Dr. Michael P. Leonard MD, FRCSC, FAAPDr. Michael P. Leonard MD, FRCSC, FAAP

Professor of SurgeryProfessor of Surgery

University of OttawaUniversity of Ottawa

Caused by gut bacteria

E. coli most common Ascend via urethra to bladder and kidneys

Presentation varies with age: Infants – fever, lethargy, diminished feeding,

failure to thrive, diarrhea, vomiting Children – frequency, urgency, dysuria, wetting,

gross hematuria, abdominal pain, fever

Urinary Tract Infections

Incidence

< 1 yr – more common in males (peak 6 months) Increased in uncircumcised males (10x)

> 1 yr – more common in females (peak 2-3 years)

School age children: 1.2% males 5% females

Urinary Tract Infections

Obtain urine sample for urinalysis / culture Methods of obtaining urine:

Infant = bag urine, catheterized urine Child = midstream urine, catheterized urine Beware contamination!

Urinalysis: +ve nitrite, leucocyte esterase, RBC

Culture: > 108 CFU/l of one organism

Urinary Tract Infections

Diagnosis

Antibiotics

IV ± hospital admission if systemically unwell (especially infants) IV ampicillin / cephalosporin and gentamicin initially

Oral if reasonably stable and not toxic Trimethoprim, TMP-SMX, nitrofurantoin,

cephalosporin Broad spectrum to cover gram negative and some

gram positive (Staph, Enterococcus) No worry regarding anaerobes Duration of treatment 7-14 days depending on

clinical scenario

Urinary Tract Infection

Treatment

AAP Guidelines 2011

First febrile UTI 2-24 months = renal ultrasound VCUG only if abnormal US or second febrile UTI

“Top down approach” DMSA scan to document evidence of APN VCUG only if findings APN on DMSA

Urinary Tract InfectionInvestigation

Consider referring the following to specialist:

GU anomalies on US and/or VCUG VUR, hydronephrosis, ureterocoele

Concern regarding neurogenic features Abnormal lower back exam VACTERL syndrome

Recurrent UTI in the otherwise normal child if not responsive to timed voiding and management of constipation

Urinary Tract Infection

Referral ?

Urine washing back to kidneys from bladder =

VUR Increases risk of renal infection if UTI

Renal infection may lead to scarring Associated with renal dysplasia ± renal scarring More common in males < 1 yr and females > 1

yr Seen in 35-50% of children with UTI Diagnosed by VCUG

Vesicoureteric Reflux (VUR)

VUR - Grading

Prevent UTI by antibiotic prophylaxis

Follow at intervals for resolution Follow-up comprises US and Cystogram

Surgical intervention: Breakthrough UTI New scarring Parental preference

Surgical options: Minimally invasive (STING) Open ureteric reimplantation

VUR - Management

VUR - Surgery

If child wets bed at ≥ 5 years of age = NE Common developmental issue:

15% of 5 year olds 1% of 15 year olds 15% spontaneously resolve annually

Family history common (genetic component) Several theories abound:

Developmental delay of normal maturation Deep sleep patterns Bladder over-activity at night Lack of nocturnal ADH production

Nocturnal Enuresis

Primary nocturnal enuresis (PNE)

No day time symptoms No dry interval 6 months or longer

Secondary nocturnal enuresis As above but with dry interval > 6 months at

some time in past Complicated nocturnal enuresis

Day time symptoms ± UTI

Nocturnal EnuresisClassification

Nocturnal EnuresisEvaluation (Rushton, J Pediatr)

- ve

+ ve

**

** m ino rity o f p a tie n ts

N o fu rth er s tud ies

U rin a lys is / cu ltu reP h ys ica l e xam

U N C O M P L IC A T E DP rim a ry o n se t

N o rm a l d a ytim e h a b its

U ro d yn a m icsN e u ro su rg e ry co n su lt

R e n a l U SV C U G

C O M P L IC A T E DD ys fu nc tio n a l e lim in a tion

U T I

N O C T U R N A L E N U R E S ISE va lu a tion

Nocturnal Enuresis:

Treatment

Three primary treatment modalities: Observation:

fluid restriction, double void at night, star charts Conditioning therapy:

bedwetting alarm system Pharmacotherapy:

DDAVP

Daytime Wetting

Toilet training complete at 2-3 years 5% of 5 year olds experience occasional

daytime wetting Causes:

anatomical (ectopic ureter, epispadias) pseudo-incontinence (vaginal voiding) neurogenic (spina bifida) dysfunctional elimination (DE)

Daytime wetting - DE

Bladder problems: overactive bladder (OAB) hypoactive bladder detrusor / sphincter incoordination

Bowel problems: fecal impaction colonic distension hypotonicity pelvic floor / sphincter tone

Daytime wetting -Rx

Anatomical: surgery (i.e. hemi-nephrectomy)

Pseudo-incontinence: change of voiding posture

Neurogenic: improve storage (anti-cholinergics) improve emptying (IMC)

Daytime wetting -Rx

Dysfunctional elimination: improve bowel function (diet) timed voiding (q 2-3h) biofeedback medication:

anti-cholinergics -blockers

psychotherapy

NORMAL SCROTAL NORMAL SCROTAL ANATOMYANATOMY

Acute Scrotum

Case study #1: 14 year old boy with right hemi-scrotal pain Duration of pain = 6 hours No history of trauma or LUTS What else do you need to know?? What is your differential diagnosis?? Are any ancillary investigations useful??

TESTIS TORSIONTESTIS TORSION

• Clinical Presentation:Clinical Presentation:– pubertal boy (12-16 years)pubertal boy (12-16 years)– abrupt onset lower abdominal / abrupt onset lower abdominal /

testicular paintesticular pain– pain usually severe, unrelentingpain usually severe, unrelenting– associated with nausea, vomiting, associated with nausea, vomiting,

anorexiaanorexia– prior history of trauma (minor)prior history of trauma (minor)– previous episodes which resolvedprevious episodes which resolved

TESTIS TORSIONTESTIS TORSION

• Physical Findings:Physical Findings:– elevated testis with abnormal lieelevated testis with abnormal lie– ““knotting” of spermatic cordknotting” of spermatic cord– absent cremasteric reflexabsent cremasteric reflex– scrotal erythema / edemascrotal erythema / edema– reactive hydrocoelereactive hydrocoele– ““bell clapper” contralaterallybell clapper” contralaterally

TESTICULAR TORSION

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

• Emergent:Emergent:– Testicular torsionTesticular torsion– Traumatic testicular ruptureTraumatic testicular rupture– Incarcerated inguinal herniaIncarcerated inguinal hernia– Peritonitis with patent processus Peritonitis with patent processus

vaginalisvaginalis– Fournier’s gangreneFournier’s gangrene

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

• Non-emergentNon-emergent– Torsion of testicular or epididymal Torsion of testicular or epididymal

appendageappendage– Acute epididymo-orchitisAcute epididymo-orchitis– Idiopathic scrotal edemaIdiopathic scrotal edema– Henoch-SchHenoch-SchÖÖnlein purpuranlein purpura– Hydrocoele / herniaHydrocoele / hernia– Acute hemorrhage into testicular Acute hemorrhage into testicular

neoplasmneoplasm

TESTIS TORSIONTESTIS TORSION

• Laboratory Studies:Laboratory Studies:– urinalysis typically negative, but may urinalysis typically negative, but may

contain WBC’scontain WBC’s– CBC and differential not useful CBC and differential not useful

discriminatordiscriminator

• Radiographic Studies:Radiographic Studies:– notnot indicated if typical clinical case indicated if typical clinical case

with duration of pain < 12 hours!with duration of pain < 12 hours!

TESTIS TORSIONTESTIS TORSION

• When should radiographic studies When should radiographic studies be considered?be considered?– duration of pain > 12 hours duration of pain > 12 hours and / orand / or

diagnosis is uncertain diagnosis is uncertain

• Which study is indicated?Which study is indicated?– Color Doppler ultrasonographyColor Doppler ultrasonography

TESTIS TORSIONTESTIS TORSION

• Color Doppler ultrasoundColor Doppler ultrasound– readily available in most localesreadily available in most locales– positive finding = no or decreased positive finding = no or decreased

flow in affected testisflow in affected testis– sensitivity 91% (range 82-100%)sensitivity 91% (range 82-100%)– pitfalls:pitfalls:

•small (infant) testis = no flow small (infant) testis = no flow

•peri-testicular flow due to inflammation peri-testicular flow due to inflammation around torted testisaround torted testis

TESTIS TORSIONTESTIS TORSION

TESTIS TORSIONTESTIS TORSION

• Time is of the essence!Time is of the essence!– salvage is usually successful within 6-salvage is usually successful within 6-

8 hours after onset of pain8 hours after onset of pain– salvage possible up to 24 hours, but salvage possible up to 24 hours, but

rate declines exponentiallyrate declines exponentially– pain > 24 hr invariably = necrotic pain > 24 hr invariably = necrotic

testis (very rare exception!)testis (very rare exception!)

TESTIS TORSIONTESTIS TORSION

• Surgical Results:Surgical Results:– salvage rates approximate 60-70%salvage rates approximate 60-70%– factors contributing to missed torsion:factors contributing to missed torsion:

•patient delay in presentation = 80%patient delay in presentation = 80%

•physician mis-diagnosis = 20%physician mis-diagnosis = 20%

– suggests need for education through suggests need for education through school health / physical education school health / physical education programsprograms

TESTIS TORSION

EXTRA-VAGINAL TESTIS EXTRA-VAGINAL TESTIS TORSION (NEONATAL)TORSION (NEONATAL)

• Occurs ante-natally (in utero) or in Occurs ante-natally (in utero) or in the first week post-natallythe first week post-natally

• Testis and tunica vaginalis rotate Testis and tunica vaginalis rotate together (inadequate scrotal wall together (inadequate scrotal wall fixation)fixation)

• Presents as painless scrotal Presents as painless scrotal swelling with scrotal erythema / swelling with scrotal erythema / bluish discolorationbluish discoloration

• Testis rarely viable - ? need for Testis rarely viable - ? need for surgerysurgery

TORSION OF TESTICULAR APPENDAGE

Case study #2: 8 year old boy 2 day history right hemiscrotal pain

Anything else you want to know??

TORSION OF TESTICULAR TORSION OF TESTICULAR APPENDAGEAPPENDAGE

• Clinical presentation:Clinical presentation:– 7-12 year old (pre-pubertal) boy7-12 year old (pre-pubertal) boy– pain more indolent, not as severe as pain more indolent, not as severe as

testis torsiontestis torsion– pain may resolve with restpain may resolve with rest– usually no accompanying nausea or usually no accompanying nausea or

vomitingvomiting

TORSION OF TESTICULAR TORSION OF TESTICULAR APPENDAGEAPPENDAGE

• Physical Exam:Physical Exam:– earlyearly

•testis has a normal lietestis has a normal lie

•maximal tenderness at upper polemaximal tenderness at upper pole

•tender nodule may be seen (“blue dot”) tender nodule may be seen (“blue dot”) or feltor felt

– latelate•progressive scrotal erythema and edemaprogressive scrotal erythema and edema

•reactive hydrocoelereactive hydrocoele

•more difficult to differentiate from testis more difficult to differentiate from testis torsiontorsion

TORSION OF TESTICULAR TORSION OF TESTICULAR APPENDAGEAPPENDAGE

• Laboratory investigations:Laboratory investigations:– urinalysis usually negativeurinalysis usually negative

• Radiographic evaluation:Radiographic evaluation:– Color Doppler ultrasound shows Color Doppler ultrasound shows

increased flow to upper pole testis / increased flow to upper pole testis / epididymis. May also see small epididymis. May also see small hypoechoic torted appendage.hypoechoic torted appendage.

– Radionuclide scan shows increased Radionuclide scan shows increased blood flow to the affected hemi-blood flow to the affected hemi-scrotumscrotum

TORSION OF TESTICULAR TORSION OF TESTICULAR APPENDAGEAPPENDAGE

• Treatment:Treatment:– limit physical activitylimit physical activity– analgesiaanalgesia– expect an initial increase in swelling / expect an initial increase in swelling /

redness with resolution over 7-10 redness with resolution over 7-10 daysdays

– surgery only necessary if diagnosis in surgery only necessary if diagnosis in doubt and / or pain not well managed doubt and / or pain not well managed by analgesicsby analgesics

– no long term sequelae re: testicular no long term sequelae re: testicular functionfunction

EPIDIDYMITIS

Case study #3: 10 year old boy 2 day history left hemiscrotal pain and swelling LUTS for 3 days Febrile (39.5C) Any further investigations / information

required??

EPIDIDYMITISEPIDIDYMITIS

• Bacterial or chemical inflammation Bacterial or chemical inflammation of epididymisof epididymis

• Rare in pre-pubertal boysRare in pre-pubertal boys– if occurs, consider urinary tract if occurs, consider urinary tract

abnormality such as ectopic ureter, abnormality such as ectopic ureter, PUV, stricturePUV, stricture

• Common in sexually active Common in sexually active adolescentsadolescents– usually Chlamydia, rarely gonococcususually Chlamydia, rarely gonococcus

EPIDIDYMITISEPIDIDYMITIS

• Clinical presentation:Clinical presentation:– pain insidious in onsetpain insidious in onset– irritative lower urinary tract irritative lower urinary tract

symptoms may precede onset of painsymptoms may precede onset of pain– urethral discharge if STDurethral discharge if STD– may be septicmay be septic

EPIDIDYMITISEPIDIDYMITIS

• Physical examination:Physical examination:– elevated temperatureelevated temperature– scrotal edema, erythema, tenderness, scrotal edema, erythema, tenderness,

reactive hydrocoele, tender prostatereactive hydrocoele, tender prostate– early on epididymis may be increased early on epididymis may be increased

in size and exquisitely tenderin size and exquisitely tender– in later stages, loss of anatomical in later stages, loss of anatomical

landmarks with diffuse tendernesslandmarks with diffuse tenderness– Prehn’s sign unreliable!Prehn’s sign unreliable!

EPIDIDYMITISEPIDIDYMITIS

• Laboratory investigations:Laboratory investigations:– urinalysis may show pyuria, urinalysis may show pyuria,

hematuria, bacteriahematuria, bacteria– urine culture may be positiveurine culture may be positive

• Radiographic evaluationRadiographic evaluation– only necessary in pre-pubertal child only necessary in pre-pubertal child

with concurrent UTIwith concurrent UTI– renal ultrasound and VCUG renal ultrasound and VCUG

recommendedrecommended– if Color Doppler US obtained will show if Color Doppler US obtained will show

increased blood flow to affected sideincreased blood flow to affected side

Scrotal Mass

Need to distinguish where mass is coming from: Processus vaginalis:

Indirect inguinal hernia Communicating or non-communicating hydrocoele

Testicular adnexae: Epididymal cyst / spermatocoele Varicocoele

Testis Testicular tumour

Scrotal mass in children

Hernia - Hydrocoele

Embryology

As testis descends through inguinal canal into scrotum: carries along a tongue of peritoneum (processus

vaginalis) normally communication of processus with

peritoneum closes leaves potential space (tunica vaginalis) over

antero-lateral testis

Hydrocoele - Hernia

Anatomy

Hernia - Hydrocoele Management

Communicating hydrocoele: may resolve spontaneously < 2 yr. if persists > 2 yr. repair

Indirect inguinal hernia: repair at any age risk of incarceration small but real

Non-communicating Hydrocoele

Localized collection of fluid in tunica vaginalis May be secondary to:

inflammatory process trauma, infection, torsion

tumor If concern re: testis ultrasound Surgical intervention is option

Hydrocoele - US

Epididymal cyst common in pre-pubertal boys

Usually seen on scrotal US (non-palpable) Benign course May grow and become palpable

Spermatocoele seen in post-pubertal boys Blow out of efferent duct encysted collection

of spermatozoa Both conditions may cause cosmetic concerns

and mandate surgical excision

Epididymal Cyst / Spermatocoele

Varicocoele

15% of adolescents have varicocele: rare to have onset prior to adolescence >90% left sided not likely to spontaneously regress

Clinical conundrum: how can we predict which patients will suffer

gonadal damage from varicocele?

Varicocoele - Anatomy

Varicocoele

Indications for surgery: absolute

volume difference > 20% on affected side caveat re: differential growth and need for more

than one measurement relative

pain cosmesis

VaricocoeleAblation Outcomes

Testicular Tumour

Rare 0.5-2/100,000 children

Presents as painless scrotal mass Mass is firm and non-transilluminating Caveat re: hydrocoele and inadequate

testicular exam

Testis Tumour

Histology

Testis Tumour

Obtain serum markers: -fetoprotein HCG

Ultrasound of testis: confirm diagnosis treatment planning

Imaging - Testis Tumour

Surgical Management

Testis Tumour

Radiological Staging

CXR CT abdomen / pelvis Bone scan (RMS)

Management - Non RMS

Orchiectomy and surveillance: teratoma / dermoid cyst stage I yolk sac tumour gonadal stromal tumour (Leydig, Sertoli)

Chemotherapy (BEP) for yolk sac if: stage II-IV disease relapse stage I

Limited role for RPLND in yolk sac

Management RMS

Radical inguinal orchiectomy Children > 10 yr. undergo ipsilateral RPLND

before chemotherapy Chemotherapy in all age groups Radiotherapy in addition to RPLND in children

> 10 yr. Higher risk of relapse / spread

Neonatal Abdominal Mass

Abdominal mass (75% arise in the GU tract) #1-Hydronephrosis (UPJO, VUR, UVJO, PUV) #2-Multicystic dysplastic kidney (MCDK) #3-Tumours account for 12 %

Neuroblasoma, CMN and teratoma (sacrococcygeal)

Hydronephrosis MCDK

Neonatal Abdominal Mass

Neuroblastoma is the most common malignancy in the neonate

Wilms’ tumour is extremely rare in this age group

Abdominal mass + hematuria = renal vein thrombosis

Girl with abdominal mass + interlabial bulging = hydrocolpos

Congenital Mesoblastic Nephroma (CMN) is the most common renal tumour

Abdominal Mass After Neonatal Period

From 1 month to 1 year of age: Hydronephrosis – 40% Solid masses and tumour – 40%

Older than 1 year of age: Tumour is the most common cause of abdominal

mass

Neuroblastoma (NB)

Most common malignant tumour of infancy 8% to 10% of all childhood cancers Annual incidence 10 cases per 1 million Median age at diagnosis: 22 mo 50% of cases < 2 years of age (75% <4yrs)

(Fortner et al, 1968)

NB - What and Where?

Tumours of neural crest cell origin: Cells that form the adrenal medulla and

sympathetic ganglia 75% are retroperitoneal

50% adrenal 25% sympathetic chain (from neck to

pelvis)

NB - Presentation

Often has systemic symptoms (different from WT) Fever, abdominal pain or distension, abd mass,

weight loss, anemia, bone pain, proptosis and periorbital ecchymoses (retro-orbital metastasis)

Metastases are present in 70% at diagnosis VMA (vanillylmandelic acid), HMA (homovanillic

acid) Elevated in > 90% of the neuroblastomas 24 hr urine collection (catecholamine metabolites)

NB - Imaging

US is usually the first exam in child with abdominal mass

CT or MRI Both detect extension beyond midline and

hepatic involvement MRI: better displays the relationship with

great vessels and detects intraspinal extension (tumor of sympathetic chain)

CT may show calcifications (rare in Wilms tumor)

NB - Treatment

Generally based on risk assessment Tumour stage Grade Biochemical risk factors Genetic risk factors

Low-stage favorable Surgery alone Higher risk tumor Adj chemo +/- RT Very aggressive tumor Autologous bone

marrow transplantation

Wilms' Tumor

Most common primary malignant renal tumour of childhood

Embryonal tumour develops from remnants of immature kidney

Annual incidence 7 to 10 cases per million Median age 3.5 yrs 80% diagnosed < 5 yrs of age Worldwide sex ratio is close to 1

(North American girls slightly > boys)

Congenital Anomalies and WT

Genitourinary anomalies in 4.5% of WT Renal fusion anomalies Cryptorchidism Hypospadias (Breslow et al, 1993)

These are common disorders and screening for WT is not necessary in most children with genital anomalies

Syndromes and WT

Without overgrowth: Denys-Drash syndrome (DDS)

Male pseudohermaphroditism, renal mesangial sclerosis and WT ( Drash et al, 1970)

Aniridia (Found in 1.1% of patients with WT) WAGR syndrome

Wilms' tumor, Aniridia, Genital anomalies, mental Retardation

(Clericuzio , 1993)

Horseshoe kidney (NWTSG found 7 times incidence of WT)

With overgrowth

Hemihypertrophy May occur alone or with syndromes

Beckwith-Wiedemann (BWS) Perlman Soto Simpson-Golabi-Behmel

Syndromes and WT

Imaging in WT

Ultrasound is the first study performed in most children with an abdominal mass Solid nature of the lesion

CT shows the relationship with other organs MRI is the study of choice if extension of tumour

into the inferior vena cava cannot be excluded by ultrasound (Weese et al, 1991)

Treatment of WT

Surgical Radical nephrectomy Accurate staging to determine need RT +/-

chemo Exploration of the abdominal cavity

Liver, nodal metastases, peritoneal seeding Formal exploration of the contralateral kidney

Not necessary with modern imaging Formal retroperitoneal lymph node dissection

not recommended