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 7thand 17th 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

Use of Urine Testing in Outpatients Treated for Urinary Tract Infection

ObjectiveTo characterize urine test use in ambulatory, antibiotic-treated pediatric urinary tract infection (UTI).MethodsWe 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.ResultsOf 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.ConclusionsProviders 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

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, 2,794 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

Timing of Orchiopexy in the United States: A Quality-of-Care Indicator

OBJECTIVE: To investigate whether orchiopexies are occurring later than recommended by American Academy of Pediatrics 1996 guidelines (around age one). Adherence to guidelines is poorly studied. METHODS: Main Cohort: 4,103 boys insured from birth (Innovus i3, insurance claims database) Complementary cohort: 17,010 insured and non-insured boys (Pediatric Health Information System, PHIS) Inclusion criteria: age ≤5 years at time of ICD-9-defined cryptorchidism diagnosis Primary outcome: timely surgery (orchiopexy by age 18 months) RESULTS: In Innovus, 87% of boys who underwent an orchiopexy had a timely orchiopexy. Of those who did not undergo surgery (n=2738), 90% had at least one subsequent well-care visit. Those who underwent timely surgery were referred to a surgeon at a younger age compared with those who underwent late surgery (4.1 months vs. 16.1 months, p<.00005). Predictors of timely surgery were number of well-care visits (OR 1.5, 95% CI 1.3–1.7), continuity of primary care (OR 1.9, 95% CI 1.3–2.7), and use of laparoscopy (OR 4.5, 95% CI 1.4–14.9). Family/internal medicine as referring provider was predictive of delayed surgery (OR 0.5, 95% CI 0.3–0.8). In PHIS, 61% of those with private insurance had timely surgery compared with 54% of those without private insurance (p< 0.0001). CONCLUSIONS: We found an unexpectedly high adherence to guidelines in our continuously insured since birth Innovus population. Primary care continuity and well-care visits were associated with timely surgery. Further studies can confirm these findings in non-privately insured patients with the ultimate goal of instituting quality improvement initiatives