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The accuracy of telemedicine for pediatric penile anatomy
Andrea K. Balthazar, MD, MPH, Tanya Logvinenko, PhD, Ozge Yetistirici, PhD, Caleb P. Nelson, MD, MPH, Julia B. Finkelstein, MD, MPH.
Boston Children's Hospital, Department of Urology, Boston, MA, USA.

Background: In pediatric urology, many new patient encounters are related to penile anatomy questions. Although diagnosis during in-person (IP) physical examination is usually straightforward, it is unknown if assessing penile conditions via telemedicine (TM) provides similar certainty. Our objective was to determine the agreement between initial TM encounter diagnoses with subsequent IP diagnoses for penile conditions. We hypothesized that agreement would be high, with less than 10% of cases resulting in diagnostic disagreement.
Methods: At a single pediatric tertiary center, we evaluated all patients <21 years who were initially seen and had an exam by 1 of 11 pediatric urologists via TM for a penile condition from 8/2020-12/2021. Patients who had a subsequent IP encounter with the same clinician within 12 months of the original TM encounter were included. Patient age and time between encounters was noted. Diagnoses for TM and IP encounters were collected via provider surveys, triggered at charge entry for penile diagnoses. Agreement between the initial TM diagnoses and subsequent IP diagnoses was calculated; agreement was defined as an identical match for the diagnoses listed for both encounters. The association of time between TM and IP visits with diagnostic agreement was assessed using the Wilcoxon test. Association of device type (laptop/computer, smartphone used "camera style", smartphone used "selfie-style") with diagnostic agreement was assessed using logistic regression.
Results: 225 patients had initial examination via TM at median age of 14.2 months (IQR 4.1-92.1). Of these, 194 had an exam performed and a subsequent IP encounter available for comparison. The most frequent TM diagnoses were phimosis (n=40), post-circumcision adhesions (n=39), "other" category (n=30), post-circumcision redundancy (n=25), and buried penis (n=15). The most frequent IP diagnoses were post-circumcision adhesions (n=43), "other" category (n=39), phimosis (n=33), post-circumcision redundancy (n=28), and normal anatomy (n=21). The proportion assessed as "normal anatomy" increased from 1.5% on TM to 10.8% on IP. The proportion of encounter pairs where the initial and final clinical diagnosis matched was 39.2% (76/194). Among the 118 (60.8%) encounter pairs where the initial and final clinical diagnoses did not match, none of the diagnoses overlapped in 61.9% (73/118) cases, and some overlapped in 38.1% (45/118). There was no significant difference in median time between encounters for patients with agreement vs. disagreement (101 days (IQR 51.8-207.3) vs. 113 days (IQR 47.8-221.5), p=0.584). There was no significant association between the agreement of diagnoses with the type of device used (p=0.464).
Conclusions: To our knowledge, this is the first pediatric urology study to assess this clinically-relevant endpoint. Agreement between TM and IP assessment of penile conditions is poor, with fewer than half of cases resulting in the same diagnosis being made at a subsequent IP encounter. Although TM exam may be helpful in many situations, these results suggest that IP evaluation is appropriate to confirm suspected penile anatomic conditions before planning surgery. Digital technology has the potential to facilitate and improve patient care, but future studies are necessary to investigate ways to improve the accuracy of TM assessments for penile conditions.


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