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Back To Basics Pediatric Urology

Back To Basics Pediatric Urology. Dr. Michael P. Leonard MD, FRCSC, FAAP Professor of Surgery University of Ottawa. Urinary Tract Infections. Caused by gut bacteria E. coli most common Ascend via urethra to bladder and kidneys Presentation varies with age:

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Back To Basics Pediatric Urology

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  1. Back To BasicsPediatric Urology Dr. Michael P. Leonard MD, FRCSC, FAAP Professor of Surgery University of Ottawa

  2. Urinary Tract Infections • Caused by gut bacteria • E. coli most common • Ascend via urethra to bladder and kidneys • Presentation varies with age: • Infants – fever, lethargy, diminished feeding, failure to thrive, diarrhea, vomiting • Children – frequency, urgency, dysuria, wetting, gross hematuria, abdominal pain, fever

  3. Urinary Tract Infections • Incidence • < 1 yr – more common in males (peak 6 months) • Increased in uncircumcised males (10x) • > 1 yr – more common in females (peak 2-3 years) • School age children: • 1.2% males • 5% females

  4. Urinary Tract InfectionsDiagnosis • Obtain urine sample for urinalysis / culture • Methods of obtaining urine: • Infant = bag urine, catheterized urine • Child = midstream urine, catheterized urine • Beware contamination! • Urinalysis: • +ve nitrite, leucocyte esterase, RBC • Culture: • > 108 CFU/l of one organism

  5. Urinary Tract InfectionTreatment • Antibiotics • IV ± hospital admission if systemically unwell (especially infants) • IV ampicillin / cephalosporin and gentamicin initially • Oral if reasonably stable and not toxic • Trimethoprim, TMP-SMX, nitrofurantoin, cephalosporin • Broad spectrum to cover gram negative and some gram positive (Staph, Enterococcus) • No worry regarding anaerobes • Duration of treatment 7-14 days depending on clinical scenario

  6. Urinary Tract InfectionInvestigation • AAP Guidelines 2011 • First febrile UTI 2-24 months = renal ultrasound • VCUG only if abnormal US or second febrile UTI • “Top down approach” • DMSA scan to document evidence of APN • VCUG only if findings APN on DMSA

  7. Urinary Tract InfectionReferral ? • Consider referring the following to specialist: • GU anomalies on US and/or VCUG • VUR, hydronephrosis, ureterocoele • Concern regarding neurogenic features • Abnormal lower back exam • VACTERL syndrome • Recurrent UTI in the otherwise normal child if not responsive to timed voiding and management of constipation

  8. Vesicoureteric Reflux (VUR) • Urine washing back to kidneys from bladder = VUR • Increases risk of renal infection if UTI • Renal infection may lead to scarring • Associated with renal dysplasia ± renal scarring • More common in males < 1 yr and females > 1 yr • Seen in 35-50% of children with UTI • Diagnosed by VCUG

  9. VUR - Grading

  10. VUR - Management • Prevent UTI by antibiotic prophylaxis • Follow at intervals for resolution • Follow-up comprises US and Cystogram • Surgical intervention: • Breakthrough UTI • New scarring • Parental preference • Surgical options: • Minimally invasive (STING) • Open ureteric reimplantation

  11. VUR - Surgery

  12. Nocturnal Enuresis • If child wets bed at ≥ 5 years of age = NE • Common developmental issue: • 15% of 5 year olds  1% of 15 year olds • 15% spontaneously resolve annually • Family history common (genetic component) • Several theories abound: • Developmental delay of normal maturation • Deep sleep patterns • Bladder over-activity at night • Lack of nocturnal ADH production

  13. Nocturnal EnuresisClassification • Primary nocturnal enuresis (PNE) • No day time symptoms • No dry interval 6 months or longer • Secondary nocturnal enuresis • As above but with dry interval > 6 months at some time in past • Complicated nocturnal enuresis • Day time symptoms ± UTI

  14. Nocturnal EnuresisEvaluation (Rushton, J Pediatr)

  15. Nocturnal Enuresis:Treatment • Three primary treatment modalities: • Observation: • fluid restriction, double void at night, star charts • Conditioning therapy: • bedwetting alarm system • Pharmacotherapy: • DDAVP

  16. Daytime Wetting • Toilet training complete at 2-3 years • 5% of 5 year olds experience occasional daytime wetting • Causes: • anatomical (ectopic ureter, epispadias) • pseudo-incontinence (vaginal voiding) • neurogenic (spina bifida) • dysfunctional elimination (DE)

  17. Daytime wetting - DE • Bladder problems: • overactive bladder (OAB) • hypoactive bladder • detrusor / sphincter incoordination • Bowel problems: • fecal impaction • colonic distension  hypotonicity •  pelvic floor / sphincter tone

  18. Daytime wetting -Rx • Anatomical: • surgery (i.e. hemi-nephrectomy) • Pseudo-incontinence: • change of voiding posture • Neurogenic: • improve storage (anti-cholinergics) • improve emptying (IMC)

  19. Daytime wetting -Rx • Dysfunctional elimination: • improve bowel function (diet) • timed voiding (q 2-3h) • biofeedback • medication: • anti-cholinergics • -blockers • psychotherapy

  20. NORMAL SCROTAL ANATOMY

  21. Acute Scrotum • Case study #1: • 14 year old boy with right hemi-scrotal pain • Duration of pain = 6 hours • No history of trauma or LUTS • What else do you need to know?? • What is your differential diagnosis?? • Are any ancillary investigations useful??

  22. TESTIS TORSION • Clinical Presentation: • pubertal boy (12-16 years) • abrupt onset lower abdominal / testicular pain • pain usually severe, unrelenting • associated with nausea, vomiting, anorexia • prior history of trauma (minor) • previous episodes which resolved

  23. TESTIS TORSION • Physical Findings: • elevated testis with abnormal lie • “knotting” of spermatic cord • absent cremasteric reflex • scrotal erythema / edema • reactive hydrocoele • “bell clapper” contralaterally

  24. DIFFERENTIAL DIAGNOSIS • Emergent: • Testicular torsion • Traumatic testicular rupture • Incarcerated inguinal hernia • Peritonitis with patent processus vaginalis • Fournier’s gangrene

  25. DIFFERENTIAL DIAGNOSIS • Non-emergent • Torsion of testicular or epididymal appendage • Acute epididymo-orchitis • Idiopathic scrotal edema • Henoch-SchÖnleinpurpura • Hydrocoele / hernia • Acute hemorrhage into testicular neoplasm

  26. TESTIS TORSION • Laboratory Studies: • urinalysis typically negative, but may contain WBC’s • CBC and differential not useful discriminator • Radiographic Studies: • not indicated if typical clinical case with duration of pain < 12 hours!

  27. TESTIS TORSION • When should radiographic studies be considered? • duration of pain > 12 hours and / or diagnosis is uncertain • Which study is indicated? • Color Doppler ultrasonography

  28. TESTIS TORSION • Color Doppler ultrasound • readily available in most locales • positive finding = no or decreased flow in affected testis • sensitivity 91% (range 82-100%) • pitfalls: • small (infant) testis = no flow • peri-testicular flow due to inflammation around torted testis

  29. TESTIS TORSION

  30. TESTIS TORSION • Time is of the essence! • salvage is usually successful within 6-8 hours after onset of pain • salvage possible up to 24 hours, but rate declines exponentially • pain > 24 hr invariably = necrotic testis (very rare exception!)

  31. TESTIS TORSION • Surgical Results: • salvage rates approximate 60-70% • factors contributing to missed torsion: • patient delay in presentation = 80% • physician mis-diagnosis = 20% • suggests need for education through school health / physical education programs

  32. TESTIS TORSION

  33. EXTRA-VAGINAL TESTIS TORSION (NEONATAL) • Occurs ante-natally (in utero) or in the first week post-natally • Testis and tunica vaginalis rotate together (inadequate scrotal wall fixation) • Presents as painless scrotal swelling with scrotal erythema / bluish discoloration • Testis rarely viable - ? need for surgery

  34. TORSION OF TESTICULAR APPENDAGE • Case study #2: • 8 year old boy • 2 day history right hemiscrotal pain • Anything else you want to know??

  35. TORSION OF TESTICULAR APPENDAGE • Clinical presentation: • 7-12 year old (pre-pubertal) boy • pain more indolent, not as severe as testis torsion • pain may resolve with rest • usually no accompanying nausea or vomiting

  36. TORSION OF TESTICULAR APPENDAGE • Physical Exam: • early • testis has a normal lie • maximal tenderness at upper pole • tender nodule may be seen (“blue dot”) or felt • late • progressive scrotal erythema and edema • reactive hydrocoele • more difficult to differentiate from testis torsion

  37. TORSION OF TESTICULAR APPENDAGE • Laboratory investigations: • urinalysis usually negative • Radiographic evaluation: • Color Doppler ultrasound shows increased flow to upper pole testis / epididymis. May also see small hypoechoictorted appendage. • Radionuclide scan shows increased blood flow to the affected hemi-scrotum

  38. TORSION OF TESTICULAR APPENDAGE • Treatment: • limit physical activity • analgesia • expect an initial increase in swelling / redness with resolution over 7-10 days • surgery only necessary if diagnosis in doubt and / or pain not well managed by analgesics • no long term sequelae re: testicular function

  39. EPIDIDYMITIS • Case study #3: • 10 year old boy • 2 day history left hemiscrotal pain and swelling • LUTS for 3 days • Febrile (39.5C) • Any further investigations / information required??

  40. EPIDIDYMITIS • Bacterial or chemical inflammation of epididymis • Rare in pre-pubertal boys • if occurs, consider urinary tract abnormality such as ectopic ureter, PUV, stricture • Common in sexually active adolescents • usually Chlamydia, rarely gonococcus

  41. EPIDIDYMITIS • Clinical presentation: • pain insidious in onset • irritative lower urinary tract symptoms may precede onset of pain • urethral discharge if STD • may be septic

  42. EPIDIDYMITIS • Physical examination: • elevated temperature • scrotal edema, erythema, tenderness, reactive hydrocoele, tender prostate • early on epididymis may be increased in size and exquisitely tender • in later stages, loss of anatomical landmarks with diffuse tenderness • Prehn’s sign unreliable!

  43. EPIDIDYMITIS • Laboratory investigations: • urinalysis may show pyuria, hematuria, bacteria • urine culture may be positive • Radiographic evaluation • only necessary in pre-pubertal child with concurrent UTI • renal ultrasound and VCUG recommended • if Color Doppler US obtained will show increased blood flow to affected side

  44. Scrotal Mass • Need to distinguish where mass is coming from: • Processus vaginalis: • Indirect inguinal hernia • Communicating or non-communicating hydrocoele • Testicular adnexae: • Epididymal cyst / spermatocoele • Varicocoele • Testis • Testicular tumour

  45. Scrotal mass in children

  46. Hernia - HydrocoeleEmbryology • As testis descends through inguinal canal into scrotum: • carries along a tongue of peritoneum (processus vaginalis) • normally communication of processus with peritoneum closes • leaves potential space (tunica vaginalis) over antero-lateral testis

  47. Hydrocoele - HerniaAnatomy

  48. Hernia - Hydrocoele Management • Communicating hydrocoele: • may resolve spontaneously < 2 yr. • if persists > 2 yr.  repair • Indirect inguinal hernia: • repair at any age • risk of incarceration small but real

  49. Non-communicating Hydrocoele • Localized collection of fluid in tunica vaginalis • May be secondary to: • inflammatory process • trauma, infection, torsion • tumor • If concern re: testis  ultrasound • Surgical intervention is option

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