Urologic Emergencies in Children, MSN Penang 28 July 2018

Urologic Emergencies in Children

Dr Clarence Lei, FRCS Urol, FEBU

Urologist (Adult, Paediatric and Renal Transplantation)

Adjunct Professor,Universiti Malaysia Sarawak

 Honorary Consultant Urologist, HKL, SGH and Sarawak Heart Centre

 c/o Normah Hospital, Kuching

Introduction, objective and Methodology:

This important topic is illustrated by cases seen at the Urology Departments of Hospital Kuala Lumpur and Sarawak General Hospital, especially since the establishment of the Combined Paediatric-nephrology-urology Clinics at Institute of Urology and Nephrology, Hospital Kuala Lumpur (around 1991) and later at Sarawak General Hospital.

Results:

The urologic emergencies seen in children include the following: 

(a)       Hydronephrosis with renal failure: 

i.           Bladder outlet obstruction: PUV, posterior urethral valve and neuropathic bladder.  PUVs can nowadays be fulgrated with laser via miniature scopes and vesicostomy is seldom necessary, except in remote areas when the baby is very sick. This is the ONLY indication for emergency VCUG.

ii.         Solitary kidney with obstructive hydronephrosis: PUJO, UVJO (other kidney absent or dysplastic).  Unilateral obstructive hydronephrosis is often a dire emergency, fortunately rare.  A caring and patient radiologist can save the child’s life with a percutaneous nephrostomy!  Thereafter, an open direct ureteric re-implantation can be done but with minimal dissection of the trigone of the neonatal bladder.  

iii.       Bilateral hydronephrosis, PUJO/UVJO with renal failure. The renal function is usually adequate to allow the child to grow until it is safer for surgery, usually around 10 kgs when the child can have an open pyeloplasty or even an open tunnelled ureteric re-implantation (Politano Leadbetter type is physiological).

iv.        Hydronephrosis with renal failure from urinary stones. Paediatric stones can be treated just as in adults but with miniature equipment and with minimal use of radiation.

(b)      Acute urinary retention is another urologic emergency and the following are possible causes: 

i.           Phimosis.

ii.         Prolapsed ureterocele in the female.

iii.       Episode of urinary tract infection with underlying chronic retention.

An impacted urethral stone or a prostatic rhabdomyosarcoma is occasionally a cause of urinary retention. The initial urethral catheterisation MUST be done by a doctor with experience in catheterising neonates. Half cc of pure Lignocaine gel can be instilled with a syringe into the urethra.  A small feeding tube (usually 6 Fr) or a smaller umbilical catheter may be inserted. After a few days, the urethra becomes dilated and an 8 Fr silicone Foley’s catheter may then be inserted for a longer term drainage. The neonatal urethra can be easily traumatised by catheterisation and damaged by ischaemic pressure by prolonged catheterisation.  

(c)     Pain of the genital urinary tract is another emergency. The pain can originate from:

i.           Penile pain from balanitis, posthitisor both or para-phimosis or post circumcision complications.  

ii.         Scrotal skin cellulitis.

iii.       Torsion of the testes or the appendix testes: just mention TORSIONand the patient will be seen by the hospital surgical staff urgently!

iv.        Inguino-scrotal swelling including infection, hydrocele, varicocele and hernia.

(c)  Parents are getting more distracted by social media and devices; neglected children may suffer  genital urinary trauma.  Depending on the severity, most patients will get an ultrasound and a low dose contrast enhanced CTU as baseline documentation.  Most such cases can nowadays be treated conservatively (even in kidney fracture) with rest, antibiotics and follow-up with serial ultrasounds.

In April 2017, the US Food and Drug Administration issued a public notification that the use of general anaesthetic and sedations in children younger than 3 years adversely affect brain development.

Conclusions:

Urologic emergencies in children are often present to the family doctor or paediatrician.  Particular care has to be taken when there is acute pain, fever especially with evidence of infection of the genital urinary tract, phimosis, para-phimosis; the acute scrotum is torsion until proven otherwise although only 20% of all scrotal pain is due to torsion.  The child should be referred urgently to a paediatric surgical team with the optimal amenities including nursing care, peri-operative anaesthesia, in addition to specialised surgical operation with magnification and miniaturised tools.