Pediatric Urology Part I
With Dr. Patricio Gargollo · hosted by Dr. Todd Ponsky · StayCurrentMD
Part of
Urinary Tract Infection 4 items
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
UTI risk in the first year of life is 3-4% overall, with uncircumcised boys having 1/100 risk vs circumcised boys 1/1000 risk
Circumcision provides decreased risk for HIV, syphilis, gonococcus, HPV, and HSV-2, but not for chlamydia
Kenya trial of ~3000 men showed 53% protection against HIV in circumcised cohort, trial stopped early due to significance
Uganda trial of ~5000 males showed 50% of circumcised men became infected vs control group, also stopped early
AAP policy states data are not sufficient to recommend routine neonatal circumcision, parents should receive accurate unbiased information
Office circumcision cutoff: 3 months of age or less than 13 pounds (personal practice guideline, no data support)
Literature suggests exposing younger children to elective cases like circumcision under general anesthesia is not recommended from anesthetic safety standpoint
Best analgesia method for circumcision is dorsal penile nerve block combined with ring block using 0.25% bupivacaine without epinephrine
Plastibel device subjectively has more postoperative complications than Gomco or Mogan clamps
Major injuries (glans amputation) from circumcision have been seen only with Mogan clamp use (2-3 cases observed)
Dorsal penile nerves run at 2 o'clock and 11 o'clock positions, block placed below pubic symphysis at ~1.5cm depth using 1cc/kg of 0.25% bupivacaine
Mogan clamp glans amputation occurs when glans is pulled through the slit along with foreskin, especially with smaller glans
Gomco bell sizes are 1.1, 1.3, 1.45, and 1.6 cm; 75% of time a 1.3 bell is used
Mismatched Gomco bell and base can cause bell to pull up, exposing glans and causing injury during cutting
Must take down preputial adhesions completely to see ridge under corona all around, or will leave asymmetric skin
Gomco bell should be left on for at least 5 minutes for older kids (near 3 months/13 lbs), 1-2 minutes for newborns
Vaseline dissolves Dermabond, so parents must be instructed not to use Vaseline on Dermabond-dressed circumcisions
For bleeding control, have 6-0 chromic or fast-absorbing plain suture and 1:1000 diluted epinephrine available in circumcision tray
Fast-absorbing plain gut (6-0 or 5-0) leaves nicer cosmetic appearance than Vicryl for circumcision closure
Physiologic adhesions (distinct line visible) do not need treatment and will lyse on their own as baby grows
Lysing physiologic adhesions in office can turn a non-problem into a problem by creating raw surface and true bridges
Skin bridges (no distinct line, two holes on each side) need treatment as they will not lyse and can tether penis with growth
Most skin bridges can be treated in office with EMLA cream 30-40 minutes, hemostat clamp, and fine scissor division
Redundant foreskin appearance often due to fat pad; if penis looks circumcised when fat pad pushed down, no intervention needed
Have never seen an adolescent complain of too much foreskin; suspect most cases resolve with puberty and penile growth
Perform 1-2 redo circumcisions per year in high-volume practice, suggesting most resolve spontaneously
Meatal stenosis is exclusively seen in circumcised boys, caused by meatal rubbing against diaper/underwear creating inflammatory web at 6 o'clock
Meatal stenosis requires intervention only when symptomatic: urine shoots straight up toward ceiling, child must sit to void
Have never seen an adolescent with meatal stenosis; many subjectively narrow meatuses become normal with growth
Meatotomy can be done in office with EMLA cream, straight hemostat crush of 6 o'clock web, and fine scissor incision without sutures
No data shows sutures at 3 and 6 o'clock reduce meatotomy recurrence rate compared to no sutures
Micropenis clinical definition: stretched penile length >2.5 standard deviations below normal mean for age
Mean stretched penile length for 6-12 month old is about 4 cm (reference: Bin Abbas 1999)
Buried penis looks like a short squat pyramid, not a structure coming out of the body
Congenital megaprepuce occurs mostly in Hispanic patients and should not be circumcised due to risk of complete shaft skin loss
Physiologic phimosis (soft, supple skin, no symptoms) does not require treatment regardless of age
Betamethasone 0.1% TID for 2-3 months results in >50% of children with phimosis having retractile foreskins
Lower betamethasone doses (0.05% BID for few weeks) are too low in dose and duration to see effect
Secondary phimosis (hard stenotic ring after circumcision) responds to betamethasone 0.1% TID for 2-3 months in >50% of cases
Balanitis xerotica obliterans (BXO) presents with paper-white, scaly, hard skin at prepuce tip and will not respond to steroids
BXO can spread onto glans and into urethra causing significant urethral strictures; requires circumcision
Paraphimosis occurs when retracted foreskin is not brought back over glans, can become medical emergency with vascular compromise
Paraphimosis treatment: pain control (EMLA or penile block), D50-soaked bandage wrap to reduce swelling, manual reduction
Manual paraphimosis reduction: thumbs on glans, fingers on shaft skin, pinch shaft skin and push glans back into foreskin
Manual reduction works 9 out of 10 times with good pain control and D50 swelling reduction; have never needed dorsal slit
Main cause of penile trauma is zipper injuries; treatment is cutting zipper bridge with bolt cutter rather than manipulating zipper
Second most common penile trauma is toilet seat crush injuries; conservative management if child voids without gross hematuria
Gross hematuria after penile trauma requires urologist involvement for potential urethral injury evaluation
Buck's fascia violation in penile trauma requires OR repair to prevent long-term scarring and potency issues
Gross blood at meatus or gross hematuria after trauma requires full urinary tract evaluation and retrograde urethrogram before catheterization
Hypospadias incidence is about 1 in 150 live births
Hypospadias etiology is multifactorial; higher incidence in children conceived via in vitro fertilization
Foreskin is not used for distal hypospadias reconstruction; can complete circumcision if found during procedure
Undescended gonad with hypospadias requires full DSD workup; bilateral non-palpable gonads suggests congenital adrenal hyperplasia
Two palpable testicles with hypospadias means DSD risk is almost zero
Hypospadias repair indications: cosmetic appearance and functional (ability to void standing, normal emission for fertility)
Midshaft and distal hypospadias likely have no functional problems; repair is primarily cosmetic
Controversy exists about repairing very mild hypospadias variants in young children given anesthesia exposure concerns
Hypospadias repair involves urethroplasty (bringing meatus to tip) and phalloplasty (straightening curvature)
Most chordee resolves after penile degloving; sometimes requires additional maneuvers for significant curvature