Pediatric Urology Part I

Pediatric Surgery
This podcast is a discussion between Dr. Todd Ponsky and Dr. Patricio C. Gargollo,  the Senior Associate Consultant Pediatric Urologist at the Mayo Clinic Rochester and Associate Professor of Urology at the Mayo Medical School. The goal of this podcast is to serve as an overview of what pediatric surgeons should know about external genitalia as it relates to pediatric urology.


Additional Content

Today were to be talking about pediatric urology, we've decided to break this up into a few sessions. Today were to be mostly talking about external genitalia and this is going to be an overview for pediatric surgeons to get an idea about all the things that we probably should know about external genitalia as a relates to pediatric urology.


Dr. Patricio C. Gargollo is the senior associate consultant pediatric urology at the Mayo Clinic Rochester and associate professor of urology at the Mayo medical school.


At the AAP meeting and like always there's a lot of protesters out there having trouble with the fact that we do circumcisions. So, this is clearly a very controversial topic. Tell me your thoughts and what is the literature say, do we need to be doing this, when we do it, and how do we do it?


This is a very controversial topic. The US is one of the few industrialized countries that routinely circumcise our newborn. So, certainly we have some controversies that have to deal with that especially since again our rate of circumcisions very high and the way I like the break down circumcisions when a parent comes to me and say we are expecting a boy, what you think we should do? What is the evidence show regarding circumcisions? I basically break it down into three main areas and that's the risk of urinary tract infections (UTI), the risk of sexually transmitted diseases, and the risk of penile cancer. Those are the main three things that people should worry about. So, we break these individually.


The UTI risk is very low overall, we are talking about 3/4 of 1% in the first year of life. So, even the risk of UTIs is much lower than a lot of people think, no granting kids that are uncircumcised that that equals out to about 1/100 children will have a urinary tract infection at some point, versus a certain size shall it does chances go up to 1/1000. So, clearly a lot more common to have UTI but again the numbers are very small.


There are three main subsets of sexually transmitted diseases (STDs) and circumcision and that's which in which one of these has a decrease risk in a circumcised child, and which is there no change. So, decreased risks for STD in circumcised males we see in for HIV, syphilis, and gonococcus and we also see it for HPV and HSV-2. So, there's decrease risks and all of those and really the only STD that does not have a change in risk is chlamydia and all of the studies have come out of Africa. It is actually been several very interesting studies out of Africa that show that the sexual transmitted disease risk is significantly lower. One of the studies came out of Kenya, I think they had close to 3000 people and basically, they were randomized to either circumcision or control and they were followed up at three month intervals 1,3,6,12,18 and 24 and he showed that the rate of protection for HIV was exceedingly high. It was about a 53% less chance of getting HIV in the circumcised cohort and it was actually so significantly so they stop the trial early. Second study from Uganda looked almost at 5000 males were randomized circumcision versus control and a look at the same thing, HIV transmission and percent protection and it was also about the same. So, only 50% of men that were circumcised became infected while when compared to the control group in that was also stopped early. So, again, very significant decrease risks for STDs and some for UTIs.


Lastly, penile cancer which is exceedingly rare, we really don't see it even in countries that do routinely circumcise their newborns. so when you cannot put all those things together and this is where you know we've gotten to the AAP policy statement that you are mentioning they have basically said that all of this data of the one I talked about and other data and that their exact statement as these data are not sufficient to recommend routine neonatal circumcision. According to the AAP even though the date is very strong for certain things they do not routinely recommend it and may they go on to say to make an informed choice parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. So, there a little bit neutral as the recommendation this is a very strong cultural thing and that's what I usually tend to tell parents, these are the risk and these are the benefits of going one way or another and in many cases, it is a cultural thing. So, if the father circumcised or the other brother circumcised and most families will choose to have kind of all boys in the family appear the same.


How do you usually do your circumcision and what are the pitfalls that can happen when doing a circumcision?


Doing a circumcision falls into two broad areas for me and that's whether or not you can I do a circumcision in the office versus the circumcision in the operating room. I realize some people just do not do office circumcisions and that's perfectly fine. My routine and what I recommend for other surgeons to do is to have a definitive cut off for your office circumcisions that you feel comfortable with whatever that number may be. My personal numbers, I will do a newborn circumcision in the office under local if the child is either three months of age or younger or weighs less than 13 pounds which is a total random, I have no data to support that, that's just how I was trained, and honesty that is worked very well for me that the two main concerns being that if you're going to restrain the child in any way either use a Papoose board or anything else that when they get a little bigger it's going to be a little harder to do that and the second is obviously the older the child the higher the bleeding risk.


07:25  So, do you think that if a one-month old baby has a circumcision that it's okay for a surgeon to take that child under general anesthesia for circumcision?


No, actually, I do not, some literature now suggesting that exposing younger children to elective cases much of the circumcision not particularly recommended from an anesthetic safety point of view. What I meant more was that if in your practice you feel comfortable with doing these neonatal circumcision in the office and a lot of people don't. This is my practice, I personally feel that if you don't do them there is really no reason to not refer that child to somebody who does do.


I think you need to know what the materials are you're going to need and we can certainly provide for the audience a little bit of a list of what I personally do but again I think you need some basic things one is what he can use for an anesthetic agent to is what you use for your restraining device, and three what he can use for your actual circumcision tool of choice. I personally use a Papoose board, there is a lot of literature suggests that the absolute best method of analgesia is a dorsal penile nerve block combined with a ring block, so I personally like to use quarter percent bupivacaine without epinephrine. For my newborn circumcisions some people put emla before which I think it is perfectly fine. I don't tend to do that necessarily and in the baby seem to be very comfortable as long as you give the block a little bit of a chance to set. Then the question is will use for your tool is basically three tools that most people that do these neonatal circumcisions were utilized and that is either a Mogen clamp, a Gomco clamp or a plastibell device so certain about the mean three devices to use. I would say that subjectively speaking I feel that the plastibell device is a little bit more postoperative post procedure complications associated with it again that's just from a subjective point of view. I know there has been some literature randomizing children to Gomco and platibell showing no difference, but I tend to ask most parents when I do see them post circumcision problem what devices use, within the vast majority of them utilized plastibell. So, I prefer to use the Gomco device, I think it does very well now say that the Mogen claim which I know a lot of people use a lot of people use very efficiently and very well, the only time I've ever seen a major injury from circumcision like a glans amputation has been when the Mogen plant has been used again people use what they're comfortable with, and I think that's perfectly fine but again the main issue that I've seen is been with the Mogen and I have seen 2 to 3 glands avulsion's which of course is a catastrophic injury.


11:15 Can you take us through the key points of a dorsal penile block?


The main nerves run if you cut out facing the penis estate you run up at about 2 o'clock to about 11 o'clock so you need to be able to numb the nerves right at that location. What I tend to do is I feel for the pubic symphysis and go a little bit below when I put the needle and I try to use a small needle die you know 25-gauge you do not need anything very big and I do initially just going in right around the area with a pubic symphysis dips down and do my initial infiltration is a weight based quarter percent bupivacaine so you know 1cc per kilogram and that I do about half of the block there and then proceed with a ring blocked is directly around the base of the penis.

How deep do you go with the needle?

I use a shorter 25-gauge needles, I pretty much hobbit to the skin and I would not it's probably about 1.5 cm perhaps, so I go fairly deep again as long as you don't hit anything vascular I think you're perfectly safe to do that, then you do ring block.


12:35 When using a Mogen clamp, how does it happen that that they would do glans amputation, is it that they would have a small glans that would fit through the opening?


So, if anybody not familiar with a Mogen clamp basically it's a metal slit what you do is you grab the foreskin, then you pull it through that slit and hopefully the glans stays behind underneath the slit so you really just have foreskin exposed up and that's what's cut. When people force the skin up through that slit the glans a smaller or if the practitioner doesn't pay close attention you can pull the glans up and so when you go to cut that foreskin off the glands get right in that wedge and just gets amputated off.


13:29 When people do the bedside plastibell and the tie the rope around it, do they usually just let the skin fall off or did they cut the skin off in the office?


I've seen it both ways, honestly. I think a lot of the obstetricians like to either just take a little bit of the skin off or just leave it on to kind of necrosis on its own. Then I've seen people cut it, and I don't really feel that there's a better way or less way; I think it's a little less gross to have you know noted skin there on your newborn baby. But, it's protect practitioner dependent.


14:00 I do think that the Gomco was probably the most commonly preferred method; can you tell us the pearls and pitfalls using the Gamco?


The main thing is that it to be able to size the bell, the Gomco basically has four components and so it has a bell which is what is going to fit over the glands and that has to fit fairly well the bell sizes are in in centimeters so it's they have a and 1.6 and those are the main sizes of some others and again that's based on this centimeter width of the gland. So, if you were newer to Gomco clamps and haven't gotten used to measuring and kind of knowing which bells size is to use you can just use a simple ruler and a lot of people do that a measure and then call for whatever clamp they want most of the time I would say 75% of the time it's going to be a 1.3 in the other only important component is you have to make sure that the bell is matched with the rest of the device because of you have a mismatch bell that happened to get sterilized and put in a pan would say 1.3 bell with a 1.45 base you'd run the risk that that bell will put pull straight up and that will also expose the glands and I have seen some glands injuries when you go to cut this foreskin off after you kind of set the Gomco because it was a recognizer the bell size was too small or too large for the rest of the device. So, I would say that pitfall and technique point number one the other thing which gets done very frequently in and I think is a source of error and this can happen with you know the plaster bell or the Gomco clamp and that people don't take down the perpuce adhesions all the way down. So, you really have to make sure that when you bring the skin down whether you like to do a dorsal slit or just basically pull the skin straight back you just have to make sure that you see that ridge underneath the corona you should see all around you should see a little ridge to tell you that the adhesions are all the way down if you don't do that you're going to leave some skin behind and it's good to be asymmetric so that a second point is fairly important. Third point that's very important is if you do a dorsal slit you have to make sure that when you bring the skin through the hole of the base of the Gomco device that you have the inner and the outer prepuce up I've seen it numerous times where people will either pull the inner prepuce only or the outer prepuce only and then becomes very messy if you don't kind of know what you're looking at people can get very confused and can be a little nerve-racking if you don't know where you are. I think those are the main three points the last thing is again that the bell of the Gomco is what's crushing the skin that your hemostatic agent. So, I tend to leave it on for at least a few minutes at least five minutes for the older kids and another important pearl is when you remove the bell you just want to yank the bell off the glands of the penis because actually separate your skin edges that you worked hard to crush together so you really want to force the skin off the bell rather than pull the bell off the skin.


17:11 What pearls you have to know exactly the right amount of skin pull up?


I would say that with Gomco it's hard to pull too much skin up because as soon as you put that bell on the glands of the penis you can't really pull skin much past that mean you have to try really hard to do it. So, what I tend to do is once the bell is on the skin is brought up and I personally like to put the bell on and then put a little a sterile safety pin through both edges of my dorsal slit because one of the more difficult parts of doing a Gomco circumcision is pulling the foreskin through the little hole at the base of the gone go device and if you have a little safety pin in there that snuggles the skin around your bell. The you grab a safety pin through the whole pull on the safety pin and that'll actually bring the skin up a little easier than going all the way circumferentially to try to get that skin up. You have to make sure to obviously to put the bell on the glans first, so you do your dorsal slit take your adhesions down put the bell on the glans and then skewer like you said both edges of your dorsal slit so it will basically snug around that bell and then you put the bell through the hole on the base of the Gomco device and then you pull the safety pin through the hole and that'll bring the entire foreskin up and you won't have to struggle trying to bring the whole foreskin all around so it is a really nice trick.


19:07 one trick that a colleague of mine taught me early on was to look and see with the scrotal skin if your points any scrotal skin up to the base of the penis you've gone too far. So, pull down until that there is no scrotal skin pulling up under the penis that was a nice trick he showed me and that's maybe using other things other than just the Gomco.


I think that's a great point and I actually always teach my residents and fellows always to look underneath the bell for two reasons one exactly like you said you want to make sure that you see shaft skin and that you're not on top of the scrotum and two you want to make sure that you didn't accidentally twist the foreskins you want to make sure that that median raphe that line the goes up and down the penis is pretty much in the center where it should be because of its twisted then you know that you twisted of the skin as you brought it up which can happen very easily so those are two tricks to do after he actually crank the clamp down.


20:03 Then you leave it on for a few minutes after you made your cut?


Yes, so the older kids I try to really time in and do close to five minutes were talking about the kids are closer to three months or 13 pounds the younger kids the newborns especially one or two minutes is perfectly plenty of time



20:20 How you dress it, do use bacitracin, or use to dermabond?


I personally have been using dermabond. I know that's not particularly cost-conscious but since a lot of our patients live from little bit farther away it gives me a little bit of peace of mind from a hemostasis point of view to do that and in the only thing because people are so ingrained I’m talking about parents are so ingrained to think all circumcision of the put a bunch of vaseline on which eventually will dissolve dermabond. So, I tell parents make sure you do not put vaseline on it because it, used to doing that. If it's a little bloodier and this kind of goes to more like you know what should you have in your tray for any potential problems you may encounter one of them is obviously is going to be bleeding as a little bloodier I will wrap it I won't derma- bond it, I’ll just a apply a little bit compressive dressing and then tegaderm the penis to the babies abdomen. But I think the two things to just have available in case there is bleeding one is just small caliber stitch maybe like a 60 chromatic or six so fast absorbing plane in case you have a little pumper a little bleeder that you just can't get under control with pressure just put a little figure of eight stitch on the skin and number two is just some epinephrine so if you no worse comes to worse you put a little 1 to 1000 diluted epinephrine just as a as a topical agent to try to get any that oozing to decrease.


21:56 In the operating room, do you do the same thing or is there anything different?


In the operating room, I use stitches and you know everybody has their own particular way of doing this I'll say that some of my mentors were of course I have immense respect for them to use some sutures that sticks around for quite a bit. I would say that if you can use any sort of vicral stitch that you should do more of a subcuticular closure because vicral does tend to leave some pie-crusting and the skin doesn't tend to look as nice I tend to use depending on the size of the kid either six or five o fast absorbing plane gut which you know again a lot of plastic surgeons use in the face and it heals very nicely. I personally just interrupted circumferentially all the way around I do quadrant stitches and then fill in the gaps. Some people have described doing quadrant stitches as a dermabond. I don't think there's a right answer it's whatever works for you the only thing I would say use suture that goes away quicker will definitely leave a nicer cosmetic appearance.


23:50 Tell me about issues you see and how and how we can avoid and manage these?


We talked about bleeding briefly I mean you know obviously surgeons can handle bleeding there's lots of different ways to do that there shouldn't be anything too excessive unless the child has some kind of coagulopathy that's not been previously diagnosed which I've seen once and that can be a little bit of a mess. The main things are the postoperative things that happen with circumcision are not particularly secondary to any sort of technique but these are just kind of things that happen, the most common ones are meatal stenosis and penile skin bridges and sort of secondary phimosis, and we can talk about those separately. I will say one sort of extra thing is that I've had children either seen by pediatric urologist, general practitioner or pediatric surgeon that have certain odd, not necessarily straightforward conditions of the foreskin where a circumcision was attempted and obviously I mean if you see something that you're not familiar with I would advise people to not proceed with the circumcision to certain conditions such as congenital mega prepuce a couple others that if you proceed with the circumcision not knowing and not recognizing these things you can get in a little bit of trouble. So, obviously one doing the right thing for the right patient of course, but as far as other postoperative problems we can take those one at a time so there is a difference between post circumcision what I call physiologic adhesions meaning adhesions where the prepuce skin is just happens to ride up on to the glans, tend to see that a lot with kind of chubbier babies that fatback kind of pushes that skin forward and in the skin kind of adheres back to the underside of the glans and of it is between that type of adhesion and a skin bridge where the skin is actually fused with the glans and now you have a little bridge of skin there that you have to deal with, and the way to differentiate that is that a physiologic adhesion you will see a distinct line where the adhesion occurs to the glans. In those, don't really need any treatment as the baby grows the fat goes away in the and the penis grows. Those tend to lyse on their own and certainly no need to lyse some in the office in fact they encourage people not to lyse because you can end up having a rough surface in turning a physiologic adhesion into a bridge. Absolutely and in I think you know again if it's just you can turn a problem that's not a problem into a problem. I warned parents looking to see a collection of smegma underneath the skin they look like white little dots, don't worry about it that's the way those adhesions will lyse on their own, but yeah regularly don't touch him.


27:10 What about the skin bridges?


In case of the bridges you will see no line there will be an area of skin that can arise up in the glans you will not see a line usually you tend to see two little holes on each side of the bridge and again this is not necessarily a problem that occurred during the circumcision. I think it happens to all of us but those do need to be dealt with because eventually you know they will not lyse on their own and as a child grows and get erections in that penis grows that they can tether the penis fairly significantly. Personally, and again this may be an area of controversy as well as, I take care of these in the office most of them you can take care the office. I just put some emla cream on it, put tegaderm and let it sit for about 30 to 40 minutes and then just get a little hemostat underneath the bridge, clamp the bridge, and just divide it with fine scissor. Now some bridges are very thick, some bridges are very long, in that case the emla cream won't get behind the bridge so when you put that clamp in between the glans skin and the bridge patients will feel that so obviously if the bridge is too thick or too extensive as some of them go all the way around the subcoronal margin, those cases need to go to the operating room to be done under GA, but I tell you if I can avoid a general anesthetic in a child I'm absolutely all in.


28:58: what the indications of redo circumcision?


We see it all the time and I think in those cases you have to go to step back and in really asked is the foreskin redundant or is there a fat pad displacing the skin distally? So, what I always do, is when ice and that's usually what it is you know you get these kind of babies are little chubby or they have that fat pad right underneath the penis and that that that pushes the skin forward and yeah the penis is the look either uncircumcised of the can look like there's a lot of redundant foreskin and in that case I in front of parents, I just push that fat pad down. if the penis looks circumcised and looks fine when you do then there is no need to do anything that baby will start walking around they will lose that fat pad and that penis will you know pop out on its own. In cases where you look at the penis or do that maneuver we push the fact that down and the penis still looks uncircumcised, I give parents the option, I say, I personally in my career have never seen an adolescent come in complaining of too much foreskin and I suspect that a lot of these cases were we think there's too much foreskin as soon as they hit puberty it can be perfectly fine and things are to stretch out, but it's hard to predict that and you know some parents are very adamant about you know having a penis look circumcised and again when there's not a condition of the fat pad being too prominent in those cases of the parents understand the potential risks of anesthesia that's when you got to say okay I will redo circumcision is fairly reasonable, but I really tell parents what if it looks circumcised even if it looks like it has a little bit of redundant skin as soon as a penis grows I suspect that would go away and I'll tell you that my practice I maybe do about 1 to 2 redo circumcisions a year and that was here in Minnesota and also down in Texas were volume was you know we had a lot more kids we took care of. I think most of these cases probably are fine by themselves but it's a very subjective area and I know that a lot of people will feel very strongly about taking his kids and redoing their circa I don't I think a lot of them get better on their own.I never have and I used to have a senior mentors been in practice 30+ years and he said “I’ve never done a redo circumcision in an adolescent probably because these children grow in their penises grown the skin stretches and we don't need to do anything”.


31:56 Talk to me about meatal stenosis?


This is one of these diagnoses which can be a little tricky, I think a lot of these meatal stenosis can look subjectively small and I think people can certainly talk themselves into doing something when they see that. Meatal stenosis is a condition exclusively seen in circumcised boys the tip of the meatus rubs against the diaper, or against the underwear, that causes an inflammatory reaction at the edge of the meatus which causes a little web at the 6 o'clock position in the meatus. I get these referrals for rule out meatal stenosis and the kid is urinating perfectly fine, he doesn't have to push, maybe has a little bit narrower caliber stream than one of their brothers or something but there having no symptoms and in that case, I don't do anything. I think the cases of the meatal stenosis did need an intervention is where the parents will tell you Dr. this child when urinate shoots straight up towards the ceiling, some parents will say it's so bad that they have to sit to pee to push the penis way down because it shoots straight up where the urine is hitting that little 6 o'clock web deviating straight up and then you get the stream that this completely deviated upwards. if I don't hear that in the history, I don't do anything about it, again a subjectively small meatus because I think a lot of these look small, and back to what we discussed before I've never seen adolescent with meatal stenosis and I think is that a lot of these kids grow maybe those subjectively narrow meatuses become totally normal meatus.


When I do see meatal stenosis, it depends on the child but you know you see this a lot between the three and six-year-old range, again I personally do this in the office, I put emla cream on the tip of the penis, let it sit for a little while, then I uses a straight hemostatic kind of crush that little 6 o'clock web and use fine little scissors to incise it. I personally don't use any sutures, although I know people that like to put a fine suture three and 6 o'clock I'm not aware of any data that shows that has less of a recurrence rate, unless the child is very nervous or has some kind of learning disability that may make it difficult for them to understand what you're doing they do great. I have the parents show them their phone or their iPad and they almost never know I am doing anything. I think a key for that if you are you doing the office hide the instruments, make sure they don't see a pair of scissors and a big shiny hemostat clamp, hide them under a paper towel, remove the tegaderm where the emla sitting and I just say “ I am going to clean things up, and you feel that cleaning” while they are watching the iPad and then I go ahead with me and told me to less than 10 seconds they don't know what's I am going on and they do fantastic.


35:18 How do deal with the micro-penis kids in need of circumcision?


If it's a true micro-penis and honestly I have a lot of those kids see endocrinology because as urologists were certainly not to be able to do much for them. The clinical definition of a micro-penis is yet to have a stretch penile length of greater than 2.5 standard deviations below the normal mean and the means are by age rights. It is an example that the mean stretches penile length for a six month to 12-month-old when most parents tend to be concerned about this is about 4 cm. So again anything greater than 2.5 standard deviations and this has been published. There are actual tables of stretch penile length in centimeters means for our newborn all the way to adult, then you can get those I think there's one from 1999, I believe the authors of Bin-abbas that has a nice stretch penile length “Congenital hypogonadotropic hypogonadism and micropenis: effect of testosterone treatment on adult penile size why sex reversal is not indicated”


36:36: Buried penises though if we see one of these kids in and have I think of these can be tricky if you don't want to take off too much skin in these kids?


I just tell people don't be a hero with these things, one of the highest areas of litigation are circumcisions that are done and then there's a problem afterwards and if you really see something that just doesn't look right whether hypospadias or penile torsion where the penis, turn off to one side it is a big web between the penis and scrotum so-called penal-scrotal wedding or if there's a true buried penis not a penis that you can kind of push out if you push on the baby fat pad. I tell people that that the main way to recognize that the penis will look like a little pyramid it doesn't look kind of like a little structure that's coming out of the body looked like a little short squat pyramid and those are the true buried penis or the other conditions called congenital mega prepuce tend to happen mostly in Hispanic patients. Those are the cases you just really do not want to even attempt the circumcision because like you said you can take the entire shaft can often I've seen patients that have needed skin grafting very complex reconstructive surgery but doesn't look quite writer quite like what you're used to just referring to pediatric urologist save yourself the hassle is not worth.


38:09 about phimosis, how do these patients usually present and how do you usually treat them?


We see this very commonly in the office. A practitioner see child they think the foreskin should be retracted it's not and what is the issue. My main approach to phimosis is when you do your physical exam you have to rule out between what I call again physiologic phimosis and pathologic phimosis. physiologic phimosis is again what you would see in a newborn baby with the sort of the adhesions when you do a newborn circumcision, and the skin looks supple and looks soft the child has never had a problem with their penis, if the child comes in the parent say my child a had 2-3 episodes the balanitis and terrible infections that's the time when if the skin is tight if you cannot retract the foreskin you may want to institute some treatment for that or not I'll go over that what that is here in a second, but even though the AAP has published guidelines as to when the foreskin should retract based on age, I don't really go those because I've seen 5-8 year-old kids with a foreskin does not retract all but they had zero problems, the skin is supple and soft it doesn't look diseased or scarred in those cases I don't do anything. I have seen younger kids where the foreskin should be retracted at the stage but they are having a lot of infections, a lot of ballooning of the foreskin with urination where I think management is indicated. It would be sort of cases of phimosis where you just treat them mostly for balanitis, if you don't see anything in the skin that's abnormal or concerning I personally treat them with betamethasone ointment 0.1% three times a day for 2 to 3 months some people do .052 times a day for a few weeks. I honestly think that that dose this too low in that time period is too low to actually see in a fact. The literature shows that if you use it for about three months greater than 50% of those children are going to have retractable foreskins at that time, and that is my first line of therapy especially in inpatients if they are Hispanic and don't necessarily want to circumcision anyway I think that's a really good bridge before you decide to go ahead and perform the circumcision. The main two pathologic phimosis where there actually is a legitimate problem that you are going to need to do something about, one of them is what's called secondary phimosis when you tend to see that a lot after a circumcision and basically what happens is the cicatrix contracts and you get the sort of very hard stenotic ring in the penis completely buries down. This is more common in the younger babies, newborn circumcision just with a bad scar reaction and in those case betamethasone ointment tends to do the trick 0.1% three times a day for 2 to 3 months, greater than 50% of children with secondary fibrosis will do great with that therapy, will not need anything else. but the other really important because of pathologic phimosis which I don't think pediatric surgeons see much of what pediatric urologist we don't see much of either but I always tell my trainees to look for what is called balanitis xerotica obliterans (BXO) which will not respond to steroids there is some literature that suggests that it may respond to topical chemotherapeutic agents by fluorouracil etc. but it tends to be a tough agent and you don't want to miss it because it will actually spread onto the glands and into the urethra can cause some fairly significant urethral strictures and the way you look at that is if you have a child or concerned for phimosis  you look at the skin the skin will be white like paper the very temple be super white usually tends to be a little scaly and a little hard. If you see that at the tip of the prepuce with my phimosis and again mostly because you will not be able to track the foreskin, that the BXO until proven otherwise. In those cases I don't mess around with any steroids I just tell the parents look you can see it right at the penis is very obvious the parents will be able to see it right away and I just go straight to circumcision.


42:57 What is paraphimosis?


Paraphimosis when children that are uncircumcised have the foreskin retract for whatever reason. They either do it themselves or they go under a catheterization or procedure and then the foreskin isn't brought back over the head of the penis. Paraphimosis can become a medical emergency you get a lot of swelling and entrapment of the glands you can get vascular compromise to the glands and usually these patients will present with a whole lot of pain and redness and swelling to the foreskin. In most of the time if you get to the point where there is swelling there it is very difficult to reduce that foreskin. So, we get this phone call from the emergency room not too infrequently and I'm sure you know if you if you don't happen to have urology coverage at your institution you will likely get this call as well so that the main things to do is one is you need pain control whether you do that through some emla cream or a penile block and lightens to be perfectly fine as you're going to need to manipulate that foreskin and again it's it can be very tender so pain control is very important sometimes need to do a little bit of conscious sedation to reduce the foreskin. if you happen to be a little bit far away are you get a phone call from an ER that's a few hours away when I tell them to do is to wrap the penis in a bandage soaked with D50 what that does is in osmotic it tends to take a lot of the fluid out of the foreskin it decreases the swelling and it makes your manual reduction a lot easier once you get to your manual reduction the trick is that you're going to have the your thumbs on the glands and your fingers on the shaft you in a pinch that shaft skin between your fingers and push the dog glanced back into the foreskin that tends to work I would say 9/10 especially if you've done good the pain control and the D50 decrease the swelling. I personally never had to do a dorsal slit for paraphimosis, although I know people have done them. So, again it's just a matter of quick diagnosis and quick intervention they happen to be a little bit farther away the main thing is to go ahead and get that wrapped with D50 and that that helps quite a bit.


45:19 About penile trauma what usually see and how to treat them?


I like to breakup it up into two basic categories: trauma to the shaft whether it's just the skin or the subcutaneous tissues in the skin and actually trauma to the urethra.  Urethral traumas that totally good topic and of itself I'll mention just a few things that I think are important to just keep in mind at the end but you know there's been actually several papers that that have shown that that the main cause of peanut promise from zipper injuries which is not a big surprise and in the main thing to do if that happens the con is to really cut the zipper off the pants and in cut the bridge on the actual zipper itself rather than trying to manipulate the zipper either closed or open. So if you get a nice bone cutter from the operating room cut the bridge on the actual zipper that's the part right underneath the little handle that will usually separate the device completely and you can just separate the zipper. The second most common thing in that I think we see is injuries from toilet seats falling on penises and so we tend to see a lot of toilets you can drop on penis you see some crush injuries of the penis. They look fairly terrible when you look at them, the glance can have a big hematoma, and it can almost look necrotic. As long as the child is avoiding and not having any gross hematuria there is really no need to do much else as far as a diagnostic workup at the moment mostly just conservative management but that tends to be the second thing. If there is gross hematuria I would get urologist involved because then you know now you're talking about a potential urethral injury. Lastly we know we feel kind of weird avulsions of the skin kids getting caught up on fences and in the sort of things. The vast majority of these can be repaired fairly easily whether in the ER under conscious sedation or in the OR but the main thing that they just make sure is that the tunic up that the buck’s fascia of the penis, the harder part of the penis underneath that the dartos fascia isn't broken into or violated into. Because if you have a buck’s fascia injury that requires a little bit more work again it's nothing to complicated but that's the sort of thing that should be taken to the operating and make sure you get the stitches there because you can't lead to long-term issues with scaring potential potency issues down the line. Again rare but things that should be watch out for, those are the main three categories.


Lastly, the urethral injuries, gross visible blood at the meatus or gross hematuria after, especially any kind of pelvic fracture, lower abdominal injury your good mechanism requires a full evaluation of the urinary tract from the urethra all the way up to the kidneys to make sure the now kidney lacerations, ureteral problems, bladder or of course some kind of urethral injury. Like in the adult world, if you see gross hematuria in a trauma patient the main thing we say is please do not instrument that child because of there is a urethral injury you can create a much bigger problem if you don't have the right person placing the catheter in. So you have to rule out a urethral problem if you see gross blood in a trauma patient at the urethra level and then proceed with the retrograde uretrogram.


48:58 With our kids of hypospadias tell me how they usually present to you and how do you work these kids up?


Mostly kids are diagnosed at birth, very rarely will get a call from neonatal nursery or pediatrician's office that says all we were doing the circumcision and we happen to find a mild hypospadias. Most of the hypospadias where you can see very clearly that there's a problem or diagnose the birth and it's a fairly high incidence which is you know about one in 150. We don't really know what the etiology of the hypospadias is are likely multifactorial whether it's exposure where some children with and in that have had in vitro fertilization have a higher propensity of hypospadias. I am not sure about what the etiology is, but that the main problem is that the urethral folds just don't use in the midline. So, you have kind of an open urethral or urethral plate and then you have the meatus where the urine comes out anywhere along the shaft from the distal area underneath what glances all the way down to the perineum. In bit associated problem with hypospadias tends to be ventral penile curvature or sometimes called chordee. So, when you look at hypospadias, you have to assess two things, one is what's where is the meatus what's the location of the meatus obviously the more proximal to the meatus is the more complex the procedure to fix that is going to be and second is what is the degree of curvature of the penis and that is also been a determine a little bit of our intraoperative algorithm as to how we are going to repair this. Hypospadias is a very obvious we talked earlier about not circumcising a penis that shows any kind of abnormality no one would miss the hypospadias that's obvious. Back to the condition where they find this on a nursery and they get very concerned because they think were to utilize the foreskin to do a reconstruction, we don't utilize a foreskin to do a reconstruction for mild hypospadias almost ever if ever so if I ever get that phone call I say finish the circumcision no normally the skin cannot hang in there just get it done, because again these are hypospadias is that the foreskin probably looked completely normal and the only happen to find that the meatus was not at the tip when they reduce the foreskin down and took the adhesions down. This can be a very distal mild hypospadias and we just do not use the foreskin for those reconstructions.

Actually, I see patients in my office refer for hypospadias that had just the dorsal slit and the people of the board of the circumcision because they're under the impression that we utilize a foreskin and you know yes we did 20 years ago very commonly but now with that the current techniques the surgical techniques are distal hypospadias, we almost never do. But if you happen to get called again if you don't have urology covered you get called to the nursery for hypospadias as long as the baby is voiding, it's not really an issue the only other thing to really consider is whether or not the hypospadias actually is not a hypospadias but it represents some sort of disorder sexual differentiation (DSD). I mean that's what you really have to watch out for and they conceded that is whether or not there is two palpable gonads in the scrotum so you can feel to testicles and there's a hypospadias the chances that that's a patient with DSD is almost zero. If there is an undescended gonad associates and non-palpable gonad and hypospadias that child needs a full DSD work because you may be dealing with one of again just a multitude of different DSD patients you know have likely been covered in the podcast elsewhere. Undescended gonad, hypospadias equals the DSD workup certainly if there is bilateral non-palpable gonads in hypospadias then your number one thought you be that it could be a good congenital adrenal hyperplasia baby and again that baby needs a full DST work up. But that's kind of a basic approach to hypospadias the surgical techniques to fix it varies and most of the scissors and end up seeing a pediatric urologist anyway.


53:41: Do all patients with hypospadias need surgical repair?


This goes back to some of that slightly more controversial areas we touched upon. The main two reasons to fix the hypospadias one is cosmetic right you want the penis look fairly normal and the second is functional you want a child to be able to urinate standing up like the rest of his friends that don't have hypospadias and you obviously want to them when they're having sexual activity to have an emission at the distal tip of their penis and not have any fertility issues from that and that really tends to be a problem only for the proximal hypospadias mean the functionality aspect of it. Patients that have a mid-shaft hypospadias the distal hypospadias could they urinate normally standing up and what they have any fertility problems probably they be fine on both of those issues, but cosmetically a lot of people get that fixed which I think is perfectly legitimate when you get into a little bit of a controversy is when you get these very mild variance of hypospadias was called a mega meatus variant where the meatus had a big some of them you can see a little urethral pit and then a little tiny meatus right below that a lot of those were you just really doing it for cosmetic reasons I don't know what the answer is honestly. it just makes me think because of the literature we have available regarding the exposure to anesthesia to young brains about whether these very mild cosmetic only hypospadias is should be done when the children are young or if we should just be waiting to do them electively when they're older if it evens bothers you know I've had patients that come in they have super mild hypospadias and a mom says all yeah dad as you know you never had to fix or you know uncle John has added it's not an issue it's more when you get into bad curvature of the state's proximal meatus yeah those you really need to take care for those children are to have functional problems in the future.


55:45 Can you tell us in very brief the essence of the elements of repair of a hypospadias?


The basic two things are the urethral plasty meaning bring in the urethral meatus to the tip and the phalloplasty is straightening out the penis from any curvature that might be there. A lot of these patients with hypospadias will have until the dorsal hooded prepuce and you can deal with that in one of two ways, some people to do a hypospadias repair with prepuce reconstruction with all actually fix the curvature, fix the urethra and then reconstruct the foreskins of the penis looks like an uncircumcised penis then again that's most of cultural reasons or you go ahead and do a circumcision and just remove that dorsal hooded prepuce because it does look a little bit different, but those of the basic to tenets are just the urethroplasty were you can a tubularize that urethra you're going to cover it with a second layer usually some kind of pedicle flap to protect against any fistualization and you're going to do your corporoplasty where you are going to straighten the penis. The vast majority of the time once you kind of bring all the skin off the shaft of the penis what's called penis degloving the chordee most of the time tends to go away. Sometimes the chordee is significant enough that we need to do some other maneuvers to strengthen them out, but those are the two basic tenets of hypospadias surgery.


57:16: what is at the epispadias?


Epispadias is the total opposite of hypospadias is that of having a urethral meatus on the on the ventral surface of the penis on the dorsal aspect of the meatus and that it's extremely rare it's you know less than one and 50,000 live births.It's a defect of the dorsal urethra and this is not a mild thing or a subtle thing you know once you see it you will notice something abnormal there. The main issue with these babies is that they basically represent a spectrum along the bladder exstrophy and the epispadias spectrum and they can have a lot of the associated problems that exstrophy babies have. The main ones being urinary incontinence, a pubic diastasis and vesicle ureteral refluxes. If you see if this baby is that's the kind of baby that's going to end up going through the doorstep of some pediatric urologist, but that is good to know that those are some of the associated things that the epispadias can have.


58:19: If we are going to do a circumcision and see that how do we handle that situation?


In those cases, I would not proceed with the circumcision most of these penises don't look normal. I mean you will know that there's something not quite right. I have seen a few cases where the epispadias only becomes noticeable once you reduce the foreskin, but again want to reduce the foreskin you'll know there's something.


58:43 We had talked briefly about micro penis before you said you send that to an endocrinologist, anything else we need to know about that?


The main thing is just to keep in mind that the true diagnoses of a micropenis is an objective measure diagnosis. We have a lot of kids who come in that are on the chubbier side. Parents are concerned about “micropenis” it's a pubic fat pad issue once you push that down the penis becomes exposed and clearly there's not an issue with length. True micro penises there just extraordinarily small and most of the time these children will have small testes will have other issues but for true micropenis to exist, there is very strict guidelines for which I mentioned earlier, and those patients should be referred to endocrinology. There's nothing as urologist that we can do because it tends to be hormonal deficiency issue.


59:37 Wat we need to know about penile torsion?


Penile torsion is the twisted penis and most of the time is very obvious. if the baby is uncircumcised the way to tell is that the raphe won't be at its normal 6 o'clock location tend to twirl around the penis, and then you just have to keep in mind that it may be a penile torsion now if during a circumcision you happen to notice penile torsion and not the end of the world all. We don't tend to fix these the less the torsion's close to 90° to one side or the other and it certainly were not to use that foreskin for anything in the repair but if the torsion significant or the parents are concerned that should come see us.


01:00:19 What is about isolated chordee?


Chordee is ventral penal curvature the penis had a hook stand down most of the time associated with some degree of hypospadias will but we do see it without hypospadias and in in those instances if the baby was in I have a circumcision anyway that's probably the kind of child that would benefit from an operative in or circumcision. So we can actually take those skin adhesions down all the way down the base of the penis to the penis scrotal junction, the release held that kind of chordee tissue there and straighten the penis out.


01:00:51 What is about peno-scrotal webbing?


We talk about that a little bit before and that in do not circumcise category where there again just know that the penal chapters have the web to the scrotum it is very obvious that is not subtle so again just to the idea that it if the penis does not look normal don't proceed with circumcision in a penis-scrotum wedding case, we do tend to use some flaps sometimes for the foreskin, I personally don't, but I know some people to do so in those cases better to refer.


01:01:25 How do you approach labial adhesions?


These are just interesting because people become very concerned about appearance to of the female external genitalia which can range from a little bit of adhesions all the way to complete fusion where you don't see anything. It doesn't happen very often the incidences at the high is about 2% in the first two years of life, I don't see in newborns of how to stop the maternal estrogen is protective so we see any kids that are a little bit closer to toddler years. The only real issue with labial adhesions is because the labor minora closed you can have some post avoid dribbling kind of pooling of urine in the vagina that lead a lot of skin breakdown or yeast infections you think of the moisture which can contribute to UTIs. So, if I see isolated labial adhesions much like the meatal stenosis we discussed earlier without any symptoms whatsoever, I don't treat them you know I look for those things that I mentioned, post void dribbling or incontinence, skin breakdown, or recurring UTIs if that's happening I do think merits treatment and there are two schools of thought for initial treatment. I personally don't know of any literature that shows a one is better than the other and the first is your estrogen cream, premarin cream multiple use that BID for about six weeks people don't like to use it for a very long time because obviously can actually lead to pubic hair development which is a problem in two years old. The other approach is to use a betamethasone ointment much like you did for phimosis. I tend to use betamethasone only because it makes me feel better about not putting estrogens on prepubertal child. in my experience they were quite well you know again if they don't work if it recurs and the child is having no actual symptoms then we do tend to taken to the operating room for no formal lysis of adhesions although I've only had to do that I think once in my career so it's pretty rare that we have to go to that degree of aggressiveness with these. So that's it that's new to me I've always use the estrogen cream but the steroid cream works pretty good to intrinsic okay horse really well loud switch to that then I agree with you it sounds like that's the better way to start first and then maybe if that doesn't work then maybe try to estrogen cream Yep okay absolutely.


01:04:06 Let's talk about the 13 years old girl had abdominal pain for a couple months and they get a CAT scan and she's got hydrometrocolpos, how do you manage that patient?


I like to think about that problem along with a couple other problems that I think are present very similarly especially in in young babies. They can look almost identical and that's sort of that the bulge between the labia in the midline and the different things that that can such as an imperforate hymen which will tend to have a bulge between the labia minora and the introits and this tends to be again just retain vegetal secretions in the treatment for this is a decision. In your patient's case you had a CT scan which I confirmed this big fluid-filled vagina I and then the diagnosis becomes fairly straightforward and then just again opening the hymen will usually do the trick if that's the case of courses a lot of Mullerian duct anomalies they can give hydrocolpos which need to be differentiated out but in in the younger kids tends to be imperforate hymen.


 01:05:45 what else can cause a bulge between the labia minora?


The main other things to keep in mind and the more common things besides an imperforate hymen, the other causes include prolapse ureterocele which is a bladder problem. The second one is a paraurethral paravaginal cyst this can look like the sort of midline bulges and the last one which is a little bit easier to differentiate, not really a bulge more of a mass which is vaginal rapidomyosarcoma: I think those are the three main things besides imperforate hymen to keep in mind the diagnosis of these midline bulges. Prolapse urethrocele tends to be smooth, it's mucosa covered it looks a lot like an imperforate hymen, it usually protrudes from the urethra but is distinct from the vagina, so that's kind of a way to tell, so if you really spread the labia majora apart you should be able to tell that the vagina is not where this is coming from. Prolapse urethrocele babies tend to have other issues with prenatal diagnoses most of these babies will have some sort of hydronephrosis diagnosed prenatally and you happen to see this bulge and then you have to worry about a prolapsed urethrocele but if you think it is urethrocele, the main two things to get are a renal-bladder ultrasound which will almost always pick it up and voiding cystourethrogram at that point you're probably involving your pediatric urology colleagues. The treatment for those prolapse urethrocele is fairly extensive and I won't get into that but it just important that to differentiate that that's coming from the urethra not the vagina. The second diagnosis is paraurethral or paravaginal cyst, it can either Gaertner's duct cysts or Skene gland cyst. So, when you do your physical exam this tends to be a midline bulge, they tend to be present at birth and then just resolve with the maternal estrogens are gone. They don't tend to cause any sort of either urethral or vaginal obstruction and most of these will spontaneously regress and you will see patency of the urethra and vagina that's the key, so if you see patency of the urethra and vagina you can suspected to be one of those two either paraurethral or paravaginal cyst. Like I said they tend to resolve on their own unless they get infected there's no need to really mess with them. Last, vaginal rhabdomyosarcoma which doesn't look that much like a like a single bulge “bunch of grapes” which were all kind of taught in residency medical school and the treatment for that is fairly extensive and I will not get into that, but then you really have to you know involve your oncology colleagues in either your pediatric urologist or pediatric  surgeon depending on your institution's preference.