Transcript 44-COMMON PEDIATRIC UROLOGY.ppt

Common problems in
Pediatric Urology
Dr. Khalid Fouda Neel, FRCSI
Associate Professor of Urology and Consultant Pediatric Urology
College of Medicine and
King Khalid University Hospital
King Saud University
Common problems in
Pediatric Urology
Hydronephrosis in children
Pediatric Uro-Oncology
UTI
Neuropathic bladder in children
Voiding dysfunction and Nocturnal enuresis
External congenital anomalies
Pediatric Urolithiasis
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Antenatal Hydronephrosis
Causes
Pelviureteric junction obstruction (41%)
Ureterovesical junction obstruction (23%)
Vesicoureteric reflux (7%)
Duplication anomalies (13%)
Posterior urethral valves (10 %)
MCDK
Others (6%)
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Evaluation of Hydronephrosis
Antenatal Hydronephrosis
Postnatal Evaluation &
stabilization
Renal Ultrasound
after 48 hours
Negative
Repeat RUS 4-6 weeks
Positive
+/_ VCUG
Early evaluation in case
of ? PUV
VCUG
Nuclear Scan(5-30 days)
All patients should be on prophylactic Amoxcicillin 20 mg /kg/Day
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Presentation of UPJO
Incidental in Neonates
Incidental in Children
Symptomatic:
UTI
Pain
Mass
Hematuria
Stone
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Surgical Treatment of UPJO
Indications of Surgery
Symptomatic patients
Incidental finding in neonates:
Worsening hydronephrosis “Pattern”
 Reduced differential renal function
 Bilateral disease
 Poor family compliance
 Poor hospital setup******

Incidental finding in children?
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Obstructive pattern in Renal
scan and
IVU is not an indication for
surgery by
itself
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Ureterovesical Junction
Obstruction
Same principle of management of UPJ
IVP might be helpful > 6 months
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Duplication Anomalies
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MCDK
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Posterior Urethral Valves
Presentation:
Antenatal
 UTI
 Urine retention in neonatal life
 Poor urinary stream
 Uremia

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Management
Early:
Diagnosed bilateral hydronephrosis antenatally:
1. catheterization
2. prophylactic antibiotics
3. confirm diagnosis
4. stabilization
5. cystoscopic fulgration of PUV
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Management
Not diagnosed antenatally:
1. catheterization
2. Treatment of infection
3. stabilization
4. cystoscopic fulgration of PUV
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Management
Late:
Management of secondary complications
(VUR, valve bladder, CRF...)
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Vesicoureteric Reflux
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Normal anti-reflux mechanism
“flap valve”
1.Oblique course as it enters the bladder.
2. Proper muscular attachments to provide
fixation.
3. Posterior support to enable its occlusion.
4. Adequate submucosal length.
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Resolution of reflux
87% of Grade I
63%5 of Grade II
53% of Grade III
33% of Grade IV
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over 3 y. period
of follow up
Resolution rate is 30 to 35% each year.
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Management
Decision depend on:
1. Chance of spontaneous resolution (Age and
grade at presentation).
2. Breakthrough infection.
3. Renal scarring and renal function.
4. Compliance with medication.
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Vesicoureteric Reflux
Medical Management
In patients with UTI, and VUR can be
suspected, the child should be continued on
prophylactic antibiotics after Rx till the
VCUG is done.
If you decided this patient is for
conservative management, he/she is to
continue meticulously on prophylactic
antibiotic with surveillance with C/S, U/S
and DMSA.
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Typical indications of antireflux procedure
1. Breakthrough infection despite prophylactic
antibiotics.
2. Noncompliance with medical treatment.
3. Severe reflux (IV and V) especially with renal
scarring.
4. Failure of renal growth (renal U/S).
5. New scar formation.
6. Deterioration of renal function (Renal scan).
7. Reflux in girls at puberty.
8. Reflux with congenital anomalies (ureterocele,
diverticula).
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Antireflux procedure
1.Sting
2. Intravesical reimplant.
3. Extravesical reimplant.
4. Laparoscopic reimplant.
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ENDOSCOPIC INJECTION
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Urinary Tract Infections
* After treatment of the acute febrile
infection ; the child should receive daily
administration of a prophylactic
Antibiotic agent until full radiological
evaluation of urinary tract is done
(****hospital setup****)
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Neurovesical Dysfunction
Causes
1. Neural tube defects.
2. Anorectal malformation.
3. PUV.
4. High grade neonatal reflux.
5. Non-Neuropathic Bladder Sphincter
Dysfunction.
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Neurovesical Dysfunction
Management
Proactive vs. reactive management
All patients with anomalies which might
cause Neurovesical dysfunction showed
be periodically screened
If there are any initial signs of bladder
dysfunction prompt management should
start
RUS, VCUG, C/S, Urodynamic study
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Neurovesical Dysfunction
Indications for Surgical Reconstruction &
Diversion
Conservative management should
start first
Conservative management failed to
protect the upper tract
Conservative management failed to
gain normal bladder compliance
Poor family/child compliance
Refractory incontinence
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•3 y Female, known with spina
bifida
• was not seen by a urologist
before
•Came with history of Rec. UTI
•Paraplegic, constipated
•Normal renal function
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External Congenital Anomalies
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Voiding Dysfunction
Lazy voider
NNBSD
Pseudo-incontinence (vaginal voider)
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Non-Neuropathic Bladder
Sphincter Dysfunction
NNBSD
Triad of incontinence , UTI, and constipation
Squatting and urge incontinence
Management depend on the severity
Severity start from only mild diurnal
incontinence to sever bilateral VUR with CRF
Urodynamic study is helpful
Treatment spectrum from behavior
adjustment to major reconstructive surgery
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Nocturnal Enuresis
15% of all children at the age of 5
The incidence is declined by 1-2% /year
2% has NE at the age of 15
1% of adults population
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Nocturnal Enuresis
Keys for Effective Management
Child motivation
Monosymptomatic VS multisymptomatic
R/O voiding dysfunction
Small bladder capacity VS normal bladder
capacity
Convert the patients to the normal habits
Proper selection of the mode of the
management
Following proper steps
The physician should be convinced
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Nocturnal Enuresis
Nocturnal Enuresis
Mono symptomatic
Normal bladder
capacity
Small bladder
capacity
DDAVP
At least 3 months
Gradual tapering
Poly symptomatic
Management of nocturnal enuresis
& voiding dysfunction
DDAVP
+
Oxybutanin chloride
Behavioral modification
Behavioral modification
Alarm + vibration
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Alarm + vibration
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