UROLOGY FOR THE

PEDIATRICIAN
David T. Bolong, MD
Clinical Presentation of Urological
Diseases
I. Urinary tract infection
II. Voiding Dysfunctions
III. Antenatal/ Postnatal hydronephrosis
IV. Abdominal masses
V. Painful scrotum
VI. Empty scrotum
VII. Anomalies of the external genitaliaConcomitant
findings with Anorectal Malformations
URINARY TRACT
INFECTION
 DEFINED
Any number of colonies
obtained by suprapubic bladder
tap
 Why early evaluation is necessary for all
infants and young children (<age 5)
Recurrence in 30-40%
High incidence of VUR-35%
Clinical parameters unreliable in detecting
those with VUR
Infants at highest risk of pyelonephritis and
renal scarring
Higher incidence of scarring with RUTI
 BASIC TREATMENT TENET:
MUST BE A PROVEN
URINARY TRACT INFECTION!
 Proper collection of urine is the
cornerstone of treatment.
Infants below one year of age, a
suprapubic tap is recommended.
A catheterized urine is a good alternative
to obtain urine specimen.
A midstream collection is acceptable for
cooperative children.
 Proving UTI by urinalysis:
Gram staining an uncentrifuged urine has
a sensitivity of 93% and a false + of 5%.
Urine dipstick has a sensitivity of 88% in
the presence of leucocyte esterase or
nitrite and a false + rate of 4%.
Pyuria alone has low true positive rate and
high false positive rate. For >5/hpf:TPR.67/FPR,21;
for >10: TPR .77/FPR.11
 RISK FACTORS FOR UTI
FEMALE
BELOW 5 YEARS OF AGE
VUR
VOIDING DYSFUNCTION
CONSTIPATION
OBSTRUCTION
RISK FACTORS FOR UTI
Toilet training
Sexual activity
Pregnancy
 Associated problems seen with
UTI: Pediatric Urology Database
4201 cases (1995-present)
1. Anatomic anomalies19%
2. Vesicoureteral reflux34%
3. Voiding Dysfunction 40%
4. Idiopathic. 25%
 Evaluation of children with UTI
History: emphasis of number of UTIs- febrile
or afebrile
presence of voiding disorders such
as daytime/nighttime wetting, urgency,
incontinence, dysuria
constipation
siblings with UTI
 Evaluation of children with UTI
History/ ROS:
passed surgeries especially at the
anorectal area
neurologic problems
Physical Examination
 Vulvar synechiae
(Before and after treatment)
Treatment: topical estrogen
Examination of the back
Dimple at the
lumbosacral area w/
recurrent UTI
neurogenic bladder
(verify by US that
shows thickened
bladder)
 WORK-UP
KUB ULTRASOUND (to 1st rule out congenital
anomalies)
VOIDING CYSTOURETHROGRAPHY
(VCUG)
RENAL SCAN
 WORK-UP
UTZ AND VCUG
1. FOR ALL CHILDREN< 5 YRS OF
AGE WITH FIRST UTI.
2. SCHOOL-AGE GIRLS WITH FIRST
FEBRILE UTI.
3. SCHOOL-AGE AND ADOLESCENT
BOYS WITH FIRST FEBRILE UTI
FEBRILE UTI
 WORK-UP
UTZ ONLY ( VCUG OR RENAL SCAN IF
SONOGRAM IS ABNORMAL):
1. SCHOOL AGE BOYS WITH FIRST
AFEBRILE UTI.
2. SCHOOL-AGE GIRLS WITH RECURRENT
CYSTITIS.
3. ADOLESCENT GIRLS WITH FIRST
FEBRILE UTI.
PRIMARY VESICOURETERAL
REFLUX
 MEDICAL MANAGEMENT OF
VUR
Daily antibiotic prophylaxis (does not affect children
even as long as 5 years, so its ok to give antibiotics long term
provided its low dose)

Regular volitional voiding

In children with unstable bladder:
anticholinergics+ timed voiding+ pelvic
floor exercises
 MEDICAL MANAGEMENT OF
VUR
Manage constipation
Periodic urinalysis-suspect-culture/treat
VUR follow-up and upper tract
assessment
Principle of medical management
of patients with VUR
40-60% recurrence of UTI in 18 months
If with scarring, likely to get worse with
every UTI
Most mild to moderate VUR resolve
spontaneously
 Pelvic floor Exercise program
Patients with VUR.. 30
Indication: UTI, overactive bladder,
bladder-sphincter discoordination
18 patients had a minimum 1 year follow-
up: 8 patients cured (44%), 6 patients
partial response (33%), 4 patients no
response (22%)
 Pelvic Floor Exercises
Without VUR- 13
Indications: overactive bladder in 16,
Bladder sphincter discoordination in 4,
bedwetting in 2
10 had a one year minimum follow-up
Response: 7 had good response (70%),
3 partial response (30%)
 Voiding dysfunction
( on those children with UTI)
1. Lazy bladder Syndrome86 (14.3%)
2. OveractiveBladder.174(28.9%)
B-S discoordination.. 341 (56.7%)
 Constipation:
a cause of bladder dysfunction
and UTI
( 34% incidence: Neumann 1973)
Rectum is distended, bladder does not contract well
and the rectum and bladder has the same embryonic
origin
Rome II definition of Constipation:
Two or more of the following symptoms present for a total
of at least 12 weeks in the preceeding year:
1. Straining in more than 25% of defecations
2. Lumpy or hard stools in more than 25% of defecations
3. Sensation of incomplete evacuation in more than 25%
of defecations
4. Sensation of anorectal obstruction in more than 25% of
defecations
5. Use of manual maneuvers to facilitate more 25% of
defecations
6. Fewer than 3 defecations per week.
 Constipation:
1) Increased post void residual.
2) Pressure of stool on the bladder
causes:
reduced functional capacity
stimulation of stretch receptors
triggers overactivity
Hinman 1973, ORegan 1986, Brading
1994, Fernandez 1991
 Constipation:
3.) Functional Discoordination of the anal
sphincter (and also the external urethral
sphincter)
Amongst constipated patients,53%
contracted instead of relaxed the ext.
anal sphincter and PF during defecation
attempts.
Leonig-Baucke 1989, Wald 1986, Benninga 1993, Emery
1988
Treatment of constipation leads
to remarkable improvement of
incontinence and UTI.
Leonig-Baucke 1991, 1996
 Neonatal evaluation of
abdominal mass
80-90% of neonatal masses are renal in
origin
Ureteropelvic junction obstruction is the
most common cause, followed by the
MCKD
Frequency of neonatal
abdominal masses

renal
retroperitoneum
female tract
GI
hepatobiliary
Neonatal Hydronephrosis
Ureteropelvic junction obstruction is the most common

upjo
PUV
defunc kidney
MCK
reflux
UVJO
others
 Prenatal hydronephrosis
Will resolve spontaneously
Wait until mother gives birth because its
the placenta that is responsible for the role
of the kidney except in oligohydramnios, in
which prenatal intervention does not work)
Prenatal Hydronephrosis
 EXTERNAL GENITALIA
(PAINFUL SCROTUM)

Testicular Torsion
Torsion of Appendix Testis
Epidydymitis/ Orchitis
Incarcerated Hernia
Torsion Testicular Appendages
Physical exam
Mild scrotal erythema
(+) cremasteric reflex
Localized tenderness
blue dot sign
Findings less specific later in course
Testicular appendages
Neonatal Torsion
 Epididymitis secondary to an
ectopic ureter to the vas deferens

Epididymitis- most common: sexual

experimentation with a promiscus woman
Key mgt: Doppler US
 Trauma to the testis
Sorry, puro pictures, walang notes
Acute Scrotum: Henoch scholein Purpura

Systemic vasculitis skin, joints, GI, GU

Nonthrombocytopenic purpura
Purpuric skin lesion
2-30% scrotal findings
Normal color doppler US
RX: steroids/expectant
 Acute scrotum: idiopathic scrotal
edema
Scrotal edema, erythema:
Prepubertal boys, waddling gate
Testis +/- palpable, but nontender
Normal color doppler flow
Resolve in 49-72hrs
Bug bite, allergic reaction, cellulitis
 History/PE

Definite Possible
Torsion Torsion

Surgery Color Doppler utz

no normal

blood flow Observe

 EXTERNAL GENITALIA
THE EMPTY SCROTUM

Undescended Testis
Retractile Testis
Ectopic Testis
Impalpable Testis
 Cryptorchidism
Age-related effect on the gonocyte
number
1. Age 2 shows drop in total number of
germ cells.
2. Age 3: 1/3 normal, 1/3 diminished, 1/3
markedly diminished germ cell count
3. The higher the level of the testis , the
greater the effect on the germ cell
4. By puberty, 90% reduction in the germ
cell count in the abdominal testis.
The cryptorchid testis
 Age and infertility
Age (years) at % fertile
orchidopexy
1-2 90%

3-4 50%

5-8 40%

9-12 30%

>13 15
 Early orchidopexy ( 2y/0) is
associated with higher inhibin
and lower FSH: Early
orchidopexy is beneficial
Malignant Tendency
 AAP- Committee on External
Genitalia:
Strongly recommend
orchidopexy at one year of age
as optimal
 EXTERNAL GENITALIA
THE SMALL PENIS

1. Micropenis
2. Webbed penis
3. True Concealed penis
Normal penis of a newborn Filipino
2.64 +/- .26 cm( first standard deviation)
Cunanan S, Bolong D,- 100 consecutive newborns at the
Chinese General Hospital
Proper measurement
B: due to fat
 EXTERNAL GENITALIA
ENLARGED SCROUTM

1. Hernia/ hydrocele
2. Testicular enlargement
3. Varicoceles
Abnormal closure of the patent
processus vaginalis
 Manual reduction:
- no systemic signs toxicity
- IV sedation
- Trendelenberg position
- mild manual pressure
Emergency surgery
 Incidence and Risk Factors
Hydroceles
Incidence- 6%
Majority resolve by 12-18 months
Minimal risk of incarceration
Pediatric Hydrocele: Mgt
Observation:
- 1-2 years age
- Recurrence rate 2%
- Contralateral hernia 7%
Surgical repair:
- inc. size
- Age > 2yrs
ANOMALIES OF THE EXTERNAL
GENITALIA:
HYPOSPADIAS
AMBIGUOUS GENITALIA
EPISPADIAS/ EXTROPHY
 Epispadia opening at dorsum
Hypospadia opening at ventral
- occurs 1/200 male births
component of hypospadia:
1. ventrally displaced meatus
2. cording
3. no prepuce (only dorsal hood)
4. transposition of scrotum
When to work-up hypospadias
Severe- scrotal/ perineal
One undescended testis
UTI
SUBMUCOSAL INJECTIONS
 VUR

PRIMARY SECONDARY
PRIMARY VESICOURETERAL
REFLUX
CONSERVATIVE- SPONTANEOUS
RESOLUTION
SUBMUCOSAL INJECTIONS
SURGERY
 SECONDARY
VESICOURETERAL REFLUX

INCREASED BLADDER PRESSURE

CONGENITAL ANOMALIES
 SECONDARY VUR
INCREASED BLADDER PRESSURE

URETHRAL SPHINCTER DYSFUNCTION

OBSTRUCTION
BLADDER DYSFUNCTION