Elsevier

Journal of Pediatric Urology

Volume 12, Issue 3, June 2016, Pages 151.e1-151.e7
Journal of Pediatric Urology

Educational survey of regional general practitioner's management of paediatric patients with undescended testis

https://doi.org/10.1016/j.jpurol.2015.11.010Get rights and content

Summary

Introduction

Recent recommendations have lowered the ideal age of surgery for undescended testis (UDT) to 3–6 months of age. However, many publications demonstrate that age at surgery is still above the recommended age of 1 year as originally suggested in 1996.

Aim

Through a web-based educational survey, we aimed to combine questions regarding General Practioner's (GPs) management of these patients with educational slides with advice to update them with current recommendations.

Methods

The regional GPs were invited by email and letter to undertake the web-based questionnaire devised using SurveyMonkey®. Educational slides were shown after each questionnaire slide. Feedback was immediate and a one-page summary was emailed to the GP on completion. A pre- and post-educational intervention audit was undertaken to ascertain the change in age of referral for patients <5 years of age.

Results

144 (36%) of 401 GPs undertook this survey. 84% were happy assessing infants (<1year) with UDT. 16% were unhappy discussing management with parents for palpable UDT. 52% were happy discussing malignant risk with parents. 80% thought that ultrasonography was routinely used. Optimal referral time was thought to be 6–12 months (42%) and time of surgery was 1–2 years (50%). 72% would refer a patient with palpable UDT after 6 months of age. Only 41% were happy to assess testicular size at puberty.

98% found this format of an educational survey was helpful. The average age of referral for patients <5 years improved significantly after educational intervention from 2.8 years in 2010 to 1.25 years in 2013 (p < 0.01).

Discussion

With an interactive survey, we were able assess and also educate the regional GPs with regard to management of paediatric patients with UDT. There is a varied range of knowledge and practice demonstrated which we hoped to standardise and thereby increase efficiency and decrease the age of referral.

A large majority would refer patients with UDT after 6 months of age that would make the target of surgery <6 months unachievable unless they are aware of current recommendations.

This study is limited by a 36% response rate but that is comparable to other surveys. Also, referrals come from other sources that were not included. The causal effect of the educational survey is hypothesised.

Conclusion

This educational survey has confirmed the varied management by GPs. The referral age was demonstrated to be reduced after this intervention and this process was widely accepted by GPs that undertook the educational survey.

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Figure. Example question to GP's from web-based questionnaire.

Introduction

The undescended testis (UDT) is one of the commonest congenital abnormalities in male infants. Approximately 4–5% of males at birth have undescended testes at birth but this incidence reduces to 1–2% by 3 months of age [1].

Despite its common occurrence, there is debate currently regarding the timing of orchidopexy for these patients. In 1975, an action committee of the American Academy of Pediatrics (AAP) recommended “the ideal age for orchidopexy is after age 4 and before age 6 unless a symptomatic hernia is present” [2]. In 1996, they revised their recommendations so that “orchidopexy should be performed at or near 1 year of age” [3]. More recently, the British Association of Paediatric Urology (BAPU) has released a consensus statement stating that “timing – 3–6 months now ideal. 6–12 months acceptable” [4]. This is based on evidence that germ cell loss begins at 3–6 months in a UDT and no spontaneous descent occurs after 3 months of age [5].

Despite these recommendations, there are several publications that have shown that the age at time of surgery is well above the suggested age recommended back in 1996 [6], [7], [8], [9], [10], [11], [12]. A retrospective audit at our institution in 2010 found that the average age of referral of patients under the age of 5 years with UDT was 2.8 years of age (unpublished data).

As the average age at surgery has already been shown to be higher than recommended, how can we expect this to improve without actively updating the referring practitioner with the most recent recommendations?

We sought to survey the regional GPs regarding their management of paediatric patients that they encounter with undescended testis. Unlike previous published literature, we aimed also to combine the survey with an educational aspect so that the same GPs would be aware of the current local paediatric surgical department's guidelines regarding patients with UDT and thereby align actual age of referral with current recommendations.

Section snippets

Methods

A departmental consensus was developed and agreed by the Paediatric Surgical Consultants based on the current recommendations and evidence at that time. A web-based questionnaire was then devised using SurveyMonkey. Questions were devised to ascertain the GP's knowledge, attitudes, and management of paediatric patients with UDT, including preoperative and postoperative management and long-term complications (Fig. 1). Where appropriate, an educational slide was shown after the question to

Results

A total of 401 GPs were identified from electronic databases. One hundred and forty-four (36%) started the survey and 118 GPs (30%) completed the entire survey. Of the respondents, there was a wide range of experience as a GP: 41.7% had less than 10 years, 23.9% had 10–20 years, and 34.7% had more than 20 years. Ninety-one per cent thought that they would see children with undescended testis UDT in their clinic.

Discussion

E-learning refers to “electronically-mediated learning in a digital format to enhance or facilitate teaching and learning” [12]. Its current use for medical teaching is commonplace with much published literature on how to maximise its effectiveness [13], [14]. For this study, we have combined two aspects of e-learning: e-teaching and e-assessment [15]. By doing this, we could ascertain the current knowledge of the regional GPs and their management of patients presenting with UDT while also

Conclusion

This project demonstrates that there is still varying practice of the GP's management of paediatric patients presenting with UDT, and in part explains the reason for delay in age at time of orchidopexy. We have also demonstrated the feasibility of surveying and educating the target population, and we suggest that it is an effective method of active communication to improve outcomes with the GPs with specific regard to referral times and perhaps other targets.

Conflict of interest

None.

Funding

None.

References (27)

  • P.J. Kokorowski et al.

    Variations in timing of surgery among boys who underwent orchidopexy for cryptorchidism

    Pediatrics

    (2010)
  • C.J.P. Bruijnen et al.

    Age at orchidopexy as an indicator of the quality of regional child health services

    J Paediatr Child Health

    (2012)
  • M. Bullen

    When worlds collide: project management and the collegial culture

  • View full text