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Genitourinary Tract Conditions

Cryptorchidism

  • Definition: Condition where one or both testes fail to descend into the scrotum before birth.
  • Incidence:
    • 30% of preterm infants and 23% of full-term infants present with undescended testis.
    • Some testes may descend by 1 year of age.
  • Complications:
    • Histologic and morphologic changes as early as 6 months of age.
    • Leydig cell atrophy, decreased tubular diameter, and impaired spermatogenesis by 2 years of age.
  • Common locations: Most commonly in the inguinal canal.
    • Retractile testis: A normally descended testis that retracts into the inguinal canal due to hyperreflexive cremasteric muscle (no surgery required).
    • Nonpalpable testes: Could be intraabdominal, absent, or vanishing.
    • Ectopic testes: Aberrant descent, found in locations like the perineum, femoral canal, or suprapubic region.

Management

  • Palpable testis in the inguinal canal:
    • Dartos pouch orchidopexy performed at 6-12 months of age.
  • Nonpalpable testis:
    • Diagnostic laparoscopy to locate the testis.
    • If the testis is intraabdominal, a two-stage Fowler-Stephens orchidopexy may be considered (ligating testicular vessels in stage one, followed by orchidopexy 6 months later).
    • Laparoscopic orchidopexy is increasingly used as a single-stage procedure.
  • Nonpalpable bilateral testis: A hCG stimulation test can confirm the presence of functioning testes.
  • Malignancy risk:
    • Increased in men with undescended testes.
    • Orchidopexy does not reduce this risk but facilitates earlier detection.
    • Nonseminomatous germ cell tumors are the most common tumor type in undescended testes.

Testicular Torsion

  • Most common in early adolescence, peaking at 14 years of age.
  • Types:
    • Extravaginal torsion: More common in neonates, torsion of the spermatic cord outside the tunica vaginalis.
    • Intravaginal torsion: Associated with a bell clapper deformity (suspended testis prone to torsion).

Presentation

  • Acute scrotal pain is the primary symptom.
  • High-riding, edematous, and tender testis.
  • Differential diagnosis: Urinary symptoms (frequency, urgency, dysuria) can indicate infectious causes like epididymitis, but these symptoms do not rule out torsion.

Diagnosis

  • History and physical exam are usually sufficient.
  • Ultrasound may be used to assess vascular flow.
  • Radioisotope scanning is the most specific diagnostic test.

Management

  • Immediate surgical detorsion through a scrotal medial raphe approach.
  • After detorsion, testis is assessed for viability and fixed to the scrotum.
  • The contralateral testis is also fixed to prevent future torsion.
  • Time sensitivity:
    • <6 hours: 90% salvage rate.
    • >24 hours: <10% salvage rate.

Testicular Tumors

  • Incidence: Testicular cancer accounts for <2% of all pediatric solid tumors.
    • Peaks at 2 years of age and again at puberty.
  • Presentation: Typically presents as painless scrotal masses, often discovered incidentally.

Diagnosis

  • Ultrasound: Useful for initial evaluation.
  • CT scan: Critical for assessing retroperitoneal lymphadenopathy and metastatic disease.
  • Serum tumor markers:
    • α-fetoprotein (AFP): Elevated in yolk sac tumors.
    • β-hCG: Elevated in embryonal carcinomas and mixed teratomas.

Types of Tumors

  • Germ cell tumors are the most common prepubertal testicular cancers.
  • Yolk sac tumors (endodermal sinus tumors) and embryonal carcinomas account for nearly 40%.

Treatment

  • Surgical: Radical inguinal orchiectomy.
  • Tumors with microscopic/gross nodal involvement require systemic chemotherapy and possible retroperitoneal lymphadenectomy.
  • Prognosis:
    • Yolk sac tumors: Survival rate is 70%-90%.

Key Terms Highlighted:

  • Cryptorchidism
  • Orchidopexy
  • Testicular torsion
  • Bell clapper deformity
  • Testicular tumors
  • Yolk sac tumors
  • α-fetoprotein (AFP)
  • β-hCG

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