Transcript Pediatric urinary incontinence - Scioto County Medical Society

Pediatric Urology Update
Rama Jayanthi, M.D.
Section of Pediatric Urology
Columbus Children’s Hospital
Format and purpose
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Selected cases in pediatric urology
Stimulate discussion
Discuss management
Case 1
Hypospadias noted at birth
Both testes normally descended
Questions:
What type of work up?
What is initial management?
When do you refer to pediatric
urologist?
Hypospadias
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abnormally positioned meatus
meatus can be located anywhere from
perineum to glans
chordee- associated penile curvature
Hypospadias- associated
abnormalities
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Easy to remember - nothing!
Normal kidneys and bladder
Normal fertility
Normal sexual function
Hypospadias - management
for the pediatrician
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Do not circumcise!
No need for any imaging studies
Refer to pediatric urologist within
first months of life
Always consider intersex if
hypospadias associated with
undescended testis
Who is a boy and who is a girl?
Is it a hypo or not?
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Retract foreskin completely off glans during circ
If glans meets in midline proximal to meatus, not a
hypo!
• Even if meatus appears to be large
If a true hypo is present
• Wrap with Vaseline if not bleeding
• Otherwise close skin edges with chromic
sutures
Hypospadias - management
for the pediatric urologist
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Surgical correction at 6 - 9 months of
age
Attempt one stage reconstruction
Out patient surgery
Success rates should be > 95%
Epispadias
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Very rare - more often
associated with bladder
exstrophy
Need early referral for
parental counseling
Patients may be totally
incontinent
Case 2: Scrotal mass
Painless scrotal masses
Stable in size
No increase with crying
No inguinal bulge
Questions:
What is the diagnosis?
What should be done?
Scrotal masses
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Solid vs. cystic
• transillumination of light
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Testicular vs. extratesticular
Painful vs. painless
Hernia/hydrocele - cystic
scrotal mass
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Testes develop intraabdominally and
exit the abdomen at the internal ring
All males have a fascial defect at
some point during gestation
Persistence of defect leads to
communicating hydroceles and hernias
Hernia/hydrocele
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What is the difference between a hernia and a
communicating hydrocele?
• Both are the same anatomic defect
• If opening only large enough to admit peritoneal
fluid - communicating hydrocele
• Scrotal swelling only, “comes and goes”
• If opening large enough to admit bowel- clinical
hernia
• “inguinal bulge”
Hernia/hydrocele
Hernia/hydrocele management
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Observation:
• Noncommunicating hydrocele < 12 - 18 months
of age
• Hernia - very premature infants with easily
reducible large hernias
Surgery:
• Hydrocele - persistent, enlarging, painful
• Hernia - always
Surgical correction involves ligation of peritoneal
sac
What is the diagnosis?
Findings:
Painless right scrotal mass
Does not transilluminate
Ultrasound: solid mass
Diagnosis: yolk sac tumor
Case 3
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A 15 year old boy is noted
to have a left scrotal mass
during a sports physical.
The mass is soft, painless,
located above the testis
and disappears when the
boy is recumbent
What is the most likely
diagnosis?
Varicocele
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Represents dilation of left spermatic
veins
Etiology unknown
• ? Lack of venous valves
• ? High intravenous pressure
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Incidence: 15% of all teenage males
• rare in prepubertal males
Significance of varicoceles
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Infertility
• Most common surgically correctable cause of
male factor infertility
• Reason unclear
• ? Increased temperature of scrotum
• ? Primary endocrinopathy
Pain
• Uncommon in teenagers
• “Dull ache”
Management of pediatric
varicocele
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“Clinically significant varicoceles” requires surgical
ligation
Problem:
• Most teenagers have varicoceles detected on
routine physical examination
• Usually asymptomatic
Management of adolescent varicoceles
• Yearly measurement of testicular size
• Symmetric testes - observe
• Indications for intervention:
• Development of size discrepancy > 2cc
• Pain
• Personal opinion:
• Spermatic vein embolization may be the
simplest and least invasive option
Case 4
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A 4 month old boy on routine
examination is found to have a
normally descended right testis but
no palpable left testis. His exam is
otherwise normal.
What workup is needed?
When should he be referred?
What to do with a missing
testis?
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Issues:
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palpable or nonpalpable?
Unilateral or bilateral?
Associated hypospadias?
Associated syndromes?
• Most will have isolated unilateral
undescended testis
Should an ultrasound be
performed?
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If an US reveals a testis, then surgery is required
for orchidopexy
If an US shows no testis it may be inaccurate
because the child may have a small intraabdominal
testis that was not detected
Regardless of US findings, the child needs
exploration
Thus, there is no need for radiological evaluation
for a nonpalpable testis
Classification of UDT
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Intraabdominal
• testis located above internal ring
• usually nonpalpable
Canalicular- “routine” undescended testis
Retractile - not a UDT
• due to hyperactive cremaster reflex
• only in prepubertal males
• no hormonal/testis defects
Management of UDT
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Observation until 6 -12 months of age
If still undescended, surgical
correction
No advantage to further observation
after 12 months of age
• testis will not descend
• germ cell fibrosis evident by three years
of life
Bilateral nonpalpable testes
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Karyotyping essential
Main question: Is there functional
testicular tissue present?
No functional tissue present if
• marked elevation baseline FSH and LH
• no rise in serum testosterone with HCG
stim
Fertility after
cryptorchidism
Formerly
unilateral
UDT
Formerly
bilateral
UDT
Control
Number
313
50
336
Married
244
(78%)
183
(75%)
38
(76%)
20
(53%)
269
(80%)
203
(76%)
Married
with
children
Lee, Brit J Urol, 1995
Risk of Neoplasia
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UDT has 10X greater risk
• Abdominal testis has 4X greater risk than
inguinal
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Tumors occur after puberty
• Mean age 25 - 30 years
25% occur in normally descended testis
Early orchidopexy may be protective
Seminoma most common, embryonal cell
2nd
Case 5
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A nine year-old uncircumcised boy
presents with a tightly phimotic
foreskin.
He has had a few episodes of
balanitis
His parents to do not want him to be
circumcised if possible
What can be done?
Natural history of phimosis
Medical management of
phimosis
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Prospective trial
Diprolone cream (0.05%) applied TID
for 4 weeks to preputial band
Patients reevaluated at one month
Medical management of
phimosis
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Results
• n = 21
• Signs and symptoms
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UTI
Balanitis
Preputial ballooning
Asymptomatic
Medical management of
phimosis
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Success
17/21 (81%)
• 11 complete, 7 partial
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Failure
4/21 (19%)
What does a bladder do??
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Store urine
Empty urine
In a 24 hour time period
• Bladder is in storage mode for 23 hours
and 45 minutes
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Thus, storage function is of greater
importance than emptying
Normal bladder function
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Storage
• Storage must take place at low
pressures
• Intravesical pressures must be low enough
to…
• Not impede urine transport from kidneys via the
ureters
• Hydronephrosis/renal injury
• Not overwhelm sphincteric resistance
• Urinary incontinence
Emptying function
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First step in voiding is relaxation of
sphincteric mechanism followed by
bladder contraction
Normal voiding is a “passive” process
with no involvement of the abdominal
muscles
Case 6
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A 7-year-old girl complains of new onset daytime wetting. She has
always been a bed wetter. She has never had any urinary tract
infections. She does note that she often will leak while running and
exerting herself. She furthermore does not realize that she has to
go prompting her parents to wonder whether the child can even tell
that she needs “to go”. Sometimes the family will see her doing the
“pee-pee dance” and sometimes they will see her suddenly squat on
her heel. Occasionally she will have a precipitous urge to void but
when she makes it the bathroom nothing comes out. Her leakage
can vary from damp spots on the underpants to complete soaking of
her clothes. When the family is out they will often have to stop to
find a restroom for her prompting the family to wonder whether
her bladder is “too small”. She occasionally will complain of mild
nonspecific abdominal pain.
What kind of evaluation is required?
Aspects of the history
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Daytime wetting vs. nighttime wetting vs. both
Urgency?
Frequency? Infrequent voiding?
Damp pants vs. soaking?
Does leakage occur prior to going to restroom or
after voiding ?
Does the child care if he/she is wet?
Frequency of bowel movements?
Common myths
Voiding dysfunction may be due to
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“small bladder” that the child has to grow
into
“narrow urethra” that needs to be
stretched
“inability to sense fullness”
Urgency and/or frequency in a male may be
due to meatal or urethral stenosis
Evaluation of voiding
dysfunctions
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History most important
Screening renal ultrasound
• Ensure normal kidneys
• Alleviates parental anxiety
• Bladder wall thickness
• Subtle sign of bladder overactivity
• Post-void residual
• ? Incomplete sphincter relaxation
Voiding cystourethrography??
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A child should almost never have a
catheter inserted in the initial
evaluation of pure incontinence!!!
“Functional bladder capacity” better evaluated by
voiding diary
• Expected bladder capacity: Age + 2 in ounces
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VCUG rarely needed
• history of significant UTI
• symptoms of obstruction in males
Varieties of voiding
dysfunction
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In order of frequency
• Bladder instability/overactivity
• Infrequent voiding
• Incomplete emptying
• Hinman’s syndrome
• “Nonneurogenic neurogenic bladders”
Bladder instabilty
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Clinical manifestations
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wetting
infections
pelvic/vaginal pain
penile/scrotal pain
Forms of bladder instabilty
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Urgency incontinence syndrome
• predominant symptom is wetting
• infections less likely
Hypertonic bladder
• predominant symptom is UTI
• may also have associated wetting
Urgency incontinence
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More common than hypertonic
bladder
Usually associated urgency/frequency
Severity of wettings ranges from
damp pants to soaking
Hypertonic bladder
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VCUG trabeculated
bladder, may have
diverticulae
Main point:
Infections (and
reflux) are
secondary problem
“Distal urethral stenosis”
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Spinning top
urethra
NOT due to
obstruction
A sign of bladder
instability
Urethral dilation is NEVER indicated!!!
Management of bladder
instability
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Anticholinergics
Bowel management
Consider prophylactic antibiotics only
if has recurrent infections
refractory to standard management
• The older I get, the less I use
prophylactic antibiotics
Choice of anticholinergics
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Oxybutinin
• Ditropan XL 5 -15 mg qAM
• Advantages:
• once a day dosage
• fewer side effects
• Elixir (0.2 mg/dose/BID -TID)
• only if cannot swallow pills
Role of bowel dysfunction
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Fecal retention
• Incomplete or
infrequent emptying
of bowels
• Subtle clues
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abdominal pain
perineal pain
vaginal “itching”
penile pain
Relationship of constipation
and wetting
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234 constipated/encopretics
29% day and 34% night wetting pretreatment, UTI in 11%
52% had improvement in constipation
• 89% improved day
• 63% improved night
• no more UTI
Loening-Baucke, Pediatrics, 1997
Importance of UTIs and
bowel/bladder disturbances
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143 children with reflux
+ breakthrough UTI
• 77% had dysfunction
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- breakthrough UTI
• 16% had dysfunction
Koff, J Urol, 1998
Infrequent voiding
syndromes
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“lazy bladder syndrome”
• an inappropriate term that incorrectly
labels a child as being lazy
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Fact of life for children:
• Children usually have more important
things to do than urinate and defecate
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Sensation normal - children “tune out”
the bladder
Management of infrequent
voiding syndromes
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timed voiding
behavioral modification
• controlled bribery
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intermittent catheterization
The overwhelming majority of
patients can be evaluated with
only a careful history. Only a
small number may need
“objective” measurements of
bladder function.
Case 7
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A 8 year old girl has her first episode
of UTI
How do you evaluate her?
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Observation?
US?
VCUG?
DMSA scan?
What is a urinary tract infection?
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Positive culture in a child with
appropriate symptoms
What is not an infection, and thus
should not receive antibiotics
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Red introitus
Perineal discomfort
Dysuria in the absence of a positive culture
• A positive urinalysis is not sufficient to
definitively diagnose an infection
Microscopic hematuria
Philosophical questions
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Why do we treat urinary tract
infections?
What are the ramifications of UTI’s?
Renal scarring
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may cause hypertension
if present diffusely and
bilaterally, may lead to
renal failure
most likely will occur after
pyelonephritic episodes in
children less than 4 years
of age
Therefore
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if older child has episode of cystitis,
recommend US
if older child has pyelonephritic
episode, recommend VCUG/US
if younger child has any type of UTI,
recommend complete workup,
especially if male
Case 8
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Four year old girl with recurrent UTI,
some with fever
US - normal, VCUG - normal
Repeat nuclear cystogram also normal
What do you do???
Non-reflux pyelonephritis
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The majority of children with febrile
pyelonephritis do not have reflux or
any other urinary tract abnormalities
What causes urinary tract infections
in the absence of anatomic
abnormalities?
Non-anatomic causes of UTI
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“sticky bacteria”
dysfunctional bladder habits
dysfunctional bowel habits
all the above
Role of VCUG in children with
UTI
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A VCUG is necessary to diagnose
reflux
Treatment of reflux is helpful to
prevent pyelonephritis and renal
scarring
Thus a VCUG is not necessarily
needed in a child with normal kidneys
and lower urinary tract infections
Case 9
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A 15 year old girl notes that she leaks only
when she laughs. She is a cheerleader and
never wets during her routines. She is also
is a star soccer player and never wets
during her games.
Case 9 (cont’d)
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What is the diagnosis?
• “Giggle incontinence”
• Part of the cataplexy/narcoplexy
complex
• Treatment consists of behavioral
modifications
• Consider Ritalin for nonresponders
Case 10
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8 year old male
who presented
with urinary tract
infections
• Fever and flank
pain
Case 10 (cont’d)
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On further questioning….
• Previously was dry but now
has day and night wetting
• Significant daytime urgency
and occasional back pain
• Rarely has good stream
• Parents have noted that the
child also “walks funny.”
Case 10 (cont’d)
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Main diagnostic consideration: occult
tethered spinal cord
Relatively uncommon
Importance in early detection in that
delay in diagnosis may lead to
permanent neurological deficit
Case 11
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4 year old girl who is always wet. She has no
urgency, voids regularly, and has failed treatment
with empiric anticholinergics.
Key is the history of being “always wet”
Consider ectopic ureter.
• Ureter does not insert into bladder. Inserts into urethra
or vagina
• Surgery is curative
• Key is to consider the diagnosis
• Intravenous pyelography has very poor sensitivity.
Imaging for ectopic ureter
Imaging for ectopic ureter
Case 12
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5 year old boy who suddenly developed severe
daytime frequency. He doesn’t have any associated
wetting, has had no infections, will occasional wake
up at night to void.
He literally will void every 10 minutes and each
time he voids a small amount of urine will pass
Renal ultrasound is normal and anticholinergics
have not helped
What is the diagnosis?
Case 12
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“Daytime Frequency Syndrome”
• Unknown etiology
• Spontaneous improvement is the
rule
Thank you for listening