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Pediatric Urology
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Introduction
Pediatric urology is the diagnosis and
treatment of congenital and acquired
urological conditions and diseases in
children.
Pediatric urologists treat conditions of the
male reproductive tract and the male and
female urinary tracts.
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Embryology
Most of the genitourinary tract is derived from
mesoderm.
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The mesonephric (Wolffian) ducts develop
laterally, and advance downwards to fuse
with the primitive cloaca (hindgut).
At week 5, a ureteric bud grows from the
distal part of the mesonephric ducts and
induces formation of the metanephros in the
overlying mesoderm . caudal growth .. Abdominal organ .
Urine production starts at week 10.
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Thus, in both males and females, the
mesonephric duct forms the ureters and renal
collecting system.
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Content
Cryptorchidism
Vesicoureteral reflux
Ureteral anomalies Bladder anomalies
Penile and urethral anomalies
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Cryptorchidism
Definition:
Cryptorchidism literally means hidden or
obscure testis and generally refers to an
undescended or maldescended testis.
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Undescended testes
It is the most common abnormality of male sexualdevelopment. In this condition, the testis is not located inthe scrotum.
The testis can be ectopic, incompletely descended,
retractile, and absent oratrophic . A palpable undescended testis is found in 3%-5% of
newborns
3030% in premature male neonates.% in premature male neonates.
only 0.7%-1% of 1-year-old infants have a persistentundescended testis.
Spontaneous descent after the first year of life isSpontaneous descent after the first year of life isuncommonuncommon
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The maldescented testes may be arrested at any
point on its path of descent from the posterior
abdominal wall to the scrotum;
Abdominal
Inguinal canal
At theexternal ring
Upper part of the scrotum
Perineal
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Failure of testicular descent is likely to be caused by
either
1. A disturbance of the hormonal environment
(LHRH -> LH-> testicular hormone axis)
incompletely descended testis2. Mechanical factors obstructing the progress of
testicular migration. ectopic testis.
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Complications
1. Testicular malignancy: the risk is increased40 times more. Surgical correction doesnt
reduce the risk, however it is more likely to be
discovered early if the testis is in the scrotum2. Subfertility: unless corrected, all bilaterally
cryptorchid adult males become sterile.
3. Traumatic injury4. Torsion
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Predisposing factors:
1. Prematurity
2. Low birth weight,3. Small size for gestational age
4. Twinning
5. Maternal exposure to estrogen during the firsttrimester.
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Clinical features
The condition is unilateral in the right in 50% and
on the left in 30%. Arrested descent of both testes
occur in 20%.
secondary sexual characteristics are normal but
other abnormalities of the genitourinary tract may
be present including: hypospadias, patent
processus vaginalis
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Treatment
Hormonal vs. Surgical
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Hormonal
HCG or LH-releasing hormones are mainlyused.
HCG and LHRH have been used incombination, with initial success rates of 14-
65%.
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Surgical : Orchidopexy
Orchidopexy is the surgical correction of thecondition that is best performed by the age of2
years
Principles of the operative procedure consist of :
mobilizing the spermatic cord,
placing the testes in a subcutaneous serotal pouch
outside the dartos muscle.
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Retractile testis
Here the testes dont appear to be fully descended,and can be palpated in the scrotal neck and gently
manipulated into its correct position.
It is due to an overactive cremasteric muscle in
children under 3 years of age and the small testes.
It is a variant of normal
It requires no treatmentprovided that the testesbecome less retractile as the boy grows.
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2. Vesicoureteric Reflux
It is the retrograde flow of urine from the bladder into the ureter,
Primary reflux is VUR in an otherwise normally functioning lowerurinary tract (anomalies as ectopic U, double U,congenital megaU,ureterocele
secondary reflux is VUR that is associated with or caused by anobstructed or poorly functioning lower urinary tract. (neuropathicdys, bladder outlet obs, Iatrogenic etc )
In both conditions, the ureterovesical junction fails to function as aone-way valve, giving lower urinary tract bacteria access to the
normally sterile upper tracts. ratio of tunnel length to ureteral diameter must be at least 5:1
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Aims of treatment:
1. prevention of episodes of acute pyelonephritis2. to prevent the scarring of the kidney associated
with VUR (reflux nephropathy), which
increases the risk of HTN and renal failure.
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Clinical presentation:
1. Hydronephrosis, often prenatally identified using U/S.
2. Urinary tract infection (UTI),Children often present with
nonspecific signs and symptoms.- failure to thrive, with or without fever
- vomiting and diarrhea
- Anorexia
- lethargy.
Older children may report voiding symptoms orabdominal pain.
Pyelonephritis ; vague abdominal discomfort, fever and chills.
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Work up:
Laboratory studies
Urine analysis and urine cultures
serum chemistries to assess for baseline renal
function.
Imaging Studies
renal and bladder ultrasonography
voiding cystourethrography (VCUG).
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The International Classification System for vesicoureteral reflux
Grade I - Reflux into nondilated lower ureter
Grade II - Reflux into renal pelvis and calyces without
dilation
Grade III - Reflux with mild-to-moderate dilation and
minimal blunting of fornices
Grade IV - Reflux with moderate ureteral tortuosity and
dilation of pelvis and calyces
Grade V - Reflux with gross dilation of ureter, pelvis, and
calyces, loss of papillary impressions, and ureteral tortuosity
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A voiding
cystourethrogr
am (VCUG) of apatient with
grade III
vesicoureteral
reflux
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grade Vvesicoureteral
reflux (VUR)
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Management
When there is no ureteral dilation, there is an 85%chance of spontaneous resolution as the childgrows. In the meantime, the urinary tract must bekept free of infection, and this is done by:
Regular voiding High fluid intake
Avoiding constipation
Maintaining perineal hygiene
Anti-bacterial chemotherapy
Regular follow up, with charting of growth anddevelopment.
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In obstructive 2 reflux (as post. Urethral valve), release
of obstruction may cure reflux.In neuropathic reflux, intermittent catheterization for
control of infection may allow return of valvularcompetence.
Surgical correction, it is done by re-implanting theureter in the bladder wall so that a length of it lies deepto the bladder mucosa. This is indicated for:
Severe reflux with dilated ureters For other anatomical abnormalities
For children who fail to progress on conservativemanagement.
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3. Ureteral anomalies
Ureteral duplication is the most common renal
abnormality, occurring in approximately 1% of
the population and 10% of children who are
diagnosed with UTIs
Other abnormalities include, ectopic ureteral
orifice, ureterocele, and congenital obstructionof the ureter.
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A ureterocele is a cystic dilatation of the terminal
intravesical ureter.
Intravesical ureteroceles: entirely contained within
the bladder.
Ectopic uretrocele: if any portion is permanently
situated at the bladder neck or the urethra, regardless
of the position of the orifice.
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4. Bladder Anomalies
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Bladder agenesis is rare and incompatible with
life
Associated with hydroureteronephrosis and renal
dysplasia are present.
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Bladder duplication is rare.
Duplication can be completeorpartial, with
complete duplication more common than
incomplete duplication.
The 2 halves of the bladder are on either side of the
midline, with the corresponding ipsilateral ureter
draining each bladder half
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Urachal anomalies
A urachal cyst is a fluid-filled structure occurring in between
the two obliterated ends of the urachus, ie, the umbilicus and
bladder dome.
A urachal sinus : a persistently patent urachus. The sinus
drains to the umbilicus.
A patent urachus is a communication from the umbilicus to
the bladder. Infants present with continuous or intermittentdrainage from the umbilicus. The tract may become
inflamed, resulting in tenderness, periumbilical swelling, and
serosanguineous or purulent discharge.
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Extrophy ofthe bladder
It results from a complete ventral defect of the UG sinus
and the overlying inferior abdominal wall
musculature.
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Presentation:
- The lower central portion is devoid of skin and muscles.
- The anterior bladder wall is absent, the posterior wall iscontiguous with the surrounding skin.
- The rami of the pubic bone are widely separated, and
the open pelvic ring may affect gait.
- Urine drains onto the abdominal wall
- In males, the penis is shortened, and the urethra is
epispadiac
- The exposed bladder mucosa tends to be chronicallyinflamed.
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Treatment:
- Closure of the bladder in the newborn period
- Urethral closure and penile reconstruction
- Ureteral reimplantantion
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5. Penile and urethral anomalies
Hypospadias
Epispadias
Uretheral strictures Posterior uretheral valves
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Hypospadias
Results from failure of fusion of the uretheral folds on theundersurface of the genital tubercle.
Incidence is 1 in 400 male births
Hypospadias is classified according to the position of themeatus into:
1. Glandular hypospadias
2. Coronal.
3. Penile and penoscrotal.
4. Perineal. It's the most severe abnormality; the scrotum issplit and the urethra opens between it's two halves
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The remnant of urethraltissue distal to the meatus
is fibrotic, causing the
penis to bend downwards-
chordee. The more
proximal is the uretheral
meatus, the worse is the
chordee.
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The ventral part of theforeskin is absent giving
rise to a hooded
appearance.
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Treatment
Create a straight penis by repairing any chordee Create a urethra with its meatus at the tip of the
penis (urethroplasty)
Reform the glans into a more natural conical
configuration (glansplasty)
Achieve cosmetically acceptable penile skin
coverage
Create a normal-appearing scrotum.
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Timing of surgery:
child is aged 4-18 months, trending toward earlierintervention.
Late hypospadias repair in the pubertal and
postpubertal period is associated with
complications, primarily urethro cutaneousfistula, in nearly half of patients.
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Epispadias
The urethra opens on the dorsum of the penis,
with deficient corpus spongiosum and loosely
attached corpora cavernosa
The pubic bones are separated
Marked dorsiflexion of the penis
Associated with bladder extrophy, and if present
alone is considered as a mild degree of theextrophy complex.
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Treatment
Correction of penilecurvature
Reconstruction of the
urethra and bladderneck.
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Urethral Strictures
Most common in the fossa navicularis & in
bulbomembranous urethra
They are thin diaphragms that respond to simple
dilation or direct vision internal uretherotomy,
and rarely open surgery is required
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Posterior Urethral Valves
The most common obstructive urethral lesions in
newborn and infant males.
The most common cause of ESRF in boys
PUV are obstructive mucosal folds, seen only in males,which originate at the veru muntanum at the prostatic
urethra.
Clincal manifestations: difficult voiding, weak stream,
lower abdominal mass, palpable kidneys, incontinence,and UTI.
Up to 70% have VUR
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Lab findings
BUN and creatinine
Evidence of UTI
U/S shows evidence of bladder thickening and
trabeculation, hydroureter, and hydronephrosis.
Voiding CUG demonstrating the urethral valves
establishes the diagnosis.
Treatment
Endoscopic destruction of the valves as soon aspossible.