PEDI GU REVIEW-External Genitalia


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PEDI GU REVIEW-External Genitalia

  1. 1. ABNORMALITIES OF THE EXTERNAL GENITALIA Pediatric GU Review UCSD Pediatric Urology George Chiang MD Sara Marietti MD Outlined from The Kelalis-King-Belman Textbook of Clinical Pediatric Urology 2007 (not for reproduction, distribution, or sale without consent)
  2. 2. Hypospadias <ul><li>Etiology </li></ul><ul><ul><li><10% have defect in testosterone production or androgen receptor defects </li></ul></ul><ul><ul><li>Environmental endocrine disruptors </li></ul></ul><ul><ul><li>IVF, maternal age >35, monozygotic twins </li></ul></ul><ul><ul><li>10% familial </li></ul></ul>
  3. 3. Hypospadias <ul><li>Associated anomalies </li></ul><ul><ul><li>Usually an isolated defect </li></ul></ul><ul><ul><li>Arrested development after 9 weeks which is after ureteral bud induction therefore urinary tract imaging unnecessary </li></ul></ul><ul><ul><li>Intersex: 15% with palpable UDT </li></ul></ul><ul><ul><ul><li>50% in nonpalpable UDT </li></ul></ul></ul><ul><ul><ul><li>CAH (bilateral nonpalpable) </li></ul></ul></ul><ul><ul><ul><li>MGD (1 UDT) </li></ul></ul></ul><ul><ul><ul><li>True hermaphrodite (UDT) </li></ul></ul></ul><ul><ul><li>Karyotype should be considered in UTD and penile anomaly </li></ul></ul>
  4. 4. Hypospadias <ul><li>Pre-op hormonal therapy </li></ul><ul><ul><li>Increase penile/glans size or improve vascularity </li></ul></ul><ul><ul><li>No difference between topical /parental although elevated serum levels with excessive ointment </li></ul></ul><ul><ul><li>Side effects include aggressive behavior and pubic hair growth which regresses after treatment stops (penile length also regresses) </li></ul></ul>
  5. 5. Hypospadias <ul><li>Surgical complications </li></ul><ul><ul><li>Corrected at least 6 months after prior surgery </li></ul></ul><ul><ul><li>Fistulas: most common complication </li></ul></ul><ul><ul><ul><li>Reduce incidence with 2-layer closure, turning epithelium into neourethra, and barrier layers of spongiosum/dartos/tunica vaginalis </li></ul></ul></ul><ul><ul><ul><li>Coronal fistulas best corrected by redo distal urethroplasty/glansplasty </li></ul></ul></ul>
  6. 6. Hypospadias <ul><li>Meatal stenosis </li></ul><ul><ul><li>Technical error or ischemia </li></ul></ul><ul><ul><li>Late presentation may be BXO </li></ul></ul><ul><li>Urethral stricture </li></ul><ul><ul><li>Most common at proximal anastomosis </li></ul></ul><ul><ul><li>Short strictures may resolve with IU </li></ul></ul><ul><ul><li>Longer/recurrent strictures may require buccal </li></ul></ul><ul><li>BXO </li></ul><ul><ul><li>Last-onset of symptoms </li></ul></ul><ul><ul><li>White scar at meatus </li></ul></ul><ul><ul><li>Complete excision and staged buccal </li></ul></ul>
  7. 7. Micropenis <ul><li>Stretched length <2 cm (normal formation is between 9-12 weeks) </li></ul><ul><li>Etiology </li></ul><ul><ul><li>Hypogonadotropic hypogonadism (50%); renal u/s since dysplasia or agenesis common </li></ul></ul><ul><ul><ul><li>Kallman’s syndrome </li></ul></ul></ul><ul><ul><ul><li>Noonan syndrome </li></ul></ul></ul><ul><ul><ul><ul><li>Heart disease and 50% UDT </li></ul></ul></ul></ul><ul><ul><ul><li>Prader-Willi </li></ul></ul></ul><ul><ul><ul><li>Laurence-Moon-Biel syndrome </li></ul></ul></ul><ul><ul><ul><ul><li>obesity, mental retardation, polydactyly, hypogonadism, and pigmented retinal dystrophy </li></ul></ul></ul></ul><ul><ul><ul><li>Down’s </li></ul></ul></ul>
  8. 8. Micropenis <ul><li>Hypergonadotrophic hypogonadism (25%) </li></ul><ul><ul><li>Incomplete (LH receptor defects, testosterone steroidgenesis, 5 alpha reductase activity, androgen receptor defects) </li></ul></ul><ul><ul><li>Klinefelter’s </li></ul></ul><ul><li>GH deficiency (15%) </li></ul><ul><li>Idiopathic </li></ul>
  9. 9. Micropenis <ul><li>Evaluation </li></ul><ul><ul><li>Karyotype </li></ul></ul><ul><ul><li>Newborns: serum LH,FSH, testosterone at birth and monthly for 3 months to document postnatal surge </li></ul></ul><ul><ul><li>> 3months, hCG stim test </li></ul></ul><ul><ul><li>MRI to eval hypothalamus, pituitary </li></ul></ul><ul><li>Therapy </li></ul><ul><ul><li>Androgen (IM testosterone) once monthly for 3 months or monthly at puberty </li></ul></ul><ul><ul><li>Growth hormone </li></ul></ul>
  10. 10. Interlabial masses <ul><li>Labial fusion </li></ul><ul><ul><li>Low estrogen state after puberty </li></ul></ul><ul><ul><li>Local irritation </li></ul></ul><ul><ul><li>Treatment: topical estrogens or excision/suturing </li></ul></ul><ul><li>Prolapsed ureterocele </li></ul><ul><ul><li>Bulging urethral mass, urinary retention </li></ul></ul><ul><ul><li>Tx: incision </li></ul></ul>
  11. 11. Introital Cysts <ul><li>Paraurethral cycts </li></ul><ul><ul><li>Eccentric </li></ul></ul><ul><ul><li>Dilation of skene’s glands: homologues of prostate </li></ul></ul><ul><ul><li>Present in newborns and rupture spontaneously or can be punctured </li></ul></ul><ul><li>Gartner’s duct cyst </li></ul><ul><ul><li>Mesonephric duct remnant along anteromedial wall of vagina </li></ul></ul><ul><ul><li>Can cover ectopic ureter </li></ul></ul><ul><li>Vaginal rhabdomyosarcoma </li></ul><ul><ul><li>Grape-like mass <2 yo </li></ul></ul>
  12. 12. Cryptorchidism <ul><li>Phases in descent </li></ul><ul><ul><li>Transabdominal: testis is located adjacent to kidney at 8 weeks </li></ul></ul><ul><ul><ul><li>Testis at internal ring by 21 weeks mediated by MIS </li></ul></ul></ul><ul><ul><li>Transinguinal: between 24-48 weeks descent through canal mediated by androgen </li></ul></ul><ul><ul><li>Scrotal: testes moves from external ring to scrotum </li></ul></ul>
  13. 13. Cryptorchidism <ul><li>Incidence: </li></ul><ul><ul><li>3.5% at birth decreasing to 1% at birth </li></ul></ul><ul><ul><li>Prematurity/low birth weight </li></ul></ul><ul><li>Pathology </li></ul><ul><ul><li>By age 1 year there is decreased Leydig cell, Sertoli cells, delayed disappearance of gonocytes, delayed appearance of spermatogonia and decreased germ cells </li></ul></ul>
  14. 14. Basic Differences <ul><li>Congenital </li></ul><ul><ul><li>Diagnosed at earlier age </li></ul></ul><ul><ul><li>May be located proximal to external ring </li></ul></ul><ul><ul><li>Frequently in association with wide open processus vaginalis </li></ul></ul><ul><ul><ul><li>Associated with epididymal deformities </li></ul></ul></ul><ul><li>Acquired </li></ul><ul><ul><li>Present later in childhood </li></ul></ul><ul><ul><li>Usually located distal to external ring </li></ul></ul><ul><ul><li>Associated with absent or small hernia sac </li></ul></ul><ul><ul><ul><li>No association with epididymal deformities </li></ul></ul></ul>
  15. 15. Incidence
  16. 16. Incidence* * The Epidemiology of Congenital Cryptorchidism, Testicular Ascent and Orchiopexy . Barthold et al.Jn of Urology, 2003
  17. 17. Incidence <ul><li>Most common genital anomaly identified at birth in males. </li></ul><ul><li>“… not increased in the last few decades.” </li></ul><ul><ul><li>(Barthold et al, 2003) </li></ul></ul>
  18. 18. Examine Incidence Data
  19. 19. 1.) Spontaneous Descent <ul><li>Reported to occur in 50-70% usually by age 1 to 3 months in full-term males and/or ≥ 2500 gm . </li></ul>Insert table Barthold, pg2397.
  20. 20. Clinical Implication: <ul><li>The recommended age of definitive treatment has trended down. </li></ul>(Barthold et at, 2003)
  21. 21. <ul><li>More recent data shows*: </li></ul><ul><ul><li>Spontaneous testicular descent is uncommon infants with cryptorchidism </li></ul></ul><ul><ul><ul><li>Occurred in only 6.9% of 278 patients </li></ul></ul></ul><ul><ul><li>Testicular descent occurring beyond 6 months is rare. </li></ul></ul>What is The Rate of Spontaneous Testicular Descent in Infants with Cryptorchidism? Wenzler et al. Journal of Urology, 2004
  22. 22. 2.) Smaller/Premature Neonates <ul><li>Present differently: </li></ul>Characteristic Premature % Full Term % Cryptorchidism 8-20% 2-4 Bilateral presentation 50-75 10-45 Complete spontaneous descent * *may occur later in first year of life 80-90 50-70
  23. 23. <ul><li>Birth weight alone is the principal determinant of cryptorchidism at birth and 1 year of life </li></ul><ul><ul><li>compared to IUGR, preterm, presentation </li></ul></ul><ul><li>Cryptorchidism Study Group: </li></ul><ul><ul><li>≤ 2000gm = 7.7% </li></ul></ul><ul><ul><li>2000-2499gm = 2.5% </li></ul></ul><ul><ul><li>≥ 2500gm = 1.41% </li></ul></ul><ul><ul><ul><li>At 3 months of age </li></ul></ul></ul>
  24. 24. Classification
  25. 25. Clinical Classification
  26. 26. Palpable: Retractile <ul><li>Exaggerated cremasteric reflex pulls a normal testis out of the scrotum at the least provocation </li></ul><ul><li>Easily brought down and remains in orthotopic position after traction has been released </li></ul><ul><li>Presents clinically between ages 3-7 years old </li></ul><ul><li>Does not require therapy, however, should be monitored regularly until puberty, testis is no longer retractible and remains intrascrotal </li></ul>
  27. 27. Palpable: Ectopic <ul><li>Testes descend normally through the inguinal canal but deviates into unusual sites below the external inguinal ring </li></ul><ul><li>10% of extrascrotal testis </li></ul><ul><li>Sites: </li></ul><ul><ul><li>Denis-Browne pouch ◄ most common </li></ul></ul><ul><ul><ul><li>Superficial pouch between external oblique fascia and Scarpia’s fascia </li></ul></ul></ul><ul><ul><li>Femoral triangle, perineum, transverse scrotum </li></ul></ul><ul><li>Treatment is orchiopexy </li></ul>
  28. 29. Impalpable <ul><li>Absent </li></ul><ul><li>“ Vanishing” </li></ul><ul><li>Encountered during exploration for nonpalpable testis </li></ul><ul><li>Anatomic hallmark is blind-ending spermatic vessel found proximal to the internal inguinal ring </li></ul><ul><li>Dysplastic </li></ul><ul><li>Atrophic </li></ul><ul><li>Small and usually very abnormal </li></ul><ul><li>Torsion </li></ul>Prevalence of Nonpalpable is 20-30%
  29. 31. Classify by Position <ul><li>Intra-abdominal Testis </li></ul><ul><ul><li>Prevalence 40% </li></ul></ul><ul><ul><li>Located just inside the internal ring, usually within a few centimeters </li></ul></ul><ul><ul><li>rarely in ectopic intra-abdominal positions </li></ul></ul>
  30. 32. <ul><li>Intracanalicular </li></ul><ul><ul><li>Prevalence 17% </li></ul></ul><ul><ul><li>Between internal and external ring </li></ul></ul><ul><ul><li>Difficult to palpate </li></ul></ul>
  31. 33. <ul><li>Extracanalicular </li></ul><ul><ul><li>Suprapubic </li></ul></ul><ul><ul><ul><li>“ Emergent” </li></ul></ul></ul><ul><ul><ul><li>Beyond external ring </li></ul></ul></ul><ul><ul><ul><li>Above level of pubis </li></ul></ul></ul><ul><ul><li>Infrapubic </li></ul></ul><ul><ul><ul><li>Just below pubic symphysis </li></ul></ul></ul><ul><ul><ul><li>Often just outside the anatomic scrotum in the retroscrotal space </li></ul></ul></ul>
  32. 34. Cryptorchidism <ul><li>Pre-op Eval </li></ul><ul><ul><li>Bilateral nonpalpable </li></ul></ul><ul><ul><ul><li><3 months: serum LSH,FSH,testosterone </li></ul></ul></ul><ul><ul><ul><li>> 3 months:hCG stim test </li></ul></ul></ul><ul><ul><li>LH,FSH >3x suggests anorchia </li></ul></ul><ul><ul><li>No rise in testosterone after single hCG requires additional hCG due to false negatives from unresponsive Leydig cells </li></ul></ul><ul><ul><li>Undetectable MIS suggests anorchia </li></ul></ul>
  33. 35. Cryptorchidism <ul><li>Unilateral nonpalpable </li></ul><ul><ul><li>50% have testes, 50% have testicular loss </li></ul></ul><ul><ul><li>Nubbins most found in upper scrotum indicating loss after descent </li></ul></ul><ul><ul><ul><li>Hemosiderin, variable calcification, fibrous tissue </li></ul></ul></ul><ul><ul><ul><li>Compensatory hypertrophy </li></ul></ul></ul><ul><ul><ul><li>Patent PV with apparent nubbin may indicate intraabdominal testis is present </li></ul></ul></ul><ul><ul><ul><li>May be approached via a scrotal incision ?nubbin or inguinal incision with peritoneal opening or laparoscopically </li></ul></ul></ul>
  34. 36. Cryptorchidism <ul><li>Gaining additional length </li></ul><ul><ul><li>Incision of lateral RP attachments, Prentiss maneuver </li></ul></ul><ul><ul><li>Intraabdominal testes and inguinal testes not reaching pubic tubercle should have peritoneum preserved between vas and spermatic cord vessels to allow Fowler-Stevens </li></ul></ul><ul><ul><ul><li>FS transection should not occur after dissection of the hernia sac </li></ul></ul></ul>
  35. 37. Cryptorchidism <ul><li>Surgical complications </li></ul><ul><ul><li>Testicular atrophy, retraction, ureteral obstruction, trocar injuries </li></ul></ul><ul><li>Malignancy risk </li></ul><ul><ul><li>40% over general population; incidence .05-2% </li></ul></ul><ul><ul><li>Most common tumor is seminoma </li></ul></ul><ul><li>Infertility </li></ul><ul><ul><li>Reduced transformation of fetal gonocytes into spermatogonia at 3 months and reduced transformation of spermatogonia to spermatocytes at 5 years </li></ul></ul><ul><ul><li>Unilateral 90% paternity; bilateral 62% </li></ul></ul><ul><ul><li>Monorchidism is not associated with decreased paternity </li></ul></ul>
  36. 38. Cryptorchidism:Hormonal Tx <ul><li>hCG stimulates testosterone production </li></ul><ul><li>1500IU/m2 IM 2x per week for 4 wk </li></ul><ul><li>More success in retractile, older kid, lower testicles </li></ul><ul><li>Side effects – scrotal pigmentation, incr penis size, pubic hair, regresses after cessation </li></ul><ul><li>Success depends on location, but pexy is gold standard </li></ul>
  37. 39. Vasal Agenesis <ul><li>Associated anomalies </li></ul><ul><ul><li>CF [65-95% of males with CF have vasal agenesis, ED anomalies, or epididymal obstruction] </li></ul></ul><ul><ul><ul><li>Related to CFTR gene </li></ul></ul></ul><ul><ul><li>Other wolffian duct anomalies </li></ul></ul><ul><ul><ul><li>Absence of epididymis </li></ul></ul></ul><ul><ul><ul><li>Absent seminal vesiclae </li></ul></ul></ul><ul><ul><li>Renal agenesis </li></ul></ul>
  38. 40. Hernia/Hydrocele <ul><li>Hernia – protrusion of tissue/organ through opening in abdominal wall or fascia </li></ul><ul><li>Non-communicating hydrocele – fluid from mesothelial lining, MC in adolescence </li></ul><ul><li>Communicating hydrocele – patent processus, small, MC in children </li></ul><ul><li>Hernia/Hydrocele - 1-3% of term infants </li></ul><ul><li>3X more common in pre-term </li></ul>
  39. 41. H&P <ul><li>Painless lump/bulge, enlarges with straining </li></ul><ul><li>10% will present with bowel obstruction, vomiting, abd distention, abd pain </li></ul><ul><li>Many times no PE findings, must rely on history </li></ul><ul><li>Hydrocele of the cord – cystic swelling along the cord, not reducible </li></ul>
  40. 42. H&P <ul><li>If testicle not palpable – ultrasound to identify any underlying pathology </li></ul><ul><li>If hernia is diagnosed, should not wait to repair because of risk of incarceration </li></ul><ul><li>Simple non-communicating hydrocele – conservative management, may resolve spontaneously within first year </li></ul>
  41. 43. Management of Contralateral Side <ul><li>Incidence of patent PV is 90% if pre-term, 80% in newborns, 60% in child less than 1, 15-30% in adults </li></ul><ul><li>Incidence of contralateral hernia after repair is 4-10% </li></ul><ul><li>85% of parents when given these numbers will choose to do bilateral exploration out of convenience </li></ul><ul><li>Explore bilateral, ultrasound, pneumoperitoneum, laparoscopy, observe </li></ul>
  42. 44. Complications of Repair <ul><li>Complication rate increases if emergent vs elective </li></ul><ul><li>Testicular ascent – 1% </li></ul><ul><li>Damage to cord – 1%, increased to 10% when incarcerated </li></ul><ul><li>Recurrence – 3%, 20% in premature infants (failure to dissect sac, tearing of sac, slipped suture) </li></ul><ul><li>Hydrocele after hernia repair – 1% </li></ul>
  43. 45. Testicular Torsion <ul><li>Extravaginal torsion </li></ul><ul><ul><li>Descent occurs around 28 weeks and torsion can occur during this </li></ul></ul><ul><li>Nubbins </li></ul><ul><ul><li>Most reside in upper scrotum indicating prenatal torsion occurs usually after testis has descended </li></ul></ul><ul><li>Perinatal and postnatal torsion </li></ul><ul><ul><li>Occurs shortly before or after birth with palpable mass and discoloration of hemiscrotum </li></ul></ul><ul><ul><li>Indicate response to ischemia so urgent exploration unlikely to salvage testicle </li></ul></ul><ul><ul><li>Controversy still exists re: prompt exploration for contralateral pexy </li></ul></ul>
  44. 46. Testicular Torsion <ul><li>Imaging </li></ul><ul><ul><li>Doppler can be challenging in newborn </li></ul></ul><ul><li>Differential </li></ul><ul><ul><li>Testis tumors: yolk sac, teratomas, juvenile granulosa cell tumors </li></ul></ul><ul><ul><li>Inguinal vs. scrotal incision </li></ul></ul>
  45. 47. Testicular Torsion <ul><li>Intravaginal torsion </li></ul><ul><ul><li>Usually in puberty </li></ul></ul><ul><ul><li>Abrupt onset of pain and variable nausea/vomitting </li></ul></ul><ul><ul><li>Within a few hours of onset, no edema or erythema; high-riding and absent cremasteric </li></ul></ul><ul><li>Therapy: </li></ul><ul><ul><li>reduce ipsilateral torsion and pex contralateral </li></ul></ul>
  46. 48. Testicular Torsion <ul><li>Torsion of vestigial remnants </li></ul><ul><ul><li>Young children present with signs of scrotal reaction </li></ul></ul><ul><ul><li>“ blue dot” sign </li></ul></ul><ul><ul><li>Less pain than testicular ischemia and are comfortable at rest but bothered by movement </li></ul></ul><ul><ul><li>Surgery is rarely indicated unless testicular torsion can’t be ruled out </li></ul></ul>
  47. 49. Testicular Torsion <ul><li>Acute scrotum differential </li></ul><ul><ul><li>Torsion, epididymitis, hydroceles, insect bites, idiopathic scrotal edema, HSP </li></ul></ul><ul><li>Epididymitis </li></ul><ul><ul><li>Infectious: usually diagnosed with UTI or sexual activity with teens </li></ul></ul><ul><ul><li>Drug-related with amiodarone </li></ul></ul>
  48. 50. Varicoceles <ul><li>15% of males usually detected after age 10 </li></ul><ul><li>90% left sides </li></ul><ul><li>Typically large (Grade 3) </li></ul><ul><li>Testicular growth failure in up to 80% of grade 3 </li></ul><ul><ul><li>Histological changes include tubular thickening, impaired spermatogenesis, maturation arrest, Sertoli cell degeneration </li></ul></ul><ul><ul><li>Leydig cell changes most predictive of testicular damage </li></ul></ul><ul><ul><ul><li>Leydig cell atrophy carried better prognosis for improved fertility </li></ul></ul></ul><ul><ul><ul><li>Leydig cell hyperplasia carries poor prognosis for fertility </li></ul></ul></ul><ul><ul><li>Increased LH/FSH may indicate Leydig cell and tubular dysfunction </li></ul></ul>
  49. 51. Varicocele <ul><li>Rare if less than 10 </li></ul><ul><li>10-15% incidence in adolescence </li></ul><ul><li>Speculated etiology: incompetent valves, abnormal development, increased pressure from drainage into renal vein </li></ul>
  50. 52. Varicocele <ul><li>I – palpable only with valsalva </li></ul><ul><li>II – palpable without valsalva </li></ul><ul><li>III – visible through scrotal skin </li></ul><ul><li>Testicular volume loss in 35% of II, 81% of III </li></ul>
  51. 53. Varicocele <ul><li>Decreased motility, more immature forms, impaired morphology </li></ul><ul><li>Surgery can improve semen parameters in 50% </li></ul>
  52. 54. Presentation <ul><li>3% are symptomatic (dull ache/pain) </li></ul><ul><li>Thorough exam, standing and valsalva </li></ul><ul><li>Operate for pain, bilateral varicocele, volume differential </li></ul>
  53. 55. Varicoceles <ul><li>Intervention: </li></ul><ul><ul><li>Decreased volume >20% </li></ul></ul><ul><ul><li>Catch-up growth in 80% </li></ul></ul><ul><ul><li>Grade 3 varicocele </li></ul></ul><ul><ul><ul><li>Repairing all of these would result in all patients undergoing intervention although the incidence of male factor infertility is less than incidence of varicocele </li></ul></ul></ul><ul><li>Complications </li></ul><ul><ul><li>Persistence/recurrence </li></ul></ul><ul><ul><li>Hydrocele </li></ul></ul><ul><ul><li>atrophy </li></ul></ul>
  54. 56. Treatment <ul><li>Percutaneous – coil migration, 11% hydrocele, 5% recurrence </li></ul><ul><li>Inguinal – loupe or scope, can spare or take artery, 5% hydrocele, 15% recurrence, reduce both with use of microscope </li></ul><ul><li>Artery sparing decreases hydrocele but increases recurrence </li></ul>
  55. 57. Surgical Treatment <ul><li>Palomo – Just above inguinal canal, muscle splitting, fewer vessels, vas separate from vessels, 7% hydrocele, 11% recurrence </li></ul><ul><li>Sub-inguinal – microscope, hydrocele 0.8%, recurrence 2% </li></ul><ul><li>Laparoscopic – hydrocele 7%, recurrence 15% </li></ul>
  56. 58. Post-Op Hydrocele/Recurrence <ul><li>80% of post-op hydrocele will resolve gradually or after percutaneous drainage </li></ul><ul><li>Recurrence is decreased by mass ligation as opposed to artery sparing </li></ul><ul><li>Go after cord at higher level than first repair </li></ul>
  57. 59. QUESTIONS
  58. 60. <ul><li>A 15 year-old boy is undergoing revision of a colonic pull-through. During the operation, the left spermatic vessels are ligated and transected above the iliac vessels. The vas deferens is intact. Both testes are palpable in the scrotum. The next step is: </li></ul><ul><li>Observation </li></ul><ul><li>Intraoperative doppler ultrasound of testis </li></ul><ul><li>Microvascular reanastamosis of the spermatic vessels </li></ul><ul><li>Epigastric arterial revascularization </li></ul><ul><li>Left orchiectomy </li></ul>
  59. 61. <ul><li>In-vitro fertilization and ICSI is associated with which of the following birth defects </li></ul><ul><li>Multicystic dysplastic kidneys </li></ul><ul><li>Ureteral atresia </li></ul><ul><li>Hypospadias </li></ul><ul><li>UPJ obstruction </li></ul><ul><li>VUR </li></ul>
  60. 62. <ul><li>A 12 year-old boy has intermittent right scrotal pain for 2 weeks after being kicked in the groin. Both physical exam and U/A during an episode of pain are normal. Doppler ultrasound of the testis demonstrates normal flow, and a 5 mm subtunical cystic lesion in the lower pole of the right testis without internal echoes or calcification. The next step is: </li></ul><ul><li>Radical orchiectomy </li></ul><ul><li>Scrotal exploration and biopsy of the lesion </li></ul><ul><li>Repeat physical exam and u/a in 3 months </li></ul><ul><li>Repeat u/s in 3 months </li></ul><ul><li>Bilateral orchiopexy </li></ul>
  61. 63. <ul><li>A 2 year old boy undergoes a left inguinal exploration for a nonpalpable testis. At the internal ring, the vas deferens is noted to end blindly. The next step is: </li></ul><ul><li>Close </li></ul><ul><li>Close and then perform transumbilical laparoscopy </li></ul><ul><li>Explore peritoneal cavity </li></ul><ul><li>Explore the retroperitoneum </li></ul><ul><li>Close, then obtain CT scan </li></ul>
  62. 64. <ul><li>A 12 year-old prepubertal boy has severe right scrotal pain one day after being kicked in the groin. There is a bluish area over the superior portion of the testis but the examination is difficult due to a hydrocele. U/A is normal. The next step is: </li></ul><ul><li>Immediate exploration </li></ul><ul><li>Scrotal ultrasound with Doppler </li></ul><ul><li>Scrotal nuclear scan </li></ul><ul><li>Manual detorsion and delayed fixation </li></ul><ul><li>Observation with anti-inflammatories </li></ul>
  63. 65. <ul><li>An 11 year old boy has a swollen,ecchymotic scrotum 3 hours after being hit in the perineum. U/A is normal. The next step is: </li></ul><ul><li>Scrotal exploration </li></ul><ul><li>Isotope testicular scan </li></ul><ul><li>Doppler scrotal ultrasound </li></ul><ul><li>RUG </li></ul><ul><li>Scrotal elevation, ice, and bedrest </li></ul>
  64. 66. <ul><li>IVF is associated with an increased incidence of which GU anomaly: </li></ul><ul><li>Hypospadias </li></ul><ul><li>Wilms </li></ul><ul><li>Renal fusion abnormalities </li></ul><ul><li>Exstrophy-epispadias </li></ul><ul><li>UPJ </li></ul>
  65. 67. <ul><li>A 10 year old has a solitary right testicle on his physical exam for football. Left inguinal exploration has verified bline-ending gonadal vessels. The preferred recommendation is: </li></ul><ul><li>MRI Scan of the abdomen and pelvis </li></ul><ul><li>Laparoscopy </li></ul><ul><li>Abdominal exploration </li></ul><ul><li>He play football using a cup </li></ul><ul><li>He not play football </li></ul>
  66. 68. <ul><li>In men with a history of surgically treated cryptorchidism, the factor which most influences the risk of developing testicular cancer is: </li></ul><ul><li>Original location of the testis </li></ul><ul><li>Gonocyte transformation failure </li></ul><ul><li>Testicular-epidydmal nonunion </li></ul><ul><li>Carcinoma in situ </li></ul><ul><li>Age at orchiopexy </li></ul>
  67. 69. <ul><li>A 10 year old boy has a perineal “butterfly” hematoma following a straddle injury. This suggest rupture of the: </li></ul><ul><li>Tunica albuginea </li></ul><ul><li>Corpus spongiosum </li></ul><ul><li>Corpus cavernosum </li></ul><ul><li>Posterior urethra </li></ul><ul><li>Colles’ fascia </li></ul>
  68. 70. <ul><li>The most frequent histologic finding in the cryptorchid testis of a 4 year old boy is: </li></ul><ul><li>Decreased number of germ cells </li></ul><ul><li>Increase in peritubular fibrosis </li></ul><ul><li>Late maturation of the Sertoli cell </li></ul><ul><li>Alteration of the tubular basement membrane </li></ul><ul><li>Decreased number of interstitial cells </li></ul>