonly asked about the benefits of circumcision by both, uh, families and primary care physicians, um, based on a policy statement from the, uh, AAP. Several years ago, um, they say that the benefits include significant reductions in the risk of urinary tract infection in the first year of life. Although health benefits are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it, um, and to warrant third-party payment for circumcision of male newborns. Uh, among all these risk factors on the community practice tool, I think the most important ones for recurrent urinary tract infections include high-grade vesicoureteral reflux, typically grade 34, or 5, underlying bladder and bowel dysfunction, and presence of renal scarring. Uh, several studies have demonstrated that they are independent risk factors for developing recurrent urinary tract infections. Uh, prior to management, I think the most important question is who to assess. Um, children with risk factors for UTI and no other source for fever should generally be assessed for UTI. Uh, the most recent guidelines from the AAP focused on children between 2 to 24 months of age and recommended that the following be assessed. Um, female children with fever, um, and at least two of the following risk factors, including white race, less than 12 months of age, uh, temperature greater than 39 °C, fever for 2 days or longer, and absence of other source for fever. Um, all uncircumcised male children with fever should be assessed for urinary tract infection, and then lastly, circumcised male children with fever and at least three of the following risk factors, non-black race, temperature greater than 39 °C, fever for 2 days or longer, and absence of other sources for fevers. Uh, with regard to diagnosis, a urine specimen should be obtained prior to the initiation of antibiotic therapy, um, in order to determine an accurate diagnosis. The likelihood of contamination of a urine specimen is greatest with a bag specimen, uh, followed by a clean catch midstream, catheterization, and lastly, suprapubic aspiration. A bag specimen is therefore only useful if negative, and must be followed by a catheterized specimen, if positive, to confirm the presence of UTI. Catheterization or suprapubic aspiration is generally recommended in non-toilet chain children younger than 2 years of age. Um, I would say that catheterization is the most common, uh, means for, uh, obtaining a specimen in the United States, um, whereas suprapubic aspiration is performed fairly commonly in Europe. Uh, the urine specimen should be sent for a urine dipstick and microscopy if available. The latter is important to determine the presence of pyuria or white blood cells in the urine to differentiate between the UTI and colonization. Uh, colonization does not generate an immune response and therefore should not have pyuria. Um, and we do not always treat, um, colonization, um, if there isn't any associated symptoms. Urine specimen should also be sent for a urine culture, which is the gold standard for diagnosis. A possible contamination can be indicated by a low colony count, mixed growth of bacteria, and non-neuropathogenic organisms such as Lactobacillus, coag-negative staph, corny bacterium, alpha-haemolytic strep in Canada. Uh, most importantly, a diagnosis of UTI requires all the following to be present a positive urine culture with greater than 50,000 colony forming units per milliliter of a uropathogenic organism, positive urinalysis for pyuria, and lastly, associated symptoms. With regard to treatment, the early initiative of antibiotic therapy is important for the prevention of renal involvement and subsequent renal scarring. Empiric antibiotic therapy can therefore be considered for febrile infants and young children with a high index of suspicion for UTI. 2nd and 3rd-generation cephalosporins are typically the best options due to their broad-spectrum coverage. Um, Bactrim can also be considered in certain communities without significant antibiotic resistance, and then nitrofurotin can be considered as well, um, except for a febrile urinary tract infection or pyelonephritis due to its poor tissue penetration. Many children with, um, who developed a febrile UTI warrant a renal and bladder ultrasound to screen for any anatomic abnormalities of the urinary tract. Um, of these patients, up to 15% will have an abnormal, um, renal and bladder ultrasound. Uh, furthermore, up to 40% have a vesicco uterine reflux or, um, VUR, and voiding cystourethrogram. Um, and of those, about half will have high-grade dilating reflux, grade 34, or 5. I think the main controversy um with imaging is the routine use of BCG to screen for VUR with the goal of preventing the long-term sequela of renal scarring and hypertension. Uh, guidelines have been published by the AAP as well as the ISPN in Italy, NICE in UK and Royal Children's Hospital in Australia. Uh, they all generally recommend a renal and bladder ultrasound after For a first febrile urinary tract infection. Uh, they also recommend a VCG, uh, when there's an abnormal ultrasound or with other risk factors and atypical clinical presentations, um, such as abnormal prenatal ultrasound, family history of VUR, sepsis, renal failure, male infants younger than 6 months of age, a non-compliant family, and a non-E. coli organism. Um, that covers most that I wanted to discuss today with, um, assessment, management, and treatment of urinary tract infections. I'm open to any questions that the audience has. I did have actually one question, uh, that came through for Doctor Defore, and it is, um, how often is an underlying etiology found in an otherwise healthy child with first-time kidney stones, and which are the most common? Thank you for that question. So, um, actually the most, the far and away the most common thing that we find on the metabolic evaluation is that they're sort of chronically dehydrated. The, um, the other sort of more common things we find one is, uh, hypercalceuria, um, and also hypocitraturia. So citrate is a, uh, calcium stone inhibitor. Um, that's what's in lemonade. So almost all of our patients, um, are advised, uh, to drink lemonade. Um, and so, um, that, those would be sort of the most common things. And so, uh, if they fail, sort of conservative management with hydration and lemonade and eliminating table salt, then the nephrologist will often try a, um, potassium citrate, uh, which goes by the trade name Euroce K. Um, to try to supplement that citrate, uh, change the pH and, uh, decrease the calcium stone, um, A formation. Great, thank you, thank you. So, next up we have uh Doctor Reddy and Doctor Garrison talking about uh the undescended testes. Thank you, Doctor De Blasio. So, um, before we start on the topic, I just want to thank my colleagues for taking time to discuss some of these, uh, very important and commonly occurring pediatric conditions, and, uh, I just wanna reach out to all of our colleagues that have logged in, uh, from around the world and say, you know, the division of Urology here is open to any questions that you have. You can just email us at Purology. I'm sorry, Piurology at CCHMC.org. Once again, Prology at CCHMC.org. And if you have any future needs for us to put on similar events, uh, discussing more specific topics and in, in-depth, we're happy to do that. So just reach out to us. We're very happy to partner with you. Now for something different, um, because this is a topic that both pediatric urology and pediatric surgery deal with, uh, we've invited Doctor Garrison, one of my colleagues from pediatric surgery, to partner with us for this part of the presentation. And together, we're gonna talk about, uh, the management, evaluation and treatment of undescended testes. So unascended testes is defined as a testicle that cannot be bought into the lower half of the respective hemiscrotum, and you have to differentiate that from an ectopic testes, where the testes is outside of the normal pathway of testicular descent. So it may be in the perineum, it may be in the medial aspect of the thigh, or maybe uh in the suprapubic region, and an ectopic testes is never going to descend. So if you find a testicle in one of those abnormal locations, There is no benefit of obser observation. It's not gonna move into the scrotum. The other thing we have to differentiate an undescended testes from is a retractile testes, and a retractile testes is a normal occurrence. All male infants have a cremasteric reflex, which is a protective reflex. If uh something touches the medial aspect of their thigh or something startles a child, the cremasteric reflex will pull the testicle up into the upper part of the scrotum or even into the inguinal canal, and that's designed from an evolutionary standpoint to protect the testicles. This reflex gets dampened by the time the child's about 4 or 5 years old. And so, uh, it is important to keep an eye on that. Uh, certainly, if the testicle is not able to be brought down into the respective hemiscrotum and remain there after you let go, that would be an undescended testicle. But if you can milk it down into the scrotum and it stays there until you initiate that reflex, that's a retractile testis. And again, that's a normal reflex found in children up to about 4 or 5 years of age. So the incidence of undescended testes, you know, 6% of newborn infants will be found to have undescended testes, much more common in premature infants, and by about 4 months, this decreases to 3%. And why is that? Well, the incidence decreases from birth to about 4 months of age to 3% because children, all boys, will go through something called a mini puberty. And that happens 3 months after the child leaves the maternal womb. So whether they're born full term, prematurely, 3 months into life, they have a pituitary mediated stimulation of the testes, and the testes briefly come on and make testosterone that can be measured in the blood. And that is a very important uh initiation for the testicular development that primes the testicle for the subsequent puberty that happens around 1112 years of age. So we call that mini puberty. It's a well-defined, well studied phenomenon and it is very important. And what we'll see is that with the mini puberty, we will see the testes descend one station. So if you have an intraabdominal testicle that's non-palpable. After mini puberty, we might be able to palpate it in the anal canal. If it's in the inguinal canal, it might descend down into the upper part of the scrotum. If it's at the upper part of the scrotum, it'll descend into a normal location. So one station descent of the testes is pretty well recognized with the mini puberty. Now, the descent of the testes is a multiphasic event. Initially, during the 1st 6 months of pregnancy, the intraabdominal pressure allows the testes to descend from its origin close to the kidneys down to the pelvis by the level of the internal ring. So any condition that affects the formation of the abdominal wall, like an omphalocele or prune belly syndrome, will be associated with intraabdominal testes. After 6 months, then the gubernaculum plays a role, and so the initial part of descent is being pushed by intraabdominal pressure, and then the gubernaculum swells and allows the path for the testicle to descend down from the anal canal into the scrotum. So you can see that there's a temporal def uh temporal location of where the testes are gonna be based on the gestational age of the child. So if you have an extreme premature infant, you know that biologically, those testes may have not had the opportunity to descend, and there's gonna be a higher incidence of testicular undescent in children who are born prematurely. Now one thing about uh normal virilization, so there are 33 signs of external virilization of a normal male, and that is both testes are descended in their respective hemiscorti and that the urethral meatus is orthotopic. If you're missing two of those 3, so you have either bilateral undescended testes or an undescended testes associated with the hypospadius. It would be important to check a karyotype on that child to make sure that you're not dealing with a DSD, a disorder of uh sexual development that uh might change your management of that child. Now, the main risk factors for having a child born with undisended testes are prematurity. low birth weight, other associated anomalies of the genitary tract such as a hypospadius, and also having a first-degree relative who also had undescended testes. There are a couple of key milestones to keep in mind. So, one is that at birth, if the testes are undescended, you know, be patient, wait till that exam after mini puberty, about 4 months, with the exception of if the testes are ectopic, then there's no benefit of waiting. After 4 months of age, if the testes is still undescended, there's not gonna be any significant benefit of waiting, and this is a departure from traditional teaching where we used to say, But, you know, 1015 years ago, pediatric girls say, well, I don't need to see the child just yet. Let's let them get a little bit older and see what happens. We now know that waiting beyond 4 months is not going to cause any difference in the location of the testicle. So any descent that's gonna happen spontaneously after birth is gonna happen in that 1st 4 months. Um, if the testis is not brought down by the first year of life, we know that there is going to be some impact on the health of the testicles. And again, this is again, a big departure from past teachings, but we used to say as long as the testicle was brought down before puberty, that the testicles are going to be healthy. We now know that by bringing it down before the first year of life, we're going to preserve the complement of primary spermatagonia, which are going to be the stem cells for future sperm development. Um, there is, uh, microscopic evidence on testes that have been biopsied during the ochiopexy that show that beyond year one of life, if the testes is not down in the scrotum, that there's gonna be irreversible changes to the number of spermatogonia, so definite impact on fertility. And also traditionally, we used to say that undescended testes, truly intraabdominal testes, had a higher risk of cancer. Uh, and again, it's very important to distinguish that that risk of cancer truly applies to intraabdominal non-palpable testes. If the testes is palpable in the inguinal canal, the risk of cancer is probably very similar to a normally descended testes. By bringing the testes down sooner, we are affecting some change in that cancer risk, not ovviating it completely, but we are affecting a change. So these are important things. Uh, one thing before I turn over to Doctor Garrison to talk about the assessment of a child who is suspected of having undescended testes, I think it's really important to keep in mind that there is no imaging modality that is indicated in the assessment of a child with an undescended testes. The most important thing is the physical exam. Getting an ultrasound, getting CT scans, MRI's, they've not been shown to be beneficial and certainly not cost-effective. So the most important thing is your physical examination, and I'm gonna have Doctor Garrison talk about the importance of a proper physical examination. Thanks, Doctor Reddy. Um, and thank you guys for including me. This has been interesting to hear you guys talk about some of these topics. So, um, when I'm evaluating a patient for an undescended testicle, it, it's, um, really the main thing is a good history and physical. Doctor Reddy said, it's not, uh, something that we typically need an ultrasound for. Um, history, I, I wanna know if there's prematurity or if they're outside of that, um, age range that's listed on the, on the practice tool. I want to know if there's a family history of undescended testicles, and if it's, if the testicles have been documented, uh, either at birth and now are, are no longer seen. So, uh, has there been a pattern or has it never been, uh, visualized? Um, Any congenital issue like gastroschisis, something like that, which we know carries a very high risk of undescended testicle would make me a little more um likely to um investigate that further. So, physical exam, I always try to grab a resident or um fellow when there's a, a, a tough um testicle to find or to bring down because it really can be challenging when they hide into the inguinal ring. So, um, as is listed on the support tool, um, having the child as relaxed as possible, frog leg position, um, can help to avoid, um, stimulating the cremasteric reflex. And I usually use two hands, one to try to, um, guide the testicle down past the inguinal ring until you can, um, get fingers above it or more superiorly to it to try to bring it down into the scrotum. And I think 11 key thing is that if that testicle then does come down into the dependent part of the scrotum, then that patient doesn't typically need surgery at that, at that point. If you can, if you cannot move that testicle down past the ring or into the scrotum, then that's someone that, um, you know, we should see. And, and I do agree, Doctor Reddy. I was, I was trained, you can kind of wait till a year to, to make a decision. And now it seems like we're, if you wait that long, that's kind of at the, at the Further end of the, of the spectrum. So, um, I did have a question for you about karyotyping, Doctor Reddy. So if, if you do see someone who meets those criteria having two of the three, issues needing a karyotype, do you wait on those results before surgery, or does it, is it a case by case basis? Uh, I think that, uh, you know, the finding a child who has a DSD condition is a significant enough of an event that I would wait. So it's usually during the clinical exam that, uh, if I see that, uh, we're missing two of those external signs of virilization, I'll tell the parents that, you know, we're just gonna do some additional testing or the karyotype, and then I'll either call the parent back with the result or do a televisit, telehealth visit. If the karyotype comes back abnormal, then we do have a very, uh, well, um, represented DSD center here with all disciplines of medicine represented that need to provide that very delicate discussion with the parents about the diagnosis of a DSD condition. So I do think it's important enough that we would wait before recommending any surgery because sometimes the surgery may not be indicated or you might actually need to do something different such as a biopsy of the testicle. Um, there is now a move for doing fertility preservation. If there is a test that's not congruent with the gender of rearing of that child, um, we can preserve the gonadal tissue so that that child then has the ability to have biological children of their own, irrespective of the gender that they choose to be raised. Uh, and there's also another movement afoot where we're not recommending any sort of gender assignment surgery until the child is old enough to be a participant in that decision making. So, I think for all those reasons, it's important that we pause and get more information, allow the family to have the appropriate consultation. Again, it's very delicate, that discussion, and there's no reason to rush into it. So, uh, now that you've made the diagnosis of an undescended testes, and one caveat I would say there is that, you know, so you have a child who has well-documented physical examinations where the testis has been documented on the well-child checkups to be descended, and now all of a sudden at age 5, the testicle is not palpable. There is a defined condition called an ascended testicle. Uh, can happen in about 2% of children who've had normally descended testes before, and oftentimes in those individuals we'll find that either they had retractile testes where the cremasteric muscle just becomes so hypertrophied that it pulled the testicle out of the scrotum, or there may be an associated hernia sac or a prosthesis vaginalis that is tethering the testicle, and as the child grows, the testicle moves out. So testicular ascent is a real thing, uh, and it's not something that is a missed diagnosis of an undescended testes. It does happen in some instances. So, uh, once we made the diagnosis, what's the treatment? Uh, as you heard us mentioned that, you know, we are departing from traditional teaching of waiting till the child is older, no proven benefit, and in fact, there may be harm to the testicle by waiting longer than the 1st 1 or 2 years of life. And anytime we talk about surgery, we have to balance what are the risks of the surgery with the benefit. I think that, uh, you know, anesthesia has gotten safer, certainly beyond a full-term infant, um, over 6 months of age can be done safely in an outpatient setting. And so that's kind of what we recommend is that, you know, the earliest we'd start thinking about surgical intervention for these children is about 6 months of age. Uh, keep in mind that, um, 70 to 80% of undescended testes will be palpable somewhere along the inguinal canal, and 20-30% of them may be intraabdominal. So I'm gonna have Doctor Garrison talk about the Uh, open surgery for a testicle that is palpable, and then I'll come back and speak about the management of an intraabdominal testicle. Sure, thank you. Um, the, um, uh, the inguinal approach is really very similar to a hernia repair, and so is the, so the recovery is very similar also. Um, and the physical exam is important to localize where that testicle is so you can decide if you're gonna approach it from the belly or, uh, from the groin. Um, I, I don't think everyone's terribly interested in the surgical details, but I'll, basically, we make a little incision down in the groin, go through some of the abdominal, uh, layers, and we separate the testicle and the vessels from, uh, what typically is, is, uh, a small hernia sac down at the level of the ring. And there are a few maneuvers we can do to try to bring the testicle down into the scrotum and Um, most people at that point then secure the, uh, testicle into the scrotum with, uh, a few sutures or, or some even still use buttons and things like that. So, um, recovery is typically an outpatient procedure unless there's some prematurity or other comorbidity that, uh, would require them, uh, to stay in, in the hospital. Uh, and pain control is typically Tylenol, um, and doesn't typically require, uh, more than that. Perfect. Thank you, Erin. And, uh, you know, for the non-palpable testes nowadays, again, no reason for any imaging because the diagnostic laparoscopy is gonna be both diagnostic and therapeutic. Uh, the success rate of bringing a high undescended test is down laparoscopically now. We're, uh, reaching a 70 to 80% success rate. And in certain instances, we might do a stage approach where we want to preserve the blood vessels, um, of the vass. Separate the gonadal vessels and allow those collaterals to develop and bring even a very high testicle down safely. And as Doctor Garrison said, we're not gonna talk about the details of surgery, but I think the importance is how do you care for this child after the surgery. Uh, these are typically outpatient surgeries also and small incisions, usually one in the belly button and two other small incisions. Usually, it's a week of restricted activity, and then the child can go back to any sort of activity. Uh, in this age group, it's really straddle toys and, uh, you know, bathing restrictions. Uh, one important thing, since that Children's Hospital is committed to being very safe in terms of narcotic use, and so all of our patients nowadays, after most surgeries, we're just doing alternating Tylenol and Motrin or ibuprofen, avoiding the need for any narcotics. Um, and we do recommend the use of, uh, topical antibiotic ointments over the incisions to reduce the risk of any wound infections. Now, One key age group is children over the age of 14. Now, if you have a child who has a documented undescended testes over the age of 14, we would recommend doing a biopsy of that testicle at the time of the orchiopexy and wait to get the results to see if there is any evidence of intratubular neoplasm. These are the precursors of cancer. If there's any evidence of cancerous changes happening in that testicle, then we would have already prepared the family that at that point, we're gonna remove that unhealthy testes. Uh, and, um, you know, prevent that further deterioration of cancer in that, uh, testicle. So that age 14 seems to be an important age where if the testicle is not down in the scrotum by that point, it's probably best to be extra careful, do the biopsy, and ensure that we're putting down a healthy testicle. So again, thank you very much for this opportunity to talk about a very common topic. Uh, we do see still a lot of people ordering imaging, uh, studies on these patients and again, I want to emphasize that really the best way to diagnose this is your physical examination. Thank you, Doctor De Blasio. Thank you, Eric. So a couple things just kind of housekeeping stuff in order to get the CME stuff, um, we're gonna put up like the screen for how to claim credit. Please realize in order to get credit you need to have, um, kind of the the CME kind of CCHMC cloud account and enter the code in. I'm going to go over the answers to the polling questions in just a second, but I did want to ask, um, a question to, um, Doctor, uh, Doctor Reddy. A question came through. At what age do you, uh, actually, uh, have to operate on retractile testes? At which age is it just too old for, Still be retractile. That's a great question. What we recommend is when we referred a patient with retractile testes, we say until the age of 5, it's a normal physiological process, and we just encourage the parents while they're bathing the child, let the child relax in a warm tub bath. And if you can see the testes descend, no reason for any intervention. Beyond the age of 6 is now where we start to say, OK, now, depending on how retractile, how far they go up, and how difficult is it to bring the testicle back down into the scrotum. That's when we start thinking about intervention for these children, uh, rather than even the inguinal approach for an orchiopexy, we can often do something called a Bianchi technique, which is a small incision in the side of the scrotum. Uh, it takes us literally 10 minutes to do that procedure, and all we do is we go and release all the cremasteric muscles and place the testicle in a new pocket. The recovery from that is very rapid, and, um, it allows the testicle to be placed into a healthier position in the testicle, so, sorry, into the scrotum. So I think after age 6 is where we would think about uh bringing a retractile testes down so it stays in the scrotum all the time rather than moving up and down. Um, but certainly the, the age of referral, I would say by the time the child's 4 or 5, if you're still dealing with the retractile testes, we're happy to see that child and make sure there's nothing else going on. OK, perfect, perfect. Just to kind of wrap up, we just have like 2 minutes left. I want to go through the answers to, um, the, the polling questions that we sent out. So the first one, is the initial imaging for children with a suspected kidney stone is the following, and the answer is A, a renal and bladder ultrasound. The second question was, what percentage of boys are born with a physiological thymosis, and the correct answer is C, 95%. The third question is, what diagnostic imaging modality is recommended to locate an undescended testes? And the answer is E, none of the above. So it's a trick question, uh, just to, uh, remind people, no imaging is, uh, is recommended. And then our final question was, a 10 month old uncircumcised boy presents with a 2 day history of fevers up to 39 degrees. The patient is well appearing and feeding well with no apparent source of fevers. What is the most appropriate next step? And the correct answer is D, obtain a urinalysis and urine culture, uh, via a catheterized specimen. So, um, I just want to emphasize again uh people did send some questions we didn't get a chance to get to. We will email results to those all of these questions or um all of the, uh, the kind of these practice guidelines are available, uh, on the website as well. So all the information that was discussed today will be available, um, to all the participants as well. And is there any other last minute stuff that uh anyone want to chime in about or anything at all, uh, before we wrap up? It's 8 o'clock right now. Uh, so I just wanna say thank you very much to our Cincinnati Children's Hospital team for putting this opportunity together, uh, and thank you, most importantly to our pediatric colleagues from around the world. Uh, you know, you are our, our dear colleagues and Together, we take care of these patients and I just wanna emphasize that if there are other topics that you would like a little bit more in-depth discussion, please email me. My email address is promote P R A M O D. R E D D Y at CCHMC.org. I'm happy to bring the division of Pediatric Urology and if there are other topics that my colleagues from pediatric surgery can partner with to give you more in-depth discussions on topics that you choose. We're happy to put similar events together and we can do those in a more formalized traditional, um, teaching method with uh the slides and everything. For today's purpose, we really wanted to be a little bit more interactive and answer questions and also showcase the practice, um, uh, educational tools that we put together and I would encourage you to download those. They, uh, I think that my team and the Children's Hospital team has done a good job of putting all of the pertinent topics that you need to know about management of these conditions together in a simple to read format on one page. So please take advantage of them. Thank you so much for your time and attention. Great, and thank you to all of you as well. I know, uh, it was an early mor, probably not for the surgeons, not an early morning, um, but, uh, thank you to all of you for joining us and, uh, you know, sharing your expertise. Very much appreciated from, you know, all of, all of us in pediatrics. So thank you so much, guys. All right, have a great day. Stay safe and healthy. You, you guys do the same. Thank you.