I've never done a redo circumcision in an adolescent, probably because these children grow and their penises grow and the skin stretches, and we don't need to do anything
I've never done a redo circumcision in an adolescent, probably because these children grow and their penises grow and the skin stretches, and we don't need to do anything
I've never done a redo circumcision in an adolescent, probably because these children grow and their penises grow and the skin stretches, and we don't need to do anything
if you're going to restrain the child any way either use a papoose board or anything else that when they get a little bigger it's going to be a little harder to do that
epidemiologicalUTI risk in the first year of life is 3-4% overall, with uncircumcised boys having 1/100 risk versus circumcised boys 1/1000 risk↗
▶Ep 9 · 2:40
epidemiologicalUTI risk in the first year of life is 3-4% overall, with uncircumcised boys having 1/100 risk versus circumcised boys 1/1000 risk↗
▶Ep 9 · 3:16
clinicalCircumcision decreases risk of HIV, syphilis, gonococcus, HPV, and HSV-2, but does not change chlamydia risk↗
▶Ep 9 · 3:16
clinicalCircumcision decreases risk of HIV, syphilis, gonococcus, HPV, and HSV-2, but does not change chlamydia risk↗
▶Ep 9 · 4:16
clinicalCircumcision provides 53% protection against HIV transmission in randomized trials from Kenya and Uganda, with both trials stopped early due to significant benefit↗
▶Ep 9 · 4:16
clinicalCircumcision provides 53% protection against HIV transmission in randomized trials from Kenya and Uganda, with both trials stopped early due to significant benefit↗
▶Ep 9 · 5:19
guidelineThe AAP states that data are not sufficient to recommend routine neonatal circumcision, and parents should be given accurate, unbiased information↗
▶Ep 9 · 5:19
quotethese data are not sufficient to recommend routine neonatal circumcision↗
▶Ep 9 · 5:19
host_summaryThe AAP states that data are not sufficient to recommend routine neonatal circumcision, and parents should be given accurate, unbiased information↗
▶Ep 9 · 5:19
quotethese data are not sufficient to recommend routine neonatal circumcision↗
▶Ep 9 · 5:30
quoteparents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision↗
▶Ep 9 · 5:30
quoteparents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision↗
▶Ep 9 · 6:56
opinionOffice circumcision should be limited to infants 3 months or younger or weighing less than 13 pounds to minimize restraint difficulty and bleeding risk↗
▶Ep 9 · 6:56
opinionOffice circumcision should be limited to infants 3 months or younger or weighing less than 13 pounds to minimize restraint difficulty and bleeding risk↗
▶Ep 9 · 7:53
clinicalExposing young children to elective general anesthesia such as for circumcision is not recommended from an anesthetic safety standpoint↗
▶Ep 9 · 7:53
clinicalExposing young children to elective general anesthesia such as for circumcision is not recommended from an anesthetic safety standpoint↗
▶Ep 9 · 8:05
quoteI personally feel that if you don't do them that there's really no reason to not refer that child to somebody who does do them↗
▶Ep 9 · 8:05
quoteI personally feel that if you don't do them that there's really no reason to not refer that child to somebody who does do them↗
▶Ep 9 · 9:28
clinicalThe best analgesia for circumcision is a dorsal penile nerve block combined with a ring block using 0.25% bupivacaine without epinephrine↗
▶Ep 9 · 9:28
clinicalThe best analgesia for circumcision is a dorsal penile nerve block combined with a ring block using 0.25% bupivacaine without epinephrine↗
▶Ep 9 · 10:22
opinionThe Gomco clamp is preferred over Plastibell (subjectively more complications) and Mogen clamp (risk of glans amputation)↗
▶Ep 9 · 10:22
opinionThe Gomco clamp is preferred over Plastibell (subjectively more complications) and Mogen clamp (risk of glans amputation)↗
▶Ep 9 · 11:07
clinicalGlans amputation during circumcision has been seen 2-3 times with Mogen clamp when small glans is pulled through the slit↗
▶Ep 9 · 11:07
clinicalGlans amputation during circumcision has been seen 2-3 times with Mogen clamp when small glans is pulled through the slit↗
▶Ep 9 · 15:55
clinicalComplete preputial adhesion takedown is essential—you must see the ridge under the corona all the way around to avoid asymmetric skin removal↗
▶Ep 9 · 15:55
clinicalComplete preputial adhesion takedown is essential—you must see the ridge under the corona all the way around to avoid asymmetric skin removal↗
▶Ep 9 · 16:56
clinicalWhen using Gomco, leave the bell on for at least 5 minutes for older infants (closer to 3 months/13 pounds) and 1-2 minutes for newborns↗
▶Ep 9 · 16:56
clinicalWhen using Gomco, leave the bell on for at least 5 minutes for older infants (closer to 3 months/13 pounds) and 1-2 minutes for newborns↗
▶Ep 9 · 17:01
clinicalWhen removing the Gomco bell, force the skin off the bell rather than pulling the bell off the skin to avoid separating crushed edges↗
▶Ep 9 · 17:01
clinicalWhen removing the Gomco bell, force the skin off the bell rather than pulling the bell off the skin to avoid separating crushed edges↗
▶Ep 9 · 17:51
clinicalA safety pin through both edges of the dorsal slit helps pull foreskin through the Gomco base hole more easily↗
▶Ep 9 · 17:51
clinicalA safety pin through both edges of the dorsal slit helps pull foreskin through the Gomco base hole more easily↗
▶Ep 9 · 19:35
clinicalBefore clamping, check underneath the bell to ensure shaft skin (not scrotal skin) is visible and the median raphe is centered to avoid twisting↗
▶Ep 9 · 19:35
clinicalBefore clamping, check underneath the bell to ensure shaft skin (not scrotal skin) is visible and the median raphe is centered to avoid twisting↗
▶Ep 9 · 20:47
clinicalVaseline dissolves Dermabond, so parents must be instructed not to apply Vaseline after Dermabond circumcision↗
▶Ep 9 · 20:47
clinicalVaseline dissolves Dermabond, so parents must be instructed not to apply Vaseline after Dermabond circumcision↗
▶Ep 9 · 21:27
clinicalOffice circumcision tray should include 6-0 chromic or fast-absorbing plain suture for bleeding and 1:1000 epinephrine for topical hemostasis↗
▶Ep 9 · 21:27
clinicalOffice circumcision tray should include 6-0 chromic or fast-absorbing plain suture for bleeding and 1:1000 epinephrine for topical hemostasis↗
▶Ep 9 · 22:17
clinicalFor OR circumcision, 6-0 or 5-0 fast-absorbing plain gut (used by plastic surgeons on face) heals nicely; Vicryl causes pie-crusting unless subcuticular↗
▶Ep 9 · 22:17
clinicalFor OR circumcision, 6-0 or 5-0 fast-absorbing plain gut (used by plastic surgeons on face) heals nicely; Vicryl causes pie-crusting unless subcuticular↗
▶Ep 9 · 25:38
clinicalPhysiologic post-circumcision adhesions (distinct line visible, common in chubby babies) do not need treatment and will lyse spontaneously as the child grows↗
▶Ep 9 · 25:38
clinicalPhysiologic post-circumcision adhesions (distinct line visible, common in chubby babies) do not need treatment and will lyse spontaneously as the child grows↗
▶Ep 9 · 26:21
clinicalLysing physiologic adhesions in the office can turn a non-problem into a problem by creating a raw surface that forms a true skin bridge↗
▶Ep 9 · 26:21
clinicalLysing physiologic adhesions in the office can turn a non-problem into a problem by creating a raw surface that forms a true skin bridge↗
▶Ep 9 · 26:48
quoteyou can turn a problem that's not a problem into a problem↗
▶Ep 9 · 26:48
quoteyou can turn a problem that's not a problem into a problem↗
▶Ep 9 · 27:15
clinicalTrue skin bridges (no line, two holes on each side) require treatment because they tether the penis and do not resolve spontaneously↗
▶Ep 9 · 27:15
clinicalTrue skin bridges (no line, two holes on each side) require treatment because they tether the penis and do not resolve spontaneously↗
▶Ep 9 · 27:47
clinicalMost skin bridges can be lysed in office with EMLA cream for 30-40 minutes, hemostat placement, and fine scissor division↗
▶Ep 9 · 27:47
clinicalMost skin bridges can be lysed in office with EMLA cream for 30-40 minutes, hemostat placement, and fine scissor division↗
▶Ep 9 · 29:25
clinicalRedundant foreskin appearance after circumcision is usually due to suprapubic fat pad displacing skin distally; if penis looks circumcised when fat pad is pushed down, no revision is needed↗
▶Ep 9 · 29:25
clinicalRedundant foreskin appearance after circumcision is usually due to suprapubic fat pad displacing skin distally; if penis looks circumcised when fat pad is pushed down, no revision is needed↗
▶Ep 9 · 29:57
clinicalDr. Gargollo has never seen an adolescent complain of too much foreskin after circumcision, suggesting most cases resolve with puberty↗
▶Ep 9 · 29:57
clinicalDr. Gargollo has never seen an adolescent complain of too much foreskin after circumcision, suggesting most cases resolve with puberty↗
▶Ep 9 · 30:53
clinicalDr. Gargollo performs only 1-2 redo circumcisions per year despite high volume, indicating most redundant skin resolves spontaneously↗
▶Ep 9 · 30:53
clinicalDr. Gargollo performs only 1-2 redo circumcisions per year despite high volume, indicating most redundant skin resolves spontaneously↗
▶Ep 9 · 31:42
quoteI've never done a redo circumcision in an adolescent, probably because these children grow and their penises grow and the skin stretches, and we don't need to do anything↗
▶Ep 9 · 31:42
quoteI've never done a redo circumcision in an adolescent, probably because these children grow and their penises grow and the skin stretches, and we don't need to do anything↗
▶Ep 9 · 32:11
clinicalMeatal stenosis is a condition exclusively seen in circumcised boys, caused by meatal inflammation from rubbing against diaper/underwear creating a 6 o'clock web↗
▶Ep 9 · 32:11
clinicalMeatal stenosis is a condition exclusively seen in circumcised boys, caused by meatal inflammation from rubbing against diaper/underwear creating a 6 o'clock web↗
▶Ep 9 · 32:45
clinicalMeatal stenosis requires intervention only when urine stream deviates straight upward or child must sit to void, not for subjectively narrow meatus alone↗
▶Ep 9 · 32:45
clinicalMeatal stenosis requires intervention only when urine stream deviates straight upward or child must sit to void, not for subjectively narrow meatus alone↗
▶Ep 9 · 33:29
quoteI've never seen an adolescent with meatal stenosis↗
▶Ep 9 · 33:29
clinicalDr. Gargollo has never seen an adolescent with meatal stenosis, suggesting many subjectively narrow meatuses normalize with growth↗
▶Ep 9 · 33:29
quoteI've never seen an adolescent with meatal stenosis↗
▶Ep 9 · 33:29
clinicalDr. Gargollo has never seen an adolescent with meatal stenosis, suggesting many subjectively narrow meatuses normalize with growth↗
▶Ep 9 · 33:44
clinicalOffice meatotomy can be performed with EMLA cream, straight hemostat crush of 6 o'clock web, and fine scissors; sutures at 3 and 6 o'clock have no proven benefit for reducing recurrence↗
▶Ep 9 · 33:44
clinicalOffice meatotomy can be performed with EMLA cream, straight hemostat crush of 6 o'clock web, and fine scissors; sutures at 3 and 6 o'clock have no proven benefit for reducing recurrence↗
▶Ep 9 · 35:37
clinicalMicropenis is defined as stretched penile length greater than 2.5 standard deviations below the mean for age; mean is 4 cm at 6-12 months↗
▶Ep 9 · 35:37
clinicalMicropenis is defined as stretched penile length greater than 2.5 standard deviations below the mean for age; mean is 4 cm at 6-12 months↗
▶Ep 9 · 36:47
quotedon't be a hero with these things, you know, one of the highest areas of litigation are circumcisions that are done and then there's a problem afterwards↗
▶Ep 9 · 36:47
quotedon't be a hero with these things, you know, one of the highest areas of litigation are circumcisions that are done and then there's a problem afterwards↗
▶Ep 9 · 36:58
clinicalHypospadias, buried penis, penile-scrotal webbing, penile torsion, and congenital megaprepuce are contraindications to routine circumcision and should be referred to pediatric urology↗
▶Ep 9 · 36:58
clinicalHypospadias, buried penis, penile-scrotal webbing, penile torsion, and congenital megaprepuce are contraindications to routine circumcision and should be referred to pediatric urology↗
▶Ep 9 · 37:22
clinicalA buried penis appears as a short squat pyramid rather than a protruding structure; attempting circumcision can result in complete shaft skin loss requiring skin grafting↗
▶Ep 9 · 37:22
clinicalA buried penis appears as a short squat pyramid rather than a protruding structure; attempting circumcision can result in complete shaft skin loss requiring skin grafting↗
▶Ep 9 · 38:47
clinicalPhysiologic phimosis (soft, supple foreskin without symptoms) requires no treatment regardless of age, even in 5-8 year olds↗
▶Ep 9 · 38:47
clinicalPhysiologic phimosis (soft, supple foreskin without symptoms) requires no treatment regardless of age, even in 5-8 year olds↗
▶Ep 9 · 40:15
clinicalFirst-line treatment for symptomatic phimosis is betamethasone 0.1% three times daily for 2-3 months, with >50% success rate↗
▶Ep 9 · 40:15
clinicalFirst-line treatment for symptomatic phimosis is betamethasone 0.1% three times daily for 2-3 months, with >50% success rate↗
▶Ep 9 · 41:13
clinicalSecondary phimosis (post-circumcision cicatrix causing stenotic ring) responds to betamethasone 0.1% TID for 2-3 months in >50% of cases↗
▶Ep 9 · 41:13
clinicalSecondary phimosis (post-circumcision cicatrix causing stenotic ring) responds to betamethasone 0.1% TID for 2-3 months in >50% of cases↗
▶Ep 9 · 42:20
clinicalBalanitis xerotica obliterans (BXO) presents with white paper-like, scaly, hard skin at prepuce tip and does not respond to steroids; requires circumcision to prevent urethral stricture↗
▶Ep 9 · 42:20
clinicalBalanitis xerotica obliterans (BXO) presents with white paper-like, scaly, hard skin at prepuce tip and does not respond to steroids; requires circumcision to prevent urethral stricture↗
▶Ep 9 · 44:02
clinicalParaphimosis management includes pain control, D50-soaked bandage wrap to reduce edema, and manual reduction with thumbs on glans pushing back through foreskin↗
▶Ep 9 · 44:02
clinicalParaphimosis management includes pain control, D50-soaked bandage wrap to reduce edema, and manual reduction with thumbs on glans pushing back through foreskin↗
▶Ep 9 · 45:02
clinicalDr. Gargollo has never had to perform a dorsal slit for paraphimosis, as manual reduction with proper pain control and D50 wrap is successful↗
▶Ep 9 · 45:02
clinicalDr. Gargollo has never had to perform a dorsal slit for paraphimosis, as manual reduction with proper pain control and D50 wrap is successful↗
▶Ep 9 · 45:55
clinicalThe main cause of penile trauma is zipper injuries; treatment is cutting the zipper bridge with bolt cutters rather than manipulating the zipper↗
▶Ep 9 · 45:55
clinicalThe main cause of penile trauma is zipper injuries; treatment is cutting the zipper bridge with bolt cutters rather than manipulating the zipper↗
▶Ep 9 · 46:32
clinicalToilet seat crush injuries to penis can be managed conservatively if child is voiding without gross hematuria; glands hematoma may look necrotic but resolves↗
▶Ep 9 · 46:32
clinicalToilet seat crush injuries to penis can be managed conservatively if child is voiding without gross hematuria; glands hematoma may look necrotic but resolves↗
▶Ep 9 · 47:36
clinicalBuck's fascia violation in penile trauma requires OR repair to prevent long-term scarring and potency issues↗
▶Ep 9 · 47:36
clinicalBuck's fascia violation in penile trauma requires OR repair to prevent long-term scarring and potency issues↗
▶Ep 9 · 48:11
clinicalGross blood at urethral meatus or gross hematuria after trauma mandates full urinary tract evaluation and retrograde urethrogram before catheterization↗
▶Ep 9 · 48:11
clinicalGross blood at urethral meatus or gross hematuria after trauma mandates full urinary tract evaluation and retrograde urethrogram before catheterization↗
▶Ep 9 · 49:34
epidemiologicalHypospadias incidence is approximately 1 in 150 live births, likely multifactorial etiology including in vitro fertilization exposure↗
▶Ep 9 · 49:34
epidemiologicalHypospadias incidence is approximately 1 in 150 live births, likely multifactorial etiology including in vitro fertilization exposure↗
▶Ep 9 · 50:34
clinicalHypospadias assessment requires evaluation of meatus location and degree of ventral curvature (chordee); more proximal meatus and greater curvature indicate more complex repair↗
▶Ep 9 · 50:34
clinicalHypospadias assessment requires evaluation of meatus location and degree of ventral curvature (chordee); more proximal meatus and greater curvature indicate more complex repair↗
▶Ep 9 · 51:14
clinicalFor distal hypospadias discovered during circumcision, the circumcision can be completed because foreskin is not used in modern distal hypospadias repairs↗
▶Ep 9 · 51:14
clinicalFor distal hypospadias discovered during circumcision, the circumcision can be completed because foreskin is not used in modern distal hypospadias repairs↗
▶Ep 9 · 51:20
quotefinish the circumcision, you know, don't leave the skin kind of hanging there, just get it done↗
▶Ep 9 · 51:20
quotefinish the circumcision, you know, don't leave the skin kind of hanging there, just get it done↗
▶Ep 9 · 52:46
clinicalNon-palpable gonad with hypospadias requires full disorder of sexual differentiation (DSD) workup; bilateral non-palpable gonads suggests congenital adrenal hyperplasia↗
▶Ep 9 · 52:46
clinicalNon-palpable gonad with hypospadias requires full disorder of sexual differentiation (DSD) workup; bilateral non-palpable gonads suggests congenital adrenal hyperplasia↗
opinionVery mild hypospadias variants (megameatus, distal) raise controversy about timing of repair given anesthesia exposure concerns in young children↗
▶Ep 9 · 54:40
opinionVery mild hypospadias variants (megameatus, distal) raise controversy about timing of repair given anesthesia exposure concerns in young children↗
▶Ep 9 · 56:12
clinicalHypospadias repair involves urethroplasty (tubularizing urethra with second-layer coverage) and phalloplasty (straightening chordee, often resolved by degloving alone)↗
▶Ep 9 · 56:12
clinicalHypospadias repair involves urethroplasty (tubularizing urethra with second-layer coverage) and phalloplasty (straightening chordee, often resolved by degloving alone)↗
▶Ep 9 · 57:22
clinicalEpispadias (dorsal urethral defect) is extremely rare (<1/50,000) and represents the bladder exstrophy-epispadias spectrum with associated incontinence, pubic diastasis, and vesicoureteral reflux↗
▶Ep 9 · 57:22
clinicalEpispadias (dorsal urethral defect) is extremely rare (<1/50,000) and represents the bladder exstrophy-epispadias spectrum with associated incontinence, pubic diastasis, and vesicoureteral reflux↗
▶Ep 9 · 59:58
clinicalPenile torsion (twisted median raphe) requires surgical correction only if rotation is ≥90 degrees↗
▶Ep 9 · 59:58
clinicalPenile torsion (twisted median raphe) requires surgical correction only if rotation is ≥90 degrees↗
▶Ep 9 · 1:01:48
epidemiologicalLabial adhesions occur in approximately 2% of girls in the first 2 years of life, not in newborns due to protective maternal estrogen↗
▶Ep 9 · 1:01:48
epidemiologicalLabial adhesions occur in approximately 2% of girls in the first 2 years of life, not in newborns due to protective maternal estrogen↗
▶Ep 9 · 1:02:29
clinicalLabial adhesions require treatment only for symptoms: post-void dribbling, skin breakdown, or recurrent UTIs; asymptomatic adhesions should not be treated↗
▶Ep 9 · 1:02:29
clinicalLabial adhesions require treatment only for symptoms: post-void dribbling, skin breakdown, or recurrent UTIs; asymptomatic adhesions should not be treated↗
▶Ep 9 · 1:02:53
clinicalFirst-line treatment for symptomatic labial adhesions is betamethasone ointment BID for 6 weeks, preferred over estrogen cream to avoid pubic hair development in prepubertal girls↗
▶Ep 9 · 1:02:53
clinicalFirst-line treatment for symptomatic labial adhesions is betamethasone ointment BID for 6 weeks, preferred over estrogen cream to avoid pubic hair development in prepubertal girls↗
▶Ep 9 · 1:03:31
clinicalSurgical lysis of labial adhesions is rarely needed; Dr. Gargollo has performed it only once in his career↗
▶Ep 9 · 1:03:31
clinicalSurgical lysis of labial adhesions is rarely needed; Dr. Gargollo has performed it only once in his career↗
▶Ep 9 · 1:04:52
clinicalDifferential diagnosis for midline genital bulge includes imperforate hymen, prolapsed urethrocele, paraurethral/perivaginal cysts, and vaginal rhabdomyosarcoma↗
▶Ep 9 · 1:04:52
clinicalDifferential diagnosis for midline genital bulge includes imperforate hymen, prolapsed urethrocele, paraurethral/perivaginal cysts, and vaginal rhabdomyosarcoma↗
▶Ep 9 · 1:06:30
clinicalProlapsed urethrocele is distinct from vagina on exam, associated with prenatal hydronephrosis, and requires renal bladder ultrasound and VCUG↗
▶Ep 9 · 1:06:30
clinicalProlapsed urethrocele is distinct from vagina on exam, associated with prenatal hydronephrosis, and requires renal bladder ultrasound and VCUG↗
▶Ep 9 · 1:07:34
clinicalParaurethral and perivaginal cysts (Gardner's duct, Skene's gland) present at birth, spontaneously regress with loss of maternal estrogen, and show patent urethra and vagina on exam↗
▶Ep 9 · 1:07:34
clinicalParaurethral and perivaginal cysts (Gardner's duct, Skene's gland) present at birth, spontaneously regress with loss of maternal estrogen, and show patent urethra and vagina on exam↗
▶Ep 9 · 1:08:03
clinicalVaginal rhabdomyosarcoma appears as a 'bunch of grapes' mass rather than a single bulge and requires oncology involvement↗
▶Ep 9 · 1:08:03
clinicalVaginal rhabdomyosarcoma appears as a 'bunch of grapes' mass rather than a single bulge and requires oncology involvement↗
epidemiologicalUTI risk in the first year of life is 3-4% overall, with uncircumcised boys having 1/100 risk vs circumcised boys 1/1000 risk↗
▶Ep 2 · 3:20
epidemiologicalCircumcision provides decreased risk for HIV, syphilis, gonococcus, HPV, and HSV-2, but not for chlamydia↗
▶Ep 2 · 3:40
epidemiologicalKenya trial of ~3000 men showed 53% protection against HIV in circumcised cohort, trial stopped early due to significance↗
▶Ep 2 · 4:05
epidemiologicalUganda trial of ~5000 males showed 50% of circumcised men became infected vs control group, also stopped early↗
▶Ep 2 · 4:25
guidelineAAP policy states data are not sufficient to recommend routine neonatal circumcision, parents should receive accurate unbiased information↗
▶Ep 2 · 4:25
quotethese data are not sufficient to recommend routine neonatal circumcision↗
▶Ep 2 · 4:35
quoteparents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision↗
▶Ep 2 · 6:50
opinionOffice circumcision cutoff: 3 months of age or less than 13 pounds (personal practice guideline, no data support)↗
▶Ep 2 · 7:00
quoteif you're going to restrain the child any way either use a papoose board or anything else that when they get a little bigger it's going to be a little harder to do that↗
▶Ep 2 · 7:49
clinicalLiterature suggests exposing younger children to elective cases like circumcision under general anesthesia is not recommended from anesthetic safety standpoint↗
▶Ep 2 · 8:10
quoteI personally feel that if you don't do them that there's really no reason to not refer that child to somebody who does do them↗
▶Ep 2 · 8:51
clinicalBest analgesia method for circumcision is dorsal penile nerve block combined with ring block using 0.25% bupivacaine without epinephrine↗
▶Ep 2 · 9:50
opinionPlastibel device subjectively has more postoperative complications than Gomco or Mogan clamps↗
▶Ep 2 · 11:05
quotethe only time I've ever seen a major injury from a circumcision like Glands amputation has been when the Mogan clamp has been used↗
▶Ep 2 · 11:05
clinicalMajor injuries (glans amputation) from circumcision have been seen only with Mogan clamp use (2-3 cases observed)↗
▶Ep 2 · 11:28
clinicalDorsal penile nerves run at 2 o'clock and 11 o'clock positions, block placed below pubic symphysis at ~1.5cm depth using 1cc/kg of 0.25% bupivacaine↗
▶Ep 2 · 12:43
clinicalMogan clamp glans amputation occurs when glans is pulled through the slit along with foreskin, especially with smaller glans↗
▶Ep 2 · 14:13
clinicalGomco bell sizes are 1.1, 1.3, 1.45, and 1.6 cm; 75% of time a 1.3 bell is used↗
▶Ep 2 · 14:40
clinicalMismatched Gomco bell and base can cause bell to pull up, exposing glans and causing injury during cutting↗
▶Ep 2 · 15:10
clinicalMust take down preputial adhesions completely to see ridge under corona all around, or will leave asymmetric skin↗
▶Ep 2 · 17:00
quoteyou really want to force the skin off the bell rather than pull the bell off the skin↗
▶Ep 2 · 17:16
clinicalGomco bell should be left on for at least 5 minutes for older kids (near 3 months/13 lbs), 1-2 minutes for newborns↗
▶Ep 2 · 20:32
clinicalVaseline dissolves Dermabond, so parents must be instructed not to use Vaseline on Dermabond-dressed circumcisions↗
▶Ep 2 · 21:20
clinicalFor bleeding control, have 6-0 chromic or fast-absorbing plain suture and 1:1000 diluted epinephrine available in circumcision tray↗
▶Ep 2 · 22:04
opinionFast-absorbing plain gut (6-0 or 5-0) leaves nicer cosmetic appearance than Vicryl for circumcision closure↗
▶Ep 2 · 25:20
clinicalPhysiologic adhesions (distinct line visible) do not need treatment and will lyse on their own as baby grows↗
▶Ep 2 · 26:00
clinicalLysing physiologic adhesions in office can turn a non-problem into a problem by creating raw surface and true bridges↗
▶Ep 2 · 26:50
quoteyou can turn a problem that's not a problem into a problem↗
▶Ep 2 · 27:12
clinicalSkin bridges (no distinct line, two holes on each side) need treatment as they will not lyse and can tether penis with growth↗
▶Ep 2 · 27:50
clinicalMost skin bridges can be treated in office with EMLA cream 30-40 minutes, hemostat clamp, and fine scissor division↗
▶Ep 2 · 29:40
clinicalRedundant foreskin appearance often due to fat pad; if penis looks circumcised when fat pad pushed down, no intervention needed↗
▶Ep 2 · 30:20
quoteI personally in my career have never seen an adolescent come in complaining of too much foreskin↗
▶Ep 2 · 30:20
opinionHave never seen an adolescent complain of too much foreskin; suspect most cases resolve with puberty and penile growth↗
▶Ep 2 · 30:50
clinicalPerform 1-2 redo circumcisions per year in high-volume practice, suggesting most resolve spontaneously↗
▶Ep 2 · 31:59
clinicalMeatal stenosis is exclusively seen in circumcised boys, caused by meatal rubbing against diaper/underwear creating inflammatory web at 6 o'clock↗
▶Ep 2 · 32:40
clinicalMeatal stenosis requires intervention only when symptomatic: urine shoots straight up toward ceiling, child must sit to void↗
▶Ep 2 · 33:10
quoteI've never seen an adolescent with meatal stenosis↗
▶Ep 2 · 33:10
opinionHave never seen an adolescent with meatal stenosis; many subjectively narrow meatuses become normal with growth↗
▶Ep 2 · 33:40
clinicalMeatotomy can be done in office with EMLA cream, straight hemostat crush of 6 o'clock web, and fine scissor incision without sutures↗
▶Ep 2 · 34:20
clinicalNo data shows sutures at 3 and 6 o'clock reduce meatotomy recurrence rate compared to no sutures↗
▶Ep 2 · 36:23
clinicalMicropenis clinical definition: stretched penile length >2.5 standard deviations below normal mean for age↗
▶Ep 2 · 36:36
quotedon't be a hero with these things, you know, one of the highest areas of litigation are circumcisions that are done and then there's a problem afterwards↗
▶Ep 2 · 36:50
clinicalMean stretched penile length for 6-12 month old is about 4 cm (reference: Bin Abbas 1999)↗
▶Ep 2 · 37:30
clinicalBuried penis looks like a short squat pyramid, not a structure coming out of the body↗
▶Ep 2 · 37:40
quoteif it doesn't look quite right or quite like what you're used to just refer him to a pediatric neurologist, save yourself the hassle. It's just, it's not worth it↗
▶Ep 2 · 37:50
clinicalCongenital megaprepuce occurs mostly in Hispanic patients and should not be circumcised due to risk of complete shaft skin loss↗
▶Ep 2 · 38:50
clinicalPhysiologic phimosis (soft, supple skin, no symptoms) does not require treatment regardless of age↗
▶Ep 2 · 39:10
quoteeven though the AAP has published guidelines as to when the foreskin should retract based on age, I don't really go on those↗
▶Ep 2 · 40:00
clinicalBetamethasone 0.1% TID for 2-3 months results in >50% of children with phimosis having retractile foreskins↗
▶Ep 2 · 40:20
quoteI honestly think that that dose is too low and that time period is too low to actually see an effect↗
▶Ep 2 · 40:30
opinionLower betamethasone doses (0.05% BID for few weeks) are too low in dose and duration to see effect↗
▶Ep 2 · 41:30
clinicalSecondary phimosis (hard stenotic ring after circumcision) responds to betamethasone 0.1% TID for 2-3 months in >50% of cases↗
▶Ep 2 · 42:10
clinicalBalanitis xerotica obliterans (BXO) presents with paper-white, scaly, hard skin at prepuce tip and will not respond to steroids↗
▶Ep 2 · 42:40
clinicalBXO can spread onto glans and into urethra causing significant urethral strictures; requires circumcision↗
clinicalParaphimosis occurs when retracted foreskin is not brought back over glans, can become medical emergency with vascular compromise↗
▶Ep 2 · 43:40
clinicalParaphimosis treatment: pain control (EMLA or penile block), D50-soaked bandage wrap to reduce swelling, manual reduction↗
▶Ep 2 · 44:20
clinicalManual paraphimosis reduction: thumbs on glans, fingers on shaft skin, pinch shaft skin and push glans back into foreskin↗
▶Ep 2 · 44:50
clinicalManual reduction works 9 out of 10 times with good pain control and D50 swelling reduction; have never needed dorsal slit↗
▶Ep 2 · 45:00
quoteI personally have never had to do a dorsal slit for a paraphymosis↗
▶Ep 2 · 45:26
clinicalMain cause of penile trauma is zipper injuries; treatment is cutting zipper bridge with bolt cutter rather than manipulating zipper↗
▶Ep 2 · 46:10
clinicalSecond most common penile trauma is toilet seat crush injuries; conservative management if child voids without gross hematuria↗
▶Ep 2 · 46:50
clinicalGross hematuria after penile trauma requires urologist involvement for potential urethral injury evaluation↗
▶Ep 2 · 47:50
clinicalBuck's fascia violation in penile trauma requires OR repair to prevent long-term scarring and potency issues↗
▶Ep 2 · 48:20
clinicalGross blood at meatus or gross hematuria after trauma requires full urinary tract evaluation and retrograde urethrogram before catheterization↗
▶Ep 2 · 48:30
quoteplease do not instrument that child because if there is a urethral injury, you can create a much bigger problem↗
▶Ep 2 · 49:40
epidemiologicalHypospadias incidence is about 1 in 150 live births↗
▶Ep 2 · 49:55
epidemiologicalHypospadias etiology is multifactorial; higher incidence in children conceived via in vitro fertilization↗
▶Ep 2 · 51:40
quotewe don't utilize the foreskin to do a reconstruction for mild hypospadius almost ever, if ever↗
▶Ep 2 · 51:40
clinicalForeskin is not used for distal hypospadias reconstruction; can complete circumcision if found during procedure↗
▶Ep 2 · 52:20
clinicalUndescended gonad with hypospadias requires full DSD workup; bilateral non-palpable gonads suggests congenital adrenal hyperplasia↗
clinicalPenile torsion repair not needed unless close to 90 degrees; foreskin not used in repair↗
▶Ep 2 · 1:00:50
clinicalPenoscrotal webbing is obvious, not subtle; some surgeons use foreskin flaps for repair↗
▶Ep 2 · 1:01:50
epidemiologicalLabial adhesions incidence is about 2% in first two years of life, not seen in newborns (maternal estrogen protective)↗
▶Ep 2 · 1:02:25
clinicalLabial adhesions require treatment only if symptomatic: post-void dribbling, skin breakdown, or recurrent UTIs↗
▶Ep 2 · 1:03:00
opinionBetamethasone ointment works well for labial adhesions; preferred over estrogen cream to avoid pubic hair development in toddlers↗
▶Ep 2 · 1:03:40
clinicalHave performed formal lysis of labial adhesions in OR only once in career; most respond to topical treatment↗
▶Ep 2 · 1:05:00
clinicalImperforate hymen treatment is incision to open the hymen and drain retained vaginal secretions↗
▶Ep 2 · 1:06:10
clinicalProlapsed urethrocele is smooth, mucosa-covered, protrudes from urethra distinct from vagina, associated with prenatal hydronephrosis↗
▶Ep 2 · 1:06:50
clinicalParaurethral and perivaginal cysts (Gartner's duct, Skene's gland) present at birth, spontaneously regress with maternal estrogen loss↗
▶Ep 2 · 1:08:00
clinicalVaginal rhabdomyosarcoma appears as 'bunch of grapes' mass, not a single bulge↗
Urology Part I
▶Ep 4 · 2:40
epidemiologicalUTI risk in the first year of life is 3-4% overall, with uncircumcised boys having 1/100 risk versus circumcised boys 1/1000 risk↗
▶Ep 4 · 3:16
clinicalCircumcision decreases risk of HIV, syphilis, gonococcus, HPV, and HSV-2, but does not change chlamydia risk↗
▶Ep 4 · 4:16
clinicalCircumcision provides 53% protection against HIV transmission in randomized trials from Kenya and Uganda, with both trials stopped early due to significant benefit↗
▶Ep 4 · 5:19
quotethese data are not sufficient to recommend routine neonatal circumcision↗
▶Ep 4 · 5:19
host_summaryThe AAP states that data are not sufficient to recommend routine neonatal circumcision, and parents should be given accurate, unbiased information↗
▶Ep 4 · 5:30
quoteparents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision↗
▶Ep 4 · 6:56
opinionOffice circumcision should be limited to infants 3 months or younger or weighing less than 13 pounds to minimize restraint difficulty and bleeding risk↗
▶Ep 4 · 7:53
clinicalExposing young children to elective general anesthesia such as for circumcision is not recommended from an anesthetic safety standpoint↗
▶Ep 4 · 8:05
quoteI personally feel that if you don't do them that there's really no reason to not refer that child to somebody who does do them↗
▶Ep 4 · 9:28
clinicalThe best analgesia for circumcision is a dorsal penile nerve block combined with a ring block using 0.25% bupivacaine without epinephrine↗
▶Ep 4 · 10:22
opinionThe Gomco clamp is preferred over Plastibell (subjectively more complications) and Mogen clamp (risk of glans amputation)↗
▶Ep 4 · 11:07
clinicalGlans amputation during circumcision has been seen 2-3 times with Mogen clamp when small glans is pulled through the slit↗
▶Ep 4 · 15:55
clinicalComplete preputial adhesion takedown is essential—you must see the ridge under the corona all the way around to avoid asymmetric skin removal↗
▶Ep 4 · 16:56
clinicalWhen using Gomco, leave the bell on for at least 5 minutes for older infants (closer to 3 months/13 pounds) and 1-2 minutes for newborns↗
▶Ep 4 · 17:01
clinicalWhen removing the Gomco bell, force the skin off the bell rather than pulling the bell off the skin to avoid separating crushed edges↗
▶Ep 4 · 17:51
clinicalA safety pin through both edges of the dorsal slit helps pull foreskin through the Gomco base hole more easily↗
▶Ep 4 · 19:35
clinicalBefore clamping, check underneath the bell to ensure shaft skin (not scrotal skin) is visible and the median raphe is centered to avoid twisting↗
▶Ep 4 · 20:47
clinicalVaseline dissolves Dermabond, so parents must be instructed not to apply Vaseline after Dermabond circumcision↗
▶Ep 4 · 21:27
clinicalOffice circumcision tray should include 6-0 chromic or fast-absorbing plain suture for bleeding and 1:1000 epinephrine for topical hemostasis↗
▶Ep 4 · 22:17
clinicalFor OR circumcision, 6-0 or 5-0 fast-absorbing plain gut (used by plastic surgeons on face) heals nicely; Vicryl causes pie-crusting unless subcuticular↗
▶Ep 4 · 25:38
clinicalPhysiologic post-circumcision adhesions (distinct line visible, common in chubby babies) do not need treatment and will lyse spontaneously as the child grows↗
▶Ep 4 · 26:21
clinicalLysing physiologic adhesions in the office can turn a non-problem into a problem by creating a raw surface that forms a true skin bridge↗
▶Ep 4 · 26:48
quoteyou can turn a problem that's not a problem into a problem↗
▶Ep 4 · 27:15
clinicalTrue skin bridges (no line, two holes on each side) require treatment because they tether the penis and do not resolve spontaneously↗
▶Ep 4 · 27:47
clinicalMost skin bridges can be lysed in office with EMLA cream for 30-40 minutes, hemostat placement, and fine scissor division↗
▶Ep 4 · 29:25
clinicalRedundant foreskin appearance after circumcision is usually due to suprapubic fat pad displacing skin distally; if penis looks circumcised when fat pad is pushed down, no revision is needed↗
▶Ep 4 · 29:57
clinicalDr. Gargollo has never seen an adolescent complain of too much foreskin after circumcision, suggesting most cases resolve with puberty↗
▶Ep 4 · 30:53
clinicalDr. Gargollo performs only 1-2 redo circumcisions per year despite high volume, indicating most redundant skin resolves spontaneously↗
▶Ep 4 · 31:42
quoteI've never done a redo circumcision in an adolescent, probably because these children grow and their penises grow and the skin stretches, and we don't need to do anything↗
▶Ep 4 · 32:11
clinicalMeatal stenosis is a condition exclusively seen in circumcised boys, caused by meatal inflammation from rubbing against diaper/underwear creating a 6 o'clock web↗
▶Ep 4 · 32:45
clinicalMeatal stenosis requires intervention only when urine stream deviates straight upward or child must sit to void, not for subjectively narrow meatus alone↗
▶Ep 4 · 33:29
clinicalDr. Gargollo has never seen an adolescent with meatal stenosis, suggesting many subjectively narrow meatuses normalize with growth↗
▶Ep 4 · 33:29
quoteI've never seen an adolescent with meatal stenosis↗
▶Ep 4 · 33:44
clinicalOffice meatotomy can be performed with EMLA cream, straight hemostat crush of 6 o'clock web, and fine scissors; sutures at 3 and 6 o'clock have no proven benefit for reducing recurrence↗
▶Ep 4 · 35:37
clinicalMicropenis is defined as stretched penile length greater than 2.5 standard deviations below the mean for age; mean is 4 cm at 6-12 months↗
▶Ep 4 · 36:47
quotedon't be a hero with these things, you know, one of the highest areas of litigation are circumcisions that are done and then there's a problem afterwards↗
▶Ep 4 · 36:58
clinicalHypospadias, buried penis, penile-scrotal webbing, penile torsion, and congenital megaprepuce are contraindications to routine circumcision and should be referred to pediatric urology↗
▶Ep 4 · 37:22
clinicalA buried penis appears as a short squat pyramid rather than a protruding structure; attempting circumcision can result in complete shaft skin loss requiring skin grafting↗
▶Ep 4 · 38:47
clinicalPhysiologic phimosis (soft, supple foreskin without symptoms) requires no treatment regardless of age, even in 5-8 year olds↗
▶Ep 4 · 40:15
clinicalFirst-line treatment for symptomatic phimosis is betamethasone 0.1% three times daily for 2-3 months, with >50% success rate↗
▶Ep 4 · 41:13
clinicalSecondary phimosis (post-circumcision cicatrix causing stenotic ring) responds to betamethasone 0.1% TID for 2-3 months in >50% of cases↗
▶Ep 4 · 42:20
clinicalBalanitis xerotica obliterans (BXO) presents with white paper-like, scaly, hard skin at prepuce tip and does not respond to steroids; requires circumcision to prevent urethral stricture↗
▶Ep 4 · 44:02
clinicalParaphimosis management includes pain control, D50-soaked bandage wrap to reduce edema, and manual reduction with thumbs on glans pushing back through foreskin↗
▶Ep 4 · 45:02
clinicalDr. Gargollo has never had to perform a dorsal slit for paraphimosis, as manual reduction with proper pain control and D50 wrap is successful↗
▶Ep 4 · 45:55
clinicalThe main cause of penile trauma is zipper injuries; treatment is cutting the zipper bridge with bolt cutters rather than manipulating the zipper↗
▶Ep 4 · 46:32
clinicalToilet seat crush injuries to penis can be managed conservatively if child is voiding without gross hematuria; glands hematoma may look necrotic but resolves↗
▶Ep 4 · 47:36
clinicalBuck's fascia violation in penile trauma requires OR repair to prevent long-term scarring and potency issues↗
▶Ep 4 · 48:11
clinicalGross blood at urethral meatus or gross hematuria after trauma mandates full urinary tract evaluation and retrograde urethrogram before catheterization↗
▶Ep 4 · 49:34
epidemiologicalHypospadias incidence is approximately 1 in 150 live births, likely multifactorial etiology including in vitro fertilization exposure↗
▶Ep 4 · 50:34
clinicalHypospadias assessment requires evaluation of meatus location and degree of ventral curvature (chordee); more proximal meatus and greater curvature indicate more complex repair↗
▶Ep 4 · 51:14
clinicalFor distal hypospadias discovered during circumcision, the circumcision can be completed because foreskin is not used in modern distal hypospadias repairs↗
▶Ep 4 · 51:20
quotefinish the circumcision, you know, don't leave the skin kind of hanging there, just get it done↗
▶Ep 4 · 52:46
clinicalNon-palpable gonad with hypospadias requires full disorder of sexual differentiation (DSD) workup; bilateral non-palpable gonads suggests congenital adrenal hyperplasia↗
opinionVery mild hypospadias variants (megameatus, distal) raise controversy about timing of repair given anesthesia exposure concerns in young children↗
▶Ep 4 · 56:12
clinicalHypospadias repair involves urethroplasty (tubularizing urethra with second-layer coverage) and phalloplasty (straightening chordee, often resolved by degloving alone)↗
▶Ep 4 · 57:22
clinicalEpispadias (dorsal urethral defect) is extremely rare (<1/50,000) and represents the bladder exstrophy-epispadias spectrum with associated incontinence, pubic diastasis, and vesicoureteral reflux↗
▶Ep 4 · 59:58
clinicalPenile torsion (twisted median raphe) requires surgical correction only if rotation is ≥90 degrees↗
▶Ep 4 · 1:01:48
epidemiologicalLabial adhesions occur in approximately 2% of girls in the first 2 years of life, not in newborns due to protective maternal estrogen↗
▶Ep 4 · 1:02:29
clinicalLabial adhesions require treatment only for symptoms: post-void dribbling, skin breakdown, or recurrent UTIs; asymptomatic adhesions should not be treated↗
▶Ep 4 · 1:02:53
clinicalFirst-line treatment for symptomatic labial adhesions is betamethasone ointment BID for 6 weeks, preferred over estrogen cream to avoid pubic hair development in prepubertal girls↗
▶Ep 4 · 1:03:31
clinicalSurgical lysis of labial adhesions is rarely needed; Dr. Gargollo has performed it only once in his career↗
▶Ep 4 · 1:04:52
clinicalDifferential diagnosis for midline genital bulge includes imperforate hymen, prolapsed urethrocele, paraurethral/perivaginal cysts, and vaginal rhabdomyosarcoma↗
▶Ep 4 · 1:06:30
clinicalProlapsed urethrocele is distinct from vagina on exam, associated with prenatal hydronephrosis, and requires renal bladder ultrasound and VCUG↗
▶Ep 4 · 1:07:34
clinicalParaurethral and perivaginal cysts (Gardner's duct, Skene's gland) present at birth, spontaneously regress with loss of maternal estrogen, and show patent urethra and vagina on exam↗
▶Ep 4 · 1:08:03
clinicalVaginal rhabdomyosarcoma appears as a 'bunch of grapes' mass rather than a single bulge and requires oncology involvement↗
