1. Pediatric Urology Update
Rama Jayanthi, M.D.
Section of Pediatric Urology
Columbus Children’s Hospital

2. Format and purpose Selected cases in pediatric urology
Stimulate discussion
Discuss management

3. 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?

4. Hypospadias abnormally positioned meatus
meatus can be located anywhere from perineum to glans
chordee- associated penile curvature

5. Hypospadias- associated abnormalities
Easy to remember - nothing!
Normal kidneys and bladder
Normal fertility
Normal sexual function

6. 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

7. Who is a boy and who is a girl?

8. 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

9. Hypospadias - management for the pediatric urologist
Surgical correction at months of age
Attempt one stage reconstruction
Out patient surgery
Success rates should be > 95%

10. Epispadias Very rare - more often associated with bladder exstrophy
Need early referral for parental counseling
Patients may be totally incontinent

11. 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?

12. Scrotal masses Solid vs. cystic Testicular vs. extratesticular
transillumination of light
Testicular vs. extratesticular
Painful vs. painless

13. 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

14. 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”

15. Hernia/hydrocele

16. Hernia/hydrocele - management
Observation:
Noncommunicating hydrocele < 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

17. What is the diagnosis? Findings: Painless right scrotal mass
Does not transilluminate
Ultrasound: solid mass
Diagnosis: yolk sac tumor

18. 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?

19. 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

20. 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”

21. Management of pediatric varicocele
“Clinically significant varicoceles” requires surgical ligation
Problem:
Most teenagers have varicoceles detected on routine physical examination
Usually asymptomatic

22. 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

23. 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?

24. 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

25. 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

26. 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

27. 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

28. 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

29. Fertility after cryptorchidism
Lee, Brit J Urol, 1995

30. Risk of Neoplasia UDT has 10X greater risk Tumors occur after puberty
Abdominal testis has 4X greater risk than inguinal
Tumors occur after puberty
Mean age years
25% occur in normally descended testis
Early orchidopexy may be protective
Seminoma most common, embryonal cell 2nd

31. 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?

32. Natural history of phimosis

33. Medical management of phimosis
Prospective trial
Diprolone cream (0.05%) applied TID for 4 weeks to preputial band
Patients reevaluated at one month

34. Medical management of phimosis
Results
n = 21
Signs and symptoms
UTI
Balanitis
Preputial ballooning
Asymptomatic

35. Medical management of phimosis
Success 17/21 (81%)
11 complete, 7 partial
Failure 4/21 (19%)

36. 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

37. 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

38. 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

39. Case 6 What kind of evaluation is required?
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?

40. 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? 40

41. 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 41

42. 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

43. 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

44. Varieties of voiding dysfunction
In order of frequency
Bladder instability/overactivity
Infrequent voiding
Incomplete emptying
Hinman’s syndrome
“Nonneurogenic neurogenic bladders” 44

45. Bladder instabilty Clinical manifestations wetting infections
pelvic/vaginal pain
penile/scrotal pain 45

46. 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 46

47. Urgency incontinence More common than hypertonic bladder
Usually associated urgency/frequency
Severity of wettings ranges from damp pants to soaking 47

48. Hypertonic bladder VCUG - trabeculated bladder, may have diverticulae
Main point: Infections (and reflux) are secondary problem 48

49. “Distal urethral stenosis”
Spinning top urethra
NOT due to obstruction
A sign of bladder instability
Urethral dilation is NEVER indicated!!! 49

50. 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 50

51. Choice of anticholinergics
Oxybutinin
Ditropan XL mg qAM
Advantages:
once a day dosage
fewer side effects
Elixir (0.2 mg/dose/BID -TID)
only if cannot swallow pills 51

52. Role of bowel dysfunction
Fecal retention
Incomplete or infrequent emptying of bowels
Subtle clues
abdominal pain
perineal pain
vaginal “itching”
penile pain 52

53. 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 UTI
Loening-Baucke, Pediatrics, 1997 53

54. 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 54

55. 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 55

56. Management of infrequent voiding syndromes
timed voiding
behavioral modification
controlled bribery
intermittent catheterization 56

57. The overwhelming majority of patients can be evaluated with only a careful history. Only a small number may need “objective” measurements of bladder function. 57

58. Case 7 A 8 year old girl has her first episode of UTI
How do you evaluate her?
Observation?
US?
VCUG?
DMSA scan?

59. What is a urinary tract infection?
Positive culture in a child with appropriate symptoms

60. 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

61. Philosophical questions
Why do we treat urinary tract infections?
What are the ramifications of UTI’s?

62. 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

63. 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

64. 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???

65. 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?

66. Non-anatomic causes of UTI
“sticky bacteria”
dysfunctional bladder habits
dysfunctional bowel habits
all the above

67. 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

68. 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.

69. 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

70. Case 10 8 year old male who presented with urinary tract infections
Fever and flank pain

71. 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.”

72. 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

73. 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.

74. Imaging for ectopic ureter

75. Imaging for ectopic ureter

76. 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?

77. Case 12 “Daytime Frequency Syndrome” Unknown etiology
Spontaneous improvement is the rule

78. Thank you for listening