Pediatric Urology Update
Rama Jayanthi, M.D.Section of Pediatric Urology
Columbus Children’s Hospital
Format and purpose
Selected cases in pediatric urology Stimulate discussion Discuss management
Case 1
Hypospadias noted at birthBoth testes normally descended
Questions:What type of work up?What is initial management?When do you refer to pediatric
urologist?
Hypospadias
abnormally positioned meatus meatus can be located anywhere
from perineum to glans chordee- associated penile
curvature
Hypospadias- associated abnormalities
Easy to remember - nothing! Normal kidneys and bladder Normal fertility Normal sexual function
Hypospadias - management for the
pediatrician Do not circumcise! No need for any imaging studies Refer to pediatric urologist within
first months of life Always consider intersex if
hypospadias associated with undescended testis
Who is a boy and who is a girl?
Is it a hypo or not?
Retract foreskin completely off glans during circ
If glans meets in midline proximal to meatus, not a hypo!• Even if meatus appears to be large
If a true hypo is present• Wrap with Vaseline if not bleeding• Otherwise close skin edges with chromic
sutures
Hypospadias - management for the pediatric urologist
Surgical correction at 6 - 9 months of age
Attempt one stage reconstruction Out patient surgery Success rates should be > 95%
Epispadias
Very rare - more often associated with bladder exstrophy
Need early referral for parental counseling
Patients may be totally incontinent
Case 2: Scrotal mass
Painless scrotal massesStable in sizeNo increase with cryingNo inguinal bulge
Questions:What is the diagnosis?What should be done?
Scrotal masses
Solid vs. cystic• transillumination of light
Testicular vs. extratesticular Painful vs. painless
Hernia/hydrocele - cystic scrotal mass
Testes develop intraabdominally and exit the abdomen at the internal ring
All males have a fascial defect at some point during gestation
Persistence of defect leads to communicating hydroceles and hernias
Hernia/hydrocele
What is the difference between a hernia and a communicating hydrocele?• Both are the same anatomic defect• If opening only large enough to admit
peritoneal fluid - communicating hydrocele• Scrotal swelling only, “comes and goes”
• If opening large enough to admit bowel- clinical hernia• “inguinal bulge”
Hernia/hydrocele
Hernia/hydrocele - management
Observation:• Noncommunicating hydrocele < 12 - 18
months of age• Hernia - very premature infants with easily
reducible large hernias Surgery:
• Hydrocele - persistent, enlarging, painful• Hernia - always
Surgical correction involves ligation of peritoneal sac
What is the diagnosis?
Findings:
Painless right scrotal massDoes not transilluminateUltrasound: solid mass
Diagnosis: yolk sac tumor
Case 3
A 15 year old boy is noted to have a left scrotal mass during a sports physical.
The mass is soft, painless, located above the testis and disappears when the boy is recumbent
What is the most likely diagnosis?
Varicocele
Represents dilation of left spermatic veins
Etiology unknown• ? Lack of venous valves• ? High intravenous pressure
Incidence: 15% of all teenage males • rare in prepubertal males
Significance of varicoceles
Infertility• Most common surgically correctable cause
of male factor infertility• Reason unclear
• ? Increased temperature of scrotum• ? Primary endocrinopathy
Pain• Uncommon in teenagers• “Dull ache”
Management of pediatric varicocele
“Clinically significant varicoceles” requires surgical ligation
Problem:• Most teenagers have varicoceles detected
on routine physical examination• Usually asymptomatic
Management of adolescent varicoceles
• Yearly measurement of testicular size• Symmetric testes - observe• Indications for intervention:
• Development of size discrepancy > 2cc• Pain
• Personal opinion:• Spermatic vein embolization may be the
simplest and least invasive option
Case 4
A 4 month old boy on routine examination is found to have a normally descended right testis but no palpable left testis. His exam is otherwise normal.
What workup is needed? When should he be referred?
What to do with a missing testis?
Issues:• palpable or nonpalpable?• Unilateral or bilateral?• Associated hypospadias?• Associated syndromes?
• Most will have isolated unilateral undescended testis
Should an ultrasound be performed?
If an US reveals a testis, then surgery is required for orchidopexy
If an US shows no testis it may be inaccurate because the child may have a small intraabdominal testis that was not detected
Regardless of US findings, the child needs exploration
Thus, there is no need for radiological evaluation for a nonpalpable testis
Classification of UDT
Intraabdominal• testis located above internal ring• usually nonpalpable
Canalicular- “routine” undescended testis Retractile - not a UDT
• due to hyperactive cremaster reflex• only in prepubertal males• no hormonal/testis defects
Management of UDT
Observation until 6 -12 months of age If still undescended, surgical
correction No advantage to further observation
after 12 months of age• testis will not descend• germ cell fibrosis evident by three years
of life
Bilateral nonpalpable testes
Karyotyping essential Main question: Is there functional
testicular tissue present? No functional tissue present if
• marked elevation baseline FSH and LH
• no rise in serum testosterone with HCG stim
Fertility after cryptorchidism
Formerly unilateral
UDT
Formerly bilateral
UDT
Control
Number 313 50 336
Married 244 (78%)
38 (76%)
269 (80%)
Married with
children
183 (75%)
20 (53%)
203 (76%)
Lee, Brit J Urol, 1995
Risk of Neoplasia
UDT has 10X greater risk• Abdominal testis has 4X greater risk than
inguinal Tumors occur after puberty
• Mean age 25 - 30 years 25% occur in normally descended testis Early orchidopexy may be protective Seminoma most common, embryonal cell
2nd
Case 5
A nine year-old uncircumcised boy presents with a tightly phimotic foreskin.
He has had a few episodes of balanitis
His parents to do not want him to be circumcised if possible
What can be done?
Natural history of phimosis
Medical management of phimosis
Prospective trial Diprolone cream (0.05%) applied
TID for 4 weeks to preputial band Patients reevaluated at one month
Medical management of phimosis
Results• n = 21• Signs and symptoms
• UTI• Balanitis• Preputial ballooning• Asymptomatic
Medical management of phimosis
Success 17/21 (81%)• 11 complete, 7 partial
Failure 4/21 (19%)
What does a bladder do??
Store urine Empty urine In a 24 hour time period
• Bladder is in storage mode for 23 hours and 45 minutes
Thus, storage function is of greater importance than emptying
Normal bladder function
Storage• Storage must take place at low
pressures• Intravesical pressures must be low
enough to…• Not impede urine transport from kidneys via
the ureters• Hydronephrosis/renal injury
• Not overwhelm sphincteric resistance• Urinary incontinence
Emptying function
First step in voiding is relaxation of sphincteric mechanism followed by bladder contraction
Normal voiding is a “passive” process with no involvement of the abdominal muscles
Case 6
A 7-year-old girl complains of new onset daytime wetting. She has always been a bed wetter. She has never had any urinary tract infections. She does note that she often will leak while running and exerting herself. She furthermore does not realize that she has to go prompting her parents to wonder whether the child can even tell that she needs “to go”. Sometimes the family will see her doing the “pee-pee dance” and sometimes they will see her suddenly squat on her heel. Occasionally she will have a precipitous urge to void but when she makes it the bathroom nothing comes out. Her leakage can vary from damp spots on the underpants to complete soaking of her clothes. When the family is out they will often have to stop to find a restroom for her prompting the family to wonder whether her bladder is “too small”. She occasionally will complain of mild nonspecific abdominal pain.
What kind of evaluation is required?
Aspects of the history
Daytime wetting vs. nighttime wetting vs. both Urgency? Frequency? Infrequent voiding? Damp pants vs. soaking? Does leakage occur prior to going to restroom
or after voiding ? Does the child care if he/she is wet? Frequency of bowel movements?
Common myths
“small bladder” that the child has to grow into
“narrow urethra” that needs to be stretched
“inability to sense fullness” Urgency and/or frequency in a male
may be due to meatal or urethral stenosis
Voiding dysfunction may be due to
Evaluation of voiding dysfunctions
History most important Screening renal ultrasound
• Ensure normal kidneys• Alleviates parental anxiety
• Bladder wall thickness• Subtle sign of bladder overactivity
• Post-void residual• ? Incomplete sphincter relaxation
Voiding cystourethrography??
A child should almost never have a catheter inserted in the initial evaluation of pure incontinence!!!
“Functional bladder capacity” better evaluated by voiding diary• Expected bladder capacity: Age + 2 in ounces
VCUG rarely needed• history of significant UTI• symptoms of obstruction in males
Varieties of voiding dysfunction
In order of frequency•Bladder instability/overactivity• Infrequent voiding• Incomplete emptying•Hinman’s syndrome
•“Nonneurogenic neurogenic bladders”
Bladder instabilty
Clinical manifestations•wetting•infections•pelvic/vaginal pain•penile/scrotal pain
Forms of bladder instabilty
Urgency incontinence syndrome•predominant symptom is wetting•infections less likely
Hypertonic bladder • predominant symptom is UTI• may also have associated wetting
Urgency incontinence
More common than hypertonic bladder
Usually associated urgency/frequency
Severity of wettings ranges from damp pants to soaking
Hypertonic bladder
VCUG - trabeculated bladder, may have diverticulae
Main point: Infections (and reflux) are secondary problem
“Distal urethral stenosis”
Spinning top urethra
NOT due to obstruction
A sign of bladder instability
Urethral dilation is NEVER indicated!!!
Management of bladder instability
Anticholinergics Bowel management Consider prophylactic antibiotics
only if has recurrent infections refractory to standard management• The older I get, the less I use
prophylactic antibiotics
Choice of anticholinergics
Oxybutinin• Ditropan XL 5 -15 mg qAM
• Advantages:• once a day dosage• fewer side effects
• Elixir (0.2 mg/dose/BID -TID)• only if cannot swallow pills
Role of bowel dysfunction
Fecal retention• Incomplete or
infrequent emptying of bowels
• Subtle clues• abdominal pain• perineal pain• vaginal “itching”• penile pain
Relationship of constipation and wetting
234 constipated/encopretics 29% day and 34% night wetting
pre-treatment, UTI in 11% 52% had improvement in
constipation• 89% improved day• 63% improved night• no more UTILoening-Baucke, Pediatrics, 1997
Importance of UTIs and bowel/bladder disturbances
143 children with reflux + breakthrough UTI
• 77% had dysfunction - breakthrough UTI
• 16% had dysfunction
Koff, J Urol, 1998
Infrequent voiding syndromes
“lazy bladder syndrome”• an inappropriate term that incorrectly
labels a child as being lazy Fact of life for children:
• Children usually have more important things to do than urinate and defecate
Sensation normal - children “tune out” the bladder
Management of infrequent voiding syndromes
timed voiding behavioral modification
• controlled bribery intermittent catheterization
The overwhelming majority of patients can be evaluated with only a careful history. Only a small number may need “objective” measurements of bladder function.
Case 7
A 8 year old girl has her first episode of UTI
How do you evaluate her?• Observation? • US? • VCUG?• DMSA scan?
What is a urinary tract infection?
Positive culture in a child with appropriate symptoms
What is not an infection, and thus should not receive antibiotics
Red introitus Perineal discomfort Dysuria in the absence of a positive
culture• A positive urinalysis is not sufficient
to definitively diagnose an infection Microscopic hematuria
Philosophical questions
Why do we treat urinary tract infections?
What are the ramifications of UTI’s?
Renal scarring
may cause hypertension if present diffusely and
bilaterally, may lead to renal failure
most likely will occur after pyelonephritic episodes in children less than 4 years of age
Therefore
if older child has episode of cystitis, recommend US
if older child has pyelonephritic episode, recommend VCUG/US
if younger child has any type of UTI, recommend complete workup, especially if male
Case 8
Four year old girl with recurrent UTI, some with fever
US - normal, VCUG - normal Repeat nuclear cystogram also
normal What do you do???
Non-reflux pyelonephritis
The majority of children with febrile pyelonephritis do not have reflux or any other urinary tract abnormalities
What causes urinary tract infections in the absence of anatomic abnormalities?
Non-anatomic causes of UTI
“sticky bacteria” dysfunctional bladder habits dysfunctional bowel habits all the above
Role of VCUG in children with UTI
A VCUG is necessary to diagnose reflux
Treatment of reflux is helpful to prevent pyelonephritis and renal scarring
Thus a VCUG is not necessarily needed in a child with normal kidneys and lower urinary tract infections
Case 9
A 15 year old girl notes that she leaks only when she laughs. She is a cheerleader and never wets during her routines. She is also is a star soccer player and never wets during her games.
Case 9 (cont’d)
What is the diagnosis?• “Giggle incontinence”• Part of the cataplexy/narcoplexy
complex• Treatment consists of behavioral
modifications• Consider Ritalin for nonresponders
Case 10
8 year old male who presented with urinary tract infections• Fever and flank
pain
Case 10 (cont’d)
On further questioning….• Previously was dry but now
has day and night wetting• Significant daytime
urgency and occasional back pain
• Rarely has good stream• Parents have noted that
the child also “walks funny.”
Case 10 (cont’d)
Main diagnostic consideration: occult tethered spinal cord
Relatively uncommon Importance in early detection in
that delay in diagnosis may lead to permanent neurological deficit
Case 11
4 year old girl who is always wet. She has no urgency, voids regularly, and has failed treatment with empiric anticholinergics.
Key is the history of being “always wet” Consider ectopic ureter.
• Ureter does not insert into bladder. Inserts into urethra or vagina
• Surgery is curative• Key is to consider the diagnosis
• Intravenous pyelography has very poor sensitivity.
Imaging for ectopic ureter
Imaging for ectopic ureter
Case 12
5 year old boy who suddenly developed severe daytime frequency. He doesn’t have any associated wetting, has had no infections, will occasional wake up at night to void.
He literally will void every 10 minutes and each time he voids a small amount of urine will pass
Renal ultrasound is normal and anticholinergics have not helped
What is the diagnosis?
Case 12
“Daytime Frequency Syndrome”•Unknown etiology•Spontaneous improvement is the
rule
Thank you for listening
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