Referrals from primary care with foreskin symptoms: Room for improvement.

AIMS: Referrals to secondary care for boys with foreskin symptoms require face-to-face review, resulting in time out of school / work and costs to the family. This study aimed to review outcomes of referrals to ascertain if there was scope to reduce referrals. METHODS: New patients referred to a UK regional paediatric surgery clinic during 2019 were identified and screened retrospectively. Medical records for boys over one year of age referred due to foreskin symptoms were reviewed. RESULTS: Of 2598 referrals, 1939 (75%) were boys & 1094 were > 1 yr; 398 (21%) were referred with foreskin symptoms at median age 7.2 yrs (IQR 4-10). 307 (77%) were diagnosed with physiological phimosis, 67 (18%) with pathological phimosis, 9 (2%) with balanitis (the remainder had 'smegma' retention cysts, preputial adhesions, tight frenulum or anatomical abnormalities). 211 (53%) were discharged at the initial appointment, this was significantly more likely for younger boys, and those with physiological phimosis (p<0.001). 62 (16%) were prescribed topical steroids (more likely in older boys, p<0.001). 70 (18%) were offered surgery: circumcisions (n = 51), preputioplasties (n = 13), other (n = 4). The circumcision rate was therefore 12%. Age at referral was positively correlated with GP trial of steroid (older more likely), diagnosis (physiological phimosis more likely if younger) and outcome (topical steroids or surgery more likely if older): Spearman's rank correlation p<0.001. CONCLUSIONS: Over 75% of boys referred had a normal foreskin, over half were discharged at their first review. Improved knowledge amongst parents and primary care providers could reduce referrals and save money and resources. LEVEL OF EVIDENCE: Level IV - Case series with no comparison group.

C-reactive protein accurately predicts severity of acute pancreatitis in children.

INTRODUCTION: Predicting severity of acute pancreatitis enables optimization of care, reducing morbidity and length of stay. Modified adult scoring systems have not been able to adequately predict severity in children. METHODS: This was a retrospective study of children presenting with a first episode of acute pancreatitis from 2002 to 2020 in a single tertiary paediatric surgical centre. Serum markers including CRP at 48 h of admission were analysed. Promising biomarkers underwent ROC (Receiver Operating Curve) analysis, and these were compared to the modified Glasgow Pancreas Score. An AUC (Area Under Curve) > 0.90 was taken as an excellent predictor of severity. RESULTS: Data of 59 children were analysed, median age 13 years. 22 patients (37%) had a severe episode. ROC analysis demonstrated CRP as the best predictor of severity giving an AUC of 0.92. Optimum cut off value for CRP was 107.5 mg/L (p < 0.0001) producing sensitivity of 91%, specificity of 84%. This was superior to the modified Glasgow Pancreas score, which produced a sensitivity of 36% and specificity of 100%. CONCLUSION: We have shown that a CRP value of > 108 mg/L within 48 h of admission can be used to predict severity of acute pancreatitis in children with greater accuracy than current scoring systems. TYPE OF STUDY: Diagnostic test. LEVEL OF EVIDENCE: Level I.

Emergency scrotal exploration in children: Is it time for a change in mindset in the UK?

INTRODUCTION: Acute scrotal pain is a common problem in children. Amongst the various causes, only testicular torsion (TT) needs urgent, and arguably any, surgical intervention. However TT accounts for only approximately 25% of cases. The diagnosis of TT is currently based mainly on history and clinical examination in the UK. OBJECTIVE: We sought to find the incidence of finding TT during emergency scrotal exploration in four paediatric surgical centres in the UK. We also assessed the preoperative utilisation of clinical risk scores and Doppler ultrasound (DUS) to aid in the diagnosis. PATIENTS AND METHODS: A retrospective review of 50 consecutive scrotal explorations done for acute scrotal pain at four tertiary pediatric surgical centres in 2019, including the preoperative utilisation of DUS, was analysed. Additionally an online survey was also sent out to consultant members of the British Association of Paediatric Urology to gauge their threshold for exploration, use of preoperative investigations and incidence of finding TT in their practice. RESULTS: In the four UK centres reviewed, TT was found in 24.5% (SD = 8.54) of explorations. The overall utilisation of preoperative DUS was 10%. The online survey revealed a low threshold for exploration. However 72% of respondents recalled finding TT in <50% of explorations, with just over a third reporting finding TT in only 10% of explorations. There was low utilisation of preoperative DUS and clinical risk scores. DISCUSSION: The incidence of finding TT during exploration in this cohort is the same as the incidence of TT in a population of children presenting with acute scrotal pain. We hypothesise that this is due to low accuracy of clinical assessment, low utilisation of preoperative clinical and radiological aids and the practice of exploring torted testicular appendages. Improving awareness and training in these modalities will increase diagnostic accuracy, limiting emergency scrotal explorations to those children with a higher risk of testicular torsion. A care pathway for children presenting with acute scrotal pain is suggested () CONCLUSIONS: There is a low incidence of finding testicular torsion during paediatric scrotal explorations in the UK. There is low preoperative utilisation of clinical risk scores and Doppler ultrasound, which if utilised, could improve diagnostic accuracy.

Onabotulinum toxin-A versus extended release tolterodine in the management of idiopathic overactive bladder in children: A pilot randomised controlled trial (OVERT trial).

BACKGROUND: Idiopathic Overactive Bladder is the most common cause of urinary incontinence in children. Anticholinergic medications are successful in only 20% of those with daily wetting so there is a real need to find a more effective treatment for this condition. Onabotulinum toxin A injections are often used as a treatment but there have been no randomised controlled trials investigating effectiveness in children. OBJECTIVE: To provide information that would inform the design and conduct of a definitive trial comparing onabotulinum toxin A with extended-release tolterodine for the management of therapy resistant idiopathic overactive bladder in children. Specific objectives were to assess rates of eligibility, recruitment, acceptability of randomisation, loss to follow-up, acceptability of urodynamic assessment and obtain primary outcome data for sample size estimation. STUDY DESIGN: Single-centre, parallel, two-arm, open-label pilot randomised controlled trial. Eligible patients (aged 7-16 years) were recruited at Royal Manchester Children's Hospital and randomised (1:1) using a web-based system. TRIAL REGISTRATION: EudraCT 2014-001068-36; Funding: UK NIHR Research for Patient Benefit Programme. RESULTS: 98 patients were assessed for eligibility, 85 (87%) were eligible for screening, parents of 62 (73%) provided consent, 46 (74%) remained eligible and were randomised (onabotulinum = 22, tolterodine = 24). All participants commenced allocated treatment. Two patients withdrew from follow-up. All participants underwent urodynamic assessment at baseline and 35 (76%) additionally at week 6. The mean (standard deviation) number of wetting episodes per day at week 6 was 1.4 (1.7) in the onabotulinum group and 1.6 (1.0) in the tolterodine group. There was one serious adverse event (probably related to the drug) and 22 non-serious adverse events reported by 8 participants in the onabotulinum group (36%). There were 23 non-serious adverse events reported by 9 participants in the tolterodine group (38%). DISCUSSION: Recruitment was challenging but eligibility and consent rates were high as were retention rates. Treatment compliance in the botox group was high but it was difficult to measure in the tolterodine group. Treatment switching was also an issue. CONCLUSIONS: Recruitment to a definitive trial was demonstrated to be feasible if a large number of centres are involved, though further consideration is required regarding trial design.

Current pharmacological management of idiopathic overactive bladder in children in the UK: a national survey of practice.

BACKGROUND: Children with daytime urinary incontinence secondary to idiopathic overactive bladder (IOAB) commonly present to paediatric urologists following failure of standard urotherapy and/or 1st-line anticholinergics. Off-label oral medications and intravesical botulinum toxin A (BtA) are being increasingly used for treatment-refractory IOAB, despite the paucity of high-quality evidence and guidelines. Knowledge of contemporary paediatric urologists' practice allows specialists to keep up-to-date with current trends in the management of IOAB in children. OBJECTIVES: 1. To present an analysis of contemporary tertiary management of IOAB in children and 2. to highlight current trends in practice and identify areas of high variability in care for targeted research. METHODS: Paediatric urologists (55 individuals) who attended the 2018 national British Association of Paediatric Urologists (BAPU) congress responded to a 20-question survey presented at the congress. Respondents could submit one answer per question, and one survey was taken per respondent, using secure software to disable any manipulation. Answers were analysed prospectively by a single reviewer. RESULTS: Of UK paediatric urologists, 98% regularly manage children with IOAB, 48% use 48-h frequency/volume charts and others use three or seven-day bladder diaries to aid diagnosis. Oxybutynin is the 1st-line therapy for 85%, 2nd-line is tolterodine (53%), and 3rd-line is solifenacin (41%). Mirabegron is used either alone or in combination with solifenacin as 4th-line management by 55%. Those who use intravesical Botulinum toxin A (BtA) accounted for 81% and 84% of these perform invasive urodynamic assessment prior to BtA administration. Post-BtA, assessment was clinical in 18%, 24% use invasive urodynamics, whereas uroflowmetry is preferred by 58%. Of the paediatric urologists, 72% believe the most clinically significant outcome of treatment is patient-reported improvement. Treatment success is defined variably: 49% define success as completely dry, whereas 35% accept a 90% improvement as success. CONCLUSIONS: Off-label medications are being used widely either alone or in combination by paediatric urologists. In oral therapy-resistant IOAB, BtA is being used by the majority of specialists, usually after formal urodynamic assessment. However, post-BtA assessment and evaluation of treatment success for IOAB are variable.