UROLOGICAL CONDITIONS IN CHILDREN

UROLOGICAL CONDITIONS IN CHILDREN
by Dr Clarence Lei, FRCS Urol, Consultant Urologist, email: clarencelei@gmail.com

INTRODUCTION:
The scope of discussion will include the clinical presentation, the medical
treatment, the timing and a brief description of any paediatric urologic surgery required.

UROLOGICAL CONDITIONS in children include: circumcision, undescended testes (UDT),
scrotal swellings including hydrocele and hernia, acute scrotal pain incl torsion, hypospadias. A
dilated urinary tract is the commonest antenatal diagnosis and the causes include: PUJO, pelvi-
ureteric junction obstruction, VUJO, vesico-ureteric junction obstruction, VUR, vesico-ureteric
reflux and PUV, posterior urethral valve. Neuropathic bladder is also increasingly an important
cause of dilated urinary tract. Finally, urogenital tumours include those of the kidneys (Wilms),
testes and the rare rhabdomyosarcoma of the prostate.

The commonest medical indication for circumcision is phimosis, as manifested by ballooning
of the prepuce at micturation. Circumcision has also been shown to reduce the incidence of UTI,
urinary tract infection and probably viral infections (including HIV) of the male and the female
partners (later). Paraphimosis in a young boy is a surgical emergency.

The incidence of undescended testes at birth is 10% and this decreases to 1% at the age of 1 year.
Bilateral undescended testes can be occasionally treated by injection HCG. After the age of 1
year, any undescended or ectopic testes require surgery as soon as possible. Complications
include torsion and associated hernia. In adolescence, the testes can undergo malignant change.
Hence, orchidopexy and testicular self examination are important health education for testicular
maldescent. Hernia in children should always be operated as soon as possible to reduce the risk
of strangulation requiring emergency surgery. Persistent increasing hydrocele after the age of 1
year can also be operated electively via an inguinal approach so as to do a herniotomy at the same
time. I routinely drain the hydrocele as well.

Acute scrotal pain is testicular torsion unless proven otherwise. Such proof may be in the
form of diagnosis of torsion appendix testis or an inflammation as evidenced by urgent doppler
ultrasound, which can occur in 50% of children with scrotal pain.

Bilateral antenatal hydronephrosis in a male child is often due to PUV, posterior urethral valve.
Ultrasound would also indicate a distended and thickened bladder. PUV associated with sepsis
(often introduced during an MCU !) and renal impairment are best treated by a vesicostomy.
Where facilities are available including paediatric cystoscope, the PUV can then be fulgurated
with closure of the vesicostomy electively.

Bilateral hydronephrosis without renal impairment in the female and all unilateral
hydronephrosis can be treated electively. Ultrasound can be done within the first week of
delivery and functional study about 6 weeks later, when the kidneys have achieved some
maturity. The appropriate functional study for the kidneys is an isotope scan (usually Tc labeled
MAG-3) to see the differential function and the drainage of the dilated system. Many such
asymptomatic hydronephrotic system improves as the child grows older. It is realised nowadays
that only about 30% of such patients require surgery. The indications of surgery would be
increasing dilatation and deterioration of function on serial isotope scans (e.g. decreased to 30%).
The standard treatment would be an excision of obstruction and a pyeloplasty.

The current treatment for vesicoureteric reflux is to give a therapeutic dose of antibiotics
urgently when there is a febrile UTI. Long term prophylactic antibiotics and surgery is now
recognised as not improving the long term outcome. There is an increased usage of cystoscopic
Deflux injection of the ureteric orifice to reduce the incidence of febrile UTI. High grade reflux
tends to have more febrile UTI and therefore more interventions with injection therapy.

Where the urinary tract dilatation is due to a duplex system, a definitive treatment would be
surgical excision of the hydronephrotic poorly functioning duplex moiety. Neuropathic bladder
can be closely monitored with ultrasound, radio isotope study and referral for urodynamics,
if there is any deterioration. High pressure bladder can cause renal failure and such bladders
are best treated with cystoplasty (often a “clam” type) followed by CIC, clean intermittent
catheterisation. Urinary stones are occasionally seen in children and treatment is similar as
adults, namely, by ESWL, extracorporeal shockwave lithotripsy or by endourology.

Hypospadias occurs in 1 : 300 of newborns. The main aim of surgery is to enable the child to
pass urine standing up and also to have a penis straight enough for eventual sexual relations.
The recommended age for surgery is after the age of 1 year (unless the penis is very small) and
to finish surgery before the child goes to school. There are many techniques for hypospadias
surgery and most requires the patient to have some kind of catheter for at least a week. They will
often require a second stage operation.

CONCLUSION:
The medical personnel and parents should also know the common complications and
outcome of the conditions. The referral mechanism and the follow-up protocol depend on the local
facilities.