Dr. Sarah Gubara (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm Dr. Sarah Gubara. And today, I'm joined by Dr. Gino Vricella, a board-certified pediatric urologist and Associate Professor of Surgery at the University of Missouri Kansas City School of Medicine. Today, we're exploring conditions of pediatric urology. Dr. Vricella, thank you so much for taking the time to join us this morning.

Dr. Gino Vricella: Absolutely. My pleasure. Thanks for having me

Host: Of course. We're happy to have you. Now, to get us started, when pediatricians see common urologic findings, what are the reassuring signs that suggest the condition is benign and can be observed versus red flags that should prompt referral?

Dr. Gino Vricella: I think that a quick clinical heuristic that we can utilize is to ask yourself which of the following is true. So, is this condition symmetric? Is it painless? Is it stable? Or is the condition improving? So if so, then I think the condition is likely benign, and it's probably okay to observe. The corollary to that would be that, if the condition is, painful, or if it's asymmetric. So if it's just on one side, if it seems like it's progressive or if it's affecting their day-to-day function or their ability to do the things that they want to do, then, would be some red flags that should, probably, prompt a referral.

So across, you know, many conditions, I think the features that suggest a benign process as they relate to, say, urologic tract is in terms of the asymptomatic realm, is there a urinary issue? Is there a normal pattern of urination? So, do they have a strong, well-directed urinary stream? There doesn't seem like there's any apparent straining with urination, no urinary tract infections, and there's no associated, systemic symptoms like fevers, weight loss, or associated GI symptoms.

So, some general red flags I think that you can utilize that I think would probably, you know, prompt more urgent referral would be pain, especially if there's acute or severe pain that wakes you up from sleep or pain that does not allow you to perform those activities of either daily living or just, playing, going to school, that sort of thing. If there are recurrent, culture-proven and documented urinary tract infections or urinary tract infections that are associated with a fever, that's also kind of red flag and maybe shows that that urinary tract infection has gone from the bladder to maybe the kidneys; gross hematuria, so blood in the urine that you can see, which is in contradistinction to microhematuria, which is blood in the urine that you can't see by the naked eye, but that maybe shows up on a urine specimen.

Gross hematuria would suggest that there's a structural issue that's causing the bleeding as opposed to the microhematuria, which would suggest that there's some type of intrinsic renal disease. And, in those cases, usually, they're better served by a referral to a nephrologist or a medical doctor that deals with the urinary tract as opposed to a urologist, who's a surgeon who's going to be dealing more with reconstruction of the genitourinary tract if that were to exist in the abnormal anatomy that may affect renal function or give rise to fertility concerns

Host: Thank you for sharing those red flags with us. Now, what are the most common urologic conditions you see that are frequently over-referred and, conversely, conditions that are often underrecognized or referred a little too late?

Dr. Gino Vricella: A good way to address this is to talk about some of the most common, pediatric urologic diagnoses and then maybe discuss reassuring signs that can be monitored and then other signs that maybe should prompt referral to urologic specialist.

So, one very common finding is a hydrocele. So, that's just fluid around the testicle. And reassuring signs would be painless scrotal swelling. If you were to sort of turn off the light in the room and use the light on your camera or flashlight and you are able to trans-illuminate the scrotum, that would also tell you that likely that swelling or hydrocele is in fact just a hydrocele and only due to fluid.

The size of the hydrocele may fluctuate during the day. And this would suggest what's called a communicating hydrocele, which is essentially a tiny hernia. But since a hernia is so small, especially when children are younger and is pretty common, you know, it only allows fluid to go across this abnormal connection. And it's not large enough to admit bowel contents going through the hernia sac. And usually, these resolve on their own. And so, they can usually just be monitored over time. And if the hydrocele has been present since infancy and is gradually improving over time, this is sort of expected.

I would say referral is warranted if the hydrocele were to persist beyond 12 to 18 months. I would really expect it by around a year and a half of age, that that small connection should close up and not allow the fluid to go across and reabsorb over time. If it seems like the hydrocele's enlarging or appears symptomatic, or if you can't distinguish on physical exam if there is hernia. So if there's like an associated inguinal bulge, then that would be something else that maybe it's a sign that they need to be referred.

Another common diagnosis is an undescended testicle. So, this is reassuring if the testis can be palpated and brought down into the scrotum, so if it's in the inguinal canal. It's even more reassuring if the testis stays in the scrotum, after you let go. So, this would be more of a reassuring sign that the child has what's known as a retractile testicle, which is not undescended. So, this can be observed as well. Because over time, usually retractile testicles do just fine, and they do sit perfectly, dependent portion of the scrotum.

But if the testicle hasn't come down and sits perfectly normal in the scrotum by six months of age, certainly by 12 months of age, these children, they require a referral to a urologist because we have studies showing that there is permanent damage that's done to the testicle in terms of fertility. If the testis hasn't been brought down surgically by as young as 18 months of age.

So, this is probably one the more frustrating, I think, and common referrals that we get. When a child is now 10, 11, 12 years of age or older, this happens usually when a child is changing pediatricians, maybe the old pediatrician never did a good genital exam or, even worse, it's a pediatrician that is reassuring the parents that all is normal because they can feel a testicle. But I hear this, "Just needs a chance to drop."

And so, the testis has, at this point, potentially underwent irreversible damage, if they're older than, certainly two years of age or more. And as the child is growing, right? It's going to be more challenging operation for the surgeon and more difficult in terms of recovery for the patient. Because if you have a 10-month-old, that distance between the dependent portion of the scrotum and the inguinal canal where maybe you can feel the testicle, that length is going to be much greater at 10 years of age, than it is at 10 months of age. And so, this is sort of, I guess, undescended testicle PSA. This is a lose-lose situation for both the patient and the urology provider.

So, this is one of the more common things is like if the testicle's not down by six to 12 months of age, they should really be seen by a pediatric urologist. Certainly, if you can't feel a testicle definitively, then they should be seen by a pediatric urologist, and just for the reasons that we spoke about before.

Another common diagnosis is what's called phimosis, which essentially is just like a tight foreskin. And this is common in young boys. It is physiologic. There's no pain. It doesn't look like they've had infections or balanitis. There are no urinary issues. You may see some ballooning of the foreskin with urination, which is fine as long as there's no apparent urinary obstruction. And the boys are making normal wet diapers, or normal urine output if they're now toilet trained.

I think, probably a referral if there are pain with erections, which would suggest that you have kind of a fixed tightness that's not allowing the penis to extend and get erections without pain. If there's recurrent balanitis, so recurrent infections of the foreskin and scarring to the point where you cannot pull back the foreskin to at least see the urethral meatus, I think that's something else that we would typically see in the office and then have some shared decision-making with the parents on how much of a concern this is causing, or not we try some topical steroid creams or even go to circumcision, you know, depending on what the symptoms are.

Another is what's known as hydronephrosis, so prenatally or incidental diagnosis, backup of urine on the kidneys. It's reassuring when dilation is unilateral or mild in nature, if it's stable or if it's improving on serial imaging studies, if there aren't really any associated UTIs with the hydronephrosis, I think, it's okay to sort of monitor and just get serial imaging like an ultrasound.

I would posit that referrals should be made when the dilation appears to be worsening over time. Certainly, if there's bilateral involvement, especially in a male child, there are some other associated diagnoses that we get a little worried about and maybe should prompt referral earlier as opposed to later.

I think certainly if there have been associated urinary tract infections or it's suspected that there's an obstruction, based on the degree of dilation that's seen on the imaging and that's progressing over time as opposed to getting better. Because most hydronephrosis tends to get better physiologically on its own with spontaneous resolution over time. And so, certainly if it's not improving, I think, we should probably be sending that over at least to monitor and get further testing if we think that there's an obstruction there.

 Enuresis or bedwetting. So, it's reassuring when it's primary nocturnal enuresis. So, the child, you know, consistently wet the bed prior to or during or after toilet training, and there are no associated daytime urinary symptoms, and the physical exam is completely normal. Then, most of those children, you're going to have spontaneous resolution over time.

You should really think about referral if they also have daytime urinary symptoms. Certainly, if there are recurrent urinary tract infections or if there are associated like urologic symptoms or physical exam findings that would suggest like a spinal pathology or secondary enuresis, so meaning that the child did have an initial period of nighttime dryness, that then reverts back to wetting at night, then that that could, mean that something progressive is going on and maybe they should see a specialist to evaluate that.

And then, the other common diagnoses and this is sort of related to the hydrocele, so if there is testicular pain or swelling, this is pretty reassuring when the pain is mild, it's intermittent, it's ephemeral. If it's associated with activity and you get a scrotal ultrasound that does not demonstrate that there's any obvious pathology to explain the pain, as we're learning more and more about pain, it's sort of a complex urologic condition. There are many different reasons that a child can have pain. But certainly if physical exam and the imaging findings are normal, and doesn't explain the pain, and it seems like it's pretty mild, it doesn't seem like it's impacting their activities, then I think it's probably okay to monitor that. And hopefully, over some period of time or period of weeks to even months, that it seems to resolve.

I think immediate referral if there's sudden severe pain and swelling that doesn't go away, if there's associated nausea or emesis, largest concern here would be for something called testicular torsion, which is a surgical emergency. So, I think, in those kids when there's pain, there's swelling, there's nausea and vomiting associated with the scrotal swelling, and it's unilateral in nature, and it wakes them up from sleep, these are all concerning. They need to be seen immediately in an emergency room for physical exam and certainly an ultrasound of the scrotum to verify whether or not there's blood flow that's being impacted to the testicle, which is the testicular torsion. So, I think those would be sort of the most common diagnoses, and when you can monitor that and when you should refer out.

Host: Thank you for sharing some of those key factors about when a referral is indicated. How can pediatricians confidently differentiate between normal anatomic or developmental variations from findings that warrant further urologic evaluation?

Dr. Gino Vricella: The different providers are going to certainly have different levels of comfort, when it comes to evaluation and management of urologic anatomical variation. So, probably experience is going to be the largest driver for this. If there is a real concern that what is going on is either unlikely to resolve or is going to harm the long-term urologic health of the child, then this probably warrants further investigation by a specialist who is going to be more well-equipped to make that judgment call

Host: That makes sense. And what role does imaging, labs, trial management and primary care play, before that referral step? And when can those steps be safely skipped and referred to a specialist like you?

Dr. Gino Vricella: Probably it depends on the acute nature and severity of the illness. The overwhelming majority of the common diagnoses that we briefly went over before are not necessarily life-threatening. And so, I don't think that there is a significant role that primary care can play when it comes to evaluation and management of common urologic conditions

Host: So as you think about some of the key factors that pediatricians or families can look for, what can be helpful to keep in mind for referrals, versus continued monitoring in primary care?

Dr. Gino Vricella: I think confidence goes a long way when you're giving reassurance, a family. So I think some themes, that I think are helpful to reiterate to some of these families, that the condition is relatively common. It's not life-threatening, often resolves over time. And in the rare instances when the condition requires treatment, the success rate is very high. And most children, regardless of the diagnosis and severity, can live normal long, healthy, happy lives.

Host: Wonderful. Okay. Our wisdom question for you. What practical advice would you give pediatricians to help families understand when a urologic condition sounds scary, but isn't?

Dr. Gino Vricella: Reiterating what we were talking about before, I think that a lot of these diagnoses, as they're related to the urinary tract, I think, it's a scary thing, right? Because everybody's worried about long-term, fertility concerns, sexual function, the ability to just be a normal kid.

And so, the themes that are helpful to reiterate are that a lot of these conditions are very common. The condition oftentimes, even if it is an acute condition that requires surgical intervention, it's not life-threatening. It will oftentimes spontaneously resolve over a period of time.

I think that the instances where a child is going to require surgical intervention is rare. We evaluate many, many, many more patients and we're going to observe those patients than we actually take to surgery. But for those that do require a surgical intervention, the success rate is very high. And most of the children, regardless of the diagnosis and severity, they're going to do just fine. And so, a lot of these interventions, they're tried and true. Very, very few, experimental interventions. And so, I would say this is, you know, a way that we can reassure families that, "Listen, we have very good specialists in this field. They have a lot of experience." And the best case scenario, obviously, is not having to do anything. But in those instances where something needs to be done, we're well-equipped, we're well-trained to take care of those conditions. And we will get those children on and moving forward past this diagnosis. And something that is a lasting intervention and that these children can live normal, long, healthy, happy lives afterwards.

Host: Thank you so much for taking the time to educate us, Dr. Vricella. This has been wonderful to learn about. And as a reminder to our audience, claim your CME credits after listening to this fascinating episode today. You can do so by visiting cmkc.link/cmepodcast and then click the Claim CME button. If you enjoyed this podcast, please share it on your social channels and check out the entire podcast library for topics of interest to you. I'm Dr. Sarah Gubara, and this has been Pediatrics in Practice, a CME podcast