Pediatric Urology

Acute Scrotum

Most common: Torsion of testis (neonatal, puberty), appendix testis (any age), or epididymitis/orchitis (<1yo and 12-15yo)
- Other: Trauma, incarcerated hernia
Doppler ultrasound

Tender testis, abnormal position of testis
TWIST (Testicular Workup for Ischemia and Suspected Torsion) score
- testicular swelling (2 points)
- hard testis (2 points)
- absent cremasteric reflex (1 point)
  - (100% sensitivity, 66% specificity for testicular torsion)
- nausea and vomiting (1 point)
- high-riding testis (1 point)
  - A score of 0 is predictive of nontorsion, and a score of 6 or 7 is highly predictive of testicular torsion
Treatment
- Manual detorsion without anesthesia (outwards rotation)
  - Successful if relief of symptoms and normal physical exam, can be doppler ultrasound-guided
- Bilateral orchiopexy required after detorsion (due to risk of contralateral torsion)
- Early exploration if <24h

Tender superior pole of testis, "Blue dot" (only found in 10-20% of torsion of appendix testis)
- Treatment
  - NSAIDs
  - Surgical exploration if persistent pain

Tender epididymis, fever
- Treatment
  - Minimal physical activity and analgesics
  - Antibiotics only if bacterial infection (most self-limited)
  - Surgical exploration if abscess or necrotic testis

Physiological
- Normal congenital adhesions, resolves throughout childhood
- 1% incidence in 7th grade
Pathological (due to distal scarring from trauma, infection, inflammation)
- Secondary nonretractability (after retractibility earlier)
- Irritation/bleeding
- Dysuria
- Painful erection
- Recurrent balanoposthitis
- Chronic urinary retention with ballooning only resolved with manual compression
Paraphimosis
- Retracted foreskin with constrictive ring at level of sulcus preventing replacement of foreskin over glans

Stretching exercises 1 minute QID x 1-3 months
Betamethasone 0.05% cream BID x4-8w
Circumcision if
- Recurrent balanoposthitis and recurrent UTIs
- Secondary phimosis
Paraphimosis
- Manual compression and reposition
- Consider injection of hyaluronidase or 20% mannitol beneath band
- *Emergency* Dorsal incision of the constrictive ring

Retractile testes (testi held in scrotum by hand for 30-60s to fatigue cremasteric reflex, and on releasing testi does not immediately retract) require only observation
Bilateral non-palpable testes and sexual differentiation problems (eg. hypospadias) requires urgent endocrinology/genetic evaluation
- Non-palpable testis without evidence of sexual development disorder requires diagnostic laparoscopy to confirm absence of intra-abdominal testis
If testis has not descended by six months, surgery should be done within next year (age 18 months latest)
- If palpable - Orchidofuniculolysis and orchidopexy
- If nonpalpable - Examine under general anesthesia and laparoscopy (and removal if inguinal testis found)

Collection of fluid between parietal and visceral layers of tunica vaginalis
- Incomplete obliteration of processus vaginalis results in communicating hydrocele (or hernia if large)
- Non-communicating hydroceles secondary to minor trauma, testicular torsion, epididymitis, surgery
- Communicating if changes in size
Swelling translucent, smooth, nontender
Ultrasound +/- Doppler for definite diagnosis
Observe for first 12-24 months (most spontaneously resolve)
- Early surgery if suspicious of hernia or testicular pathology

No treatment <5 years of age (spontaneous cure likely)
Voiding diaries or questionnairs to exclude daytime symptoms (r/o lower urinary tract dysfunction)
Urine test exclude infection or diabetes insipidus
Alarm treatment is best treatment for arousal disorder (80% success rate)
Structured withdrawal of desmopressin for night-time diuresis effective

References:

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