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    Pediatric Urology

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    Sav Ga
    The document discusses various urological diseases that may present in pediatric patients, including urinary tract infections, voiding dysfunctions, hydronephrosis, abdominal masses, painful scrotum, empty scrotum, and anomalies of the external genitalia. It provides details on evaluating, diagnosing, and treating these conditions, with a focus on proper examination and workup. Key recommendations include that all infants under 5 years with a UTI should receive evaluation including a VCUG to check for issues like vesicoureteral reflux.

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    Pediatric Urology

    Uploaded by

    Sav Ga
    109 views80 pages
    The document discusses various urological diseases that may present in pediatric patients, including urinary tract infections, voiding dysfunctions, hydronephrosis, abdominal masses, painful scrotum, empty scrotum, and anomalies of the external genitalia. It provides details on evaluating, diagnosing, and treating these conditions, with a focus on proper examination and workup. Key recommendations include that all infants under 5 years with a UTI should receive evaluation including a VCUG to check for issues like vesicoureteral reflux.

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    10. Pediatric Urology

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    The document discusses various urological diseases that may present in pediatric patients, including urinary tract infections, voiding dysfunctions, hydronephrosis, abdominal masses, painful scrotum, empty scrotum, and anomalies of the external genitalia. It provides details on evaluating, diagnosing, and treating these conditions, with a focus on proper examination and workup. Key recommendations include that all infants under 5 years with a UTI should receive evaluation including a VCUG to check for issues like vesicoureteral reflux.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    109 views80 pages

    Pediatric Urology

    Uploaded by

    Sav Ga
    The document discusses various urological diseases that may present in pediatric patients, including urinary tract infections, voiding dysfunctions, hydronephrosis, abdominal masses, painful scrotum, empty scrotum, and anomalies of the external genitalia. It provides details on evaluating, diagnosing, and treating these conditions, with a focus on proper examination and workup. Key recommendations include that all infants under 5 years with a UTI should receive evaluation including a VCUG to check for issues like vesicoureteral reflux.

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    © All Rights Reserved
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    of 80

    UROLOGY FOR THE

    PEDIATRICIAN
    David T. Bolong, MD
    Clinical Presentation of Urological
    Diseases
    I. Urinary tract infection
    II. Voiding Dysfunctions
    III. Antenatal/ Postnatal hydronephrosis
    IV. Abdominal masses
    V. Painful scrotum
    VI. Empty scrotum
    VII. Anomalies of the external genitaliaConcomitant
    findings with Anorectal Malformations
    URINARY TRACT
    INFECTION
    DEFINED
    Any number of colonies
    obtained by suprapubic bladder
    tap
    Why early evaluation is necessary for all
    infants and young children (<age 5)
    Recurrence in 30-40%
    High incidence of VUR-35%
    Clinical parameters unreliable in detecting
    those with VUR
    Infants at highest risk of pyelonephritis and
    renal scarring
    Higher incidence of scarring with RUTI
    BASIC TREATMENT TENET:
    MUST BE A PROVEN
    URINARY TRACT INFECTION!
    Proper collection of urine is the
    cornerstone of treatment.
    Infants below one year of age, a
    suprapubic tap is recommended.
    A catheterized urine is a good alternative
    to obtain urine specimen.
    A midstream collection is acceptable for
    cooperative children.
    Proving UTI by urinalysis:
    Gram staining an uncentrifuged urine has
    a sensitivity of 93% and a false + of 5%.
    Urine dipstick has a sensitivity of 88% in
    the presence of leucocyte esterase or
    nitrite and a false + rate of 4%.
    Pyuria alone has low true positive rate and
    high false positive rate. For >5/hpf:TPR.67/FPR,21;
    for >10: TPR .77/FPR.11
    RISK FACTORS FOR UTI
    FEMALE
    BELOW 5 YEARS OF AGE
    VUR
    VOIDING DYSFUNCTION
    CONSTIPATION
    OBSTRUCTION
    RISK FACTORS FOR UTI
    Toilet training
    Sexual activity
    Pregnancy
    Associated problems seen with
    UTI: Pediatric Urology Database
    4201 cases (1995-present)
    1. Anatomic anomalies19%
    2. Vesicoureteral reflux34%
    3. Voiding Dysfunction 40%
    4. Idiopathic. 25%
    Evaluation of children with UTI
    History: emphasis of number of UTIs- febrile
    or afebrile
    presence of voiding disorders such
    as daytime/nighttime wetting, urgency,
    incontinence, dysuria
    constipation
    siblings with UTI
    Evaluation of children with UTI
    History/ ROS:
    passed surgeries especially at the
    anorectal area
    neurologic problems
    Physical Examination
    Vulvar synechiae
    (Before and after treatment)
    Treatment: topical estrogen
    Examination of the back
    Dimple at the
    lumbosacral area w/
    recurrent UTI
    neurogenic bladder
    (verify by US that
    shows thickened
    bladder)
    WORK-UP
    KUB ULTRASOUND (to 1st rule out congenital
    anomalies)
    VOIDING CYSTOURETHROGRAPHY
    (VCUG)
    RENAL SCAN
    WORK-UP
    UTZ AND VCUG
    1. FOR ALL CHILDREN< 5 YRS OF
    AGE WITH FIRST UTI.
    2. SCHOOL-AGE GIRLS WITH FIRST
    FEBRILE UTI.
    3. SCHOOL-AGE AND ADOLESCENT
    BOYS WITH FIRST FEBRILE UTI
    FEBRILE UTI
    WORK-UP
    UTZ ONLY ( VCUG OR RENAL SCAN IF
    SONOGRAM IS ABNORMAL):
    1. SCHOOL AGE BOYS WITH FIRST
    AFEBRILE UTI.
    2. SCHOOL-AGE GIRLS WITH RECURRENT
    CYSTITIS.
    3. ADOLESCENT GIRLS WITH FIRST
    FEBRILE UTI.
    PRIMARY VESICOURETERAL
    REFLUX
    MEDICAL MANAGEMENT OF
    VUR
    Daily antibiotic prophylaxis (does not affect children
    even as long as 5 years, so its ok to give antibiotics long term
    provided its low dose)

    Regular volitional voiding


    In children with unstable bladder:
    anticholinergics+ timed voiding+ pelvic
    floor exercises
    MEDICAL MANAGEMENT OF
    VUR
    Manage constipation
    Periodic urinalysis-suspect-culture/treat
    VUR follow-up and upper tract
    assessment
    Principle of medical management
    of patients with VUR
    40-60% recurrence of UTI in 18 months
    If with scarring, likely to get worse with
    every UTI
    Most mild to moderate VUR resolve
    spontaneously
    Pelvic floor Exercise program
    Patients with VUR.. 30
    Indication: UTI, overactive bladder,
    bladder-sphincter discoordination
    18 patients had a minimum 1 year follow-
    up: 8 patients cured (44%), 6 patients
    partial response (33%), 4 patients no
    response (22%)
    Pelvic Floor Exercises
    Without VUR- 13
    Indications: overactive bladder in 16,
    Bladder sphincter discoordination in 4,
    bedwetting in 2
    10 had a one year minimum follow-up
    Response: 7 had good response (70%),
    3 partial response (30%)
    Voiding dysfunction
    ( on those children with UTI)
    1. Lazy bladder Syndrome86 (14.3%)
    2. OveractiveBladder.174(28.9%)
    B-S discoordination.. 341 (56.7%)
    Constipation:
    a cause of bladder dysfunction
    and UTI
    ( 34% incidence: Neumann 1973)
    Rectum is distended, bladder does not contract well
    and the rectum and bladder has the same embryonic
    origin
    Rome II definition of Constipation:
    Two or more of the following symptoms present for a total
    of at least 12 weeks in the preceeding year:
    1. Straining in more than 25% of defecations
    2. Lumpy or hard stools in more than 25% of defecations
    3. Sensation of incomplete evacuation in more than 25%
    of defecations
    4. Sensation of anorectal obstruction in more than 25% of
    defecations
    5. Use of manual maneuvers to facilitate more 25% of
    defecations
    6. Fewer than 3 defecations per week.
    Constipation:
    1) Increased post void residual.
    2) Pressure of stool on the bladder
    causes:
    reduced functional capacity
    stimulation of stretch receptors
    triggers overactivity
    Hinman 1973, ORegan 1986, Brading
    1994, Fernandez 1991
    Constipation:
    3.) Functional Discoordination of the anal
    sphincter (and also the external urethral
    sphincter)
    Amongst constipated patients,53%
    contracted instead of relaxed the ext.
    anal sphincter and PF during defecation
    attempts.
    Leonig-Baucke 1989, Wald 1986, Benninga 1993, Emery
    1988
    Treatment of constipation leads
    to remarkable improvement of
    incontinence and UTI.
    Leonig-Baucke 1991, 1996
    Neonatal evaluation of
    abdominal mass
    80-90% of neonatal masses are renal in
    origin
    Ureteropelvic junction obstruction is the
    most common cause, followed by the
    MCKD
    Frequency of neonatal
    abdominal masses

    renal
    retroperitoneum
    female tract
    GI
    hepatobiliary
    Neonatal Hydronephrosis
    Ureteropelvic junction obstruction is the most common

    upjo
    PUV
    defunc kidney
    MCK
    reflux
    UVJO
    others
    Prenatal hydronephrosis
    Will resolve spontaneously
    Wait until mother gives birth because its
    the placenta that is responsible for the role
    of the kidney except in oligohydramnios, in
    which prenatal intervention does not work)
    Prenatal Hydronephrosis
    EXTERNAL GENITALIA
    (PAINFUL SCROTUM)

    Testicular Torsion
    Torsion of Appendix Testis
    Epidydymitis/ Orchitis
    Incarcerated Hernia
    Torsion Testicular Appendages
    Physical exam
    Mild scrotal erythema
    (+) cremasteric reflex
    Localized tenderness
    blue dot sign
    Findings less specific later in course
    Testicular appendages
    Neonatal Torsion
    Epididymitis secondary to an
    ectopic ureter to the vas deferens

    Epididymitis- most common: sexual


    experimentation with a promiscus woman
    Key mgt: Doppler US
    Trauma to the testis
    Sorry, puro pictures, walang notes
    Acute Scrotum: Henoch scholein Purpura

    Systemic vasculitis skin, joints, GI, GU


    Nonthrombocytopenic purpura
    Purpuric skin lesion
    2-30% scrotal findings
    Normal color doppler US
    RX: steroids/expectant
    Acute scrotum: idiopathic scrotal
    edema
    Scrotal edema, erythema:
    Prepubertal boys, waddling gate
    Testis +/- palpable, but nontender
    Normal color doppler flow
    Resolve in 49-72hrs
    Bug bite, allergic reaction, cellulitis
    History/PE

    Definite Possible
    Torsion Torsion

    Surgery Color Doppler utz

    no normal

    blood flow Observe


    EXTERNAL GENITALIA
    THE EMPTY SCROTUM

    Undescended Testis
    Retractile Testis
    Ectopic Testis
    Impalpable Testis
    Cryptorchidism
    Age-related effect on the gonocyte
    number
    1. Age 2 shows drop in total number of
    germ cells.
    2. Age 3: 1/3 normal, 1/3 diminished, 1/3
    markedly diminished germ cell count
    3. The higher the level of the testis , the
    greater the effect on the germ cell
    4. By puberty, 90% reduction in the germ
    cell count in the abdominal testis.
    The cryptorchid testis
    Age and infertility
    Age (years) at % fertile
    orchidopexy
    1-2 90%

    3-4 50%

    5-8 40%

    9-12 30%

    >13 15
    Early orchidopexy ( 2y/0) is
    associated with higher inhibin
    and lower FSH: Early
    orchidopexy is beneficial
    Malignant Tendency
    AAP- Committee on External
    Genitalia:
    Strongly recommend
    orchidopexy at one year of age
    as optimal
    EXTERNAL GENITALIA
    THE SMALL PENIS

    1. Micropenis
    2. Webbed penis
    3. True Concealed penis
    Normal penis of a newborn Filipino
    2.64 +/- .26 cm( first standard deviation)
    Cunanan S, Bolong D,- 100 consecutive newborns at the
    Chinese General Hospital
    Proper measurement
    B: due to fat
    EXTERNAL GENITALIA
    ENLARGED SCROUTM

    1. Hernia/ hydrocele
    2. Testicular enlargement
    3. Varicoceles
    Abnormal closure of the patent
    processus vaginalis
    Manual reduction:
    - no systemic signs toxicity
    - IV sedation
    - Trendelenberg position
    - mild manual pressure
    Emergency surgery
    Incidence and Risk Factors
    Hydroceles
    Incidence- 6%
    Majority resolve by 12-18 months
    Minimal risk of incarceration
    Pediatric Hydrocele: Mgt
    Observation:
    - 1-2 years age
    - Recurrence rate 2%
    - Contralateral hernia 7%
    Surgical repair:
    - inc. size
    - Age > 2yrs
    ANOMALIES OF THE EXTERNAL
    GENITALIA:
    HYPOSPADIAS
    AMBIGUOUS GENITALIA
    EPISPADIAS/ EXTROPHY
    Epispadia opening at dorsum
    Hypospadia opening at ventral
    - occurs 1/200 male births
    component of hypospadia:
    1. ventrally displaced meatus
    2. cording
    3. no prepuce (only dorsal hood)
    4. transposition of scrotum
    When to work-up hypospadias
    Severe- scrotal/ perineal
    One undescended testis
    UTI
    SUBMUCOSAL INJECTIONS
    VUR

    PRIMARY SECONDARY
    PRIMARY VESICOURETERAL
    REFLUX
    CONSERVATIVE- SPONTANEOUS
    RESOLUTION
    SUBMUCOSAL INJECTIONS
    SURGERY
    SECONDARY
    VESICOURETERAL REFLUX

    INCREASED BLADDER PRESSURE

    CONGENITAL ANOMALIES
    SECONDARY VUR
    INCREASED BLADDER PRESSURE

    URETHRAL SPHINCTER DYSFUNCTION


    OBSTRUCTION
    BLADDER DYSFUNCTION

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