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- Hypospadias is a congenital anomaly of the penis in which the opening of the tube that carries urine from the body (urethra) develops abnormally, usually on the underside of the penis. The opening can occur anywhere from just below the end of the penis (distal) to the scrotum (proximal). Depending on the degree, it may sometimes be accompanied by chordee (penile curvature).
- Hypospadias repair is an outpatient surgery that is performed after the age of 6 months. Depending upon the severity of the hypospadias, it can sometimes require 2 or more surgeries to complete the repair. The child will be sent home with a catheter for a week that will later be removed in the office.
- Chordee is a congenital curvature of the penis when erect. It can curve downwards, upwards, or to the side. Chordee often accompanies a hypospadias.
- Chordee repair is an outpatient surgery that is performed after the age of 6 months.
- Phimosis refers to the inability to retract the distal foreskin over the glans penis. Physiologic phimosis occurs naturally in newborn males. It is natural for the foreskin to not completely retract until after 2-3 years of age. Pathologic phimosis defines an inability to retract the foreskin after it was previously retractile or after puberty, usually secondary to distal scarring of the foreskin.
- The first step to treating pathologic phimosis is the use of a steroid cream, usually Triamcinolone 0.1%, twice daily in combination with gentle stretching for 4-6 weeks.
- A circumcision is the removal of the foreskin. This can be done at birth until 5 weeks of age in the office under local anesthesia. After that time, the surgery is performed only under general anesthesia as an outpatient procedure.
- The medical indications for a circumcision include frequent urinary tract infections, repeated episodes of balanitis (infection of the foreskin), congenital kidney anomalies, the presence of distal scarring of the foresking (BXO), episodes of paraphimosis, and anomalies of the foreskin.
- Balanitis is an infection of the foreskin. It can occur at any age and can be associated with poor hygiene. Typically, it is treated with either topical or oral antibiotics or a combination of the two. Repeated episodes of balanitis is an indication that a circumcision may be necessary.
- Paraphimosis occurs when the retracted foreskin remains trapped behind the head of the penis, causing the penis to appear circumcised. It results in pain, swelling, and severe inflammation to the head of the penis. Paraphismosis is an emergency which requires immediate medical attention.
- Meatal Stenosis
- Meatal stenosis occurs when the opening of the urethra becomes too small, causing an abnormal deviation or narrowing of the urinary stream. This occurs only in circumcised males.
- The repair of meatal stenosis, a meatotomy, can be performed in the office under local anesthesia or in the operating room as an outpatient procedure.
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- Undescended Testicle
- Undescended testicles, or cryptorchidism, is the most common congenital anomaly of the male genitalia occurring in 2-4% of newborns, with a prevalence of 1% at age 1. This is diagnosed if the testicles cannot be brought into or felt in the scrotum. The testicle may be in the inguinal canal or in the abdomen. Both testicles should be descended by 6 months of age. Often, the testicles may retract for a short time into the inguinal canal when the child is cold or nervous: this is normal.
- Surgery to correct undescended testicles, an orchiopexy, is performed after the age of 6 months. It is an outpatient procedure done through a small groin and scrotal incision. If the testicle is not able to be felt, the surgery will be performed with laparoscopic instruments. Occasionally, it requires 2 surgeries to bring the testicle down.
- Swelling in the groin or scrotum can indicate the presence of a hernia. In children, this is caused by an open communication between the abdomen and the scrotum, a patent processusvaginalis, and contains bowel or omentum. It can fluctuate in size and increase with valsalva or increased intrabdominal pressure that occurs with coughing or crying. Hernias should be repaired because of the risk of incarceration of the hernia contents.
- Hernia repair is an outpatient surgery done through a small groin incision.
- Swelling in the groin or scrotum can also indicate the presence of a hydrocele. In prepubescent boys, like a hernia, this is caused by an opening between the abdomen and the scrotum. With a hydrocele, it is only a small amount of fluid which is passing back and forth. This also can fluctuate in size. Usually, surgery is performed after the age of 2 years since many can resolve on their own.
- In post-pubertal males, the hydrocele is formed by excessive fluid production from a layer of the tissues surrounding the testicle or can be a reaction to injury or the presence of a tumor.
- Hydrocele surgery is an outpatient procedure done through a small groin incision in children and a scrotal incision in teenagers.
- A varicocele is an abnormal enlargement of the vein that is in the scrotum draining the testicles and most commonly occurs on the left side. It is similar to a varicose vein in the leg. Varicoceles are usually asymptomatic, but can cause atrophy in the testicle which may lead to later problems with fertility. In adolescents, we monitor the size of the testicles with yearly ultrasounds and occasionally a semen analysis. Surgery is recommended when the left testicle becomes significantly smaller than than the right side.
- Varicocele surgery is done via either the laparoscopic approach or the groin. It is an outpatient surgery.
- Epididymal Cyst
- This is a benign cyst arising from epididymis which is often called a spermatocele. It can be found on routine physical, a self-exam, or as an incidental finding on scrotal ultrasound. It is asymptomatic and does not require surgical removal.
- Testicular Pain
- Testicular Pain occurs when part or all of either one or both testicles hurt. Pain in the scrotum is also often included. Testicular pain can be caused by testicular torsion, epididymitis, torsion of appendix testicle, injury, or an incarcerated hernia. Testicular pain is an emergency and requires an immediate scrotal ultrasound to rule out the presence of testicular torsion.
- Testicular Torsion
- Torsion occurs when the testicle and spermatic cord twist on a vertical axis. It causes severe pain, swelling, and occasionally nausea and vomiting. The testicle may appear enlarged, red, and to be laying in a horizontal position. Torsion must be considered in any case of sudden onset of testicular pain. The diagnosis can be confirmed via a Doppler scrotal ultrasound. Treatment is immediate surgical exploration and detorsion which must take place within 6 hours of the onset of the pain.
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- This refers to swelling of the kidneys caused by the back-up of urine due to an obstruction in the flow of urine from the renal pelvis or ureter down to the bladder. It may be detected on prenatal ultrasound or found during an ultrasound for fever or flank pain.
- The presence of hydronephrosis may indicate a congenital anomaly of the kidney or ureter, such as a megaureter or UPJ obstruction or blockage caused by a kidney stone.
- The work-up of hydronephrosis may include a VCUG or a nuclear kidney scan.
- Vesico-ureteral Reflux (VUR)
- This refers to the abnormal back flow of urine from the bladder up to the kidneys. This is diagnosed with a VCUG, usually after the diagnosis of a urinary tract infection. Children with VUR are at risk for the development of kidney infections and subsequent kidney damage.
- The management of VUR involves the use of antibiotics for prophylaxis and sometimes surgical correction.
- Urinary Tract Infection
- A UTI refers to an infection of the bladder or kidneys. A UTI with a fever suggests the presence of a kidney infection. UTIs are diagnosed with a urinalysis and urine culture and are treated with either IV or oral antibiotics. A UTI may indicate a congenital anomaly of the urinary tract such as vesicoureteral reflux.
- Click here for the American Academy of Pediatrics current guidelines for the management of UTIs in children under age 2.
- Kidney Stone
- Stones form in the urinary tract due to a combination of factors which affect the mineral composition of the urine.
- Stones may pass without any symptoms, but others cause severe flank pain, nausea, vomiting, fevers, and hematuria which requires a visit to the emergency room. They are diagnosed with abdominal x-rays, renal ultrasounds or CT scans.
- Stones can be treated conservatively with hydration and pain management or may require endoscopic procedures to relieve the obstruction and remove them.
- The work-up of stones involves bloodwork and a 24-hour urine test in order to provide medication or dietary recommendations to prevent recurrent stones.
- Hematuria (Blood in urine)
- Hematuria refers to the presence of blood in the urine. Microscopic hematuria is detected on a urinalysis and gross hematuria is blood that is visible in the urine or on the underwear or diaper.
- The work-up of hematuria in children involves blood and urine tests and a kidney/bladder ultrasound. Occasionally, a CT scan, MRI, or cystoscopy will be performed.
- Bladder Exstrophy
- This is a rare congenital malformation of the bladder, urethra, abdominal wall, and pelvic bones in which the bladder is “inside-out”.
- This is diagnosed either on prenatal ultrasounds or immediately after birth.
- Management of bladder exstrophy involves a specialized surgical team and complex reconstruction with the goal being normal appearing external genitalia and a functional urinary tract.
- Neurogenic Bladder
- Children with neurological disorders such as spina bifida or who have sustained injuries to their spine may develop problems with their bladder, causing incontinence, urinary tract infections, and progressive kidney disease if not treated.
- We used a multi-faceted approach to treating patients with neurogenic bladders with the goal of social continence as well as protection of kidney function.
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- Daytime Wetting
- Nocturnal Enuresis or Bedwetting
- Urinary Frequency
- Urinary Urgency
- We use a multi-faceted approach to the treatment of voiding disorders which centers upon positive behavioral modification to retrain the bladder and bowel to function properly. Occasionally, medication to relax the bladder is used in combination with timed voiding, proper hygiene, and positive reinforcement. Our PA and NPs run specialty incontinence clinics that are focused upon restoring the patient’s bladder health.
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