Patterns of care in testicular torsion: influence of hospital transfer on testicular outcomes

OBJECTIVE

To investigate patterns of care for testicular torsion and influence of hospital transfers on testicular outcomes. Hospital transfer may be a source of treatment delay in a condition where delays increase likelihood of orchiectomy.

METHODS

We used a retrospective cohort of Californian males with ICD-9/CPT-defined torsion from inpatient, emergency department (ED), and ambulatory surgery center (ASC) data. Logistic regression assessed predictors of orchiectomy.

RESULTS

Predictors of orchiectomy were ages <1 year (OR 19.2, 95% CI 6.3-58.9), 1-9 years (OR 2.7, 95% CI 1.4-5.2), and ≥40 years (OR 6.6, 95% CI 3.1-13.9) (vs. masked age). Treatment at mid-volume (vs. high-volume) facilities was associated with lower odds of orchiectomy (OR 0.5, 95% CI 0.3-0.7). Rural location, non-private insurance, and hospital transfer were associated with orchiectomy on univariate but not multivariate analysis. During 2008-2010, 2794 subjects experienced torsion (average incidence 5.08 per 100,000 males yearly). Encounters occurred in ASCs (55%), inpatient facilities (36%), and EDs (9%). 60% of subjects were privately insured, 2% experienced hospital transfer, and 31% underwent orchiectomy.

CONCLUSION

Our census found that most cases of testicular torsion were treated in outpatient settings. Hospital transfer was not associated with orchiectomy.

Use of urine testing in outpatients treated for urinary tract infection

OBJECTIVE

To characterize urine test use in ambulatory, antibiotic-treated pediatric urinary tract infection (UTI).

METHODS

We studied children <18 years who had an outpatient UTI and a temporally associated antibiotic prescription from 2002 through 2007 by using a large claims database, Innovus i3. We evaluated urine-testing trends and performed multivariable logistic regression to assess for factors associated with urine culture use.

RESULTS

Of 40 603 treated UTI episodes in 28 678 children, urinalysis was performed in 76%, and urine culture in 57%; 32% of children <2 years had no urinalysis or culture performed for an antibiotic-treated UTI episode. Urine culture use decreased during the study period from 60% to 54% (P < .001). We observed variation in urine culture use with age (<2 years: odds ratio [OR] 1.0, 95% confidence interval [CI] 0.9-1.1; 2-5 years: OR 1.3, 95% CI 1.2-1.4; 6-12 years: OR 1.3, 95% CI 1.2-1.4, compared with 13-17 years); gender (boys: OR 0.8, 95% CI 0.8-0.9); and specialty (pediatrics: OR 2.6, 95% CI 2.5-2.8; emergency medicine, OR 1.2, 95% CI 1.1-1.3; urology: OR 0.5, 95% CI 0.4-0.6, compared with family/internal medicine). Recent antibiotic exposure (OR 1.1, 95% CI 1.1-1.2) and empirical broad-spectrum prescription (OR 1.2, 95% CI 1.1-1.2) were associated with urine culture use, whereas previous UTI and urologic anomalies were not.

CONCLUSIONS

Providers often do not obtain urine tests when prescribing antibiotics for outpatient pediatric UTI. Variation in urine culture use was observed based on age, gender, and physician specialty. Additional research is necessary to determine the implications of empirical antibiotic prescription for pediatric UTI without confirmatory urine testing.

Management trends in prenatally detected hydronephrosis: national survey of pediatrician practice patterns and antibiotic use

OBJECTIVE

To assess the practice patterns of general pediatricians in the management of prenatally detected hydronephrosis. Hydronephrosis is the most common abnormality found on prenatal ultrasonography. The utility of prophylactic antibiotics in the postnatal management of this condition is controversial. No study has assessed the practice patterns of general pediatricians in the management of prenatally detected hydronephrosis.

METHODS

An 18-question survey was sent to a random cross-section national sample of pediatricians from the American Medical Association Masterfile. The participants answered questions regarding practice location and type, practice experience, frequency of cases seen, familiarity with the published data, use of antibiotics, workup of hydronephrosis, and specialist referral. Multivariate logistic regression analysis was used to identify the factors associated with prescribing antibiotics.

RESULTS

Of the 461 pediatricians, 244 (53%) responded. Of the respondents, 56% routinely prescribed antibiotics for prenatally detected hydronephrosis, and 57% performed the postnatal workup themselves. Of these, 98% routinely ordered ultrasound scans and ∼40% routinely ordered voiding cystourethrograms. Of the respondents, 94% always had specialists readily available; however, only 41% always referred to a specialist. On multivariate logistic regression analysis, those who believe prophylactic antibiotics to be beneficial were significantly more likely to prescribe antibiotics than those who had not read the published data (odds ratio 6.1, 95% confidence interval 2-15). Those without specialist consultation readily available had an increased odds of starting prophylactic antibiotics compared with those who had consultation available (odds ratio 7.2, 95% confidence interval 1.3-39).

CONCLUSION

Most pediatricians initiate postnatal management of prenatally detected hydronephrosis; therefore, pediatricians truly are the gatekeepers for children with this condition. Knowledge of the practice patterns is crucial for the dissemination of evidence-based information to the appropriate providers and will enable us to learn more about the utility of antibiotic prophylaxis in future studies.

Imaging use and cryptorchidism: determinants of practice patterns

PURPOSE

We determined the rate of diagnostic imaging use for the preoperative evaluation of boys with cryptorchidism and the factors that influence referring providers to obtain imaging.

MATERIALS AND METHODS

We conducted a national cross-sectional survey of pediatricians randomly sampled from the American Medical Association Physician Masterfile. The primary outcome was whether the respondent obtained imaging at the initial evaluation of boys with cryptorchidism. Participants were queried regarding practice location and type, length of time in practice, frequency of reading academic journals and the accessibility of surgical subspecialists. For those who ordered imaging, respondents were asked how frequently they ordered imaging, and were asked to select patient factors and professional beliefs that influenced their decision to obtain imaging. Factors associated with imaging use were identified using multivariate logistic regression.

RESULTS

Of the pediatricians who acknowledged contact by surveyors 47% completed the survey and 34% of respondents reported always or usually ordering imaging. Of those who obtained imaging 96.4% used ultrasound. Pediatricians in practice fewer than 20 years (OR 3.43, 95% CI 1.92-6.16) and those in nonacademic practices (OR 3.00, 95% CI 1.34-6.71) were more likely to order imaging. Pediatricians obtained imaging because of beliefs that imaging reliably identifies a nonpalpable testis, reassures the family and assists the surgeon with operative planning.

CONCLUSIONS

Ultrasound is heavily used by pediatricians for the preoperative evaluation of cryptorchidism, especially when the testis is nonpalpable. Given the poor diagnostic performance of ultrasound in this setting, we recommend developing strategies to reduce imaging use in cryptorchidism.

Ovarian pathology for the pediatric urologist

OBJECTIVES

To report the breadth of ovarian conditions that pediatric urologists may encounter through diverse referral patterns.

METHODS

Two regional pediatric centers reviewed cases from 2000 to 2010, yielding 13 females with gonad-related conditions.

RESULTS

Six of 13 patients (46%) were referred for a presumed urological condition that was later discovered to be of ovarian origin or were already known to the urology clinic for a congenital urological anomaly. Six patients had tumor markers drawn, all of which were normal. Median age was 11.2 years. The most common presenting symptoms were pain (6/13), emesis (5/13), and precocious puberty (2/13). Median mass diameter was 7.5 cm with 2 patients having masses greater than 20 cm. Histologic diagnosis was mature teratoma (4/13), streak gonad (3/13), and hemorrhagic cyst (2/13). Two patients had potentially malignant tumors (immature teratoma and juvenile granulosa cell tumor).

CONCLUSIONS

At our centers, an ovarian condition is encountered an average of 1.3 times per year. As management of pediatric ovarian cysts and masses is controversial, pediatric urologists should be familiar with the diagnosis and treatment of such conditions.

Penile embryology and anatomy

Knowledge of penile embryology and anatomy is essential to any pediatric urologist in order to fully understand and treat congenital anomalies. Sex differentiation of the external genitalia occurs between the 7and 17 weeks of gestation. The Y chromosome initiates male differentiation through the SRY gene, which triggers testicular development. Under the influence of androgens produced by the testes, external genitalia then develop into the penis and scrotum. Dorsal nerves supply penile skin sensation and lie within Buck's fascia. These nerves are notably absent at the 12 o'clock position. Perineal nerves supply skin sensation to the ventral shaft skin and frenulum. Cavernosal nerves lie within the corpora cavernosa and are responsible for sexual function. Paired cavernosal, dorsal, and bulbourethral arteries have extensive anastomotic connections. During erection, the cavernosal artery causes engorgement of the cavernosa, while the deep dorsal artery leads to glans enlargement. The majority of venous drainage occurs through a single, deep dorsal vein into which multiple emissary veins from the corpora and circumflex veins from the spongiosum drain. The corpora cavernosa and spongiosum are all made of spongy erectile tissue. Buck's fascia circumferentially envelops all three structures, splitting into two leaves ventrally at the spongiosum. The male urethra is composed of six parts: bladder neck, prostatic, membranous, bulbous, penile, and fossa navicularis. The urethra receives its blood supply from both proximal and distal directions.

Does severity of renal scarring on DMSA scan predict abnormalities in creatinine clearance?

OBJECTIVES

To examine the relationship between severity of renal scarring and creatinine clearance. Existing studies on renal scarring and functional outcomes have focused on the presence or absence of scarring.

METHODS

Patients with a history of urinary tract infection leading to the diagnosis of vesicoureteral reflux were recruited. These subjects were admitted to a pediatric research center for an in-patient collection of 24-hour urine to be sent for creatinine and protein. DMSA scans performed at least 6 months after documented urinary tract infection were graded by 3 independent, blinded pediatric urologists for renal scarring according to the Randomized Intervention for Children with Vesicoureteral Reflux study criteria.

RESULTS

Twenty-nine subjects (14 girls, 15 boys) with a median age of 7 years were recruited. Scar grading was reliable between the observers with a Kappa score of 0.66-0.75. On DMSA scan, 10% were scar-free, 62% had unilateral scars, and 28% had bilateral scars. Mean creatinine clearance was 123 for those with unilateral disease and 100 for those with bilateral disease (P = .048). Median proteinuria (58 mg/dL) and serum creatinine (0.5 mg/dL) were similar between the 2 groups. Creatinine clearance did not differ according to average scar grade, taking both kidneys into account.

CONCLUSIONS

In children with vesicoureteral reflux, although those with bilateral scarring have a significantly lower creatinine clearance than those with unilateral scarring, the severity of scar grade alone does not predict overall creatinine clearance with short-term follow-up.

Environmental factors in genitourinary development

PURPOSE

In the last century the world has experienced an increase in the use of industrial chemicals as well as possible increases in the prevalence of hypospadias and cryptorchidism. Because hormones regulate the fetal development of many organs, numerous investigations have explored the role of environmental factors in genitourinary growth. We summarize the data regarding endocrine disruptors in human genitourinary development.

MATERIALS AND METHODS

A PubMed literature search was performed for human studies from 2004 to 2009.

RESULTS

Few data exist on environmental influences on the kidneys, ureters or bladder. Studies on the influence of pesticides, vegetarian diets, diethylstilbestrol, oral contraceptives and corticosteroids on hypospadias have yielded varied conclusions. Phthalates appear to increase the odds of hypospadias and anogenital distance. The testicular dysgenesis syndrome postulates that cryptorchidism, hypospadias, poor semen quality and testicular cancer share a common environmental origin. In utero exposure to diethylstilbestrol has been shown to increase the risk of testicular dysgenesis syndrome. However, to our knowledge no other environmental factor has been shown to cause testicular dysgenesis syndrome. Some industrial chemicals as well as the pesticide dichloro-diphenyl-trichloroethane have detrimental effects on semen quality. In cases of documented industrial accidents, chemical exposure has also decreased the male-to-female birth ratio.

CONCLUSIONS

Data on chemical exposure are largely mixed and inconclusive. Studies of populations with high exposure rates due to industrial accidents or in utero exposure to diethylstilbestrol suggest that endocrine disruptors adversely affect genitourinary development.

Histologic differences between extrinsic and intrinsic ureteropelvic junction obstruction

OBJECTIVE

Ureteropelvic junction obstruction (UPJ) can be caused by intrinsic disorganization or extrinsic compression from crossing vessels (CV). What is not clear is whether there is also intrinsic UPJ pathology in patients with CV. Recent surgeries, such as the Hellström vascular hitch procedure, move the CV cephalad without resecting the UPJ, which presumes no intrinsic narrowing. Our aim was to determine whether the histologic features of the 2 types of UPJ obstruction are distinct enough to enable a blinded pathologist to histologically identify the cause of obstruction.

METHODS

We reviewed all patients undergoing pyeloplasties from 2000 to 2006. All CV cases with available pathology were selected. A random selection of intrinsic cases was used as controls. One blinded pathologist reviewed the histology, specifically scoring muscle and collagen density.

RESULTS

Sixteen patients were reviewed. Seven had CV and 9 had intrinsic obstruction. Muscle density was different between the 2 groups with CV denser compared with intrinsic (P = .005). The pathologist correctly assigned the cause of obstruction in 5/7 (71%) of CV and 7/9 (78%) of intrinsic cases (P = .039).

CONCLUSIONS

Identification of a significant CV intraoperatively does translate to a discernible appearance histologically.

A diagnostic algorithm for urachal anomalies

OBJECTIVE

Urachal anomalies are rare. Variable presentations can be a diagnostic challenge. We combine our series with a review of literature to delineate the most common presentations, highest yield diagnostic studies and a diagnostic algorithm.

METHODS

We reviewed records of 22 boys and 15 girls with the diagnosis of a urachal anomaly from 2000 through 2005. This revealed 19 cysts, seven patent urachuses, five sinuses, four patients with unspecified "urachal anomalies," and two patients with no urachal anomaly by surgical exploration. Ultrasound was the most common diagnostic study, followed by computed tomography (CT), voiding cystourethrogram and sinogram. Thirty-five of 37 patients underwent surgery.

RESULTS

Clinical presentation included periumbilical leakage in 54%, pain in 30%, periumbilical mass in 22% and irritative voiding symptoms in 14%. In many patients diagnosis was made on clinical examination alone. When an ultrasound was used it was diagnostic for 82% of cysts, 100% of sinuses and 100% of patent urachuses. A voiding cystourethrogram was diagnostic for 100% of patent urachuses, but less successful in the other anomalies. CT scans correctly diagnosed 71% of cysts. Overall complication rate was 9%, all wound infections.

CONCLUSION

Reviewing the results of this and four other large series showed that the most common anomaly is the urachal cyst followed by urachal sinus and patent urachus. Periumbilical drainage is the most common presentation. Physical exam alone can be diagnostic. When this is not possible ultrasound is our recommended initial study, followed by a CT scan if unsuccessful.