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Pediatric Urology: When to Refer — Practical Red Flags for Pediatricians · Pediatrics in Practice: A CME Podcast

• 0:03
  Dr Sarah Gubara: Welcome to Pediatrics in Practice, a CME podcast.
• 0:07
  I'm Dr.
• 0:08
  Sara Gubara, and today I'm joined by Dr.
• 0:10
  Gino Vercelli, a board-certified pediatric urologist and associate professor of
• 0:16
  surgery at the University of Missouri Kansas City School of Medicine.
• 0:21
  Today, we're exploring conditions of pediatric urology.
• 0:26
  Dr.
• 0:27
  Vercelli, thank you so much for taking the time to join us this morning
• 0:30
  Dr Gino Vricella: Absolutely my pleasure.
• 0:31
  Thanks for having me
• 0:33
  Dr Sarah Gubara: Of course.
• 0:34
  We're happy to have you.
• 0:35
  Now, to get us started, when pediatricians see common urologic
• 0:39
  findings, what are the reassuring signs that suggest the condition is
• 0:44
  benign and can be observed versus red flags that should prompt referral?
• 0:50
  Dr Gino Vricella: I think that, a quick clinical heuristic that we
• 0:54
  can utilize is to ask yourself which of the following is true.
• 1:02
  So is this condition, symmetric?
• 1:06
  Is it, painless?
• 1:09
  Is it stable?
• 1:11
  or is the condition improving?
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  So if so, then I think the condition is likely benign, and
• 1:17
  it's probably okay to observe.
• 1:20
  The corollary to that would be that, if the condition is, painful, or if
• 1:25
  it's asymmetric, so if it's just on one side, if it seems like it's progressive
• 1:30
  or if it's affecting their day-to-day function or their ability to do the
• 1:36
  things that they want to do, then, those would be some red flags that
• 1:40
  should, probably, prompt a referral.
• 1:45
  So across, you know, many conditions, I think the features that, suggest a benign
• 1:52
  process as they relate to, say, urologic tract is in terms of the asymptomatic
• 2:01
  realm, is there a urinary issue?
• 2:05
  is there a normal pattern of urination?
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  So do they have a strong, well-directed urinary stream?
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  Doesn't seem like there's any apparent straining with urination, no urinary tract
• 2:14
  infections, and there's no associated, systemic symptoms like fevers, weight
• 2:21
  loss, or associated GI, uh, of, symptoms.
• 2:25
  So, some general red flags I think that you can utilize that I think
• 2:31
  would probably, you know, prompt more urgent referral would be, pain.
• 2:37
  , Especially if there's acute or severe pain that wakes you up from sleep
• 2:41
  or pain that does not allow you, to perform those activities of, either
• 2:46
  daily living or just, playing, going to school, that sort of thing.
• 2:50
  , If there are recurrent, , culture-proven and documented urinary tract infections
• 2:56
  or urinary tract infections that are associated with a fever, that's also
• 3:02
  kind of a, red flag and maybe, shows that that urinary tract infection has gone
• 3:07
  from the bladder to maybe the kidneys.
• 3:10
  gross hematuria, so blood in the urine that you can see, which is in
• 3:15
  contradistinction to microhematuria, which is blood in the urine that you
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  can't see by the naked eye, but that maybe shows up on a urine specimen.
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  gross hematuria would suggest that there's a structural issue, , that's causing the
• 3:30
  bleeding as opposed to the microhematuria, which would suggest that there's
• 3:35
  some type of intrinsic renal disease.
• 3:38
  And, in those cases, usually they're, better served by a referral to a
• 3:44
  nephrologist or, a medical doctor that deals with the urinary tract as
• 3:48
  opposed to a urologist, who's a surgeon who's gonna be dealing more with,
• 3:53
  reconstruction of the genitourinary tract if that, were, to exist in the abnormal
• 4:00
  anatomy that may, affect renal function or give rise to fertility concerns
• 4:07
  Dr Sarah Gubara: Thank you for sharing those red flags with us.
• 4:09
  Now, what are the most common urologic conditions you see that are frequently
• 4:14
  over-referred and conversely, conditions that are often under-recognized
• 4:20
  or referred a little too late?
• 4:22
  Dr Gino Vricella: a good way to address this, is to talk about some of the most
• 4:28
  common, pediatric urologic diagnoses and then maybe discuss reassuring
• 4:33
  signs, that can be monitored and then other signs that, maybe should prompt
• 4:40
  referral to urologic specialist.
• 4:43
  so one very common finding is a hydrocele, so that's just fluid around the testicle.
• 4:50
  and reassuring signs would be, painless scrotal swelling.
• 4:56
  if you were to sort of turn off the light in the room and use the light on
• 5:02
  your, camera or flashlight and you, are able to trans-illuminate the scrotum,
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  that would also, tell you that likely that swelling or hydrocele is in fact
• 5:16
  just a hydrocele and only due to fluid.
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  the size of the hydrocele may fluctuate during the day.
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  and this would suggest, what's called a communicating hydrocele,
• 5:27
  which is essentially a tiny hernia.
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  but since a hernia is so small, especially when children are younger and is pretty
• 5:35
  common, you know, it only allows fluid to go across this abnormal connection
• 5:42
  and it's not large enough to admit bowel contents going through the hernia sac.
• 5:47
  And usually these resolve on their own, and so th-they can usually
• 5:50
  just be monitored over time.
• 5:53
  and if, the hydrocele has been present since infancy and is gradually improving
• 5:59
  over time, this is sort of expected.
• 6:02
  Uh, would say referral is warranted, if the hydrocele were
• 6:07
  to persist beyond 12 to 18 months.
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  I would really expect it by, you around a year and a half of age,
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  that that small connection should, close up and not allow the fluid to
• 6:20
  go across and, reabsorb over time.
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  if it seems like the hydrocele's enlarging or appears symptomatic,
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  or if you can't, , distinguish on physical exam, if there is, hernia.
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  So if there's like an associated inguinal bulge, then, , that would
• 6:42
  be, something else that, maybe it's a sign that, they need to be referred.
• 6:47
  another common diagnosis is an undescended testicle.
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  So, this is reassuring if the testis can be palpated and brought down into the
• 6:57
  scrotum, so if it's in the inguinal canal.
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  it's even more reassuring if the testis stays in the scrotum, after you let go.
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  So this would be more of a reassuring sign that the child
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  has what's known as a retractile testicle which is not, undescended.
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  So th-this can be observed as well, because over time, usually
• 7:16
  retractile testicles, do just fine, and they do sit perfectly,
• 7:22
  dependent portion of the scrotum.
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  but, , if the testicle hasn't come down and sits, perfectly normal in the
• 7:29
  scrotum by six months of age, certainly by 12 months of age, these children,
• 7:35
  they require a referral to a urologist because we have studies showing that
• 7:41
  there is permanent damage that's done to the testicle in terms of fertility if the
• 7:47
  testis hasn't been brought down surgically by as young as 18 months of age.
• 7:51
  So, , this is probably one the more frustrating, I think, and
• 7:56
  common referrals that we get.
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  when a child is now 10, 11, 12 years of age or, this happens usually when,,
• 8:05
  a child is changing pediatricians.
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  Maybe the old pediatrician never did a good genital exam or even worse,
• 8:11
  it's, , a pediatrician that is reassuring the parents that all is
• 8:16
  normal because they can feel a, testicle.
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  But I hear this, quote, "Just needs a chance to drop."
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  And so, the testis has, at this point, potentially underwent irreversible
• 8:30
  damage, if they're, older than, certainly two years of age or more.
• 8:36
  and, as the child is, growing, right, it's gonna be more challenging operation
• 8:42
  for the surgeon and more difficult in terms of recovery for the patient,
• 8:47
  Because, , if you have, 10-month-old, that distance, between the dependent portion
• 8:55
  of the scrotum and the inguinal canal where maybe you can, feel the testicle.
• 9:01
  that length is gonna be much greater at 10 years of age, than
• 9:05
  it is at, 10, , months of age.
• 9:07
  And so, this is sort of, I guess undescended testicle PSA.
• 9:12
  this is a lose-lose situation for both the patient and the urology provider.
• 9:16
  So , this is one of the more common things is like if the testicle's not down
• 9:21
  by six to 12 months of age, they should really be seen by a pediatric urologist.
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  Certainly, if you can't feel a testicle definitively, then, they should be seen
• 9:30
  by a, pediatric urologist, and, just for the reasons that we spoke about, before.
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  another common diagnosis is, what's called phimosis, which essentially
• 9:41
  is just like a tight foreskin.
• 9:44
  And, this is common in young boys.
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  it is physiologic.
• 9:48
  there's no pain.
• 9:50
  it doesn't look like they've had, infections or balanitis.
• 9:53
  There are no urinary issues.
• 9:56
  You may see some ballooning of the foreskin with urination, which is fine
• 10:00
  as long as there's no apparent urinary obstruction and the boys are making
• 10:05
  normal wet diapers, or normal urine output if they're now toilet trained.
• 10:10
  I think, probably a referral if there are pain with erections, which would
• 10:17
  suggest, that you have kind of a fixed, tightness that's not allowing the penis to
• 10:24
  extend and, get erections, without pain.
• 10:28
  if there's recurrent balanitis, so, you recurrent infections of the foreskin
• 10:33
  and, scarring to the point where you cannot pull back the foreskin
• 10:38
  to at least see the urethral meatus.
• 10:40
  I think that's something else that we would typically see, in the office and
• 10:44
  then have some shared decision-making with the parents on how much of a concern
• 10:50
  this is causing and, whether or not we try some, topical steroid creams or
• 10:55
  even, go to, circumcision, you know, depending on, what the symptoms are.
• 11:01
  another is, what's known as hydronephrosis, so prenatally
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  or ins-incidental diagnosis, backup of urine on the kidneys.
• 11:09
  it's reassuring when dil-dilation is unilateral or mild in nature.
• 11:13
  if it's stable or if it's improving on serial imaging studies.
• 11:18
  if there aren't really any associated UTIs with the hydronephrosis, I think
• 11:24
  it's okay to sort of monitor and just get serial imaging like an ultrasound.
• 11:29
  Uh, I would posit that referrals should be made when the dilation
• 11:33
  appears to be worsening over time.
• 11:37
  Certainly, if there's bilateral involvement, especially in a male
• 11:40
  child, there are some other associated diagnoses that we get a little worried
• 11:44
  about and, maybe should prompt referral, earlier as opposed to later I think
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  certainly if there have been associated urinary tract infections or it's, that,
• 11:56
  there's an obstruction, based on the degree of dilation that's seen on the
• 12:00
  imaging and,, that's progressing over time as opposed to getting better.
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  Because most hydronephrosis tends to get better, physiologically, on its own
• 12:11
  with spontaneous resolution over time.
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  And so, certainly if it's not improving, I think, we should probably be
• 12:20
  sending that over at least to monitor and get further testing if we think
• 12:24
  that, there's an obstruction there.
• 12:26
  enuresis or bedwetting.
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  So it's, reassuring when it's primary nocturnal enuresis.
• 12:33
  So, the child is, you know, , consistently wet the bed prior to or during or
• 12:38
  after toilet training, and there are no associated daytime urinary
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  symptoms, a-and the physical exam is completely normal, then, mo-most of
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  those, children, you're gonna have spontaneous resolution over time.
• 12:53
  you should really think about referral if they also have
• 12:56
  daytime urinary sy-symptoms.
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  Certainly, if there are recurrent urinary tract infections or if there
• 13:03
  are associated like neurologic symptoms or physical exam, findings that would
• 13:09
  suggest like a spinal pathology or secondary enuresis, so meaning that
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  the child did have an initial period of nighttime dryness, that then reverts
• 13:21
  back to wetting at night, then that, that could, mean that, something,
• 13:25
  progressive is going on and maybe they should see a specialist, to evaluate that.
• 13:31
  And then the other common diagnoses and this is sort of related to the
• 13:36
  hydrocele, so if there is testicular pain or swelling, this is pretty
• 13:41
  reassuring when the pain is mild, it's intermittent, it's ephemeral.
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  if it's associated with activity and, you get a scrotal ultrasound that does
• 13:52
  not demonstrate that there's any obvious pathology to explain the pain, as we're
• 13:58
  learning more and more about pain, it's sort of a complex Neurologic condition.
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  There are many different reasons that a child can have pain.
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  but certainly if physical exam and the imaging findings, normal, and, doesn't
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  explain the pain, and it seems like it's, pretty mild, it doesn't seem like
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  it's impacting, their activities, then I think it's probably okay to monitor
• 14:23
  that and hopefully that, over some period of time or period of weeks to
• 14:28
  even months, that it seems to, resolve.
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  I think, immediate referral if there's sudden severe pain and
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  swelling that doesn't go away, if there's associated nausea or emesis.
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  , The largest concern here would be for something called testicular torsion,
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  which is a surgical emergency.
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  So I think, in those kids when there's pain, there's swelling, there's nausea
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  and vomiting associated with the scrotal swelling, and it's unilateral
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  in nature, and it, wakes them up from sleep, these are all, concerning.
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  They need to be seen immediately in an emergency room for, , physical exam and,
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  certainly an ultrasound of the scrotum to verify whether or not there's, blood flow
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  that's being impacted to the testicle, which is, the testicular torsion.
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  So I think those would be sort of the most common, diagnoses
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  and when you can monitor that and when you should refer out.
• 15:29
  Dr Sarah Gubara: Thank you for sharing some of those key factors
• 15:31
  about when a referral is indicated.
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  How can pediatricians confidently differentiate between normal anatomic or
• 15:41
  developmental variations from findings that warrant further urologic evaluation?
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  Dr Gino Vricella: the different providers are going to, certainly have
• 15:51
  different levels of comfort, when it comes to evaluation and management
• 15:56
  of, urologic anatomical variation.
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  so probably experience is gonna be the largest driver for this.
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  if there is a real concern that what is going on is either unlikely to resolve
• 16:09
  or is going to harm the long-term urologic health of the child, then, this
• 16:13
  probably warrants further investigation by a specialist who is, gonna be more
• 16:18
  well-equipped, to make that judgment call
• 16:21
  Dr Sarah Gubara: That makes sense.
• 16:22
  And what role does imaging, labs, trial management and primary care
• 16:28
  play, before that referral step?
• 16:31
  And when can those steps be safely skipped and referred to a specialist like you?
• 16:38
  Dr Gino Vricella: probably it depends on the acute nature
• 16:41
  and severity of the illness.
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  the overwhelming majority of the common diagnoses that we briefly went over before
• 16:49
  are not necessarily life-threatening.
• 16:51
  And so I don't, think that there is a significant role that primary
• 16:55
  care, can play when it comes to evaluation and management of,
• 16:59
  common neurologic conditions
• 17:02
  Dr Sarah Gubara: So as you think about some of the key factors
• 17:06
  that pediatricians or families can look for, what can be helpful to
• 17:11
  keep in mind for referrals, versus continued monitoring in primary care?
• 17:17
  Dr Gino Vricella: I think confidence, goes a long way when you're
• 17:21
  giving reassurance, a family.
• 17:23
  So I think some themes, that I think are helpful to reiterate to
• 17:28
  some of these families are, that the condition is relatively common.
• 17:32
  It's not life-threatening, often resolves over time.
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  And in the rare instances when the condition requires treatment,
• 17:39
  the success rate is very high.
• 17:41
  And, , most children, regardless of the diagnosis and severity, can live
• 17:45
  normal long, healthy, happy lives.
• 17:48
  Dr Sarah Gubara: Wonderful.
• 17:49
  Okay, our wisdom question for you.
• 17:51
  What practical advice would you give pediatricians to help
• 17:55
  families understand when a urologic condition sounds scary but isn't
• 18:01
  Dr Gino Vricella: reiterating what we were talking about before, I, think
• 18:04
  that, a lot of these diagnoses, as they're related to the urinary tract,
• 18:09
  I think, it's a scary thing, right?
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  Because everybody's worried about long-term, fertility
• 18:16
  concerns, sexual function, the ability to, just be a normal kid.
• 18:23
  And so The themes that are helpful to reiterate are that a lot of
• 18:30
  these conditions are very common.
• 18:33
  the condition oftentimes, e-even if it is an acute condition that requires surgical
• 18:40
  intervention, it's not life-threatening.
• 18:42
  it will oftentimes spontaneously resolve over a period of time.
• 18:49
  I think that the instances where, child is gonna require,
• 18:55
  surgical intervention, is, rare.
• 18:59
  Uh, We evaluate many, many, many more patients and, we're gonna observe those
• 19:05
  patients than we actually take to surgery.
• 19:08
  but for those that do require a surgical intervention, the
• 19:13
  success rate is very high.
• 19:15
  And, most of the children, regardless of the diagnosis and severity,
• 19:19
  they're gonna do just fine.
• 19:22
  And so, a lot of these interventions, they're tried and true.
• 19:26
  very, very few, experimental interventions.
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  and so I would say this is, you know, a way that, we can reassure
• 19:35
  families that, "Listen, we have very good specialists in this field.
• 19:41
  They have a lot of experience."
• 19:44
  And, the best case scenario obviously is not having to do anything.
• 19:49
  But in those instances where something needs to be done, we're
• 19:54
  well-equipped, we're well-trained to take care of those conditions.
• 19:58
  And we will get those children, on, and moving forward past this diagnosis.
• 20:05
  And something that is a lasting intervention and that these
• 20:11
  children can live normal, long, healthy, happy lives afterwards
• 20:16
  Dr Sarah Gubara: Thank you so much for taking the time to educate us, Dr.
• 20:19
  Vercellotti.
• 20:19
  This has been wonderful to learn about.
• 20:23
  And as a reminder to our audience, claim your CME credits after listening
• 20:28
  to this fascinating episode today.
• 20:30
  You can do so by visiting cmkc.link/cmepodcast
• 20:33
  and then click the Claim CME button.
• 20:41
  If you enjoyed this podcast, please share it on your social channels
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• 20:49
  I'm Dr.
• 20:50
  Sarah Gubara, and this has been Pediatrics in Practice, a CME podcast