1 Canadian Undergraduate Urology Curriculum (CanUUC): Pediatric UrologyLast reviewed May 2017

2 Pediatric Urology: ObjectivesDefine and describe the treatment of phimosis, paraphimosis and balanitis Outline the basic management of nocturnal enuresis Outline the investigation and management of a febrile pediatric UTI List the common causes of antenatal hydronephrosis and collecting system abnormalities Define cryptorchidism and hypospadias List the urologic causes of an abdominal mass in a child

3 Pediatric Urology: HistoryFamily History UTI Nocturnal enuresis Vesicoureteral reflux Cystic kidney disease and absence of kidney Hypospadias and cryptorchidism Age Presenting complaint History Medications and allergies PMHx Antenatal ultrasound Elimination History Voiding frequency Holding maneouvers Incontinence (day and night) Bowel movements Hard stool Fluid intake

4 Pediatric Urology: Physical ExaminationAbdominal Exam Masses Pain Palpable bladder Genitourinary Exam Rash Labial adhesions Urethral prolapse Ureterocele prolapse Urethral opening (location) Foreskin (phimosis vs retractable) Testicular position Testicular masses Back Exam Look for dimples Hairy patches Watch them pee! Postvoid residual

5 Phimosis, Paraphimosis and Balanitis

6 By 3 years of age 90% of boys have a retractable foreskin Foreskin Care By 3 years of age 90% of boys have a retractable foreskin Suggest to parents Normal cleaning – retract and clean on a daily basis No forceful retraction Teach boys to pull back foreskin to void Treatment only necessary for phimosis causing infection or difficulty voiding

8 Important to differentiate from pathologic formsPhysiologic Phimosis Important to differentiate from pathologic forms If asymptomatic: NO TREATMENT  forceful retraction bleeding scar more adhesions Elder J. Campbell Textbook of Urology 8th ed. Ch 66

11 Phimosis: Treatment Indications Symptoms Pathologic phimosis1. Corticosteroid cream (short term <2-3 months) Randomized study results = 70-85% ( F/U 18 mo.) Lund et al. Scan J Urol Neph 2006 Lindhagen T, Eur J Surg. 1996 Must use strong or moderately strong steroid (betamethasone vs clobetasol) Yang SS et al. J. Urol. 2005 2. Dorsal Slit – incising the “top” of the foreskin 3. Circumcision

12 Steroids are more cost effective than dorsal slit or circumcisionCost effectiveness Steroids are more cost effective than dorsal slit or circumcision Berdeu D. et al BJU Int Feb Van Rowe Pediatrics Oct 50 m Euro annually saved in France

14 Phimosis: CircumcisionThere is no absolute medical indication for circumcision in the neonatal period Relative indication anomaly of urinary tract and recurrent infections Potential medical advantages Decrease incidence of urinary tract infections in the first year of life Prevent phimosis Prevent balanoposthitis (infection of the glans penis) Decrease incidence of penile cancer May decrease the incidence of sexually transmitted disease

15 Circumcision Method Gomco clamp Plastibell clamp Mogen clampSurgically Complications ( %) Bleeding Injury to penis amputation of glans Skin issues Take off too much Leave on too much Skin bridges Inclusion cysts Penile curvature Urethrocutaneous fistula Long term Meatal stenosis

18 Balanitis: Symptoms Erythema (localized) Edema Purulent discharge Fever UTI? Dysuria

21 Balanitis: Treatment Topical antibiotic ( fucidin, polysporin etc)Oral Antibiotics for severe cases Warm water soaks/baths BID for treatment Topical Steroids Occasionally antifungal Do not retract the foreskin

22 Nocturnal Enuresis

23 Nocturnal Enuresis Night-time bedwetting with continence during the day Primary or secondary More common in males Most children reach night-time continence by 5 years old 23% of 5 year olds 20% of 7 year olds 4% of 10 year olds 1-2% of adolescents Secondary enuresis accounts for 20% of cases

24 Nocturnal Enuresis: BedwettingIsolated nocturnal Enuresis is usually a functional disorder Work-up Voiding log Physical exam usually normal Urinalysis

25 Nocturnal Enuresis: PathogenesisDelayed maturation of CNS Reduced functional capacity Deep sleepers Reduced renal concentration

26 Nocturnal Enuresis: TreatmentReassurance Behavioural (positive reinforcement) Alarms Can take several weeks to begin to work Minimum 4 month trial More effective than, DDAVP and tricyclic 70% average response during the treatment 50% relapse Glazener et al; Cochrane Database of Syst Rev April 2005

27 Nocturnal Enuresis: Treatment DDVAPPharmacologic DDAVP (desmopressin) Decreases urine output Taken at night Effective in the short term – 60-70% success Well tolerated Theoretical risk of seizure if taken with large amounts PO fluid High relapse rate Glazener et al; Cochrane Database Syst Rev 2002

28 Nocturnal Enuresis: Treatment Tricyclic Anti-depressants (TCA)Both anticholinergic and alpha adrenergic effects Not first line management Average one wet night per week  20-30% dry on treatment High relapse rate Potential serious side effects (sedation, etc.) Glazener et al; Cochrane Database Syst Rev 2003

29 Urinary Tract Infections (UTI)

30 Urinary Tract Infection (UTI): PresentationYoung children (infant) Febrile Vomiting Decreased appetite Lethargy Older children Febrile (implies pyelonephritis) Dysuria Frequency Abdominal pain

31 Urinary Tract Infection: InvestigationHistory and physical Voiding history and/or constiptation Family history Fever Urine Ideally catheter specimen Bag specimens are bad! (90% false positive rate) Radiology Febrile UTI in a child Ultrasound and VCUG (if US abnormal) DMSA can document a pyelonephritis

32 Urinary Tract Infection: TreatmentLower tract: short course antibiotic Upper tract (fever, back pain, nausea and vomiting) 2 week course Admission if very ill Quick treatment decreases chances of scarring Lt DMSA

33 Recurrent UTI’s: TreatmentImprove voiding patterns Timed voiding (q2h) Double Void Improve emptying Biofeedback Alpha Blocker Increase water Stool softener Antibiotic Prophylaxis Treat anatomic abnormality

34 Hydronephrosis and Collecting System Abnormalities

35 Collecting System AbnormalitiesVesicoureteral Reflux Obstruction UPJ Obstruction UVJ Obstruction Duplication

36 Ureteropelvic Junction (UPJ) ObstructionCause: Congenital stricture or adynamic segment Crossing vessel Presentation Antenatal hydronephrosis Intermittent severe flank pain (lasts about 6 hours) with nausea and vomiting Urinary Tract Infection Renal calculi

37 Ureteropelvic Junction Obstruction: Investigation and ManagementInvestigations Ultrasound Diuretic MAG3 Renal Scan Asymptomatic Observe If drop in renal function or worsening of hydro operate Symptomatic Operate

38 Hypospadias

40 Hypospadias: EpidemiologyIncidence: 1/125 male births Caucasian % Other racial groups % Associations Cryptorchidism (9.3% of patients with hypo) Incidence of chromosomal abnormality higher with proximal hypo and UDT (22%) Inguinal hernias (9%)

41 Hypospadias: Risk FactorsEndocrine Disruption in the synthetic biopathway of androgens May be a delay in the maturation of the hypothalamic-pituitary-axis Genetic Familial rate 7% Environmental Endocrine disrupters in the environment may be responsible for the increase in incidence Maternal Maternal progestin exposure may increase likelihood of hypospadias Some studies show a marked increase in hypospadias in women undergoing IVF

42 Hypospadias: InvestigationSimple distal hypospadias No evaluation Proximal hypospadias + one or bilateral impalpable testicles Intersex evaluation Electrolytes Karyotype 17 hydroxyprogesterone Ultrasound abdomen

43 Hypospadias: TreatmentReferral before 6 months of age Surgery usually between age 1 and school age Distal hypospadias Surgery mostly for cosmesis Sometimes for urinary function Proximal hypospadias Treatment for both urinary and reproductive function Higher risk of complications

44 Pediatric Scrotal Conditions

45 Scrotal Conditions: Testicular PainCauses Torsed appendix Epididymitis Testicular Torsion

47 Scrotal Conditions: EpididymitisAdolescent and older Gradual onset Tender superior portion Investigations: U/A Urine culture Sexual history Possible ultrasound to r/o torsion

48 Scrotal Conditions: Testicular TorsionSymptoms: Adolescent (not always) Severe pain Sudden onset Sometimes only abdominal pain Nausea and Vomiting Examination Abnormal lie to the testicle Absence of cremaster reflex “If it looks like a torsion go right to the O.R.” Ideally fix within 6 hours

49 Torsion: InvestigationIf it looks like torsion go straight to the OR Urinalysis and culture If normal unlikely to be epididymitis Scrotal Ultrasound

51 Scrotal Conditions: Undescended Testicles (Cryptorchidism)The most common birth abnormality involving the male genitalia (0.8% incidence at 6 months) All (except premature infants) will descend in first 3 months of life If undescended at 3 months should refer to peds urologists Retractile testicle is a normally descended testicle that is pulled out of the scrotum by an overactive cremasteric reflex

52 Undescended Testes: ComplicationsInguinal hernia Risk for torsion? Infertility Only decreased if bilateral Increased risk of testicular cancer 4-10 times normal

53 Undescended Testes: TreatmentOrchidopexy – placement of testicle in scrotum May improve fertility Easier to monitor for malignancy Surgical correction by 6 months of age

54 Scrotal Conditions: HydroceleCommunicating hydrocele Persistence of a patent processus vaginalis Accumulation of fluid around the testicle Treatment: often will close in first year of life Period of observation then surgery if remains Non-communicating hydrocele Rare in children Usually a result of inflammation

55 Pediatric Urology: Important PointsHistory and Physical Take a history on voiding and bowel habits UTI history ask about fever and symptoms of upper tract Check for scrotal position Start examining boys as they reach puberty for testicular masses and speak about self exam If testicle is not down after 3 months refer to peds urologist With hypospadias and impalpable testicle consider intersex condition Possible torsion – needs to be fixed within 6 hours