One3 44 Management of abnormalities of external genitalia in boys phimosis, torsion

  1. Normal penile size?
    • The normal penile size in a full-term male neonate is 3.5 ± 0.7 cm in the stretched length
    • Micropenis <1.9 cm in neonates

    [@ ३६ से, १९ से] 
  2. Tanner stage?

    • - Pubic hair 
    • - Penis 
    • - Testis

    [@ PTH - Tetany - Tanners] 
  3. Physiologic phimosis?
    Partial or complete inability to retract the prepuce exists because of natural adhesions between the glans and inner preputial skin and/or a preputial ring.

    • Two factors are involved in the separation of the prepuce from the glans:
    • (1) accumulation of smegma (epithelial debris) under the prepuce during the first 3 to 4 years of age and
    • (2) intermittent penile erections.

    Preputial retractability increases with age, with 90% of uncircumcised boys 3 years of age with completely retractable prepuces and less than 1% by 17 years of age with phimosis
  4. Elective circumcision?
    AAP - Although health benefits [significant reductions in the risk of UTI, risk of heterosexual acquisition of human immunodeficiency virus, and the transmission of other sexually transmitted infections] are not great enough to recommend routine circumcision for all male newborns, the benefits of circumcision are sufficient to justify access to this procedure for families choosing it and to warrant third-party payment for circumcision of male newborns”
  5. Complications of circumcision?
    Wound infections, meatal stenosis, removal of too much/too little prepuce, cicatrix, and even death are all potential complications of neonatal circumcision.
  6. Effman urethral duplication classification?
    • Types I and II distinguish between partial and complete urethral duplication
    • Type III - urethral duplication as part of bladder duplication

    • The accessory urethra should not be used as the primary urethra secondary to being hypoplastic with the risk of inadequate urine flow. 
    • Surgical repair includes complete accessory tract excision, electrofulguration or injection of sclerosing agents into the accessory tract, septotomy if the septum between the two urethras is thin, and urethrourethrostomy of the accessory tract into the functional urethra.
  7. Acute intravaginal torsion of testis?
    • Predisposing factors
    • - bell clapper deformity
    • Image Upload 1
    • - Cold temperature activating cremesteric reflex 
    • - rapid testicular growth
    • - Cryptorchid testis are at increased risk of torsion

    • Clinical features 
    • - after 10 years, peak at 12-16 years 
    • - generalized testicular tenderness 
    • - Inspection may identify the high-riding testis from a foreshortened cord and horizontally oriented testis.
    • - absent cremeseric reflex (genitofemoral reflex arc) - normally present after age 2 years, is elicited by scratching the inner thigh with resultant testis elevation

    • Diagnosis 
    • -  CDUS - reduced or absent Doppler color or waveforms and parenchymal heterogeneity compared with the contralateral testis.  Testes with heterogeneous echogenicity are necrotic,
    • whereas homogeneous echogenicity predicted a lower risk of orchiectomy

    Salvage rate - <6 hours - 90-100%, 6-12 hours - 20-50%, 12-24 hours - <20%, >24 hours - 0%

    • Treatment 
    • - Manual detorsion - medial to lateral (like opening the book) 
    • - Immediate exploration 
    • - Intermittent intravaginal spermatic cord torsion - requires elective bilateral orchidopexy. Three-point fixation in medial, lateral and in inferiorly. Use non-absorbable suture. (C12-896) Fixation in tunica albuginea and not in vaginalis. Orchiectomy is performed by dividing the cord into segments, each of which is ligated with nonabsorbable suture.
    • [@ Book open - vascularity opens, Book closes - vascularity closes] 

    • Complications 
    • - testicular compartment syndrome 
    • - poor fertility
  8. Testicular compartment syndrome?
    Intratesticular pressure elevated after prolonged torsion with tense congestion. 

    Treated with tunica vaginalis vascularized patch - used to fill the defect in tunical albuginea
  9. Torsion in neonates - extravaginal spermatic cord torsion ?
    • Torsion in the newborn period is extravaginal, which involves twisting of the tunica vaginalis and the spermatic cord contained within.
    • Torsion of the entire cord occurs before fixation of the tunica vaginalis and dartos within the scrotum (extravaginal). 
    • Extravaginal torsion may be categorized into two separate phenomena, prenatal torsion (in utero) and postnatal torsion (acute) (during the first 30 days of life). This distinction is important because the salvage rate of a prenatally torsed testis is nearly nonexistent, whereas a postnatal extravaginal torsion carries a salvage rate of up to 44%.

    • Prenatal torsion 
    • - enlarged discolored scrotum accompanied by a nontender, solid testis that is fixed to the scrotal wall.
    • - testis will likely appear hyperechoic and avascular.  
    • - contralateral orchidopexy may be performed on an urgent basis to avoid the devastating consequence of asynchronous contralateral torsion.
    • - The risk for extravaginal torsion is thought to be present for only the first few weeks of life, and intervention should be pursued  before this window closes.

    • Postnatal torsion 
    • - postnatal change in scrotal examination (erythema and/or swelling), and the testis will be tender.
    • - management should be similar to what is recommended for acute testicular torsion that appears later in life, recognizing
    • that the timing of presentation varies.
    • - The decision to proceed with immediate surgical exploration should be measured in which the parents are aware of the
    • low salvage rate for the affected testis
    • - The main rationale behind intervention for postnatal torsion is the prevention of asynchronous contralateral torsion.
  10. Whirlpool sign?
    Defined as the presence of a spiral-like pattern when the spermatic cord is assessed during ultrasonography (US), using standard, high-resolution ultrasonography (HRUS) and/or color Doppler sonography (CDS), in the presence of testicular torsion

    Image Upload 2
  11. Most common cause of acute scrotum in prepubertal children?
    Appendage torsion (Appendix of testis or epididymis) 

    Blue dot sign (discoloration of upper pole of testis) seen through stretched scrotal skin 

    It is self limiting - no treatment required
  12. Signs of torsion testis?
    • Prehn sign - relief of pain with elevation of testicle, positive in epididymorchitis 
    • Affected testicle lies high up (Deming’s sign; 26-80%)
    • The horizontal lie of the contralateral testicle (Angell’s sign; 25-90%)
    • Anterior position of epididymis rather than posterior
    • Absent cremasteric reflex (40-100%), cremasteric reflex should be present in epididymitis.
  13. Cremesteric reflex?
    • Nerve supply 
    • Image Upload 3

    The presence of a cremasteric reflex correlates with intact testicular blood flow but does not unequivocally indicate normal testicular perfusion, especially if the clinical presentation is otherwise suggestive of torsion. 

    The absence of a cremasteric reflex (light touch to inner thigh resulting in cremasteric muscle contraction and ascension of the ipsilateral testicle) is a very specific sign for testicular torsion in pediatric patients.
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One3 44 Management of abnormalities of external genitalia in boys phimosis, torsion