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Associate Professor, William Carey University College of Osteopathic Medicine

Congenital Cryptorchidism Studies of the prevalence of isolated cryptorchidism at birth are complicated by confounding factors that include subjectivity of the examination and differences in the definition of undescended testis (inclusion or exclusion of high scrotal testes) hair loss from lupus discount 5mg finasteride visa, study populations hair loss cure earth clinic order finasteride discount, and experimental design (Sijstermans et al hair loss quiz generic finasteride 5mg free shipping, 2008). Although most studies support a prevalence at birth of 2% to 4% and at 3 months of age of 1% to 2%, this varies geographically, with frequency as high as 9% in some studies (Boisen et al, 2004; Virtanen and Toppari, 2008), supporting the possibility of an increase over time. However, other data suggest that country-specific trends are not increasing (Abdullah et al, 2007; Cortes et al, 2008; Bonney et al, 2009; Wagner-Mahler et al, 2011), and overall there do not appear to be reproducible trends in prevalence (Sijstermans et al, 2008). Perinatal risk factors most consistently associated with cryptorchidism include prematurity, low birth weight or small size for gestational age, breech presentation, and maternal diabetes (Damgaard et al, 2008; Virtanen and Toppari, 2008; Jensen et al, 2012). The reported frequency of spontaneous testicular descent after birth varies among series, likely because of similar confounding Chapter148 Etiology,Diagnosis,andManagementoftheUndescendedTestis 3435 factors, most notably variable inclusion of boys with high scrotal testes. In several population-based prospective studies, the frequency of spontaneous descent by 3 months of age in boys identified as cryptorchid at birth was reported as 50% to 87% (Berkowitz et al, 1993; Ghirri et al, 2002; Radpour et al, 2007; Wohlfahrt-Veje et al, 2009; Wagner-Mahler et al, 2011; van der Plas et al, 2013b). In smaller cohorts, spontaneous descent occurred in significantly more Danish (68%) than Finnish (45%) boys at 3 months of age, possibly attributable to increased severity of the disease in the latter group (Suomi et al, 2006). In another series, extrascrotal testes were less likely to descend by 1 year of age (50%) than high scrotal testes defined as cryptorchid at birth (87. In contrast, of 95 cryptorchid infants referred to a urology practice, spontaneous descent occurred subsequently in 16% and 0% of those presented before and after 6 months of age, respectively (Wenzler et al, 2004). The lower rate of descent in this series could be related to ascertainment age and severity of cryptorchidism in this referral population, because spontaneous descent is common before 2 months of age (Kollin et al, 2013). The long-term risk of recurrent cryptorchidism is not well defined, but in two large longitudinal series, reascent occurred in 10% and 22% of boys, in most cases between 1 and 5 years of age (Wagner-Mahler et al, 2011; Kollin et al, 2013). Acquired Cryptorchidism In the past, cryptorchidism was considered a congenital anomaly identifiable at birth. However, since first reported 40 years ago (Myers and Officer, 1975), acquired cryptorchidism, or testes that are diagnosed as cryptorchid after apparent full descent at birth or in the neonatal period, is now fully accepted as a clinical entity (Barthold and Gonzalez, 2003; Taghizadeh and Thomas, 2008; Acerini et al, 2009; Wohlfahrt-Veje et al, 2009; Hack et al, 2012). Acquired undescended testes are diagnosed at an average age of 8 to 11 years and are more commonly in a lower position, associated with a closed processus vaginalis and normal epididymis, than in cases diagnosed as congenital. The reason for a later diagnosis remains unknown; theories include presence of a fibrous remnant of the processus vaginalis that tethers or foreshortens the cord over time or mobility of the testis within an open sac (Keys and Heloury, 2012). These testes may be highly mobile and initially appear descended until somatic growth results in relative widening of the distance between testis and scrotum (Redman, 2005; Agarwal et al, 2006). Acquired cryptorchidism is reportedly more common in boys with proximal hypospadias (Tasian et al, 2010; Itesako et al, 2011) and, like the congenital form, is associated with abnormal germ cell development (Rusnack et al, 2002). A diagnosis of acquired cryptorchidism may be more likely in boys with retractile testes, although testis retractility is common in normal populations. In a hospital-based study of unselected boys, the testis was initially suprascrotal on examination (retractile) in up to 30% of boys at 4 years and 10% of boys 4 to 12 years of age but was intrascrotal in all boys over the age of 12 (Farrington, 1968). In population-based studies of healthy boys, retractile testes were present in 11% to 15% of boys up to 11 years of age (WohlfahrtVeje et al, 2009; Goede et al, 2011) and 4% of 7- to 12-year-old boys (Inan et al, 2008). Both prospective and retrospective studies of the natural history of retractile testes support the concept that a subset of these becomes undescended over time. However, a selection bias exists in studies of the risk of cryptorchidism in boys with retractile testes, because those referred for follow-up by specialists are likely those with the most severe retractility. For example, Wyllie prospectively studied a cohort of 100 boys with unilateral retractile testis and identified 64 cases in which testicular position, as documented by the distance between the pubic tubercle and midtestis and/or testicular size as estimated by orchidometer, was reduced after 5 years of follow-up (Wyllie, 1984). Orchidopexy was performed in 45 of these cases, although specific documentation of testicular position and size as indications for surgery were not reported. In retrospective case series it has been reported that cryptorchidism was diagnosed in up to 7% to 32% of boys with retractile testes followed a mean of 2. However, in a prospective study of 1072 boys, 520 of whom were followed from birth to latest follow-up at 4. Although these data suggest an association between retractile testes and cryptorchidism, the nature of this association may reflect either difficulty in distinguishing the two entities or the fact that significant testicular retractility is a risk factor for acquired cryptorchidism.

The cost of the bulking agents can be excessive hair loss 5 month old buy cheap finasteride online, and there does not appear to be any financial benefit over a formal repair (Kryger et al hair loss in men makeup discount finasteride 5 mg amex, 2000) hair loss rogaine cheap finasteride 5 mg overnight delivery. At present, bulking agents play a limited role for increasing outlet resistance and should be reserved for a very select group of patients. Patients with marginal native outflow resistance are probably better candidates than those with minimal preoperative function. Technique Placement of the cuff should be at the level of the bladder neck in all females and prepubertal boys. It is also the most desirable and effective location in pubertal and adult males with neurogenic sphincter incompetence. The bulbar urethra can be used as an alternative site in men with mature spongiosum. Levesque and colleagues (1996) have indicated that age is not a factor regarding placement of the cuff around the bladder neck. Several authors have described the successful placement of the cuff around a bowel segment, particularly when omentum is interposed between the cuff and the segment (Burbige et al, 1987; Weston et al, 1991; Light et al, 1995). Development of the proper plane for the cuff is virtually identical to that described for a fascial sling. For that reason, preoperative antibiotics are a necessity, and confirmation of sterile urine required. With those precautions, there is freedom to open the bladder when dissecting around the bladder neck. Experience has shown that leaving the unit deactivated with the cuff deflated after placement allows formation of a pseudocapsule around the cuff and decreases the risk of erosion (Furlow, 1981; Hanna, 1981; Sidi et al, 1984). In investigation of continence, it must be placed in context of the cost experienced by the patient, defined by mechanical malfunctions resulting in secondary operative procedures and more catastrophic complications such as device infection or erosion. Dramatic improvement regarding the need for secondary procedures has occurred because of the technical refinements in the device. All groups report an impressive continence rate of 80% and a functioning sphincter in 95% of patients. These reports are consistent with older series in children that reported continence rates of 75% to 90% and a functioning sphincter in 85% to 97% (Nurse and Mundy, 1988; Gonzalez et al, 1989a; Bosco Chapter145 UrinaryTractReconstructioninChildren 3339 A B C Figure 145-3. C,Atunnelisthenmadeinto the scrotum or labia for positioning of the pump on the same side as the reservoir. They achieved overall continence in 86% of 142 patients with an average follow-up of 10 years. As boys approach puberty, spontaneous voiding may become progressively inadequate. It has been speculated that growth of the prostate causes an increase in native outlet resistance. Kaefer and colleagues (1997a) evaluated increases in cuff size to facilitate spontaneous voiding in boys. In their limited series, they did not find that upsizing restored the ability to void spontaneously. They found that the artificial sphincter did not alter sexual development, prostatic growth, or morphology. Fastidious attention to detail and sterile technique diminish the risk of infection but do not eliminate it.

There was a significant difference in parental satisfaction hair loss 1 year postpartum buy finasteride uk, with a higher parental satisfaction in the children treated with -blockade hair loss gene therapy effective finasteride 5 mg. The posterior tibial nerve is a mixed sensory and motor nerve originating from the L4 to S3 spinal roots that also contributes to sensory and motor control of the bladder hair loss on lower leg purchase finasteride 5mg line, urinary sphincter, and pelvic floor musculature. Since its initial description, a significant number of reports have been generated on sacral nerve root stimulation via implantable electrodes. Before sacral implantation can be performed, percutaneous transforaminal access to the S3 spinal nerve must be achieved. This lead can then be connected to an external neurostimulator device via a tunneled subcutaneous extender for programming and trial assessments. The main side effects include constipation, dry mouth, blurred vision, reduced sweating, flushing, and altered behavior and cognition. It is a diagnosis of exclusion and is usually established on history and is supplemented by the absence of other voiding symptoms and normal investigations. Currently, available treatment strategies include biofeedback or methylphenidate (Berry et al, 2009; Richardson and Palmer, 2009). Children presenting with frequency, however, merit clinical investigation to exclude other pathologic causes. It is seen in early childhood (4 to 6 years of age) in both genders and associated with a history of recent death or lifethreatening event in the family. It often can be associated with labial adhesions as a result of chronic irritation and inflammation from skin exposure to relatively caustic urine. Previous notions of voluntary control have been replaced by an appreciation of genetic and pathophysiologic mechanisms. What is known with certainty is that enuresis is a common medical condition in children (Shreeram et al, 2009). It affects millions of children throughout the world and is associated with significant negative impacts on self-esteem and health-related quality of life (Wolfe-Christensen et al, 2013). The child who wets during the day and night can be said to have daytime urinary incontinence and enuresis or nonmonosymptomatic enuresis. As we have previously seen, effective treatment of bowel problems can lead to the spontaneous remission of daytime incontinence (Loening-Baucke, 1997). Although this finding has been disputed by other groups, it is well accepted that by adolescence the prevalence in both males and females reaches equipoise (Yeung et al, 2004b). When pelvic floor activity increased in association with detrusor contractions, wetting was usually avoided, and patients often would awaken subsequently to void. Regardless of the mechanism, urine production that normally decreases at night secondary to these circadian systems fails to do so and will subsequently result in nocturnal polyuria, which can exceed the functional capacity of the bladder and result in an enuretic episode. Proof of this concept was demonstrated by Rasmussen and colleagues (1996), who were able to actually induce enuresis in normal healthy children by increasing nocturnal urine output. Enuresis is logically thought to result from a disruption or maturational lag in one or more of these critical domains. Wolfish and coworkers (1997) performed a laboratory study of 33 boys aged 7 to 12 years (15 with enuresis and 18 age-matched controls) and found that attempts at arousal were more often successful in control subjects than in boys with enuresis (40% vs. However, when volumes were measured during general anesthesia, enuretic children had similar mean bladder volumes to awake controls. In a somewhat contradictory study, Kawauchi and colleagues (2003) found that the maximal endurable bladder capacity during the daytime was similar between children with enuresis and controls.

Interpretation of more recent follow-up studies (Connolly et al hair loss cure update 2013 cheap finasteride 5mg amex, 2001) suggest that diagnosis at age 5 hair loss cure two years generic finasteride 5mg mastercard, as well as in infancy hair loss in men 70s dress purchase finasteride discount, is associated with a similar resolution rate (20% per year), regardless of age. However, as stated at the outset, it must be remembered that resolution 5 years after age 5 implies reflux has required 10 years to resolve versus resolution 5 years after birth. Moreover, the observation by McLorie and colleagues (1990) that high-grade reflux in patients presenting after birth showed no difference in resolution rates between subjects younger and older than 1 year of age may reflect the generally poor resolution rate of high-grade reflux to begin with. These principles likely underlie the observation that when reflux resolves, it often does so within the first few years of life. The study by Skoog and colleagues (1987) observed that 30% to 35% of subjects resolved their reflux each year. In the study by McLorie and coworkers (1990), 92% of resolved grade 3 reflux occurred within 4 years. There is a tendency to ascribe a benefit to the observation of interval reduction in grade. Clearly then, what constitutes reflux resolution depends on the period over which resolution is sought. Indeed, the basis of contemporary medical therapy is predicated on an expected rate of spontaneous resolution. At birth, the probability of spontaneous resolution of primary reflux is roughly inversely proportional to the initial grade. If a patient is encountered at a later age, resolution from any point in time forward will depend on initial grade of reflux, if it is known, and age at presentation. For example, unilateral grade 3 reflux at birth should resolve in 70% of cases by age 5. However, if a 6-year-old with normal bladder function presents with grade 3 reflux, it is much less likely to resolve. Given a growing tendency among some clinicians to reassess females for persistent reflux and possible endoscopic correction after a holiday period without follow-up (between 5 years and the teenage years), it is possible new information remains to be learned about reflux resolution. Conversely, failure of the latter likely accounts for reflux persistence beyond the statistical norms in many patients. Indeed, inability to strictly understand bladder dynamics may have skewed earlier determinations of absolute reflux resolution rates but in doing so provided a real-world picture of spontaneous resolution. However, the variance in reported resolution rates for low-grade reflux was 63% of grade 2 (Duckett, 1983), 80% of grade 2 (Arant, PrinciplesofManagement the medical and surgical therapy for reflux has purported to offer similar benefit to patients (Table 137-6 on the Expert Consult website). In such cases, tolerance for yet another infection despite the presence of prophylaxis may be low, or simple disquiet with the notion of ongoing reflux may invite strong consideration for reflux correction. As stated previously, it is not clear how long to wait for reflux resolution in the individual patient. In newborn patients, it is reasonable to wait until approximately 5 years of age assuming no intercurrent breakthrough infections occur. Beyond this age, it is commonly believed that the kidneys become less prone to scarring after pyelonephritis (Olbing et al, 2003), although the previously mentioned limitations in the interpretation of imaging inherent in the reflux literature should be remembered. Thus some practitioners are withdrawing prophylaxis as the child approaches the age of 5. After this age, boys with asymptomatic reflux will require little or no formal follow-up as long as lifelong attention to good bladder habits is reinforced, and they are counseled to seek prompt medical attention if a pyelonephritis were to occur in the future, as well as reassessment of their reflux status. Nevertheless, disagreement would remain as to whether to correct asymptomatic bilateral highgrade reflux with normal renal parenchyma and function in an older boy despite the thought that sterile reflux is benign. Girls have traditionally undergone open surgical correction, even for asymptomatic reflux that fails to resolve by the age of 5, on the premise that it will reduce maternal and fetal morbidity during a future pregnancy. Clinical guidelines for reflux management in children are presented in Table 137-7 on the Expert Consult website.

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