13. Pediatric urological diseases; Stress incontinency

Question 1

Types of pediatric urological diseases.

Answer 1

UTIs

Ureteropelvic Junction obstruction

Posterior urethral valves
Vesicoureteral reflux
Hydronephrosis
Predisposing to pyelonephritis

Nephrolithiasis

Renal tumors

• Wilms tumor
• Rhabdomyosarcoma of the bladder, ureter, or prostate muscle.
• Botryoid tumor, grape rhabdomyosarcoma around the vaginal vestibule.

Question 2

Abdominal pain can be what

Answer 2

Often around the umbilicus.

• UTIs,
• UPJ obstruction
• Ureterovesical obstruction.
• Nephrolithiasis
• Kidney tumors
• Spermatic cord torsion

o Chronic obstruction is often asymptomatic. The child should be
investigated at the time of acute complaints (will show dilation)

Other symptoms of pediatric renal disease: Abdominal distension, loss of appetite, vomiting, anemia and failure to
thrive.

Question 3

Pyuria with or without fever

Answer 3

Febrile UTIs should be treated acutely since severe pyelonephritis can develop rapidly.

It is important to remember that UTI can occur w/o pyuria, and pyuria may be present w/o UTI.

Question 4

Hematuria

Answer 4

o Willms tumor, nephrolithiasis, UTI, urethral prolapse, trauma, coagulation abnormalities.

o Often a benign condition called monosymptomatic hematuria

o Cystoscopy is rarely indicated compared to adults, since bleeding commonly originates higher than the bladder.

Question 5

Dysfunctional voiding

Answer 5

o Hinnman´s syndrome is disorder with functional (psychological) obstruction –> hypertrophy and fibrosis of detrusor muscle –> end stage
renal disease.

o Incontinence in girls is often due to ectopic ureter

o Phimosis, labial synchia, posterior urethral valve, and prune-belly
syndrome - lack of abdominal muscles

Question 6

Abdominal masses

Answer 6

• Abdominal mass: Wilms tumor, hydronephrosis or other retroperitoneal masses can make kidney palpable.

Neuroblastoma, lymphoma, schwannoma or neurofibromas.

Question 7

Wilm´s tumor

Answer 7

(nephroblastoma): A malignant tumor that can arise anywhere in the
renal parenchyma. Typically presents with an abdominal mass.
• Hematuria (25%), fever (15%) and abdominal pain (10%)
• Chemotherapy before surgery. Survival rate is more than 90%.

Question 8

Rhabdomyosarcoma:

Answer 8

• Soft tissue tumor that can occur anywhere, but commonly occurs along the
urogenital tract.

• The embryonic form, which is common in the urogenital tract, has good survival
rates.

• Rhabdomyosarcoma of the bladder and the prostate present with urinary
retention, increased frequency and hematuria.

• A mass is palpable over the pubic symphysis
• In girls there is a subtype called boytryoid tumor (having the shape of a grape cluster in the vaginal orifice)
• Chemo and surgery

Question 9

Stress incontinence definition

Answer 9

Patient complains of involuntary leakage of urine when the intravesical pressure
exceeds maximal urethral pressure (physical excertion, lifting, coughing, sneezing).

Question 10

Stress incontinence in women

Answer 10

• Urethral hypermobility (loss of pelvic floor support, after giving birth)
• Proximal urethra decent during stress situations
• Insufficient urethral sphincter mechanism (intrinsic sphincter deficiency)

Question 11

Stress incontinence in men

Answer 11

• Iatrogenic after prostatectomy
• After TURP (rare)
• Alpha-blocker against HTN

Question 12

Conservative treatment of stress incontinence

Answer 12

• Life style changes: Weight loss, stop smoking, reduce fluid intake
• Pelvic floor muscle training
• Duloxetine - 5HT and NE reuptake inhibitor modifying spinal control of the bladder.
• Off-label: estrogens, TCAs

Question 13

Surgical treatment of stress incontinence

Answer 13

Surgical treatment:
• Suburethral bulking agents (injectable collagen)

• Suburethral transvaginal sling procedures (rectus fascia)

• Laparoscopic colposuspensions: Stabilize the urethra by lifting vaginal wall
lateral to urethra.

• Artificial sphincter implantation (last resort)

Question 14

Overflow incontinence

Answer 14

Caused by insufficient bladder emptying, resulting in over distention of the bladder wall.

Due to:

1) Bladder outlet obstruction
- BPH
- Uretheral stricture
- Bladder neck stenosis

or

2) Poor detrusor contractility.
- Nerve damage to the sacral pelvic splanchnic nerves.
- due to bowel surgery or diabetic neuropathy.

Dribbling and fullness sensation throughout the day
Nocturia and nighttime leaking.

Question 15

Treatment of overflow incontinence

Answer 15

Drainage with a transurethral catherter or percutaneous suprapubic catheter.

BPH: alpha blockers, TURP.

Neurogenic:
parasympathomimetics, Bethanechol.
Intravesical electrostimulation or sacral neuromodulation.

Question 16

Diagnosis of overflow incontinence.

Answer 16

History

Uroflowmetry - 
- decreased flow rate suggests obstruction
- Peak urinary flow:
" Female: 20-30ml/sec
" Male: 15-25ml/sec

Cystometry
- measures bladder pressure, overflow will have increased pressure

Ultrasound
- increased residual volume.
Should be < 50 in young patients, < 100 in patients over 65.

DRE for BPH