S5E6: Paediatric Urology
Happy New Year everyone!
Welcome to our first episode of TCR for 2025 and we have got the ball rolling this February with three paediatric urological presentations to keep you refreshed on your paeds’ knowledge! We’ve covered three of the most common urological presentations in paediatric males so we hope you read the show notes to get yourself up-to date or to help cramming for your med school paediatric finals that will inevitably have some urology on them in some shape or fashion!
We are thrilled to reintroduce Dr Emma Fauteux -CUH (PEM lead), to be our AITR this week who gives us some hot tips for each of the cases!
Listen now on Spotify, Apple Podcasts or wherever you get your podcasts, and as always, be sure to follow along with the show notes at thecase.report and on socials Bluesky, Instagram, Facebook and X to keep updated with all things TCR.
Ok, let’s get started and listen to what Callum, Rachel and Stephen have to say!
Right then, let’s get to it! …. Thankfully, we have two ED Registrars free to go to triage after the tannoy bongs and the triage nurses are calling for “ED REG TO TRIAGE PLEASE”. Rachel and Stephen are on the case.
“It’s not the medicine that’s hard, it’s the infrastructure”
Case 1
Case 1
Rachel deals with the first case, where we meet Tommy, a 4 year old boy who presents with his father due to …
Presenting complaint
Refusing to go to the bathroom
Off form
Distressed
The History
She checks to see if he’s had adequate analgesia, as oftentimes parents may have withheld analgesia for fear of masking symptoms on assessment. Turns out, he had some ibuprofen pre hospital and he still appears uncomfortable and distressed. BUT, he is vitally stable thankfully. Tommy is four years old, so it is likely he has some comprehension of what Rachel might ask him but he does cower into his dad when Rachel begins to speak. She smartly involves him in the conversation, asking him if it’s ok she speaks to Dad for a little while, to which he consents. As part of the focused history, Rachel asks:
How long is it going on?
Has he been otherwise unwell?
Birth history?
Social history?
Meeting his developmental milestones?
Vaccinated? If so, up to date?
Dad updates us and reports Tommy has been increasingly upset when toileting, unable to stay in creché and now begins to cry at the mere mention of toileting. He’s otherwise well, no significant birth history and has been meeting his milestones. Tommy’s vaccines are up-to-date!
To continue with our Hx, Rachel asks Tommy about ballooning of the penis, but he’s not sure.
The Exam
The exam of choice in this scenario is a full, thorough head-to-toe assessment, followed by a focused genitalia examination.
** Note: the exam is super important in young children because they may not be able to communicate their history, and the exam may elicit important information**
The exam illustrates to Rachel that there is mild erythema at the glans, discharge from the foreskin on retraction and a “tightening” of skin. The exam was otherwise unremarkable, looking particularly for undescended testes and hernias which were not present in this case.
Can you tell what our top differential is??
Well done, you got it in one!
**BALANITIS (Inflammation of the penis foreskin) with a phimosis**
Hot tip from Dr Emma Fauteux when considering this differential: NB to distinguish between path v physiological phimosis
Phimosis at birth, only in 50% neonates can you see the meatus
Only 50% by 10years old will be retractable
Teenagers → usually resolved
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Urine
The dip was NAD. Interestingly Dr Emma Fauteux comments that urine analysis will be abnormal (especially neutrophils) due to the skin inflammation locally. She says she would only send urine if the child had a fever as it’s pretty rare that they have a co-existing UTI with balanitis. We don’t need the urine for the diagnosis so that was a hot learning point!text goes here
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Steroids
Twofold benefit of giving steroids:
The systemic steroid will act on the inflammation
Targeted topical steroids will also work at thinning the local skin (usually the unwanted side effect but beneficial in this case!) and reducing the inflammation over a two to three month period!
Analgesia
Ensure adequate analgesia is given
KEY: Utilise resources that help parents dose simple analgesia appropriately to weight
Bath salts & Hygiene
Encourage Tommy’s Dad to bring him to the bath with salts in it to aid the inflammation. In addition, the bath might be a good trial of whether he can urinate or not → NB: If Tommy has recurrence and cannot pee in the bath, it’s time to represent to the ED!
Hygiene of phimosis is super important. Another hot tip from Dr Fauteux:
If the foreskin is remotely retractable, while the child is in the bath, gently retract until mild resistance is felt and try to clean the area to keep good hygiene and also avoid paraphimosis.
Parental advice
Explain the ddx and reassure, explaining that most children in this age group have self-limiting balanitis.
Use the word “inflammation” not “infection” to differentiate that there is no need for antibiotic therapy in this situation!
Safety-net if there are any further issues.
Link in with GP
No need for GP follow-up unless there was retention, which there isn’t here.
Case 2
Case 2
We get to ED Triage where the nurse has called Stephen to assess the situation. 12year old Darren is on the examination bed, lying still. Mom is with him.
Presenting complaint
Atraumatic left testicular pain.
Sudden onset, no warning.
Regular cyclist → no recent trauma from same, or other notable trauma to the area.
Was playing x-box at the time of noticing.
Increased urinary frequency, pain like never before, well until today, otherwise well with no past medical or social history
The History
A focused history was carried out ensuring to find out if Darren experienced any of: Undescended testes / phimosis / hernia as a kid.
The Exam
Stephen goes to examine Darren, but a really important thing to note here is Darren’s age and the sensitivity of an intimate exposing examination such as a testicular examination. It’s key to this case that sensitivity, privacy and dignity are maintained at all times. Explain clearly to the patient what you’re about to carry out and ascertain if he would like his mother present for the exam. Ensure and get a chaperone! Lock the door to avoid disturbances, utilise a blanket and only expose the genitalia for the smallest amount of time that is possible. Stephen conducted the exam with the utmost sensitivity, and Dr Fauteux re-emphasised the importance of this!
Darren is lying flat, covered with a blanket
Full abdo exam showed nil of note
Hernial orifices examined: nil of note
Genitalia examination: examining the non-affected side first
At this point could note the Tanner Staging (to ascertain if developmental puberty was taking place and at what stage the patient sat at)
Cremasteric reflex
Quick strike of the inner thigh
Observe the testicle, any notable pull of the testes?
Typically there’s a reflexive response but difficult test to do
If absent, adds to decision making and differential process
Note here: Dr Fauteux commented on the reflex being hard to elicit. Especially if they’re on their back. Might need to manoeuvre the patient to ensure you can elicit it. Easier said than done!
Our exam showed: The left testicle was retracted and lying horizontal. Cremasteric reflex was absent on the left side and lifting of the testicle relieved his pain.
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Another important nugget at this point is the initial differentials: He presented just pre pubertally where there is a change from the likelihood of developing torsion of the appendage → torsion of the testicle itself. Tricky part of the case due to his age → therefore both in your ddx.
Top differential: Acute Torsion (Left-sided)
Others: Epididymo-orchitis / Torsion of the testicular appendage / Torsion-detorsion
If you were equivocal on the ddx; would you send a child home from ED?
Definitively involve urology
Equivocal: urine defo, maybe bloods, ultrasound is helpful here if the story is difficult to ascertain. Truly concerned - talk to urology
Hard decision to make, involve key stakeholders!
Involve urology
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This is a clinical diagnosis buttttt, if time allows …
ULTRASOUND
Don’t let it delay contact with urology but if they could be done sequentially that would be ideal.
Sensitivity of US is 93% 100% specific
Signs to look for: Echogenic epididymis, whirlpool sign of spermatic cord.
Bloods
Pre op is good and handy to have
Not super important at this point
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Treatment
This is a surgical emergency and needs prompt transfer to theatre for definitive treatment. In our case torsion is confirmed —>
Surgery is indicated
Sooner intervention leads to a higher likelihood of restoring blood flow to the testicle and salvaging it
Time: 6 hours to restore blood flow!
Pending local resources in the institution, if they have on call paediatric urology etc
Don’t let the 6 hours elapse, but you would still act >6hr
Dr Fauteux notes here that within 6 hours is a textbook finding, 50% at 12hours and some viability at 24hours (likely due to torsion-detorsion).
Still worth a theatre shot, always the chance of viability.
Parental advice / concerns addressed
Ensure to explain the procedure fully
Explain GA risks / sedation
Length of time in hospital discussed
Darren went on to have an orchidopexy on the affected side and the torsion was fixed.
Contralateral orchidopexy
Contralateral orchidopexy is controversial. Trials of follow-up (find trial) comparing with and without the contralateral and there was minimal result → surgeon preference then but likely to be done if the testicle is not viable to ensure fertility later on. -
We mention TWIST, the Clinical decision making tool, which:
Helps with clinical decision making (clinical decision resource)
Implementable tool if your institution uses it
Spec only 90% (gonna miss 1 out of 10 if you purely used this!)
Sens 70% → miss 3 out of 10
In reality, TWIST is not sensitive enough. It may be helpful for the elements and may be academically useful and good for your handover to urology but not clinically that useful as we want sensitivity to be 100%.
Elements of the TWIST include:
Testicular swelling
Hard testicle
High-riding testis
Absent cremasteric reflex
Nausea / vomiting
Spot diagnosis
Our mentioned spot diagnosis is twofold in its learning opportunities this week
Blue dot on the testicle → pathognomonic for a torsion of the testicular appendage HOWEVER, it is not entirely sensitive as it is often absent with a testicular appendage torsion, so don’t be fooled if it’s not present!
Talk to your colleagues, especially about patterns that are different or pathologies you’re uncertain of! Why?
““Medicine is a team sport””
Case 3
Case 3
You’ll never guess, we have ANOTHER Urology case tonight in the Paeds ED, thank god for our incredible team!
18mo toddler boy Richie brought in by mam Tara, who noticed swelling to scrotum when changing his nappy and discomfort when being changed
The history
(Richie & mam are seen in private, maintaining dignity and privacy)
When noticed first?
How has he been overall?
More irritable?
Any fevers?
Any tummy pain noticeable?
Noticed any progression of symptoms?
Birth / family / social / developmental hx?
Patient in good form. First noticed swelling this morning, as day went on redness spreading and → l scrotal area. Crying while putting cream on it. Otherwise well. No fevers. All other hx unremarkable. Parents with him. Attends local creché. Development is appropriate for age. One child family.
The Exam
All the rules above for maintaining sensitivity and dignity apply for this exam. As Richie can’t speak or communicate entirely, the exam holds a lot of gravity.
What to do?
Head to toe exam (easier when they’re small anyway!)
Focused testicular exam
Vital signs
Our case: Vitals NAD. Appears well, distractible with toys. Chest clear. Abdo SNT. No rash
Focused exam (testicular): no urethral discharge but left scrotum is erythematous and swollen - normal lie of testes. On palpation: tenderness noted to the left posterolateral and left epididymis is thickened. Cremasteric reflex is present. Swelling doesn’t transilluminate. No hernias.
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(Note: NOT always a clinical diagnosis as this diagnosis is actually very tricky in reality)
Try to get urine (C&S)
Clean catch
Hard to get
No urine bags as they may contaminate the sample
Our AITR recommends an ultrasound
Reality is the presentation is equivocal a lot of the time
Ultrasound needed as tenderness and nature of pain hard to fully determine from exam
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Our case: Most likely Ddx : epididymitis (bacterial)
Epididymitis → Literature tells us there are 2 peaks; young child and STI teen
Prepubertal → classic tx : UTI & abx
1 in 7 will have a positive urine culture only
Ireland tend to use abx - ? other aetiology such as viral but difficult to prove hence why abx often used
Younger the child: more likely that there’s a bacterial source (anatomical urogenital reasons). Recurrent especially.
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Management
Pain
Adequate relief
Guided by the above resources
Urology f/u
To outrule a structural cause
Contact them if you’re unsure, and know how and when to contact them!
“It’s not the medicine that’s hard, it’s navigating the infrastructure”
Parental advice
Reassurance
Talk to them while sitting down yourself!
Safetynet advice
Bloods would not alter the treatment and should only be done in unstable patients or patients requiring admission and IV cannula insertion.
