A/24. Pediatric urology Flashcards
what do you have to keep in mind when treating a child with urological illness?
- symptoms are often non specific
- pediatrics urology doesnt simply mean surgery
- treatment of a child has an impact on patient’s life for decades
- management is only provided in specialised centers
what do you know about prenatal diagnostics?
- Prenatal US diagnosis on pediatric urology is enormous!
- A significant proportion of congenital disorders are
detected in utero - a great number of these benefit from early diagnosis and prevention of secondary complications
pediatric urologial common symptoms?
- Abdominal pain
-Abdominal distension - loss of appetite
- vomiting
- anemia
- failure to thrive (dystrophy, atrophy)
- Pyuria with/without fever
- Hematuria
- Dysfunctional voiding, enuresis, incontinence
- Abdominal mass
abdominal pain in <6 years vs above 6 yrs
< 6yrs: localized pain around the umbilicus
>6yrs: can specify affected site
what is the etiology of abdominal pain in pediatric urology?
UTI
ureteropelvic junction (UPJ) obstruction
ureterovesical stenosis
constipation
nephrolithiasis
renal tumor
spermatic cord torsion
how do you diagnose the abdominal symptoms?
physical examination
urinalysis
abdominal US
serum chemistry
retrograde voiding
cysto.urethrography
and radioisotope studies
Pyuria with/without fever in pediatric urology
-if febrile should be treated —–
- Underlying urological abnormalities
-UTI in newborn
- Febrile UTIs should be treated acutely
(since severe pyelonephritis–> renal scarring)
-investogate underlying urological abnormalities:
-> UPJ-obstruction
->VUR
->ureterocele
->neurogenic bladder
- UTI in newborn is an emergency (can rapidly progress to urosepsis with fatal consiquences)
- UTI may be present without pyuria, and pyuria may be present without UTI
hematuria in pediatric urology..
-microscopic Vs macroscopic
microscopic: often occurs in children, and may be benign
macroscopic:
->UTI
->urethral prolapse
-> trauma
->coagulation problem
->nephrolithiasis
->wilm’s tumor
->acute GN
->UPJ-obstruction
->hemorrhagic cystitis
->foreign body
Is cystoscopy indicated in case of hematuria?
yes.
since bleeding commonly originates from upper urinary tract
describe Dysfunctional voiding, enuresis, incontinence in pediatric urology…
-illness varies from —-
- primary goal is to
-Illnesses vary from minor changes to serious bladder damages
->minor: lazy bladder
->serious: neurogenic bladder or fibrosis of bladder wall (hinmann’s synd)
- Primary goal is to differentiate benign from harmful lesions
what is the etiology of dysfunctional voiding, enuresis, incontinence in pediatric urology?
- constipation
- phimosis
- meatal stenosis
- previous urethral surgery
- hinman’s synd (non-neurogenic neurogenic bladder= functional bladder outlet obstruction in the absence of neurologic deficits.)
- ectopic ureter opening into vulva (girls)
what is the etiology behind abdominal mass in pediatric urology?
- Majority originate in genitourinary organs
1. large hydronephrosis
2. extremely filled urinary bladder
3. wilm’s tumor (nephroblastoma)
4. retroperitoneal masses that push on kidney
list the Obstructive uropathies in pediatrics urology
- Ureteroplevic junction (UPJ) obstruction
- Obstructive megaureter
- Ureterocele
- infravesical obstruction -> post. urethral valves
UPJ obstruction is the most common —–
gender
- UreteroPelvic Junction obstruction
- Most common site of obstruction
- Epidemiology: boys > girls
symp. of UPJ obstruction?
- abdominal/flank pain
- UTI
- hematuria
- abdominal masses
how do you diagnose UPJ obstruction?
- prenatal US
- diuretic renography (dynamic, noninvasive test which was developed to distinguish between the dilated non-obstructed and the dilated obstructed upper urinary tract)
- IV urography
how do you treat UPJ obstruction?
- conservative surgery:
->dismembered pyeloplasty
-> Anderson and Hynes technique - Nephrectomy if poorly functioning kidney
(<10% renal function)
what is the complication of UPJ obstruction?
hydronephrosis
what is the etiology of megaureter?
- obstructive (ureterovesical stenosis)
- non-obstructive (eg. VUR)
what are the symps of obstructive megaureter?
UTI
hematuria
flank pain
how do you diagnose megaureter?
prenatal US
how do you treat mega ureter?
- ureteric reimplantation
(methods of Cohen, Politano-Leadbetter, Jozsef Toth)
what are the complications of mega ureter?
hydroureter
hydronephrosis
describe ureterocele..
- a cystic enlargement of the intravesical segment of the ureter, containing urine
In vast majority associated with complete duplication of the urinary tract -> obstructing the orifice of the ectopic (upper pole) ureter
what are the symp. of uereterocele
UTI
prolapse of ureterocele
purulent drainage in diaper
how do you diagnose ureterocele?
prenatal US
how do you treat ureterocele?
- Endoscopic ureterocele incision in newborns
- Partial nephrectomy (upper pole heminephrectomy) due to hydronephrosis
complications of ureterocele
- Dilatation of ureter and hydronephrosis
- Obstruction of internal meatus of the urethra, and the other ureteral orifice(s) as well
describe infraurethral obstruction (post. urethral valves)
an obstructive membrane in the posterior male urethra
what is the Treatment of infraurethral obstruction
- Prenatally: intrauterin intervention attempt
- Postnatally: valve ablation and sometimes early urinary diversion
what are the complications of infravesical obstruction
- congenital urethral obstruction: urinary tract above the obst. level is subject to abnormally high intraluminal pressure
-> damage to post. urethra, bladder, ureters and kidney
–> renal insufficiency
-> oligohydraminos
-> resp. distress and suffocation
what is the prognosis of infravesical obstruction?
1/3 lethal
1/3 require renal transplantation
1/3 live with preserved kidneys
what is VUR?
epidemiology
Vesicoureteral reflux
- retrograde flow of urine from bladder to upper urinary tract
- Epidemiology: 30-50 of pediatric pts. with UTI
what is VUR etiology?
- intrinsic anatomical deficiency of VU junction
- dysfunctional VU obstruction
how do you grade VUR?
grade I: reflux into ureter
grade II: reflux into kidney with maintenance of sharp angles of the fornix
grade III: reflux into kidney with mild loss of forniceal agnle (mild hydro-ureter)
grade IV: reflux involving papillary blunting and more severe loss of forniceal angle with moderate hydroureter and hydronephrosis
Grade V: reflux with loss of papillary impression and loss of forniceal angle, presenting with hydronephrosis and hydro-ureter
how do you diagnose VUR?
contrast voiding cystourethrogram (VCUG)
US
direct isotope renography
how do you treat VUR?
- prolonged AB prophylaxis
- correction of reflux via open/endoscopic surgery
(high rate of immediate cure and small risk of complications)
what are the complications of VUR?
pyelonephritis > renal scarring> renal insufficiency and HTN
Genitourinary tumors
- Wilm’s tumor (nephroblastoma)
- Rhabdomyosarcoma
- testicular tumors
describe wilm’s tumors..
- Arise anywhere in renal parenchyma
- Expansive growth
what is the Etiology of wilm’s tumors?
there is wilm’s tumore gene on chromosome 11p
deletetion/mutation of both alleles is needed
common symps of wilm’s tumor?
abdominal mass
hematuria (25%)
fever (15%)
abdominal/flank pain (10%)
HTN
undescended testis
how do you diagnose wilm’s tumors?
US: solid lesion, sometimes cystic areas
CT: shows exact extension and potential metastases
how do you treat wilm’s tumors?
chemotherapy:
- actinomycin
- vincristine
- doxorubicin
surgery:
radical nephrectomy
rhabdomyosarcoma in pediatric urology
-most commonly affects?
-pathology?
Most commonly affects:
-> prostate
-> bladder
-> paratestis
Pathology:
->embryonal (good survival rate)
-> alveolar
-> pleomorphic
symps and treatment of Bladder and prostate in rhabdomyosarcoma
symps:
-urinary frequency
-hematuria
- urinary retention
- palpabale mass above symphysis
treatment:
-> surgery
-> chemo
symps and treatment of paratesticular in rhabdomyosarcoma
vast majority is embryonal with good prognosis
symps:
-unilateral painless scrotal swelling or mass above the testis
treatment:
radical inguinal orchiectomy followed by chemo
few words about testicular tumors in rhabdomyosarcoma…
Rare in childhood
see topic B10
