REUPLOAD2024_Pediatrics_Trans7_Pediatric Urology and Gynecology PDF

PEDIATRIC UROLOGY AND GYNECOLOGY Dr. Ana Flor Somera Abad, Balmores, Cabauatan, Clarete, de Leon, Duruin, Lim, Maramag, Tumamao, Urbano OUTLINE...

PEDIATRIC UROLOGY AND GYNECOLOGY Dr. Ana Flor Somera Abad, Balmores, Cabauatan, Clarete, de Leon, Duruin, Lim, Maramag, Tumamao, Urbano OUTLINE URINARY TRACT INFECTIONS I. Congenital Anomalies and Dysgenesis of the Kidneys PREVALENCE AND ETIOLOGY [continuation of pediatric nephrology] A. Renal Agenesis Commonly occur in children of all ages (prevalence varies with B. Renal Dysgenesis age) C. Renal Cyst Always rule out UTI up to 24 months D. Urinary Tract Infections Most common in children age female, A. Pyelonephritis B. Cystitis especially in uncircumcised) E. Vesicoureteral Reflux ✓ Afebrile: ~8% F. Obstruction of the Urinary Tract ✓ Febrile: ~7% A. Specific Types of Urinary tract Obstruction First year of life Male: female ratio (2.8:5.4) G. Anomalies of the Bladder A. Bladder Exstrophy Beyond 1-2 years Male: female ratio (1:10) B. Epispadias Female preponderance* H. Neuropathic Bladder Caused primarily by colonic bacteria: E. coli (54-67%), A. Neural Tube Defects Klebsiella spp., and Proteus spp., Enterococcus spp., and B. Urinary Incontinence Pseudomonas. I. Enuresis and Voiding Dysfunction J. Anomalies of the Penis and Urethra ✓ Less common cause S. aureus, Candida spp. And K. Disorders and Anomalies of the Scrotal Contents Salmonella spp. A. Cryptorchidism UTI has been considered a risk factor for the development of B. Varicocele renal insufficiency or ESRD in children. C. Hydrocele L. Urinary Lithiasis M. Gynecologic Problems of Childhood CLINICAL MANIFESTATIONS AND CLASSIFICATION A. Vulvovaginitis Pyelonephritis Abdominal, back or flank pain LEGEND Fever, malaise, nausea, vomiting and occasionally diarrhea Book PowerPoint Lecturer ✓ When considering fever in children, always think of UTI and Otitis media Most common serious bacterial infection in infants 39 °C without another source lasting > 24 hours for males RENAL AGENESIS and >48 hours for females Incidence is increased in newborns with a single umbilical artery Ureter and ipsilateral bladder hemitrigone are absent Unilateral – contralateral kidney undergoes compensatory hypertrophy Bilateral – produces the Potter syndrome RENAL DYSGENESIS Maldevelopment of the kidney that affects its size, shape, or structure Dysplasia – histologic diagnosis and refers to focal, diffuse, or segmentally arranged primitive structures specifically primitive ductal structures resulting from abnormal metanephric differentiation ✓ MCDK is the most common cause of an abdominal mass in newborn ✓ Usually unilateral and generally not inherited Hypoplasia – refers to a small nondysplastic kidney that has Acute Involvement of renal parenchyma, can result to fewer than the normal number of calyces and nephrons Pyelonephritis renal injury → pyelonephritic scarring ✓ Unilateral Pyelitis No renal parenchymal involvement ✓ Bilateral – manifests with signs and symptoms of chronic Localized renal parenchyma mass caused by renal failure and is a leading cause of end-stage renal Acute lobar acute focal infection without liquefaction. (older disease during the first decade of life. Nephronia children) o May be an early stage in the development of renal abscess RENAL CYSTS IN CHILDREN Follows a hematogenous spread with S. aureus Most common is the Simple Renal Cyst or pyelonephritic infection. Most are small and asymptomatic and do not require Renal abscess Most abscesses are unilateral and right sided treatment, although follow-up imaging is recommended Affects all ages If there are septations, irregular margins, calcifications, or a Can occur 2° to contagious infection in perirenal area or pyelonephritis that dissect to renal cluster of cysts, further evaluation may be indicated Perinephric capsule. abscess Differ from renal abscess in that it is diffuse Anomalies in Shape and Position throughout the capsule, not walled off and can develop septations. Ectopic Kidney may be in pelvic, iliac, thoracic, or contralateral Rare position Xantho- Granulomatous inflammation with giant cell and Renal Fusion – lower poles of the kidneys can fuse in the granulomatous foamy histiocytes midline, resulting in horseshoe kidney pyelonephritis Can be caused by: ✓ Correlated with Turners’ Syndrome and Wilms tumor o Renal calculi TRANS 7 | Abad, Balmores, Cabauatan, Clarete, de Leon, Duruin, Lim, Maramag, Tumamao, Urbano Page 1 of 9  o Obstruction Acute renal infection: leukocytosis + neutrophilia (CBC) o Proteus infection Elevated serum erythrocyte sedimentation rate, procalcitonin o E. coli Treatment: Total/ Partial nephrectomy level, and C-reactive protein are common (nonspecific markers). Cystitis Blood cultures should be drawn before starting antibiotics – bacteremia in the setting of pyelonephritis is reported to occur Only bladder involvement in 3-20% of patients and is most common in infants 2 days Often caused by E. coli Absence of another infection hemorrhagic Patients receiving immunosuppressive therapy Nonblack race Cystitis are at higher risk for hemorrhagic cystitis Risk factors of males Temperature of > 39 °C (2-24 months) Fever > 24 hours Absence of another infection Atypical features Failure to respond within 48 hr of appropriate antibiotics Poor urine flow Abdominal flank or suprapubic mass Non–E. coli pathogen Urosepsis Elevated creatinine level IMAGING FINDINGS Not needed to make clinical diagnosis of UTI or pyelonephritis PATHOGENESIS AND PATHOLOGY Only considered if there is concern for acute lobar nephronia Nearly all UTIs are ascending infections or renal abscess Occurs by hematogenous spread, as in endocarditis or in ✓ Ultrasound (first-line): enlarged kidney with possible some bacteremic neonate. mass. Children of any age with febrile UTI can have acute ✓ CT scan: more sensitive and specific for lobar pyelonephritis and subsequent renal scarring, but the risk is nephronia, wedge-shaped lower-density area after highest in those younger than 2 years of age. contrast administration DIAGNOSIS May be suspected based on symptoms or findings on TREATMENT urinalysis, or both. Acute Cystitis Urine culture: necessary for confirmation and appropriate therapy Should be treated promptly to prevent possible progression to WAYS TO OBTAIN URINE SAMPLE pyelonephritis. Midstream urine sample (satisfactory) Prophylaxis: Nitrofurantoin and Amoxicillin 1/3 of TD once Toilet-trained daily Introitus should be cleaned first before obtaining children specimen Treatment is delayed until results of culture is known; Mild Uncircumcised Prepuce must be retracted, if not: sample may culture can be repeated if the results are uncertain males be unreliable (contamination) Severe Presumptive treatment is started Catheterized/ suprapubic aspirate urine 3–5-day course therapy with 6-12 mg TMP/kg/day sample should be obtained TMP-SMX or trimethoprim is If treatment is in 2 divided doses Adhesive, sealed, sterile collection bag after effective in E. coli disinfection of the skin of genitals: if urinalysis or initiated before Nitrofurantoin has advantage 5-7 mg/kg/24 hours Children who are results of culture culture is negative (negative predictive value of for Klebsiella in 3-4 divided doses not toilet-trained and sensitivity is 99%) Amoxicillin may be effective available 50 mg/kg/24 hours in If treatment is planned immediately, bagged but high rate of resistance specimen should NOT be the method of 2 divided doses obtaining specimen (high rate of contamination) Nitrites and leukocyte esterase: positive (metabolized by Acute Febrile UTI bacteria for 4 hours, nitrates→ nitrites). Clinical symptoms of UTI and pyelonephritis are difficult to ✓ In febrile infants < 60 days old: pyuria, nitrites and differentiate. Given the presence of systemic symptoms, the leukocyte esterase have a high sensitivity and specificity infection has likely progressed to the kidneys and should be to UTI treated for pyelonephritis. Microscopic hematuria: common in acute cystitis 7–14-day course of antibiotics is capable of reaching ✓ WBC cast in the urinary sediment suggests renal significant tissue levels is preferable for pyelonephritis. (oral= involvement (rare) parenteral). ✓ If the child is symptomatic, UTI is possible, even the Children who are Should be admitted for IV rehydration and antibiotics urinalysis result is negative. dehydrated, 50 mg/kg/24 hours not Ceftriaxone Pyuria (leukocytes on urine microscopy): suggests infection, vomiting unable to exceed 2 g but infection can also occur in the absence of pyuria. to drink fluids Cefepime 100 mg/kg/24 hours q (Confirmatory > diagnostic) complicated 12h infection or 100-150 mg/kg/24 ✓ WBC count >3-6 WBCs/ high-power field: infection urosepsis is a Cefotaxime hours in 3-4 divided ✓ Cut-off: 5 WBC/HPF to start antibiotics possibility doses Sterile pyuria (positive leukocytes, negative culture): partially Nitrofurantoin: should not be routinely used in children with treated UTIs, viral infections, urolithiasis, renal TB, renal febrile UTI, does not achieve significant renal tissue levels abscess, obstruction, urethritis from STI. Fluoroquinolones: alternative for resistant microorganisms, If culture shows >50,000 colony forming units/mL + pyuria/ particularly P. aeruginosa (patients >17 years old). bacteriuria (UA) + symptomatic child = UTI ✓ Levofloxacin: potential cartilage damage TRANS 7 | Abad, Balmores, Cabauatan, Clarete, de Leon, Duruin, Lim, Maramag, Tumamao, Urbano Page 2 of 9  Acute Lobar Nephronia, Renal abscess and Perinephric Bladder-bowel dysfunction: worsen preexisting VUR if there abscess is marginally competent uterovesical junction. Treated with the same antibiotics as pyelonephritis Megacystis-megaureter syndrome: massive VUR into the ✓ Duration of treatment: 14-21 days upper tracts that the bladder becomes distended. Renal or perirenal abscess or with infection in obstructed ✓ Primarily in males urinary tracts require surgical or percutaneous drainage in ✓ Unilateral or bilateral addition to antibiotic therapy Abscess larger than 3-5 cm: immediate percutaneous drainage Traditionally, patients receive 10-14 days of IV antibiotics followed by 2-4 weeks of oral antibiotic therapy. Other Potential Treatment or Prevention Options Probiotic therapy Cranberry juice IMAGING STUDIES IN CHILDREN WITH A FEBRILE UTI International Reflux Study Classification Identify the anatomic abnormalities that predispose to infection, I VUR into a nondilated ureter determine whether there is active renal involvement, and assess II VUR into the upper collecting system without dilation. whether renal function is normal or at risk. VUR into dilated ureter and/or blunting of the calyceal Renal sonogram + voiding cystourethrogram (VCUG), III fornices. Bottom-up which will identify upper and lower tract abnormalities, IV VUR into grossly dilated ureter method including VUR, bladder-bowel dysfunction, and bladder Massive VUR, with significant ureteral dilation and abnormalities such as paraureteral diverticulum. V tortuosity and loss of papillary impression. Intended to reduce the number of VCUG examinations, Top-down it begins with a dimercaptosuccinic acid (DMSA) renal approach scan, to identify areas of pyelonephritis. CLINICAL MANIFESTATIONS Initial ultrasound of the kidneys, ureter, and bladder for children Discovered during evaluation for a UTI 2-24 months with first episode of UTI. ✓ 80% are female VCUG: indicated only if the ultrasound study indicates Average age at diagnosis is 2-3 years old hydronephrosis, scarring or other findings suggestive of reflux May be discovered during evaluation for antenatal or obstructive uropathy, of if the patient has other atypical hydronephrosis complex features. ✓ 80% of affected children are male, and the VUR grade ✓ Recommended if the child has recurrent UTI usually is higher than in females Bladder and bowel dysfunction (constipation) may be present PREVENTION OF RECURRENCES in 50% of children with reflux and a UTI Identification of predisposing factors is beneficial Long term antibiotic prophylaxis: neuropathic bladder (check DIAGNOSIS for cerebral palsy or meningocele), urinary tract stasis and Contrast VCUG obstruction, severe VUR, and urinary calculi ✓ Lower urinary Radionuclide cystogram ✓ Upper urinary VESICOURETERAL REFLUX Bladder and upper urinary tracts are imaged during bladder Retrograde flow of urine from the bladder to the ureter and filling and voiding kidney. Children with low-pressure VUR is significantly less likely to Predisposes to kidney infection by facilitating the transport of resolve spontaneously than in children who exhibit only high bacteria from the bladder to the upper urinary tract. pressure VUR The inflammatory reaction caused by pyelonephritis can result Radiation exposure during a radionuclide cystogram is in renal injury or scarring, also termed as reflux-related renal significantly less than that from a contrast VCUG injury or reflux nephropathy. Low-dose radiation contrast VCUG provides more anatomic information CLASSIFICATION After VUR is diagnosed, assessment of the upper urinary tract Graded using the International Reflux Study (IRS) is important Classification of I-V and is based on the appearance of the Renal sonogram and/or renal scintigraphy urinary tract on a contrast voiding cystourethrogram (VCUG). ✓ Assess whether renal scarring and associated urinary ↑ VUR: ↑ likelihood of renal injury tract anomalies are present VUR may be primary or secondary Serum creatinine ✓ Measured if there is renal scarring NATURAL HISTORY The incidence of reflux-related renal scarring increases with VUR grade. With renal growth and maturation, VUR grade often resolves or improves. ✓ Lower grades are much more likely to resolve than higher grades ✓ Mean age of VUR resolution is 6 yr. Bladder-bowel dysfunction and grade III-V VUR are the most common risk factors for recurrent febrile UTI and new renal scarring Likelihood of resolution is similar regardless of age at Grades I and II diagnosis and whether it is unilateral or bilateral TRANS 7 | Abad, Balmores, Cabauatan, Clarete, de Leon, Duruin, Lim, Maramag, Tumamao, Urbano Page 3 of 9  Younger age at diagnosis and unilateral VUR are Acute Ureteral Obstruction Grade III usually associated with higher rate of spontaneous ✓ Flank or abdominal pain resolution. Grade IV Bilateral is likely to resolve than is unilateral. ✓ Nausea Grade V Rarely resolves ✓ Vomiting Chronic Ureteral Obstruction TREATMENT ✓ Can be silent Goals of treatment are to prevent pyelonephritis, VUR-related ✓ Vague abdominal or typical flank pain with increased fluid renal injury, and other complications of VUR. intake Medical therapy is based on the principle that VUR often resolves over time and that if UTIs can be prevented, the morbidity or complications of VUR may be avoided without surgery. Observation with behavioral modification or behavioral modification with antimicrobial prophylaxis. ✓ Include timed voiding during the day, ensuring fecal elimination, increased fluid intake, periodic assessment of satisfactory bladder emptying, and prompt assessment and treatment of UTIs, particularly febrile UTI ✓ Most appropriate for children with grades I and II VUR, and perhaps older children with persistent VUR and normal kidneys who have not experienced clinical pyelonephritis. Antimicrobial prophylaxis Risk of recurrent UTI is highest in patients with grade III or IV reflux, those with BBD, and those whose first reflux- associated UTI was febrile rather than just symptomatic without fever Antibiotic prophylaxis after a reflux-associated UTI decreases the risk of recurrent UTI but may increase the risk of developing resistant bacteria. Surgery Minimize the risk of febrile UTI from ongoing VUR and nonsurgical therapy Modifying the abnormal uterovesical attachment If the refluxing kidney is poorly functioning, nephrectomy or nephroureterectomy is indicated. Conventional open ureteral reimplantation: success rate in primary VUR is >95-98% for grades I-IV, with 2% experiencing persistent VUR and 1% having ureteral obstruction that requires correction. ✓ Grade V VUR: success rate is approximately 80% Subureteral injection: a noninvasive outpatient procedure (performed under general anesthesia) with no recovery time. ✓ Success rate is 70-80% and is highest for lower grades DIAGNOSIS of VUR. OBSTRUCTION OF THE URINARY TRACT CLINICAL MANIFESTATIONS Hydronephrosis ✓ Generally caused by obstruction of the urinary tract Unilateral mass or upper abdominal / flank pain ✓ Obstructed kidney secondary to UPJ obstruction or ureterovesical junction obstruction Pyelonephritis ✓ Occurs due to urinary stasis Upper urinary tract stone ✓ Abdominal and flank pain ✓ Hematuria Bladder Outlet Obstruction PHYSICAL FINDINGS ✓ Weak urinary stream Urinary Tract Obstruction – often silent ✓ UTI Hydronephrotic or Multicystic Dysplastic Kidney Obstructive Renal Insufficiency ✓ Most common palpable abdominal mass in newborn infant ✓ Failure to thrive Posterior Urethral Valves (PUV) ✓ Vomiting ✓ Infravesical obstructive lesion in boys ✓ Diarrhea ✓ Walnut-sized mass – representing the bladder Infravesical Obstruction ✓ Palpable just above the symphysis pubis ✓ Overflow urinary incontinence ✓ It may cause urinary ascites in the newborn due to renal ✓ Poor urine stream or bladder urinary extravasation TRANS 7 | Abad, Balmores, Cabauatan, Clarete, de Leon, Duruin, Lim, Maramag, Tumamao, Urbano Page 4 of 9  Infection and Sepsis ✓ This provides excellent images of the upper urinary tract ✓ First indications of an obstructive lesion of the urinary tract SPECIFIC TYPES OF URINARY TRACT OBSTRUCTION IMAGING STUDIES URETEROPELVIC JUNCTION (UTJ) OBSTRUCTION Renal Ultrasound It is the most common obstructive lesion in childhood – usually Hydronephrosis – most common characteristic of obstruction caused by intrinsic stenosis It is used to assess the following: 60% of cases occurs on left side ✓ Renal length 10% occurs as bilateral obstruction ✓ Degree of caliectasis and parenchymal thickness Ultrasound shows Grade 3 or Grade 4 Hydronephrosis without ✓ Presence or absence of ureteral dilation dilated ureter Hydronephrosis is graded according to its severity using the Clinical Manifestation/s: Society for Fetal Urology (SFU) Grading System ✓ Palpable renal mass in a newborn or infant ✓ Abdominal, flank, or back pain ✓ Febrile UTI ✓ Hematuria after minimal trauma Treatment: Pyeloplasty – using laparoscopic techniques – often robotic-assisted using the da Vinci robot MIDURETERAL OBSTRUCTION Rare occurrence of congenital ureteral stenosis or ureteral valve in the midureter Treatment: Excision of the strictured segment and reanastomosis of the normal upper and lower ureteral segments Retrocaval Ureter ✓ Upper right ureter travels posterior to the inferior vena cava Voiding Cystourethrogram ✓ Retrograde pyelogram or MR urogram - shows right Neonates and infants with congenital grade 3 or 4 ureter to be medially deviated at the level of the 3rd lumbar hydronephrosis vertebra Any child with ureteral dilation ✓ Treatment: Transection of the upper ureter, moving it Also is performed to rule out urethral obstruction, particularly in anterior to the vena cava, and reanastomosing the upper cases of suspected PUVs and lower segments Acquired Midureteral Obstruction Radioisotope Studies ✓ Retroperitoneal tumors, fibrosis caused by surgical Renal Scintigraphy – is used to assess renal anatomy and procedures, inflammatory processes and radiation therapy function Mercaptoacetyl Triglycine (MAG-3) – is used to assess ECTOPIC URETER differential renal function A ureter that drains outside the bladder Technetium-99-labeled dimercaptosuccinic acid (DMSA) – 3x as common in females than males it is a renal cortical imaging agent The ureter typically drains the upper pole of a duplex collecting ✓ It is used to assess differential renal function system (two ureters) ✓ It is used to demonstrate whether renal scarring is present Females: ✓ 35% of these ureters enter the urethra at the bladder neck Magnetic Resonance Imaging ✓ 35% enter the urethrovaginal septum Is used to evaluate suspected upper urinary tract pathology ✓ 25% enter the vagina, and a few drains into the cervix, It is primarily used when renal ultrasound and radionuclide uterus, Gartner duct, or a urethral diverticulum imaging fails to delineate complex pathology ✓ Often the terminal aspect of the ureter is narrowed, causing hydroureteronephrosis Computed Tomography ✓ With the exception of the ectopic ureter entering the bladder neck, it causes continuous urinary incontinence It is a standard method of demonstrating whether a calculus is from the affected renal moiety present – its location, and whether there is significant proximal Males: hydronephrosis ✓ 47% enter the posterior urethra (above the external It may be ordered when a renal/bladder US is inconclusive sphincter) Disadvantage: significant radiation exposure – it should be ✓ 10% - prostatic utricle used only when the results will direct management decisions ✓ 33% - seminal vesicle in ✓ 5% - ejaculatory duct in 5% Ancillary Studies ✓ 5% - vas deferens Antegrade Pyelogram ✓ It does not cause incontinence ✓ This method involves insertion of a percutaneous ✓ Most patients present with a UTI or epididymitis nephrostomy tube and injection of contrast agent Diagnosis: Renal Ultrasound, VCUG, Renal Scan may ✓ It is performed to assess the anatomy of the upper urinary demonstrate whether the affected segment has significant tract function ✓ This procedure usually requires general anesthesia Treatment: It depends on the status of the renal unit drained Antegrade pressure-perfusion flow study (Whitaker test) by the ectopic ureter ✓ This procedure is done by infusion of fluid at a measured ✓ If there is satisfactory function, ureteral reimplantation into rate – usually 10 mL/min the bladder ✓ The pressures in the renal pelvis and the bladder are ✓ or ureteroureterostomy is indicated monitored during infusion ✓ If function is poor, partial or total nephrectomy is indicated ✓ Pressure differences of >20 cm H2O suggest obstruction ▪ Can be done laparoscopically and often with robotic Cystoscopy with Retrograde Pyelography assistance using the da Vinci robot TRANS 7 | Abad, Balmores, Cabauatan, Clarete, de Leon, Duruin, Lim, Maramag, Tumamao, Urbano Page 5 of 9  POSTERIOR URETHRAL VALVES ✓ Serum creatinine level >10.0 mg/d after bladder Most common cause of severe obstructive uropathy in children decompression Approximately 30% of patients experience end-stage renal ✓ Identification of cortical systs in both kidneys disease or chronic renal insufficiency ✓ Persistence of diurnal incontinence beyond 5yrs of age Vesicoureteral reflux occurs in 50% of patients PUVs diagnosed prenatally, particularly when discovered in the EPISPADIAS second trimester – carry a poorer prognosis Prepuce is distributed primarily on the ventral aspect of the Treatment: penile shaft ✓ Transurethral ablation of the valve leaflets – serum Urethral meatus is on the dorsum of the penis creatinine level remains normal Distal epispadias in males usually is associated with normal ✓ Temporary vesicostomy – if the urethra is too small for urinary control and normal upper urinary tracts transurethral ablation ✓ It should be repaired by 6-12 months of age Females – the clitoris is bifid, and the urethra is split dorsally ANOMALIES OF THE BLADDER TREATMENT BLADDER EXSTROPHY It occurs in ~1 in 35,000-40,000 births Surgical reconstruction of the bladder neck, similar to the final Its severity ranges from simple epispadias (in males) to management stage in children with classic bladder exstrophy complete exstrophy of cloaca which involves the entire hindgut and the bladder. NEUROPATHIC BLADDER CLINICAL MANIFESTATION Bladder protrudes from the abdominal wall with exposure of its mucosa Umbilicus is displaced downward Pubic rami are widely separated in the midline Rectus muscles are separated Persons with exstrophy tend to be shorter Consequences of untreated bladder exstrophy ✓ Total urinary incontinence and an increased incidence of bladder cancer – adenocarcinoma External and internal genital deformities cause sexual disability in both sexes, particularly in males CLINICAL MANIFESTATIONS Broad-based gait but no significant disability Most important urologic consequences: In males: ✓ Urinary incontinence ✓ There is complete epispadias with dorsal chordee ✓ Urinary tract infections ✓ Overall penile length is approximately half that of ✓ Hydronephrosis from vesicoureteral reflux or detrusor- unaffected males sphincter dyssynergia ✓ Scrotum typically is separated slightly from the penis and is wide and shallow DIAGNOSIS ✓ Undescended testes and inguinal hernias are common Renal Ultrasound In females: Assessment of post-voiding residual urine volumes ✓ Separation of the two halves of the clitoris and wide Voiding cystourethrogram separation of the labia Urodynamic study ✓ Anus is displaced anteriorly in both sexes and there may be rectal prolapse Renal Damage ✓ Pubic rami are widely separated Results from detrusor - sphincter dyssynergia TREATMENT It causes the following: ✓ Functional obstruction of the bladder outlet leading to Bladder should be covered with plastic wrap to keep the bladder muscle hypertrophy and trabeculation bladder mucosa moist ✓ High intravesical pressure ✓ Application of gauze or petroleum-gauze to the bladder ✓ Transmission of this high pressure into the upper urinary mucosa should be avoided, because it will result to tracts – causing hydronephrosis significant inflammation Staged reconstruction and total single-stage reconstruction TREATMENT Bilateral iliac osteotomy - allows the pubic symphysis to be approximated, which supports the bladder closure Reduction of bladder pressure with anticholinergic drugs and Staged reconstruction clean intermittent catheterization every 3-4 hours ✓ Initial stage is bladder closure, the second stage (in males) Vesicoureteral reflux or UTI - antimicrobial prophylaxis is epispadias repair, and the final stage is bladder neck Cutaneous vesicostomy reconstruction Transurethral injection of botulinum toxin Augmentation enterocystoplasty PROGNOSIS URINARY INCONTINENCE Favorable prognostic factors: It can result from total or partial denervation of the sphincter, ✓ Normal prenatal US between 18 and 24 wk of gestation bladder hyperreflexia, poor bladder compliance, chronic urinary ✓ Serum creatinine level age + 2 (in years)] x 30 2-4 years old: ready to begin toilet training Transitional phase of voiding DIAGNOSIS ✓ It is the period when child acquire bladder control Voiding Cystourethrography - dilated urethra (spinning top ✓ Girls acquire this first than boys deformity and narrowed bladder neck with bladder wall ✓ Bowel control is achieved first before bladder control hypertrophy Bladder–bowel dysfunction (dysfunctional elimination ✓ Urethral finding results from inadequate relaxation of the syndrome) – it is a disorder of bladder and/or bowel function external urinary sphincters DIURNAL INCONTINENCE TREATMENT ETIOLOGY AND EPIDEMIOLOGY Timed voiding every 1.5-2 hours – initial therapy 5 years old – 95% have been dry during time and 92% are dry Importance of treating constipation and UTI consistently Biofeedback – children were taught pelvic floor exercises 7 years old – 96% are dry, although 15% have significant (Kegel exercises) urgency at times ✓ Daily performance can reduce or eliminate unstable 12 years old – 99% are dry consistently during the day bladder contractions Most common causes of daytime incontinence: ✓ Consists of 8-10 1-hour sessions ✓ Overactive bladder (urge incontinence) ✓ Includes participation with animated computer games ✓ Bladder-bowel dysfunction Anticholinergic therapy – often is helpful if bowel function is normal Oxybutynin chloride – only FDA-approved medication in children which reduce bladder overactivity and may help the child achieve dryness α-adrenergic blocker such as Terazosin or Doxazosin – aids in bladder emptying by promoting bladder neck relaxation Sacral nerve stimulation (InterStim), Percutaneous tibial nerve stimulation, and Intravesical botulinum toxin injection – for refractory cases Polyethylene Glycol powder – generally effective in treating constipation VAGINAL VOIDING It typically occurs after urination after the female stands Volume of urine is 5-10mL Labial Adhesion – most common cause DIAGNOSIS TREATMENT Urinalysis with culture – if indicated Topical application of estrogen cream to the adhesion Bladder diary Encouraging the girl to separate the legs as widely as possible Postvoid residual urine volume- obtained by bladder scan during urination Dysfunctional voiding symptom score ✓ Have the child sit backward on the toilet seat during ✓ Females: ≥ 6 micturition ✓ Males ≥9 ▪ They are most likely to have dysfunctional voiding TRANS 7 | Abad, Balmores, Cabauatan, Clarete, de Leon, Duruin, Lim, Maramag, Tumamao, Urbano Page 7 of 9  NOCTURNAL ENURESIS CLINICAL MANIFESTATIONS Occurrence of involuntary voiding at night after 5 yr, the age Classified according to the position of the urethral meatus after when volitional control of micturition is expected taking into account whether chordee is present At age of 5 years old: 10% of males- have an undescended testis; an inguinal hernia ✓ 90-95% of children are nearly completely continent during Proximal hypospadias the day ✓ Voiding cystourethrogram should be considered because ✓ 80-85% are continent al night 5- 10% of these children have a dilated prostatic utricle, Primary Nocturnal Enuresis which is a remnant of the mullerian system ✓ estimated 75-90% of children with enuresis Complications of untreated hypospadias: ✓ nocturnal urinary control never achieved ✓ Deformity of the urinary stream, typically ventral deflection Secondary Nocturnal Enuresis or severe splaying ✓ 10-25% ✓ Sexual dysfunction secondary to penile curvature ✓ child was dry at night for at least a few months and then enuresis developed DISORDERS AND ANOMALIES OF THE SCROTAL CONTENTS 75% of children with enuresis are wet only at night UNDESCENDED TESTIS (CRYPTORCHIDISM) 25% are incontinent day and night Most common disorder of sexual differentiation in males Testicular descent occurs at 7-8 mo of gestation, 30% of ETIOLOGY AND EPIDEMIOLOGY premature male infants have an undescended testis 60% of children with nocturnal enuresis are males Congenital undescended testes descend spontaneously during Family history is positive in 50% of cases the first 3 mo of life Polygenetic, candidate genes have been localized to By 6 mo the incidence decreases to 1.5% chromosomes 12 and 13 If the testis has not descended by 4 mo, it will remain If 1 parent is enuretic – 44% risk undescended If both parents are enuretic – 77% risk CLINICAL MANIFESTATIONS: Abdominal - which are nonpalpable CLINICAL MANIFESTATIONS Peeping - abdominal but can be pushed into the upper part of Snoring the inguinal canal Sleepwalk or talk in their sleep Inguinal, gliding - can be pushed into the scrotum but retracts Palpation of the abdomen immediately to the pubic tubercle Rectal examination Ectopic - superficial inguinal pouch or, rarely, perineal Consequences: Poor testicular growth, infertility, testicular DIAGNOSIS malignancy, associated hernia, torsion of the cryptorchid testis, Ultrasound and the possible psychological effects of an empty scrotum Urinalysis At puberty, an undescended testis has no viable sperm ✓ Check for the following: components ▪ Glucosuria Treatment for a unilateral undescended testis- 85% of patients ▪ Specific Gravity are fertile ▪ Osmolality (overnight fast to exclude polyuria as a Risk of a germ cell malignancy - four times higher cause) Most common tumor- seminoma (65%) After orchiopexy- nonseminomatous tumors represent (65%) TREATMENT Indirect inguinal hernia usually accompanies a congenital Reassure the child and parents that the condition is self-limited undescended testis but rarely is symptomatic Avoid punitive measures that can affect the child's psychological development adversely DIAGNOSIS Active treatment should be avoided in children younger than 6 Examine the patient’s scrotum and inguinal canal using their years of age dominant hand Fluid intake should be restricted to 2 oz after 6 or 7 PM Nondominant hand is positioned over the pubic tubercle and is ✓ Ask the patient to void, before sleeping pushed inferiorly toward scrotum Motivational therapy Soap test: soap is applied to the inguinal canal and the ✓ Star chart for dry night examiner’s hand, significantly reducing friction and facilitating Conditioning therapy identification of an inguinal testis ✓ Use of a loud auditory or vibratory alarm attached to a Contralateral testicular hypertrophy- sign that testis is absent moisture sensor in the underwear Inguinal/scrotal sonography ✓ Alarm sounds when voiding occurs and is intended to CT scan, MRI awaken children and alert them to void Desmopressin acetate TREATMENT Oxybutynin, tolterodine Congenital undescended testis should be treated surgically by Imipramine – TCA, many SE 9-15 mo of age orchiopexy, which involves an inguinal incision ANOMALIES OF THE PENIS AND URETHRA abnormal testes are managed with laparoscopic techniques HYPOSPADIAS saline testicular implant ETIOLOGY AND EPIDEMIOLOGY solid silicone carving block implants Urethral opening on the ventral surface of the penile shaft Incidence is increased in many males with chromosomal VARICOCELE abnormalities, anorectal malformation, and congenital heart Most common surgically correctable cause of infertility in disease males Incomplete development of the prepuce, called a dorsal hood, Congenital condition in which there is abnormal dilation of the in which the foreskin is on the sides and dorsal aspect of the pampiniform plexus in the scrotum penile shaft and deficient or absent ventrally Described as a bag of worms TRANS 7 | Abad, Balmores, Cabauatan, Clarete, de Leon, Duruin, Lim, Maramag, Tumamao, Urbano Page 8 of 9  Dilation of the pampiniform venous plexus results from valvular Pain is intermittent, corresponding to periods of obstruction of incompetence of the internal spermatic vein urine flow, which increases the pressure in the collecting Occur predominantly on the left side system Varicocele in a male younger than age 10 yr or on the right side If the calculus is in the distal ureter, the child can have might indicate an abdominal or retroperitoneal mass- irritative symptoms of dysuria, urgency, and frequency abdominal sonogram, CT scan DIAGNOSIS CLINICAL MANIFESTATIONS Radiopaque on a plain abdominal film- 90% of urinary calculi: Painless paratesticular mass Struvite stones (magnesium ammonium phosphate) Dull ache in the affected testis Radiolucent but often are slightly opacified: Cystine, xanthine, Grade 1 - palpable only with Valsalva (clinically insignificant) and uric acid calculi Grade 2 - palpable without Valsalva but is not visible on Unenhanced spiral CT scan of the abdomen and pelvis inspection ✓ Most accurate study Grade 3 - visible with inspection ✓ 96% sensitivity and specificity in delineating the number and location of calculi DIAGNOSIS ✓ Demonstrates whether involved kidney is hydronephrotic Varicocelectomy - maximize future fertility ✓ Renal ultrasonography: Demonstrate hydronephrosis and Indications: possibly the calculus ✓ Males with a significant disparity in testicular size, with pain in the affected testis GYNECOLOGIC PROBLEMS OF CHILDHOOD ✓ Contralateral testis is diseased or absent VULVOVAGINITIS ✓ With oligospermia on semen analysis Most common gynecologic-based problem for prepubertal ✓ Considered in males with a large grade 3 varicocele, even children if there is no disparity in testicular size Most typically caused by either inadequate or excessive hygiene or chemical irritants HYDROCELE Peaks at 4 and 8 yr of age ETIOLOGY AND EPIDEMIOLOGY Usually improved by hygiene measures and education of the Accumulation of fluid in the tunica vaginalis caregivers and child Most cases- noncommunicating (the processus vaginalis was obliterated during development) ETIOLOGY AND EPIDEMIOLOGY Such cases, the hydrocele fluid disappears by 1 yr of age Vulvitis - external genital pruritus, burning, redness, or rash Persistently patent processus vaginalis, the hydrocele persists Vaginitis - implies inflammation of the vagina, which can and may become larger during the day and is small in the manifest as a discharge with or without an odor or bleeding morning May occur simultaneously as vulvovaginitis Abdominoscrotal hydrocele History: questions on hygiene (wiping from front to back) and ✓ There is a large, tense hydrocele that extends into the information about possible exposure to chemical irritants (bath lower abdominal cavity soaps, bubble bath, laundry detergents, swimming pools, or hot tubs): detailed history of recent diarrhea, perianal itching, or DIAGNOSIS nighttime itching is important Smooth and nontender Possibility of foreign objects being placed into the vagina Transillumination - confirms the fluid-filled nature of the mass 75% of cases of vulvovaginitis in children are nonspecific Scrotal ultrasound Infectious vulvovaginitis: Most commonly associated with fecal or respiratory pathogens TREATMENT Transmitted by the child via - Improper toilet hygiene and Most congenital hydroceles resolve by 12 mo of age manually from the nasopharynx to the vagina Large and tense: Early surgical correction should be Present with perianal redness, introital inflammation, and often considered, because it is difficult to verify that the child does a yellow-green or mildly bloody discharge not have hernia, and large hydroceles rarely disappear Observed to be grabbing their genital area or digging in their spontaneously underwear, which is usually stained with yellow-brown Hydrocele persisting beyond 12-18 mo often are discharge communicating and should be repaired: Surgical correction is Gonorrhea, syphilis, and chlamydia - If acquired after the similar to a herniorrhaphy neonatal period are virtually 100% indicative of sexual contact so report URINARY LITHIASIS Human papillomavirus infection and HSV - association with sexual contact is not as clear (hand to mouth transmission) STONE FORMATION Candida infections: Commonly cause diaper rash, but they ✓ 90% of urinary stones - contain Calcium as a major are unlikely to cause vaginitis in children because the alkaline constituent, pH of the prepubertal vagina does not support fungal infections ✓ 60% - composed of calcium oxalate Pinworms: Most common helminthic infestation with the ✓ Uric acid, cystine, ammonium crystals, or phosphate highest rates in school-age and preschool children crystals, or a combination of these substances Perianal itching can lead to excoriation and, rarely, bleeding CLINICAL MANIFESTATIONS: REFERENCE/S Gross or microscopic hematuria Dr. Somera’s PowerPoint Presentation Severe flank pain (renal colic or abdominal pain occurs: Nelson Textbook of Pediatrics. 21st Edition Calculus causes ureteral or renal pelvic obstruction Calculus typically causes obstruction at areas of narrowing of urinary tract: the ureterpelvic junction, where the ureter crosses the iliac vessels, and the ureterovesical junction Pain typically radiates anteriorly to the scrotum or labia TRANS 7 | Abad, Balmores, Cabauatan, Clarete, de Leon, Duruin, Lim, Maramag, Tumamao, Urbano Page 9 of 9