Assessment of referral patterns for boys with suspected undescended testes and identification of risk factors to aid diagnosis.

INTRODUCTION: Undescended testis (UDT) is a clinical diagnosis and a common reason for referral to paediatric urology outpatients. Our aim was to assess current referral patterns at our unit and to identify predictive factors that may better aid primary care physicians (PCP) in diagnosing UDT based on history and physical exam. METHODS: A retrospective analysis of referrals to outpatients from 2014 to 2016 was performed to assess current referral patterns including referral source, age, reason for referral and outcome following assessment by a single consultant paediatric urologist.A prospective analysis of new referrals was performed to identify predictive factors which may aid in the diagnosis of UDT including gestational age, presence of scrotal asymmetry and previously obtained imaging. RESULTS: From 2014 to 2016, 259 boys were referred with suspected UDT. The majority of referrals were received from PCPs (62%) followed by Neonatology (29%), Paediatrics (8%) and general surgery (1%). Median age at time of assessment was 29 (5-180) months. One hundred and eight (41.7%) boys were diagnosed with UDT.There were 74 boys assessed prospectively. Median age at assessment was 24.5 (6-171) months. We identified 3 predictors of a diagnosis of UDT; history of prematurity (p = 0.001), UDT mentioned to the parents at birth (p = 0.027) and scrotal asymmetry on examination (p < 0.001). Greatest diagnostic inaccuracy was found in boys referred beyond one year of age (27.7%). In this cohort, the absence of all three risk factors was associated with a negative predictive value of 94.1%. CONCLUSION: The majority of boys with suspected UDT are referred beyond the age recommended for orchidopexy (6-12 months). The majority of boys referred for assessment did not have UDT. We have identified three predictive factors that may aid referring physicians when assessing boys, particularly those older than 1 year.

Aetiology, epidemiology and management strategies for blunt scrotal trauma.

OBJECTIVES: To describe our experience of all patients presenting to a tertiary referral centre over a 3 year time period with blunt scrotal trauma and to describe a methodical approach for managing this group of patients. METHODS: A retrospective analysis was performed on all patients presenting to the Emergency Department (ED) of a level 1 trauma centre with blunt scrotal trauma from 2010 to 2013 inclusive. Inclusion criteria included a recent history of blunt scrotal trauma with associated pain and/or swelling of the affected testis on clinical examination. RESULTS: Twenty-seven male patients with a median age of 19 (range 8-65) years were included and all but 1 patient underwent scrotal ultrasonography upon presentation. Sixteen patients (59%) presented with scrotal trauma secondary to a sports related injury. Fifteen patients were managed conservatively and of the 12 who underwent urgent exploration 9 had a testicular rupture, including 1 who had an emergency orchidectomy due to a completely shattered testis. Four patients had >30% of the testis replaced by necrotic tissue/haematoma; of which 2 ultimately underwent orchidectomy and insertion of testicular prosthesis. CONCLUSION: Our findings demonstrate that the necessity for scrotal protection in sports that predispose to scrotal trauma should be reviewed. We also demonstrate the importance of scrotal ultrasonography for determining an appropriate management strategy (i.e., conservative versus surgical treatment) in this young patient cohort.

Lessons learned using Snodgrass hypospadias repair.

BACKGROUND: This is a review of our experience with the Snodgrass technique for distal hypospadias repair and we point to lessons learned in improving results. METHODS: We reviewed all patients who underwent Snodgrass hypospadias repair for distal hypospadias over a four-year period by a single surgeon. Chart review followed by parental telephone interview was used to determine voiding function, cosmesis and complication rate. RESULTS: Thirty children and three adults were identified. Age at surgery ranged from seven months to 39 years. The urinary stream was straight in 94%, and 97% reported a good or satisfactory final cosmetic outcome. One patient (3.3%) developed a urethral fistula and 21% developed meatal stenosis which required general anaesthetic. CONCLUSION: The Snodgrass urethroplasty provides satisfactory cosmetic and functional results. High rates of meatal stenosis initially encountered have improved with modifications to technique which include modified meatoplasty and routine meatal dilatation by the parents.

Re-evaluating the role of Doppler ultrasonography in patients presenting with scrotal pain.

AIM: To describe our experience of all patients presenting to a tertiary referral centre over a 5-year time period with acute scrotum and to investigate the role of Doppler ultrasonography (DUS) for investigating this group of patients. METHOD: A retrospective analysis was performed on all patients presenting to the emergency department (ED) of a level 1 trauma centre with acute scrotum from 2009 to 2014 inclusive. Inclusion criteria included all patients who underwent an investigatory DUS and/or emergency scrotal exploration. Recorded patient demographics included age, presenting symptoms, duration of symptoms and relevant examination findings. RESULT: Three-hundred and twelve patients were included with a mean age of 15 years (range 1 day-40 years). In total, 106 patients underwent immediate scrotal exploration, and testicular torsion (TT) was found in 30 % (n = 32/106). Two-hundred and twenty-two patients were initially investigated with DUS and 16 (7.2 %) proceeded to scrotal exploration. Of this sub-group, 2/16 presented with a history <24 h and exploration was negative for TT. In comparison, 14/16 presented with a history >24 h, and DUS findings were consistent with TT. No patients with a normal DUS represented to the ED after discharge. CONCLUSION: DUS may prevent unnecessary scrotal exploration in patients presenting with acute scrotal pain and is useful for diagnosing TT in patients presenting with symptoms >24 h.

Real-time ultrasound measurement of bladder volume: a comparative study of three methods.

The accuracy of different ultrasound methods for determining the volume of urine in the bladder was compared using three methods in current use. Each method was applied to the same ultrasound images from 16 patients with prostatic hypertrophy. The calculated volumes were compared with the true volumes derived by measurement of voided and catheter-drained urine. All methods showed similar degrees of accuracy in quantifying bladder volumes. The range of errors of the best method tested was +/- 35% of true volume and this suggests that ultrasound measurement of bladder volume is not sufficiently accurate for many clinical and research applications.

Digital subtraction dynamic cavernosography.

Digital subtraction angiography (DSA) was used in the investigation, by dynamic cavernosography, of 35 men with acquired erectile impotence. The benefits of using DSA included shorter examination times, lower contrast medium dosage and better definition of abnormal veins. In particular deep crural veins are more clearly seen than in conventional studies and these may be of more importance than was previously thought.

The spectrum of urological disease in patients with spina bifida.

BACKGROUND: [corrected] Urological complications are the major cause of ill health during childhood and adult life of patients with spina bifida but the significance of urinary tract disease on the individual and the healthcare services is underemphasised. AIM: To assess the effects of spina bifida on the individual and the healthcare services. METHODS: A retrospective review was performed to assess the frequency and significance of urological conditions requiring hospital attendance in patients with spina bifida currently attending a specialised multidisciplinary clinic over a period of six months. RESULTS: Urinary sepsis accounted for the majority of admissions (62%), while 38 of 62 patients required 60 surgical procedures. Targeting the primary urological abnormality (the dysfunctional and usually poorly compliant bladder) allows implementation of effective treatments, including regular intermittent bladder catherisation (52%) in order to preserve upper renal tract function. Associated postural abnormalities complicated both conservative and interventional therapies. CONCLUSION: This study highlights the surgical commitment for units caring for patients with spina bifida, the important considerations for the future healthcare services, and the range and severity of urological diseases encountered by these patients.

Endoscopic treatment of urinary tract calculi.

Removal of urinary tract calculi by endourological techniques is now widely practised and has reduced the indications for open surgical removal to a minority of cases. A review of 270 consecutive patients who presented to the Meath Hospital Urology department with urinary tract calculi and were treated by percutaneous or transurethral endoscopy is herein reported. The rates of successful clearance of renal (95%) and ureteric (78%) calculi compare well with previous reports. The majority of complications were minor and a low overall complication rate was experienced at ureterorenoscopy. In our experience, endourological treatment of urinary tract calculi is successful, efficient and safe and is the recommended approach to urinary tract calculi that require surgical intervention.

MAGPI hypospadias repair: factors that determine outcome.

BACKGROUND: This is a review of our experience with the meatal advancement and glanuloplasty incorporated (MAGPI) hypospadias repair, and we point to some of the factors that determine outcome. METHODS: We identified all patients who underwent MAGPI repair by a single surgeon over an 8-year period. We performed a retrospective chart review followed by telephone interview to assess parent satisfaction and also functional and cosmetic outcome. Decision to undergo this type of repair was intra-operative, depending on position and mobility of the meatus and the quality of peri-urethral tissue. RESULTS: We identified 48 patients, with a median age of 19 months (8 months-13 years). Position of meatus was glanular (40) or coronal (eight cases). Chordee required correction in 40 % (12/30). Urethral stenting was required in one case. There was no case of fistula, meatal regression, stenosis, or second procedure. A single case of mucosal prolapse was encountered. The majority (47/48) were performed as a day-case. Forty parents agreed to telephone interview. Cosmetic outcome was deemed satisfactory in 95 % (38/40). With regard to unsatisfactory cosmetic outcome, one had a megameatus and the other was aged 13 years and developed a mucosal prolapse. CONCLUSION: In selected cases, the MAGPI hypospadias repair provide excellent functional and cosmetic outcomes with minimal complications, and it can safely be performed as a day-case procedure.

Regional variations in testicular cancer rates in Ireland.

BACKGROUND: Traditionally, the incidence of testicular cancer (TCa) has shown a remarkable geographical variation. AIMS: To examine whether the rates of TCa varied within Ireland itself and to find possible explanations for any observations made. METHODS: We observed the incidence of TCa in counties in Ireland between January 1994 and December 2007. The rate of cryptorchidism over the same time was calculated. Incidence of TCa by socio-economic status was reviewed. The role of environmental pollutants was explored. We analysed teenage obesity data as a risk factor for the development of TCa in adulthood. RESULTS: Cork had a significantly higher rate of TCa than any other county in Ireland. Cork also had high rates of cryptorchidism, but interestingly not the highest nationwide. In Cork County specifically, least deprived areas had significantly higher rates of TCa. Organic pollutants previously linked to the development of TCa have been identified in large industries located only in Cork. Teenage obesity rates in Cork were not higher than elsewhere. CONCLUSIONS: There is a higher incidence rate of TCa in Cork than any other county. High rates of cryptorchidism alone cannot explain this. There appears to be a link with higher socio-economic status and possibly industrial pollutants. The association between sedentary lifestyle and the development of TCa is unproven.

Scientific basis of testicular descent and management implications for cryptorchidism.

Cryptorchidism occurs in about 1% of boys, but has a raised incidence in those with deficiencies of androgen function. Greater knowledge of fetal-maternal endocrinology and related experimental work has provided evidence that fetal testicular endocrine function is vital in descent of the gonad. The therapeutic use of hCG has, however, been disappointing, and its role is confined to helping to distinguish the retractile from the undescended testis. Cryptorchidism is commonly associated with congenital pathological defects such as ductal abnormalities, and others (including interstitial fibrosis and a reduction in germ cells) develop after 1-2 years, while later these patients are at greater risk of carcinoma in situ and germ cell cancer. The demonstration of the early pathological changes has recently dictated much earlier surgical correction, but long-term follow-up is needed to prove clinical benefit from this practice.

Single ectopic ureterocele associated with ipsilateral renal dysplasia and undescended testis.

Ureterocele involving an ectopic ureter is often associated with complete duplex renal units. This report describes the rare association between an ectopic ureterocele with renal dysplasia and testicular maldescent.

Penile function following intracavernosal injection of vasoactive agents or saline.

Few studies on the pharmacological assessment or treatment of impotence have included controls. In a double-blind crossover study, 18 impotent men received either a 2 ml injection of a solution containing 30 mg papaverine and 1 mg phentolamine or a similar volume of normal saline into the corpus cavernosum. The immediate and delayed effects (4 weeks later) were assessed independently and the alternative injection then given. All injections with papaverine and phentolamine were followed by an immediate increase in penile length and rigidity, and 70% of these patients were able to have sexual intercourse for periods of 1 to 4 weeks. No change in penile length or rigidity occurred following the saline injection and only one patient showed some improvement in erection over the next 4 weeks. In the crossover study, no patient developed any increase in length or rigidity of the penis following injection of saline, and improvement in spontaneous erection occurred in only two cases. In contrast, all patients who received papaverine and phentolamine had an increase in penile length and rigidity, and 50% were able to have normal sexual intercourse over the next 4 weeks. This study confirms the value of a combination of vasoactive agents in the management of impotence, irrespective of its aetiology, and suggests that any placebo effect is minimal in this group of patients with considerable psychological overlay.

Assessment of the immediate and long-term effects of pharmacologically induced penile erections in the treatment of psychogenic and organic impotence.

Thirty-eight patients with predominantly organic and 29 with psychogenic impotence had intracavernosal injections of a combination of 30 mg papaverine and 1 mg phentolamine on at least one occasion. An immediate increase in length and penile rigidity resulted in all subjects. Eighteen of the organic patients subsequently developed spontaneous erections for periods ranging from 1 week to 1 month. Nineteen of the 24 patients in the psychogenic group had spontaneous erections, five for at least 4 months and 14 for 2 to 8 weeks. Increasing the dose was of benefit only to organic patients who initially had a poor response. Three of eight patients with a poor immediate response to pharmacologically induced penile erections (PIPE) were found to have venous incompetence. PIPE is therefore of value in the diagnosis and treatment of organic and psychogenic impotence.

Intrascrotal adenomatoid tumours.

The adenomatoid tumour occurs in the genital tract of both sexes and is probably of mesothelial origin. We describe its occurrence in five men, two of whom had an intratesticular tumour, and discuss the clinical features of this lesion and the lessons to be learned regarding the management of testicular and paratesticular swellings.

Impotence: treatment by autoinjection of vasoactive drugs.

One hundred and twenty five men with psychogenic or organic impotence used autoinjection of the penile corpora cavernosa with either papaverine or papaverine and phentolamine for a mean period of 10.5 months (range 1-24 months) to achieve penile erection for sexual intercourse. Prolonged (over four hours) painless erection resulted from 34 of the 3513 self administered injections. This seems to be a highly effective approach to treating impotence irrespective of the aetiology.

Penile response to intracavernosal vasoactive intestinal polypeptide alone and in combination with other vasoactive agents.

Intracavernosally injected vasoactive intestinal polypeptide (VIP) (2 micrograms and 4 micrograms) resulted in penile tumescence even in men with predominantly organic impotence. Papaverine and phentolamine were successful in inducing erections in all subjects studied but the addition of VIP to this combination improved the erectile response further. A combination of papaverine and VIP produced penile rigidity similar to that with papaverine and phentolamine. While intracavernosal VIP alone produced disappointing penile responses, its combination with papaverine potentiated the response to this drug, probably by increasing venous outflow resistance.