Campbell-Walsh Urology, 11th Edition

PART XV

Pediatric Urology

SECTION B

Basic Principles

125

Evaluation of the Pediatric Urology Patient

Thomas F. Kolon; Douglas A. Canning

Questions

1. Which one of the following patients does NOT need to be seen emergently?
2. A newborn with hydronephrosis in a solitary kidney
3. A 4-year-old boy with acute right scrotal pain
4. A 12-year-old girl with microscopic hematuria found during a routine examination
5. An 8-year-old boy with sickle-cell anemia and a 5-hour history of priapism
6. A male newborn with a distended bladder, bilateral hydronephrosis, and respiratory insufficiency
7. Which of the following is a potential complication of neonatal circumcision?
8. Wound infection
9. Meatal stenosis
10. Cicatrix
11. Death
12. All of the above
13. The pediatric kidney is particularly susceptible to trauma due to:
14. relatively increased renal size.
15. limited visceral adipose tissue.
16. limited chest wall protection.
17. increased mobility.
18. all of the above.
19. What is the optimal timing of spinal ultrasonography during screening for occult spinal dysraphism?
20. Before 6 months of age
21. 6 months to 2 years of age
22. At any age before puberty
23. At any age
24. Never. Ultrasound is not useful to screen for dysraphism.
25. What is the most commonly detected etiology for asymptomatic microscopic hematuria in children?
26. Fibroepithelial polyp
27. Hypercalciuria
28. Poststreptococcal glomerulonephritis
29. Uncomplicated urinary tract infection
30. Hyperuricosuria
31. Findings associated with the Beckwith-Wiedemann syndrome include:
32. macroglossia.
33. hepatosplenomegaly.
34. nephromegaly.
35. macrosomia.
36. all of the above.
37. A voiding cystourethrogram is essential in the diagnosis of which clinical conditions?
38. Ureteropelvic junction obstruction
39. Primary obstructive megaureter
40. Posterior urethral valves
41. Nephrolithiasis
42. All of the above
43. When should a child with suspected congenital adrenal hyperplasia be tested?
44. Before discharge from the nursery
45. At the first well-baby visit
46. Only if undergoing general anesthesia
47. At puberty
48. No testing is required
49. All of the following statements about the pediatric abdominal examination are true EXCEPT:
50. renal pathology is the source of as many as two thirds of neonatal abdominal masses.
51. abdominal distention at birth or shortly afterward suggests either obstruction or perforation of the gastrointestinal tract.
52. the abdominal wall is normally strong, especially in infants with hydronephrosis.
53. a solid flank mass may be due to renal venous thrombosis.
54. in cloacal exstrophy, an omphalocele is superior to the cecal plate and lateral bladder halves with prolapsed ileum in the midline.
55. Which of the following statements is FALSE about cutaneous markers of occult spinal dysraphism?
56. Forty percent of patients with atypical presacral dimples have associated occult spinal dysraphism.
57. A combination of two or more congenital midline skin lesions is the strongest marker of occult spinal dysraphism.
58. A presacral dimple less than 2.5 cm from the anal verge at birth may indicate spina bifida or cord tethering.
59. Sacral hypertrichosis may be associated with spinal dysraphism.
60. All of the above are true.
61. Sexual abuse can be associated with which of the following physical examination findings?
62. Bruised vaginal mucosa in a prepubertal child
63. Penile discharge
64. A normal genital and perineal examination
65. a and c
66. a, b, and c
67. Urethral meatal stenosis in the infant occurs most commonly:
68. as a result of birth trauma.
69. after urinary tract infection.
70. after a voiding cystourethrogram (VCUG).
71. after healing of the inflamed, denuded glans after circumcision.
72. from penile adhesions.
73. In newborns with ambiguous genitalia, palpation of a gonad rules out which disorder of sexual development (DSD)?
74. Ovotesticular disorder
75. Mixed gonadal dysgenesis
76. Partial androgen insensitivity
77. Pure gonadal dysgenesis
78. Persistent müllerian duct syndrome
79. Secondary urinary incontinence is defined as:
80. diurnal and nocturnal enuresis.
81. incontinence associated with urinary tract infection.
82. urinary incontinence associated with constipation.
83. urinary incontinence after a dry interval greater than 6 months.
84. urinary incontinence associated with a neurologic condition.
85. A newborn should have a scrotal hydrocele surgically corrected in the neonatal period if:
86. it is large.
87. it is changing in volume.
88. it accompanies a symptomatic hernia.
89. a, b, and c.
90. b and c.

Answers

1. c. A 12-year-old girl with microscopic hematuria found during a routine examination. In the absence of other symptoms, microscopic hematuria in children is not an emergency. Bilateral hydronephrosis or hydronephrosis in a solitary kidney both represent emergencies and should be evaluated as soon as possible. Acute scrotal pain should always be considered testicular torsion until proven otherwise. Boys with sickle cell anemia are at increased risk for priapism and should always be treated immediately to decrease the long-term sequelae associated with priapism.
2. e. All of the above.Wound infections, meatal stenosis, removal of too much/too little prepuce, cicatrix, and even death are all potential complications of neonatal circumcision.
3. e. All of the above.The pediatric kidney is particularly susceptible to trauma due to limited visceral adipose tissue, limited chest wall protection, relatively increased renal size, and increased mobility of the kidney.
4. a. Before 6 months of age.Ossification of the posterior elements after 6 months of age prevents an acoustic ultrasound window. After 6 months, spinal magnetic resonance imaging (MRI) is recommended when an occult spinal dysraphism is suspected.
5. b. Hypercalciuria. Most microscopic hematuria in children is transient and the source is not identified. The most commonly identified etiology of asymptomatic microhematuria in children is hypercalciuria.
6. e. All of the above. Beckwith-Wiedemann syndrome is caused by a mutation on chromosome 11p15.5. Clinical features include macroglossia, nephromegaly, organomegaly (hepatosplenomegaly), macrosomia (gigantism), and hemihypertrophy. Many of the affected infants have hypoglycemia in the first few days of life. Patients are at increased risk for specific tumors (e.g., adrenal carcinoma, Wilms tumor, hepatoblastoma, and rhabdomyosarcoma).
7. c. Posterior urethral valves.The diagnosis of posterior urethral valves requires visualization of the urethra during voiding. Bladder diverticula, a pronounced bladder neck, dilated posterior urethra, vesicoureteral reflux, and valve leaflets can all be associated with posterior urethral valves and are visible on voiding cystourethrogram. Ureteropelvic junction obstruction and primary obstructive megaureter are both obstructions above the level of the urethra and are usually evaluated with ultrasonography and a MAG3 renal scan or magnetic resonance urogram. Nephrolithiasis is typically evaluated using ultrasonography and computed tomography (CT) scan when necessary.
8. a. Before discharge from the nursery. Congenital adrenal hyperplasia may result in salt wasting; therefore, infants with ambiguous genitalia must be quickly evaluated and stabilized.
9. c. The abdominal wall is normally strong, especially in infants with hydronephrosis. Renal pathology accounts for approximately two thirds of abdominal masses found in the neonate.Solid masses include neuroblastoma, congenital mesoblastic nephroma, teratoma, and renal enlargement due to renal venous thrombosis. The abdominal wall is normally weak in premature infants and on occasion in those with hydronephrosis.
10. c. A presacral dimple less than 2.5 cm from the anal verge at birth may indicate spina bifida or cord tethering.The lower back should be examined for any evidence of cutaneous markers of occult spinal dysraphisms that may account for abnormal bladder function. In a series of 207 neonates with sacral and presacral cutaneous stigmata, 40% of patients with atypical dimples were found to have occult spinal dysraphism. An "atypical" presacral dimple is defined as a dimple that is off center, more than 2.5 cm from the anal verge at birth, or deeper than 0.5 cm. Sacral hair tuft (hypertrichosis) may also be associated with spinal dysraphism.
11. e. a, b, and c.Although penile discharge and bruised vaginal mucosa can reflect sexual abuse, the possibility of sexual abuse should not be dismissed in the absence of physical examination findings. Only 11% of girls evaluated in a sexual abuse clinic demonstrated suggestive physical examination findings.
12. d. After healing of the inflamed, denuded glans after circumcision. Meatal stenosis is not unusual after circumcision.It may result from contraction of the meatus after healing of the inflamed, denuded glans tissue that occurs after retraction of the foreskin or from damage to the frenular artery at the time of circumcision.
13. d. Pure gonadal dysgenesis. Particular attention to the symmetry of the examination is important if a disorder of sex development is thought to exist. A symmetrical gonadal examination (gonads palpable on each side or impalpable on both sides) suggests a global disorder, such as congenital adrenal hyperplasia or androgen insensitivity.When a gonad is palpable, female congenital adrenal hyperplasia (ovaries are not palpable) and pure gonadal dysgenesis (bilateral streak gonads are not palpable) are ruled out.
14. d. Urinary incontinence after a dry interval greater than 6 months.Although urinary incontinence can be associated with infection, constipation, and neurologic disease, secondary urinary incontinence is defined as occurring after a dry interval greater than 6 months.
15. e. b and c. A hydrocele that changes in volume suggests a patent processus vaginalis.These infants are at risk for an inguinal hernia. The processus vaginalis is less likely to close after birth. If a hernia has been symptomatic, it should be corrected in the newborn period. A large scrotal hydrocele may still resorb and get smaller with time—distinction must be made from an abdominoscrotal hydrocele.

Chapter review

1. The most common malignant abdominal tumor in infants is a neuroblastoma, followed by Wilms tumor.
2. Undescended testes are present in 30% of preterm neonates and 3% of full-term neonates; the testis will likely not descend after 6 months of age.
3. The most common prepubertal testicular/paratesticular tumor is teratoma, followed by rhabdomyosarcoma, epidermoid cyst, yolk sac tumor, and germ cell tumor, in that order.
4. Very few children hold the urine and not the stool. Conversely, children who retain stool nearly always retain urine.
5. Gross hematuria in the newborn is an emergency, because it may indicate renal venous thrombosis or renal artery thrombosis.
6. In general, blunt renal trauma is treated nonoperatively, except when there is a major vascular avulsion or extensive urinary extravasation.
7. In the newborn, the foreskin is adherent to the glans, and adhesions should not be separated unless a circumcision is performed.
8. A positive dip stick for blood requires a microscopic examination. Absence of red blood cells in the microscopic examination indicates hemoglobinuria or myoglobinuria.
9. Continuous leakage of urine in a girl should suggest ectopic ureter.
10. Infants younger than 6 months of age and uncircumcised male infants are at increased risk for urinary tract infections.
11. Patients with myelomeningoceles are at increased risk for latex allergy.
12. Most microscopic hematuria in children is transient and the source is not identified. The most commonly identified etiology of asymptomatic microhematuria in children is hypercalciuria.
13. Beckwith-Wiedemann syndrome is caused by a mutation on chromosome 11p15.5. Clinical features include macroglossia, nephromegaly, organomegaly (hepatosplenomegaly), macrosomia (gigantism), and hemihypertrophy. Many of the affected infants have hypoglycemia in the first few days of life. These individuals are at increased risk for adrenal carcinoma, Wilms tumor, hepatoblastoma, and rhabdomyosarcoma.
14. Renal pathology accounts for approximately two thirds of abdominal masses found in the neonate.
15. If a disorder of sex development is thought to exist, a symmetrical gonadal examination (gonads palpable on each side or impalpable on both sides) suggests a global disorder, such as congenital adrenal hyperplasia or androgen insensitivity. If the gonads are nonpalpable, congenital adrenal hyperplasia is likely.
16. A hydrocele that changes in volume suggests a patent processus vaginalis.