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Pediatric Urology Update

Rama Jayanthi, M.D.


Section of Pediatric Urology
Columbus Childrens Hospital

Format and purpose


Selected cases in pediatric urology
Stimulate discussion
Discuss management

Case 1
Hypospadias noted at birth
Both 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 masses
Stable in size
No increase with crying
No 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 mass
Does not transilluminate
Ultrasound: 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%)
183
(75%)

38
(76%)
20
(53%)

269
(80%)
203
(76%)

Married
with
children

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
Voiding dysfunction may be due to

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

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
Hinmans 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 pretreatment, UTI in 11%
52% had improvement in constipation

89% improved day


63% improved night
no more UTI

Loening-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 UTIs?

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 (contd)

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 (contd)

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 (contd)
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 doesnt 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