1. Paediatric urology

2. Congenital Abnormalities
not uncommon; 1/200 have congenital abnormalities of the GU tract
1. ANTENATAL HYDRONEPHROSIS
2. POSTERIOR URETHRAL VALVES (PUV)
3.URETEROPELVIC JUNCTION (UPJ) OBSTRUCTION
4. VESICOURETERAL REFLUX (VUR)
5. HYPOSPADIAS
6. EPISPADIAS-EXSTROPHY COMPLEX
7.CRYPTORCHIDISM/ECTOPIC TESTES
8.RENAL AND URETER ABNORMALITIES
9.MEGAURETER

3. 1. ANTENATAL HYDRONEPHROSIS
Epidemiology
1-5% fetal usg, detectable as early as first trimester
Differential Diagnosis
ureteropelvic junction or ureterovesicular junction obstruction
multi-cystic dysplastic kidney
VUR
posterior urethral valve (only in boys)
duplication anomalies
ureterocele
ectopic ureter
Treatment
antenatal in utero intervention rarely indicated unless evidence of posterior urethral valve with oligohydramnios

4. Majority of antenatal hydronephroses
resolve during pregnancy or within the
first year of life.

5. 2. POSTERIOR URETHRAL VALVES (PUV)
Epidemiology
common congenital obstructive urological defect (affects only boys)
Pathophysiology
abnormal mucosal folds at the distal prostatic urethra causing varying degrees of obstruction

6. 2. POSTERIOR URETHRAL VALVES (PUV)
Clinical Presentation
dependent on age:
antenatal: bilateral hydronephrosis, distended bladder, oligohydramnios
neonatal (recognized at birth): palpable abdominal mass (distended bladder, hydronephrosis), ascites, respiratory distress (pulmonary hypoplasia from oligohydramnios), weak urinary stream
neonatal (not recognized at birth): within weeks present with urosepsis, dehydration, electrolyte abnormalities, failure to thrive
toddlers: UTIs or voiding dysfunction
school-aged boys: voiding dysfunction and urinary incontinence

7. 2. POSTERIOR URETHRAL VALVES (PUV)
Investigations
most commonly recognized on prenatal USG - bilateral hydronephrosis, thickened bladder, dilated posterior urethra (“keyhole sign”), oligohydramnios in a male fetus
voiding cystourethrogram - dilated and elongated posterior urethra, trabeculated bladder, VUR
Treatment
immediate catheterization to relieve obstruction, followed by cystoscopic resection of PUV when baby is stable
if resection of PUV is not possible, cystocostomy is indicated

9. 3. URETEROPELVIC JUNCTION (UPJ) OBSTRUCTION
Etiology
unclear: adynamic ureteral segment, stenosis, strictures, extrinsic compression, aberrant blood vessels
Epidemiology
the most common congenital defect of the ureter
M:F = 2:1
10-40% bilateral, which may be associated with worse prognosis

10. 3. URETEROPELVIC JUNCTION (UPJ) OBSTRUCTION
Clinical Presentation
symptoms depend on severity and age at diagnosis (mostly asymptomatic finding on USG)
infants: abdominal mass, urinary infection
children: pain, vomiting, failure to thrive
some cases are diagnosed after puberty and into adulthood
in adolescents and adults, the symptoms may be triggered by episodes of increased diuresis,such as following alcohol ingestion
Investigations
antenatal USG most common, IVU, and renal scyntygraphy ± furosemide
Treatment
surgical correction (pyeloplasty Hynes-Anderson), consider nephrectomy if <15% differential renal function

11. URETEROPELVIC JUNCTION

12. pyeloplasty Hynes-Anderson

13. 4. VESICOURETERAL REFLUX (VUR)
Definition
retrograde passage of urine from the bladder, through the ureterovesicular junction (UVJ), into the ureter
Epidemiology
estimated ~1% of newborns, but not well known incidence and clinical relevance higher in children with febrile UTIs and prenatal hydronephrosis
risk factors: race (white > black), female gender, age (<2 yr), genetic predisposition

14. 4. VESICOURETERAL REFLUX (VUR)
Classification
primary reflux: incompetent or inadequate closure of UVJ, lateral ureteral insertion, short submucosal segment
secondary reflux: abnormally high intravesical pressure resulting in failure of UVJ closure - often associated with anatomic (PUV) or functional (neurogenic) bladder obstruction

15. 4. VESICOURETERAL REFLUX (VUR)
Investigations
History focused particularly of voiding dysfunction (frequency, urgency, constipation)
screen for signs of infection (UTI, pyelonephritis, urosepsis) and renal failure
initial evaluation of renal status, growth parameters, and blood pressure is warranted in any child with VUR due to high incidence of renal scarring
height, weight, blood pressure
Creatinine
Urine Analysis, Urine Culture
renal usg
cystography, renal scyntygraphy if at high risk

16. 4. VESICOURETERAL REFLUX (VUR)

17. 4. VESICOURETERAL REFLUX (VUR)
Treatment
spontaneous resolution in 60% of primary reflux
in lower grades (I-III), goal is to prevent infection or renal damage via medical treatment and monitoring
medical treatment: long-term ABx prophylaxis at half the treatment dose for half the treatment time (TMP/SMX, trimethoprim, amoxicillin, or nitrofurantoin)
surgical treatment: ureteral reimplantation ± ureteroplasty, or subureteral injection with bulking agents (DefluxR or MacroplastiqueR)
Indications for surgery : failure of medical management, renal scarring (e.g. renal insufficiency), breakthrough UTIs, persistent high grade (IV or V) reflux

18. Endoscopic treatment of vur

19. Cohen's uretero-vesical reimplantation

20. 5. HYPOSPADIAS Definition
a condition in which the urethral meatus opens on the ventral side of the penis, proximal to the normal location in the glans penis
depending on severity, may result in difficulty directing urinary stream or infertility
Epidemiology
very common; 1/300 live male births
white >> black
may be associated with ventral penile curvature, disorders of sexual differentiation,undescended testicles or inguinal hernia
Treatment
early surgical correction; optimal repair before 2 yr

21. 6. EPISPADIAS-EXSTROPHY COMPLEX
Definition
a spectrum of defects depending on the timing of the rupture of the cloacal membrane
bladder exstrophy: congenital absence of a portion of lower abdominal and anterior bladder wall, with exposure of the bladder lumen
cloacal exstrophy: exposed bladder and bowel with imperforate anus, associated with spina bifida in >50%
epispadias (least severe) urethra opens on dorsal aspect of the penis
Etiology
represents failure of closure of the cloacal membrane, resulting in the bladder and urethra opening directly through the abdominal wall
Epidemiology
rare: incidence 1/30,000, 3:1 male to female predominance
high morbidity - incontinence, infertility, reflux
Treatment
surgical correction at birth
later corrections for incontinence, VUR, and bladder capacity may be needed

22. bladder exstrophy

23. bladder exstrophy

24. Cryptorchidism/Ectopic Testes
Definition
abnormal location of testes somewhere along the normal path of descent (external inguinal ring> inguinal canal > abdominal)
ectopic testis (testis found outside its normal path of descent) is most commonly located within a superficial pouch between the external oblique fascia and Scarpa’s fascia (Denis Browne pouch)
Epidemiology
• 2.7% of full term newborns
• 0.7%-0.8% at 1 yr old

25. 7.Cryptorchidism/Ectopic Testes
Treatment
orchiopexy at age of 6 months-12 months
hormonal therapy not proven to be of benefit over standard surgical treatment
Prognosis
reduction in fertility - untreated bilateral cryptorchidism: ~100% infertility
paternity rates: 1)53%, 2)90%, and 3)93% in 1)formerly bilateral cryptorchid, 2)formerly unilateral cryptorchid, and 3)normal men
increased malignancy risk intraabdominal > inguinal
surgical correction facilitates testicular monitoring and may reduce malignancy risk
increased risk of testicular torsion (reduced by surgical correction)

26. 8.Renal and ureter abnormalities
Agenesis – complete absence of one kidney, ureter and ipsilateral part of bladder triangle
Aplasia – no transformation between kidney forming tissues into proper kidney
Hypoplasia – improper growth of the kidney
Improper location (ex. Pelvical, other side)
Renal fusion (most common is horseshoe kidney 1/400 newborns)

27. 8.Renal and ureter abnormalities
Duplicated ureter - two ureters draining a single kidney, occurring in approximately 1% of the population. Can be partial (usually asymptomatic) or complete (usually the upper ureter has it orifice is in the lower part of the bladder with the risk of hydronephrosis due to UVJ obstruction, while the lower ureter is in the upper part of the bladder with the risk VUR)
Ectopic ureter – ureter terminates in inproper site

28. 8.Renal and ureter abnormalities
Ureterocele - the distal ureter balloons at its opening into the bladder, forming a sac-like pouch. It is most often associated with a duplicated collection system, where two ureters drain their respective kidney instead of one. Simple ureteroceles, where the condition involves only a single ureter, represents only twenty percent of cases. Ureteroceles affects one in 4,000 individuals, at least four-fifths of whom are female. Patients are frequently Caucasian.
Initial management is usually endoscopic incision of the ureterocele, which can be followed by surgical ureteric re-implantation to preserve renal function and prevent reflux.
In some cases: upper pole nephrectomy with ureterectomy (poor renal function), ureteropyelostomy (good renal function)

30. 9.Megaureter ureter is abnormally dilated
Usualy congenital, more common in males, may be bilateral, and is often associated with other congenital anomalies.
IVU/CT

31. 9.Megaureter
Primary – around the distal part of the ureter there is too much smooth muscles, which causes functional obstruction. The ureteric orifice appears normal and a ureteric catheter passes easily.
Secondary VUR Neurogenic bladder Ureterocele PUV Ectopic ureter

32. 9.Megaureter

33. 10.Urogynecology
10.1 STRESS INCONTINENCE
10.2 URGE INCONTINENCE

34. 10.1 STRESS INCONTINENCE
Involuntary loss of urine with increased intra-abdominal pressure (coughing, laughing, sneezing, walking, running).
The gold standard diagnostic test for urinary incontinence is multichannel urodynamics.
A large proportion of cases are correctly diagnosed from clinical history alone

35. 10.1 STRESS INCONTINENCE Risk Factors for Stress Incontinence in Women
pelvic prolapse
pelvic surgery
vaginal delivery
hypoestrogenic state (post-menopause)
age
smoking
neurological/pulmonary disease

36. 10.1 STRESS INCONTINENCE Treatment Kegel exercises
local vaginal estrogen therapy
surgical - tension-free vaginal tape (TVT), tension-free obturator tape (TOT)

37. 10.2 URGE INCONTINENCE Definition
urine loss associated with an abrupt, sudden urge to void
“overactive bladder”
diagnosed based on symptoms
Etiology
idiopathic (90%)
detrusor muscle overactivity (“detrusor instability”)
Rule Out Neurological Causes of Urge Incontinence
Multiple sclerosis
Herniated disc
Diabetes mellitus

38. 10.2 URGE INCONTINENCE Treatment
behaviour modification (reduce caffeine/liquid, smoking cessation, regular voiding schedule)
Kegel exercises
anticholinergics: oxybutinin, tolterodine, solifenacin
New drug – beta-mimetic: mirabegron
tricyclic antidepressants: imipramine