Which of the following investigations has the lowest radiation dose?
Answer B
The approximate radiation burden for these investigations:
Which of these statements is CORRECT regarding religious circumcision?
. Answer C
This is a question about consent and ethics. The starting point is that the parents are requesting a surgical procedure that does not carry a clinical benefit. The BMA and GMC recommend that the consent of both parents should be obtained for a procedure that is non-therapeutic and ‘important and irreversible.’ Previously, fathers that were not married to the mother did not have parental responsibility and so were unable to give consent for surgical procedures. However, the law has changed. For children born after 1 December 2003, if their father’s name appears on the birth certificate, then the father does have parental responsibility. This does not apply to children born before this date. It should be remembered that grandparents, close family friends, etc cannot provide informed consent for a child’s surgery. Conversely a child with sufficient capacity may provide their own consent. The problems around religious circumcision come to a focus where the child has significant co-morbidity (e.g., cardiac disease or coagulopathy). Parents are often strongly motivated to have circumcision performed for cultural reasons. Where the child has significant co-morbidity these motivations should be carefully explored with the parents. Surgical circumcision does carry risk, but circumcision performed outside of a hospital in less controlled settings is a far less satisfactory option. Parents who are denied a hospital circumcision may proceed to arrange a circumcision in the community. It can be very helpful for the parent to meet and have a discussion with the religious leader from their religion (e.g., priest). The advice is often given that their religion discourages circumcision if it endangers the child. In my practice I also recommend that the parents have a discussion with an appropriate anaesthetist who is better able to counsel about anaesthetic risks in the face of significant cardiac or respiratory disease. For example, a cardiac anaesthetist is better placed to counsel about anaesthesia risk than a paediatric cardiologist where there is congenital heart disease.
Regarding undescended testis, which is the first step to be affected by the testis not having descended into the scrotum?
Answer A
The transition from neonatal gonocyte to adult dark spermatogonia takes place at 3–12 months in humans. Between the first and fourth years of life the spermatogonia differentiate into B-spermatogonia, and then primary spermatocytes. These then remain quiescent until puberty triggers spermatogenesis. The transformation of the neonatal gonocyte into the adult dark spermatogonia appears to be a crucial stage. It seems to be dependent on the environment of these cells being at 33°C. Failure of the testicle to descend into the scrotum keeps the testis at 37°C and so adversely affects this stage. Transformation from neonatal gonocyte to adult dark spermatogonia includes a reduction in the number of these cells probably reflecting apoptosis of abnormal cells. Failure of the testicle to descend by this stage will result in reduced sperm production but also less removal of abnormal cells probably contributing to increased risk of subsequent malignant transformation. Recognition that this stage takes place quite early has resulted in the British Association of Paediatric Urologist recommending in 2011 earlier orchidopexy. Ideally orchidopexy should be performed between 3–6 months; however, 6–12 months is acceptable.
An 8-year-old boy presents with an inguinal testis. Which of the following is not true?
There had previously been an assumption that boys presenting at this late age with an undescended testis had previously had this finding missed at previous checks. However this age group represent a significant proportion of boys undergoing orchidopexy. At post-natal checks, where there is little adipose, the cremasteric reflex is weak and the testes are prominent, identifying undescended testes is relatively easy. It was realised from carefully documented examinations that testes that had previously been identified in the scrotum had subsequently ascended.
The mechanism for testicular ascent is not clear. One possibility is the presence of a processus vaginalis remnant, which because of a relatively slower rate of growth than the rest of the child would drag the testis up as the inguinal canal lengthened. Alternatively, it is possible that a proportion of these boys originally had retractile testes an overactive cremaster had permanently brought these testes up.
In the Netherlands and Scandinavia ascending testes are managed expectantly as about half will descend spontaneously. However the UK practice (according to the 2011 consensus from the British Association of Paediatric Urologists) is to offer surgery. It is not clear what effect there will be on the testis and on sperm production if the testis is left in the groin waiting for puberty. There is evidence that performing orchidopexy before puberty may halve the risk of malignancy for undescended testes. Although it is not clear that ascended testes are at increased risk of malignancy, it can be difficult in practice to distinguish an ascended from a missed undescended testis.
Which of the following are not associated with urinary incontinence in a child?
Answer C
A ‘tower’ shaped flow rate can give a useful indication of an overactive bladder. The appearance of flattened buttocks is characteristic of sacral agenesis and neuropathic bladder. The ICCS definition of abnormal residual volume a little difficult to remember. For children aged 4–6 years, the residual volume is abnormal if on repeated measures it is more than 20 mL or more than 10% of bladder capacity (bladder capacity = voided volume + residual volume). For children who are 7–12 years repeated measured residual of more than 10 mL, or 6% of bladder capacity are abnormal.
If a history of faecal incontinence is volunteered then more careful evaluation is required. Most commonly faecal incontinence is a manifestation of constipation. Assessment of a child with constipation would include asking how often the child opens their bowels, whether there is associated pain or blood, examination of the abdomen for palpable stool and checking for spinal abnormality. A bowel diary kept over a week can be useful including comparison against the Bristol stool chart. Treatment of constipation will frequently result in resolution of urinary symptoms. However, faecal leaking may be a manifestation of neuropathic bladder and bowel. It is possible however that faecal leaking may be related to spinal abnormality. It is important that this is considered, other symptoms and signs of abnormality sought, and if there is adequate concern, spinal imaging arranged.
Vaginal reflux is a cause of post-micturition wetting in girls. It is effectively treated by abducting the legs widely during voiding.
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