Pediatric Urology

Acute Scrotum

  • Most common: Torsion of testis (neonatal, puberty), appendix testis (any age), or epididymitis/orchitis (<1yo and 12-15yo)
    • Other: Trauma, incarcerated hernia
  • Doppler ultrasound

Torsion of testis

  • Tender testis, abnormal position of testis
  • TWIST (Testicular Workup for Ischemia and Suspected Torsion) score
    • testicular swelling (2 points)
    • hard testis (2 points)
    • absent cremasteric reflex (1 point)
      • (100% sensitivity, 66% specificity for testicular torsion)
    • nausea and vomiting (1 point)
    • high-riding testis (1 point)
      • A score of 0 is predictive of nontorsion, and a score of 6 or 7 is highly predictive of testicular torsion
  • Treatment
    • Manual detorsion without anesthesia (outwards rotation)
      • Successful if relief of symptoms and normal physical exam, can be doppler ultrasound-guided
    • Bilateral orchiopexy required after detorsion (due to risk of contralateral torsion)
    • Early exploration if <24h

Torsion of appendix testis

  • Tender superior pole of testis, "Blue dot" (only found in 10-20% of torsion of appendix testis)
    • Treatment
      • NSAIDs
      • Surgical exploration if persistent pain


  • Tender epididymis, fever
    • Treatment
      • Minimal physical activity and analgesics
      • Antibiotics only if bacterial infection (most self-limited)
      • Surgical exploration if abscess or necrotic testis


  • Physiological
    • Normal congenital adhesions, resolves throughout childhood
    • 1% incidence in 7th grade
  • Pathological (due to distal scarring from trauma, infection, inflammation)
    • Secondary nonretractability (after retractibility earlier)
    • Irritation/bleeding
    • Dysuria
    • Painful erection
    • Recurrent balanoposthitis
    • Chronic urinary retention with ballooning only resolved with manual compression
  • Paraphimosis
    • Retracted foreskin with constrictive ring at level of sulcus preventing replacement of foreskin over glans

Indications for Medical Managment/Referral

  • Physiologic phimosis with recurrent urinary tract infections
  • Balanoposthitis (inflammation of the entire foreskin and glans penis)
  • Persistence of phimosis beyond age 10 years


  • Stretching exercises 1 minute QID x 1-3 months
  • Betamethasone 0.05% cream BID x4-8w
  • Circumcision if
    • Recurrent balanoposthitis and recurrent UTIs
    • Secondary phimosis
  • Paraphimosis
    • Manual compression and reposition
    • Consider injection of hyaluronidase or 20% mannitol beneath band
    • *Emergency* Dorsal incision of the constrictive ring



  • Urgent bladder catheterization if urinary retention and urology consult
  • Hygiene, avoidance of forced retraction/irritants
  • Treat for candida albicans if diaper dermatitis


  • Retractile testes (testi held in scrotum by hand for 30-60s to fatigue cremasteric reflex, and on releasing testi does not immediately retract) require only observation
  • Bilateral non-palpable testes and sexual differentiation problems (eg. hypospadias) requires urgent endocrinology/genetic evaluation
    • Non-palpable testis without evidence of sexual development disorder requires diagnostic laparoscopy to confirm absence of intra-abdominal testis
  • If testis has not descended by six months, surgery should be done within next year (age 18 months latest)
    • If palpable - Orchidofuniculolysis and orchidopexy
    • If nonpalpable - Examine under general anesthesia and laparoscopy (and removal if inguinal testis found)


  • Collection of fluid between parietal and visceral layers of tunica vaginalis
    • Incomplete obliteration of processus vaginalis results in communicating hydrocele (or hernia if large)
    • Non-communicating hydroceles secondary to minor trauma, testicular torsion, epididymitis, surgery
    • Communicating if changes in size
  • Swelling translucent, smooth, nontender
  • Ultrasound +/- Doppler for definite diagnosis
  • Observe for first 12-24 months (most spontaneously resolve)
    • Early surgery if suspicious of hernia or testicular pathology

Monosymptomatic enuresis

  • No treatment <5 years of age (spontaneous cure likely)
  • Voiding diaries or questionnairs to exclude daytime symptoms (r/o lower urinary tract dysfunction)
  • Urine test exclude infection or diabetes insipidus
  • Alarm treatment is best treatment for arousal disorder (80% success rate)
  • Structured withdrawal of desmopressin for night-time diuresis effective