The paediatric urology division has remained at the forefront of urological care by performing extensive endourology and also reconstructive surgery, especially with children born with extrophy of the bladder. Short hospital stay, good post-operative analgesia and care, and excellent results have made our hospital one of the institutions of choice for this speciality.
- ANTENATAL HYDRONEPHROSIS
Antenatal Hydronephrosis, which simply means fluid-filled enlargement of the kidney before birth, is detected in the fetus by ultrasound studies performed as early as the first trimester of pregnancy. In most instances this diagnosis will not change obstetric care, but will require surveillance and possible surgery during infancy and childhood.
Possible Causes Of Antenatal Hydronephrosis:
- Blockage – This may occur at the kidney in the Ureteropelvic Junction (UPJ), at the bladder in the Ureterovesical junction (UVJ), or, in the urethra (posterior urethral valve).
- Reflux– Vesicoureteral reflux occurs when the valve between the bladder and the ureter is incompetent permitting urine to flow back into the kidney when the bladder fills or empties. Almost 75% children outgrow this during childhood, but need daily antibiotic prophylaxis to try to prevent kidney damage before they outgrow the reflux.
- Duplications etc. Perhaps 1% of all humans have two collecting tubes from a kidney. These may show up on fetal ultrasound. Occasionally patients with duplication have ureterocele, which is a balloon-like obstruction at the end of one of the duplex tubes.
- Multicystic kidney is a nonfunctional cystic kidney.
- Normal Variant: Many of the dilated kidneys are found to be normal after delivery. It is likely that the dilation was due to the high urine output in the fetus and also because of the changes that occur in the kidney during development. Minor dilation of the kidney before birth does not always need evaluation after the child is born.
Management during Pregnancy: In nearly all instances of Antenatal hydronephrosis, ultrasound surveillance is all that is necessary. In the rare fetus with severe obstruction of both kidneys and insufficient amniotic fluid, drainage of the kidneys or bladder by tube or operation has been performed experimentally. For most cases of Antenatal Hydronephrosis pregnancy is not affected and delivery can be performed normally.
Management after Birth: Postnatal ultrasound is usually performed before the child leaves the hospital. Voiding Cystourethrogram (VCUG), which requires a catheter in the bladder, is performed to exclude vesicoureteral reflux. This occurs in 25-30% of children with antenatal hydronephrosis. Obstruction is excluded with a diuretic renal scan (requiring an IV and a catheter). The renal scan is more accurate if delayed until the baby is one month of age,
Children with vesicoureteral reflux are managed with antibiotics and surveillance with periodic ultrasound and voiding cystogram. Children with an obstruction or blockage of the urinary tract may require surgical correction. In some babies, the evidence for obstruction is marginal or the degree of blockage is mild. In these babies the tests might be repeated after a few months.
A multicystic dysplastic kidney doesn’t work, but the opposite kidney is usually normal. There exists an argument whether a multicystic kidney should be removed or left alone. Unless it is causing a problem with breathing creating and if questions exist of tumor or blockage – it is usually left alone in infancy and followed-up with ultrasound at 6 months and a year after.
- BLADDER AUGMENTATION & SUBSTITUTION
Main Reasons For These Operations
In some conditions such as Spina Bifida or posterior urethral valves or bladder exstrophy the bladder becomes very small and holds the urine at high pressures.
Incontinence and kidney damage are typical results of such abnormal bladders. For these patients, relief of their symptoms and protection of the kidneys requires that the bladder be increased in size (bladder augmentation). In some patients, removal of the bladder becomes necessary. This would most commonly be needed to treat a cancer of the bladder or other pelvic organs. For these patients, a new reservoir must be created (bladder substitution) with a pathway for drainage of the urine either through the normal channel (urethra) or through a new channel (stoma). Enlarging or replacing the bladder requires major surgery. These operations require the use of intestine to replace the bladder. The intestine is opened and reconfigured to create a normal appearing bladder. After surgery, the bowel needs to rest for several days before the patient can be fed. This usually requires a tube placed down the nose into the stomach to drain intestinal fluids and air.
Problems Of Bladder Augmentation And Substitution
- Catheterization: The intestine doesn’t function like the normal bladder. All patients need to use intermittent catheterization to empty their bladder.
- Mucus Formation: The intestine produces mucus. The normal bladder does not. This mucus can create several The mucus can cause obstruction of the catheters that are draining the bladder immediately after surgery. The catheters are irrigated several times daily to prevent this occurrence. Long term, the mucus needs to be evacuated daily from the bladder, or else the mucus that stays in the bladder is a source for development of bladder stones. It can also promote infection of the bladder. Over a period of time the mucus production will decrease, but it will still remain in minor quantity.
- Intestinal Complications: Early after surgery, the patient is at risk for leakage of intestinal contents. This is a very rare event that can lead to serious infection. The other major risk of intestinal surgery is bowel obstruction. This can be the cause of severe abdominal pain and cramping. Any of these symptoms should receive prompt.
- Bladder Rupture/Perforation: One of the most serious complications after surgery for bladder augmentation is rupture of the bladder. This is not common, but can lead to severe abdominal infection and even death. Most cases of bladder rupture are due to failure to perform catheterization on a regular basis. This leads to chronic over distention of the bladder and weakens the bladder wall due to ischemia. The symptoms are that of abdominal pain, fever and generalized infection. The patients and their family members need to be acutely aware of the risk for perforation so that they can alert other physicians that may be treating them to the possibility of this complication. Many clinicians are not as likely as urologists to suspect this diagnosis in a patient who has undergone augmentation.
- Bladder Cancer: Patients that are on intermittent catheterization for neurogenic bladder do have an increased risk for bladder cancer. Patients who have undergone bladder augmentation also hove a risk for bladder cancer.
- CIRCUMCISION/CIRCUMCISION REVISION
Circumcision is one of the oldest operations ever to be performed. Sometimes it is done because of a specific problem with the foreskin (prepuce) and other times it is performed routinely. Routine circumcision was once advocated for all newborn Males. This is now performed in about 65% of newborns. Most boys will do fine later in life if their foreskins are not removed. Some may eventually need circumcision because of narrowing at the tip (phimosis), infections (posthitis or balanitis), or irritation. The foreskin may be a source for urinary tract infections, and circumcision may be a good idea in boys with any underlying kidney abnormality.
In very young babies, circumcision is performed in the hospital or clinic with local anesthesia and a clamp. Although it is a commonly performed procedure. It is technically difficult. It is not uncommon for there to be some redundant penile skin after newborn circumcision. As the child grows, this will become less noticeable. Adhesions of the foreskin to the glans, or head of the penis, are also very common. If there is significant scarring, these can develop into skin bridges. Simple adhesions will usually resolve over time, but the skin bridges will require surgical correction.
Other complications of circumcision include bleeding, infection, skin separation, narrowing of the urinary opening (meatal stenosis), concealed penis and urethral fistula. Every circumcision may not look exactly like the “ideal circumcision” in the mind of the family members. The main purpose of circumcision is to remove the preputial ring to permit exposure of the glans penis. This is more of a functional purpose than a cosmetic purpose, and although we try to get a cosmetic result in line with familial expectations this is not always the case.
When a circumcision needs to be revised, we generally wait until the child is 6 months of age to minimize anesthetic risks. This is also the age that we will perform a first time circumcision if it was not able to be completed in the newborn. The procedure is done under general anesthesia in the outpatient surgery center or hospital. Any adhesions or other abnormalities are corrected and the excess redundant foreskin is removed. The skin is closed with small absorbable sutures.
Antibiotic ointment or Vaseline is suggested to be applied to the glans with every diaper change after circumcision. This is required for at least a few months to try to protect the newly exposed meatus from diaper irritation.
Constipation can be defined as infrequent passage of stool. Painful bowel movements and stool retention can be symptoms of constipation even when stool frequency is greater than three times per week. Encopresis, or incontinence of stool, is common in children with chronic constipation.
Constipation is very common in children with urinary tract infections, daytime wetting and nighttime wetting. Treatment of constipation includes education, prevention of impaction, promotion of regular bowel habits and toilet training in older children. Constipation is not a life-threatening condition. However, several months to years of supportive intervention may be required for effective treatment.
Daily bowel movements are a mainstay in treating constipation. The goal for your child is a soft bowel movement every day. You may help your child attain this goal by providing a daily stool time (ideally, 15 to 20 minutes after eating to take advantage of the gastrocolic reflex). Do not rush- allow your child plenty of time in the bathroom – usually 5 -10 minutes. Help your child keep a stool diary – When they have a bowel movement, make note of the consistency, soft or hard,
There are several treatments for constipation. There are several dietary measures that can improve constipation. Most important is increasing fluid intake. It is important to drink enough water to maintain clear or light yellow urine. Some foods can help constipation while there are others that should be avoided.
Some examples of foods to add or increase in your child’s diet include,
- Fruit juices, i.e prune, pear, plum, pineapple, peach, papaya, apricot, orange, or apple.
- Vegetables, either raw or cooked (eat the peels as often as you can).
- Fruits (eat the peels as often as you can).
- Bran cereal, bran muffins, raisin bran.
Examples of foods that may worsen constipation include;
- Dairy products, i.e. milk, cheese, ice cream.
- Rice or rice cereal.
- Pastas white breads, potatoes.
In many children, supplements to the diet may be prescribed to produce daily bowel movements. These include magnesium citrate, Miralux, mineral oil or Milk of Magnesia. Miralax or polyethylene glycol, works by holding onto water and making the stool softer. When mixed in water, juice, or soda MiraLax has no discernible taste. Dosages will be determined by your physician.
Management of constipation requires considerable patience and effort on both the child’s and the parent’s part. Providing support and encouragement during the treatment period is extremely important. Multiple clinic visits may be required until appropriate laxative dosage has been established, as dosage adjustments may be required. It is important to keep in mind that dietary factors alone will probably not alleviate chronic constipation if stool withholding and stool retention are a problem.
- DIAGNOSIS & TESTS
1)For Sleep Enuresis
While bed-wetting can be caused by a variety of urological problems, it is very uncommon for a child with bed-wetting to have any major urinary problem. In our general clinic, we find that only 1-4% have any urinary abnormality. While bed-wetting can cause a psychological problem in children, all enuretic children are psychologically normal. A psychopathology is not a causal problem for primary enuresis, and therefore treatment for a psychopathology is ineffective in reducing bed-wetting.
There are numerous theories that have been put forth about the causation of enuresis. It is generally considered a disorder of delayed maturation.
One contributory cause may be due to a deficiency of a hormone. This deficiency permits large volumes of urine to be formed during the night, which the bladder cannot hold and therefore empties.
Some of these children are thought to have a respiratory block, either due to adenoids or tonsils, and therefore have enuresis. Removal of these tonsils has sometimes been found to lead to an improvement in their bedwetting. Foods that have been prepared using milk as an ingredient, drinks containing caffeine and a large fluid intake also contribute to bedwetting. Some allergies such as fever, eczema, rashes, food and drug allergies are also thought to contribute to this condition.
Since only a very small percentage of these children have an organic urinary abnormality, evaluation of these children is very basic, which includes the following procedures:
- Physical Examination
- Urine Microscopy
- Ultrasound Evaluation
If all these are normal, pharmacological, psychological and behavioural treatment can be administered – quite often success is achieved with a combination of all three.
Signs of urinary tract infections include:
- Foul-smelling or cloudy urine
- Pain in the side
- Burning or pain when urinating
- Frequent and urgent urination
Infants with infection may not show these signs. Instead, they may have diarrhoea, poor feeding, fever and increased irritability. If there is any question, consult your doctor and have your child’s urine checked. Children can quickly become very sick.
Any child who has had a urinary tract infection with fever should be considered for testing to VUR. Children with frequent urinary tract infections should also be considered for testing. The following test will indicate whether or not your child has VUR:
Micturating Cystourethrogram (MCU): A test using x-rays and a special dye will determine whether or not if your child has VUR. Kidney infections may cause damage or scarring in the kidneys. This can result in poor kidney function and high blood pressure. Scarring and functions of the kidneys need to be documented by a nuclear isotope renogram (DMSA).
If you had VUR as a child, there is a chance that your children will also have VUR. Also, if one of your children has VUR, his or her brothers and sisters may also have it. For these reasons, it is important to discuss testing options with your child’s doctor.
3)For Urinary Tract Infection
The diagnosis and tests for urinary tract infection are as follows:
- Urine Test: Those children, who have a fever that has an unknown cause, must have a urine test performed. It hardly costs Rs.15, even in a private clinic, and will provide a very good indication if urinary tract infection is present. Once urinary tract infection has been detected, all children under the age of 5 years must undergo further tests such as :
- A Urine Culture
- Ultrasound Evaluation or an X-Ray: to find out both the degree and cause of infection, and decide on the treatment required. All boys above the age of 5 years and those girls with recurrent infection or infection with high fever will undergo similar evaluation. The goal of current practice is the early detection of urinary tract abnormalities and prevention of renal infection by either medical or surgical means. Long-term studies have shown a 10% incidence of renal failure, a 13% incidence of blood pressure, and another 13% incidence of toxemia during pregnancy. When one considers that renal scarring is the fourth leading cause for renal transplantation in children, the need for prevention becomes obvious.
- FETAL HYDRONEPHROSIS
Due to excessive use of ultrasound screening in pregnancy now-a-days the number of children with urinary tract abnormalities who are diagnosed prenatally is increasing. Approximately 20% of fetal anomalies discovered on ultrasound involve the urinary tract. Because the diagnosis of fetal hydronephrosis is being made more frequently, the need for a coherent approach to the diagnosis and management of these patients is readily apparent.
Fetal hydronephrosis encompasses a wide variety of urinary tract abnormalities. Although hydronephrosis may initially be thought of as an obstructive phenomenon, it also may be secondary to nonobstructive entities. The most common cause of obstructive hydronephrosis would be the ureteropelvic junction obstruction which may be unilateral or bilateral. The most severe form of obstruction would be complete ureteral atresia which leads to the development of a multicystic kidney. Other less common obstructive entities leading to various presentations of hydronephrosis include ectopic ureters and ectopic ureteroceles which are usually associated with duplex collecting systems. Ureterovesical junction obstruction leads to the development of an obstructive megaureter. Severe cases of vesicoureteral reflux lead to hydronephrosis in the absence of obstruction. Prune belly syndrome also presents with severe urinary tract dilation but in most cases, obstruction is absent. Posterior urethral valves and neurogenic bladders may cause either upper urinary tract dilation or vesicoureteral reflux secondary to bladder outlet obstruction.
The kidneys are usually visualized with ultrasound by the eighteenth week of gestation. The unobstructed fetal ureter is usually not identified, and the bladder may be seen to fill and empty in a normal cyclical pattern. After 18 weeks, the amount of amniotic fluid is a reflection of fetal urine output. Fetal obstructive uropathies ore identified by demonstrating a dilated renal pelvis or calyces, ureter or bladder. An abnormal urinary tract is found on postnatal evaluation in only 85% of cases diagnosed prenatally. The other 15% of cases can be described as having physiologic hydronephrosis which can be resolved. Once fetal hydronephrosis has been identified, attempts are made to assess renal function. After 20 weeks, oligohydramnios is an indicator of possible poor renal function.
Renowned medical expert Dr. Harrison and co-workers performed bilateral cutaneous ureterostomies via hysterotomy in a 21 week fetus with posterior urethral valves in the year 1982. Since that time, in utero intervention has been undertaken in a number of centers across the country, mainly utilizing different types of internal shunts between the amniotic sac and urinary tract. Although the technical expertise in doing these procedures has improved, there is much controversy concerning whether there is any positive effect on ultimate renal function. There is general agreement that in certain cases with oligohydramnios, pulmonary hypoplasia can be prevented by restoring adequate levels of amniotic fluid. In utero interventions are not without complications which include premature labor and chorioamnionitis As expected, since the prenatal ultrasound diagnosis is often unreliable, there are numerous reports of in utero intervention for obstructive uropathies which were not actually present. Bilateral hydronephrosis secondary to ureteropelvic junction obstruction or an obstructive megaureter does not require in utero intervention or early delivery. Most of these patients will have a normal contralateral kidney and normal amniotic fluid volumes and, therefore, renal function should be adequate. In fetuses with bilateral ureteropelvic junction obstruction who have normal amniotic fluid volume, in utero intervention is not indicated and early delivery is not recommended. In fetuses with nonobstructive hydronephrosis secondary to reflux, in utero intervention is not beneficial. In cases of severe oligohydramnios where there is indication of severe renal dysplasia on ultrasound, in utero intervention will be unsuccessful in reversing ultimate renal failure. The number of fetuses who are candidates for intervention is extremely small and would include the fetuses with evidence of posterior urethral valves who has displayed some capacity for making adequate urine. Prior to placing a vesicoamniotic shunt or performing a vesicostomy through an open hysterotomy, the fetal urine is analyzed for sodium and chloride concentration and osmolality which are sometimes predictive of satisfactory renal function.
Postnatal Diagnosis And Treatment
Ultrasonography should be the initial examination in a newborn who carries an antenatal diagnosis of hydronephrosis. The ultrasound findings may be able to confirm the diagnosis, but usually further imaging studies are required in order to identify the etiology of the hydronephrosis. All children with antenatal hydronephrosis should undergo a voiding cystogram in order to rule out vesicoureteral reflux. Even though 15% of fetuses will have physiologic hydronephrosis, which may have resolved completely by the postnatal ultrasound, intermittent hydronephrosis can be caused by vesicoureteral reflux. In children whose postnatal ultrasound is normal shortly after delivery, a follow-up ultrasound should be obtained 4 to 6 weeks after birth to ensure that the absence of the hydronephrosis is a permanent finding. In some patients with significant obstruction, the ultrasound in the immediate newborn period will be normal due to transient oliguria. In those children whose ultrasound is consistent with ureteropelvic junction obstruction, the next imaging study is usually a MAG 3/DTPA renal scan with Lasix washout which can confirm the level of obstruction, as well as quantitate the degree of obstruction. A number of children will have dilation without obstruction which is documented by adequate washout of isotope from the renal pelvis after Lasix. Children with this presentation require close observation during infancy since some will subsequently develop an obstruction which requires surgery. In those children whose scans confirm a high-grade obstruction, surgery may become necessary to correct the obstruction. Even if the functioning is poor, the neonatal kidney has the capacity for significant improvement in function fallowing pyeloplasty. In children with obstructive megaureter, an intravenous pyelogram will sometimes be indicated in order to better define the anatomy of the renal unit including outlining ureterocele. Children presenting with posterior urethral valves confirmed on voiding cystogram, should undergo primary valve ablation in the newborn period. Certain newborns presenting with a history of antenatal hydronephrosis will benefit from prophylactic antibiotics until their definitive surgery is completed or their urinary tract is shown to be free of abnormality.
The detection of hydronephrosis in utero is increasing because of the widespread use of prenatal ultrasound screening, Consequently, the diagnosis of an obstructive uropathy is being made much earlier in life than in the past. Earlier diagnosis allows for earlier reconstructive surgery, thereby maximizing renal function. Although in utero intervention is indicated in only a very small percentage of cases, prenatal counseling concerning the prenatal ultrasound findings is an integral part of maternal care.
- HYDROCELES AND HERNIAS
Hydrocele is a collection of watery fluid around the testicle. This is a common problem in newborn males (6-10%) and usually goes away within the first year of life. When the testicle drops into the scrotum before birth, a sac from the abdominal cavity travels along with the testicle. Fluid from the abdominal cavity can then flow down into the scrotum to surround the testicle. The sac usually closes off and the fluid is absorbed, but sometimes the sac persists (communicating hydrocele) or the fluid fails to be absorbed (noncommunicating hydrocele). In unusual instances the hydrocele fluid can be result of an abdominal inflammation, or a testicular problem (injury, torsion, infection and tumor). Sometimes the hydrocele may not be in the scrotum, but higher up in spermatic cord. A progressively enlarging or symptomatic hydrocele should be fixed. If the hydrocele is suggestive of tumor or torsion, urgent exploration is performed. A large noncommunicating hydrocele persisting after 12-18 months of age is unlikely to go away and should also be fixed.
The extension of the abdominal sac that passes into the groin is called the processus vaginalis. This usually closes off by the time of birth. If it remains open, fluid can pass down into the groin and scrotum in boys to form a hydrocele. If the sac is wide enough it can allow other abdominal contents such as intestine or fat (in girls, the ovary) to travel down it. These structures can pass in and out of the hernia sac, but sometimes get stuck and are called incarcerated hernia. Inguinal hernias occur in both sexes, but are more common in boys, being found in 1-4%. The incidence is much greater in premature babies (30% for very low birth weights). Hernias favor the right side, but may occur on both right and left. The usual hernia is a lump or bulge in the groin or scrotum. Usually asymptomatic, the hernia can cause pain, fussiness, or even bowel obstruction. Although the hernia contents usually pass back into the abdominal cavity intermittently (reduction of the hernia), the sac does not disappear by itself; therefore a hernia should be fixed surgically. If a hernia becomes strangulated, the involved intestine will die and have to be removed. This is a life-threatening situation.
CORRECTION OF HYDROCELE/HERNIA
These problems are corrected in children via a groin incision. In children with hydroceles we ligate the patent processus vaginalis and then remove the watery fluid. Possible complications include bleeding, infection, pain and recurrence of hydrocele. A hernia is also approached through the groin and the hernia sac is separated from the spermatic cord vessels and vas deferens. The sac is then tied off, where it originates from the abdominal cavity. Pediatric hernias (indirect inguinal hernias) are usually different from adult types, which tend to have a muscle weakness that must be fixed. Muscle repair is rarely necessary for pediatric hernias. Hernia complications (in addition to bleeding, infection and recurrence) include hydrocele formation, injury to spermatic cord vessels and damage to the vas deferens. With any groin or scrotal operation there is always a small chance that the testicle could be damaged or lost.
Hypospadias is a birth defect found in boys in which the urethral opening is not at the tip of the penis. Although a genetic factor exists in the development of hypospadias, no single cause has been identified. Bending of the penis on erection may be associated with this and is known as chordee. The overall incidence of hypospadias is about 8.2 in every 1,000 male births. There is some family risk of hypospadias. When we see a boy with hypospadias there is a 15% chance of finding this in another family member such as father or a brother. There are different degrees of hypospadias, some minor and others more severe. In most children, the opening of the urethra is near the end of the penis. We name the types of hypospadias according to their anatomic location, but it is necessary to determine whether or not there is associated chordee. The degree of curvature is most important in determining the type of surgery needed and if the surgery can be completed in one operation.
Some children may have chordee without hypospadias. The urethral opening in these patients is in the normal location.
Reasons for Correction
Surgical correction of hypospadias involves straightening of any chordee and then extension of the urinary tube (urethra) out to the tip of the penis (the glans). A straight penis is necessary for satisfactory sexual function. Although this may not seem to be an important matter in childhood, this is a crucial concern later in life.
Surgical Correction of Hypospadias and Chordee
There are many operations used for treatment of hypospadias. Fortunately, the techniques have improved dramatically decreasing the number of operations needed to correct this condition. When the operation is completed, any extra skin is removed so the child will look circumcised. It is recommended that the children have surgery to correct hypospadias at about 6 to 8 months of age. Although we try and correct most children with one operation, some of the more severe cases are best managed with two surgeries. A small number of patients may also require a second surgical procedure to mange complications of the surgery. If that is necessary, the second operation is delayed for 6 to 12 months by performing the first operation early in life then both operations can be completed before the child completes toilet training. Correction of hypospadias is performed on an outpatient basis under general anesthesia. Depending upon the severity of the hypospadias, some children will need to go home with a catheter that drains urine from the bladder and allows the new urethra to heal. This tube will be left in place for one to two weeks. This will drain into the baby’s diaper until it is removed. We also leave a bandage on the penis. Due to the nature of the surgery, there can be considerable swelling and discoloration of the penis for a period of time after the surgical repair.
Infection of the skin and urine are few of the possible occurrences. Bladder spasms are usually due to indwelling catheter. Medications help but do not eliminate spasms. Fistula is another risk. This is a leak of urine from somewhere along the new urethra. This risk is minimal in simple repairs, but may occur 10% of the more extensive operations. Fistulas are usually easily repaired with an outpatient surgical procedure, although this is done no sooner than 6 to 12 months from the time of the original operation.
Stricture or stenosis consists of narrowing due to scar tissue where the new urethra joins the native urethra or at the new opening on the end of the penis.
- LABIAL ADHESIONS
Labial adhesions occur when the inner folds of the female genitalia (labia) temporarily grow or adhere together. They are most common in young girls (3 months to 6 years of age). Labial adhesions are related to hormonal influence. Labial adhesions usually occur due to inflammation of the skin which makes the labia adherent or
Labial adhesions usually occur due to inflammation of the skin which makes the labia adherent or stick to each other. Poor genital hygiene and bacteria normally present in the area may contribute to labial adhesions. Keeping the area clean and dry is important in the treatment and prevention of labial adhesions.
The majority of labial adhesions are asymptomatic. Post-void dribbling may occur due to labial adhesion. Urinary tract infections are rare with labial adhesion.
The initial treatment of labial adhesions is a trial of Estrogen cream. If this is the method chosen for your daughter, then you will need to apply the Estrogen cream 2 times per day for 2 -8 weeks as directed by your urologist. Use a pea-sized amount of cream and apply the cream to the middle of the adhesion and apply slight pressure with your finger.
Occasionally, a doctor will recommend separating the labial adhesions in the office with topical anesthetic (numbing cream). In some children, this procedure is done under general anesthesia in the hospital.
Once the adhesions are gone, you will want to prevent them from recurring. It is important to apply a thin layer of Estrogen cream on the area every night for atleast a month.
- MULTICYSTIC DYSPLASTIC KIDNEY
Multicystic dysplastic kidney (MCDK) is the term used to describe a congenital renal anomaly that consists of a kidney completely replaced by multiple cysts that are held together by connective tissue. The kidney looks like a bunch of grapes. The ureter is often atretic or absent. The cysts often do not communicate and this condition must be distinguished from hydronephrosis. With increasing utilization of prenatal ultrasound, the common mode of presentation has changed dramatically. At the present time, 47% are detected prenatally, 30% present with a flank mass, 5% urinary tract infection, 18% other presentations. It is more common in males and there is a slight left-sided predominance.
The diagnostic evaluation includes a renal ultrasound which shows several characteristic features that helps to distinguish a multicystic kidney from a hydronephrotic kidney. To substantiate the appearance of the renal ultrasonogram, a renal scan, DMSA, (or) MAG-3 is usually obtained. This test usually confirms the absence of renal function. In additions, this test helps to evaluate the contralateral kidney. In 18% of the cases, a contralateral renal abnormality may be encountered. In some cases, there might also be contralateral vesicoureteral reflux. For this reason, a nuclear cystogram or voiding cystourethrogram is also recommended.
If the condition is detected prenatally, it is important to visualize the opposite kidney to see whether it is abnormal. At the same time, the amniotic fluid volume should be assessed to make sure that it is adequate. If the amniotic fluid volume is markedly decreased and if there is bilateral renal disease, further steps should be taken to assess the viability of the baby. Luckily, the disease is rarely bilateral and the patients usually do well with one kidney.
The treatment of this condition is debatable. One group favors surgical removal of the kidney and the other favors observation. The risks of leaving the kidney in place include hypertension (rare) and the development of a renal tumor. Only 6 cases of renal tumors have been reported, 3 in childhood. The childhood tumors occurred at 10 months, 4 years, and 15 years; whereas, the adult tumors occurred 26 and 68 years. Based on the incidence of this disease, the risk of developing a tumor is low. If the kidney is left in place, the patient must be observed yearly with renal ultrasound and blood pressure measurement.
In rare occasions, the diagnosis of MCDK will be inconclusive despite the radiologic workup and in this situation, surgical exploration is indicated.
- SPINA BIFIDA
Children who are born with spina bifida frequently have abnormalities of the urinary tract. The urinary tract consist of several components (see diagram).
The kidneys are the organs that are responsible for filtering waste products from the blood stream and produce urine continuously. The urine drains down tubes called ureters to the bladder, which normally stores urine and empties intermittently by muscular contraction. The urine exits the bladder through the urethra. This process is called voiding or urination.
The proper filling and emptying of the bladder requires an intact sacral spinal cord. To achieve urinary control, one has to be able to feel bladder fullness. This signal is transmitted to the spinal cord and then to the brain. In an older child or adult who has normal urinary control, the brain is able to inhibit the bladder from contracting until it is socially acceptable.
In many children with spina bifida the nerves to the bladder that control this reflex voiding are damaged. Only about 5 to 10% of children with spina bifida have normally urinary control and are able to toilet train and void spontaneously. The remainder of the patients have some abnormality. This can result in poor urinary control and incontinence. More importantly, the neurogenic dysfunction can lead to damage to the kidneys and bladder. Evaluation of the urinary tract is done shortly after birth. We obtain a renal ultrasound of the
Evaluation of the urinary tract is done shortly after birth. We obtain a renal ultrasound of the kidneys in newborns with spina bifida. There is an increased incidence of congenital abnormalities of the kidneys in children with spina bifida and these need to be recognized early in life. It is also important to obtain an ultrasound in a newborn, so that we can later determine if there has been any damage to the kidneys from the abnormal bladder function. We also will obtain an x-ray of the bladder called a voiding cystourethrogram. This is done to assess for reflux (or backing up) of urine into the kidneys. We also can evaluate the bladder size and the urethra.
The most important evaluation by the urologist in children with spina bifida is urodynamic studies of the bladder. These are also called cystometrogram. This study involves placing a catheter into the bladder and filling the bladder with water. While this is done, the pressure in the bladder is continuously monitored. We can also measure the pressure in the urethral sphincters (the muscles that control urination). The results of this test can predict for us very accurately whether the child is at risk for developing renal damage. The critical measurement is the pressure in the bladder at which time the urine begins to leak out around the catheter when the bladder is filled. In about half of the children with abnormal function we find that a very high pressure develops before the urine begins to leak from the bladder. If this pressure is higher than 35 cm H20, then it will result in back pressure on the kidneys. The ureters that drain the urine from the kidney to the bladder are not strong enough to transport urine to the bladder when the bladder pressure is consistently higher than 35 cm H20. If these children are left untreated they will later develop problems.
Management Of Neurogenic Bladder
- Low Leak Point Pressure (<35 cm H20)
Children that are able to leak urine freely from their bladder when it is filled during the urodynamic study (pressure less than 35 cm H20) can be followed expectantly. We will repeat the urodynamic studies at about age 6 months and then again in one year. These children usually do quite well and are at low risk for infections or any other kidney problems. They will be followed with renal ultrasounds on an annual basis for the first couple of years of life.
- High Leak Point Pressure (> 35 cm H20)
Infants who are found to have high bladder pressures at the time they leak urine during the urodynamic study require early treatment. Most of these children can be managed quite effectively with intermittent catheterization. The bladder is emptied every four hours with a small tube. This is done with a clean technique. The catheter is just washed with soap and water and then rinsed carefully. The catheterization is only done every four hours during the daytime. We generally do not require that this be performed during the nighttime. Many of these children will also need to be placed on medication to lower the bladder pressure.
- Spontaneous Voiding
About 5 to 10% of children with spina bifida will be able to void on their own. When we recognize this in the newborn, the child still needs to be followed very closely. As the child grows, they can develop tethering of their spinal cord due to scarring. This can affect the bladder function. For this reason, until the child is toilet trained, we periodically repeat the urodynamic studies to look for any loss of bladder function.
Urinary Tract Problems
- Urinary Tract Infections
Urinary tract infections are common in children with spina bifida. They occur more frequently in those patients who have high bladder pressures particularly if they are not being managed appropriately. In children who are on intermittent catheterization, we frequently see bacteria in the urine. This surprisingly causes little problem for most patients. We generally do not recommend treating the bacteria unless the patient develops symptoms. This can include pain in the bladder area, fever, blood in the urine, increased wetting or occasionally a foul odor to the urine. The most important aspect of preventing urinary tract infection in children with spina bifida who are on intermittent catheterization is to be sure that the bladder is emptied at frequent intervals. Also, we need to maintain a low bladder pressure in these patients.
A. Surgical Management of High Bladder Pressure:
Temporary measures can also be used to help lower the bladder pressure. This includes cutaneous vesicostomy, which is a temporary diversion of the urine. The bladder is opened to the abdominal wall midway between the belly button and the pubic bone. This allows the bladder to continuously drain urine at a low pressure. At a later age, the vesicostomy is closed and bladder management is performed as outlined below. Another alternative is to dilate the external urethral sphincter, which will lower the pressure at which the urine leaks out the bladder. Again, these are temporizing procedures until a more definitive treatment can be done.
B. Medical Management:
As mentioned above, most children that have neurogenic bladder secondary to spina bifida require treatment for urinary incontinence. For most patients, this consists of intermittent catheterization and medications. About 50% to 60% of patients will be dry with this management alone. The medications that are used generally fall into the category of anticholinergic medication. These drugs work to counteract the activities of bladder muscle. Because they are not bladder specific, they work on other parts of the body as well as the bladder. For this reason, side effects are common, but expected. These include dryness of the mouth, facial flushing, and decreased sweating. All of these will contribute to the child having poor heat tolerance. We also see difficulty with constipation and even rarely diarrhea. This needs to be carefully watched because of the often present bowel dysfunction. Less commonly, children will have difficulty with drowsiness and headache. The different medications used include, Ditropan (oxybutynin), Levsin and Probanthine. If the anticholinergic medication fails to relax the bladder, there are other types of medications that can also be used such as Tofranil (imipramine) and Hytrin. These work on different aspects of the bladder muscle and may sometimes be successful. In some patients who cannot tolerate the medicine due to side effects, we can also place the medicines within the bladder through the catheter.
C. Surgical Management of Incontinence:
In some children the bladder muscle is so abnormal that it will not respond to the medication. This is more often the case if the child is not managed aggressively from birth. In such cases, if the pressure remains high despite putting the child on the maximal doses of medication, we may need to surgically enlarge the bladder which can be done in several ways. The most common procedure in the past has been enlargement with a segment of the intestinal tract. This will invariably ensure a low pressure reservoir for storing urine. However, there are other problems associated with this procedure such as bladder stones, mucous in the urine and increased infections. Another cause for incontinence in children is inadequate resistance in the sphincter area. For these children there are also a number of surgical treatments available. This can include a pubovaginal sling, periurethral Defiux injection or occasionally an artificial urinary sphincter.
- SLEEP ENURESIS (Bed-Wetting) IN CHILDREN
The most common urological problem seen in children is bed-wetting during sleep (medically referred to as sleep enuresis or nocturnal enuresis). About 10-20% of children between the ages of 5 to 6 years are known to wet their bed. It is estimated that there are around 80-110 million enuretic children in the world. Enuresis is more common in first-born children, more prevalent in boys than in girls, and is much more common if the parents have also had a similar problem or if there is a family history of the condition.
If one parent has had a similar problem, there is a 44% chance of his or her child, or children, having this problem. If both parents have had this problem, then there is a 77% chance of their child, or children, having a similar problem.
Enuresis is considered a disorder only if the child is at least 5 years of age and the problem continues more or less continuously for approximately one year. It is primary enuresis if it has been present since birth and considered to be secondary enuresis if it starts between the ages of 5 and 8, that is, after the child has been toilet trained.
Apart from the commonly faced problem of changing the sheets, bed-wetting needs to be handled sympathetically because it affects the self-esteem of the child. A positive change occurs in children who are successfully treated. Therefore, treatment is definitely worthwhile.
Enuretics who wet only at night and have no other abnormalities in their urological history, are termed to be monosymptomatic and have monosymptomatic nocturnal enuresis (MNE). They must be distinguished from children who have both night-time incontinence and daytime symptoms such as urgency, frequency or incontinence
Approximately 25% of children who attain initial night-time dryness by the age of 12 years, relapse and wet for a period averaging 2.5 years, relapse and wet for a period averaging 2.5 years.
Nocturnal enuresis has a spontaneous resolution rate of 15% per year so that, by the age of 15, it persists in only 1% of the population.
MNE is a symptom rather than a disease. A number of theories have been proposed which include behavioural, genetic, developmental, neurologic, psychological, urodynamic and organic causes. There is no single explanation for this symptom and an individual factor, or multiple factors, may be operating.
Clearly, the vast majority of children with MNE do not suffer from psychiatric, neurologic or urological disturbances and therefore investigation and treatment along these lines is both inappropriate and unrewarding.
There could be several causes for MNE in children:
For Sleep Enuresis : A number of treatment modalities have been used to treat nocturnal enuresis. However, their effectiveness, even in control studies, has been difficult to assess because of the high spontaneous resolution rate and the extremely high placebo improvement effect, which can exceed 65%.
Therapy generally follows two lines – drug therapy and behavioral modification.
Parents have different attitudes and expectations about bed-wetting and its cure. Treatment for MNE should generally be discouraged before the age of 7 years, because even the success rates for treatment before this age are very poor.
Urodynamic Findings: Bladder instability does not occur in children with MNE at a higher rate than in normal subjects, and in most enuretics, unstable contractions are not the cause for bed-wetting. Consequently, therapy for eliminating uninhabited contractions is generally ineffective. However, the single most important observation in MNE is a reduced bladder capacity. This reduction is functional and not anatomic. It is not the cause for enuresis, although it often increases coincidentally with cure. Those children who have diurnal symptoms of frequency, urgency or even incontinence, will have bladder instability.
Sleep Factors: Sleep patterns of enuretics are not different from those of normal children. Most enuretics neither have a disorder of arousal nor wet as a consequence of sleeping too deeply. Instead, findings support the concept that enuresis is related to a delay in CNS development, or more accurately, a dual delay in the development of perception and inhibition of filling and contraction of the bladder by the CNF.
Alteration in Vasopressin Secretions: About 50% less urine is normally excreted during the night than during the day. In many children with enuresis, the circadian rhythm of plasma vasopressin secretion is altered, with no decrease in AVP during the night. This causes them to produce larger amounts of dilute urine at night. Administration of vasopressin will be helpful only in those children in whom this increased nocturnal urine output has been documented. Studies indicate that the circadian rhythm of AVP matures over time, and it indicates that enuresis associated with AVP-induced nocturnal polyuria may simply represent another manifestation of developmental delay.
Developmental Delay: All the seemingly unrelated alterations in urodynamic function, sleep, AVP secretion, etc., that have been mentioned above, all occur normally in infants and young children and actually represent a varied expression of neurophysiological immaturity. In most children, MNE represents a delay in development, and each of these physiological alterations tends to improve with time, and to resolve spontaneously.
Organic Urinary Tract Disease: Most children with MNE do not have an organic urinary tract cause for their wetting. The incidence of an organic urinary tract cause is less than 0.4%. MNE should be distinguished from enuresis associated with daytime symptoms. Such children, especially boys, should undergo urinary tract imaging with an ultrasound to search for signs of possible obstruction.
A detailed history, physical examination and a urine analysis are sufficient for most children with primary MNE. The goal is to identify those children who require further study. History of urinary tract infection, diurnal symptoms, obstructive symptoms or certain signs of neuropathy must be pursued. In their absence, there is generally no indication for radiographic study or cystoscopy.
- TESTICULAR SELF-EXAMINATION
Regular examination of the testicles should be a routine part ‘of the health program of every adult male. The main reason for this suggestion is that cancer of the testicles is one of the more common tumors that occur in men, particularly between the ages of 20 and 40. All males should learn self-examination and make a point of checking themselves each month. Only by learning what the normal anatomy of the testicles feels like will they be able to detect any changes that might occur.
The exam should be done in a comfortable position. Some men prefer to check themselves in the shower or bathtub. The shape and position of the testicle should be inspected. On the outside or lateral surface a groove called the lateral sulcus can be felt between the testicle and the epididymis, which connects to it. The testis normally feels firm, but not too hard.
Areas of the testicle which feel very hard or tender may be due to a growth (tumor) which can sometimes be a cancer. When found these should be checked promptly by an urologist. Most testicular cancers are curable when discovered early. Boys with an undescended testis (UDT) have an increased risk of testicular cancer. Also both testicles are at increased risk of cancer even if the child had unilateral UDT. The risk of cancer is greatest after puberty. This is when routine exams should begin. Pain in the testicle may be due to injury, infection or tumor, but the most immediate worry is torsion. This is twisting of the testicle, which causes acute pain and swelling. If the twist is complete and unreleased, the testicle’s blood supply will be blocked and the testicle will die. In some cases, the twisting is intermittent. All cases of acute testicular pain should be consulted to an urologist,
- TIMED VOIDING PROGRAM
Some Children Hold Their Urine Too Long
Many children with wetting or infections are infrequent voiders, but they can be hard to recognize. After toilet training, parents don’t usually know when a child urinates and the intervals between urination may become surprisingly excessive. This is particularly true if a child has had urinary accidents or infections with burning. As a result, they may deliberately hold back on urinating. The result is stagnation (resulting in bacterial overgrowth) or spillage from an overfilled bladder.
You Can Lead a Horse to Water
It is almost impossible to make children void (pass urine) if they don’t want to do so. Furthermore, if a child has a lot of emotional pressure or fear of punishment they may be unable to relax sufficiently to void effectively. Normal urination requires relaxation of the pelvic floor coordinated with contraction of the bladder muscle. The pelvic floor, like your biceps, is a muscle that you can voluntarily move, but the bladder muscle (like your heart or intestine) is an automatic muscle that you cannot order around. Normal voiding requires relaxation, not pushing and straining.
Voiding Habits (GIRLS):
Sit back on toilet
Foot support if necessary
Relax, don’t strain or push Knees apart
Take your time
When you are finished, relax and try again – there may be more urine to empty
Voiding Habits (BOYS):
Open fly completely
Relax, don’t strain, push or rush
When finished, wait a moment and try again
Sit if it helps
In a Timed Voiding Program you will try to relearn to empty the bladder when it’s time to go, rather than waiting until you have to go (because by then it may be too late!). Voiding is done by the clock or by a schedule. The idea is to keep the bladder empty so urine will be less likely to leak or to get infected. Usually the timed voiding program is necessary only in the daytime. When at home or at play an alarm watch or alarm on the mobile phone may be a good way to remember when it’s time to void. During school, however, it’s better to establish a schedule such as: go to the bathroom as soon as you get to school, go to the bathroom at the midmorning break, go to the bathroom at the start of lunch time, go to the bathroom at the end of lunch time, go to the bathroom in mid afternoon, go to the bathroom just before leaving school, once at home go by the clock => every three hours. When following this program, the voiding habits described above are important so that the bladder can be thoroughly emptied without straining.
Sometimes people will say that they “cannot void” or “do not have to void”. This is rarely the case, because everyone makes urine continuously – so if the bladder has not been emptied in the past three hours there will be at least 100 ml to 200 ml of urine in almost anyone. The job is to learn to relax when it’s time to urinate.
The following are the various types of treatments:
- Anticholinergic Therapy: has had an effectiveness ranging from 5% to 40%. Although these ranges increase the functional capacity of the bladder, the relapse rate is also high. The usual recommended dose of Imipramine is 25 mg for children between 5 and 8 years of age and 50 mg for older children (0.8 to 1.6 mg/kg per day), which should be given as a single dose shortly before bedtime.
- DDAVP: This drug, administered in the form of a nasal spray, has been effective in about 25% of cases. It works by reducing the urine output at night. The usual clinical dose is between 10 and 20 mcg per night for the nasal spray and 200 to 400 mcg per night for the tablets. The therapeutic effect of DDAVP is temporary. Once the treatment is stopped, 50 to 90% of children relapse and resume their original pattern of wetting.
Behavioural Modification: Behavioural modification should be considered as the first line of management in enuresis. Bladder training, responsibility reinforcement, conditioning therapy using the urinary alarm, are all a part of this management – the last being considered the most effective approach available for nocturnal enuresis.
The following are the recommendations for the most effective evaluation and treatment plan:
- Screening for Urinary Abnormalities: The doctor should screen for any possible urinary abnormalities. If something is found, a referral can be made to the urologist.
- Reduction in Liquid Intake: All children should decrease their liquid intake by one-half of normal levels starting from evening onwards.
- Avoidance of Caffeine: Most children should avoid caffeine.
- Adequate Sleep: Children should get adequate time in bed. The average 8-year-old needs about 10 hours of sleep per night.
- Use of an Alarm at Night: An alarm should be used to wake up the child so that he or she can pass urine at night. Due positive reinforcement should be provided to the child for dry nights. Parents should not punish children for this problem.
- Changing of Bed Linen: To help them have a positive outlook, children may be made to change their bed linen when wet. Do not use diapers for children with this conditions.
- Progress Chart: A progress chart will be a good record for these children.
- Urination Before Going to Bed: Children should urinate just before going to bed.
For Further Information:
Please go to UrologyHealth.org (http://www.urologyhealth.org/) – a patient education site written and reviewed by urology experts in partnership with the American Urological Association Foundation.
- TORSION OF THE TESTICLE
Torsion of the testicle is the most common pediatric urologic emergency. This usually happens because the sheath of blood vessels that supply the testicle becomes twisted or torsed. In the fetus the testicle develops with the abdomen and migrates into the scrotum, trailing behind it like a leash is its blood supply. In the scrotum the testicle resides within a smooth sac called the tunica vaginalis. The testicle can spin and move about within the sac. The twisting or torsion blocks the blood vessels, which supply the testicle with oxygen and other nutrients. When torsion has occurred and is unrelieved the testicle can die.
Sudden scrotal pain is the most common symptom. This pain is due to ischemia or lack of blood flow. This is similar to the chest pain that occurs when a patient has a heart attack. The pain is usually on one side, but it can spread and be felt in the groin, abdomen, and flank. About one in four will have nausea and vomiting. The pain can come during activity such as sports or after minor accidents. It can come on at rest or even during sleep. Children, particularly teenage boys, are often reluctant to report testicular or scrotal pain. Hours and sometimes days can pass before they are seen by a doctor. The diagnosis of torsion can be difficult to make. Other illnesses can appear like torsion. But because torsion if left untreated, will lead to the loss of the testicle, any acute scrotal pain is treated as torsion until proven otherwise.
When testicles have been torsed they can sustain injury. The key factor is the length of time that the blood supply is occluded. Torsion relieved within six hours or less usually results in no lasting effects. After six hours the risk of damage increases. These injuries can cause decreased sperm production and fertility.
The only treatment of testicular torsion is immediate detorsion and operative fixation of the testicle to the scrotal wall. Occasionally it is possible to manually untwist the testicle, but the safest and surest course of action is surgical exploration. The child is put under general anesthesia and a small incision is made through the scrotum. The testicle is examined under direct vision. After the testis is untwisted, it is observed. If the testicle has already died it is removed. If it looks normal and healthy, it is securely sewn to the scrotal wall to prevent any further twisting. When torsion is found on one side the other testicle is also explored and secured to the scrotal wall with sutures. Experience has shown that if one testicle can twist the other one can as well. The surgery usually takes about one hour to perform and most children are able to go home either on the same day or next day.
Some boys and men will present with intermittent pain of the testicle. This can last for several minutes or a few seconds. This pain may be related to intermittent torsion of the testis. Due to the start time and span of symptoms, the findings have often resolved by the time the patient presents to the doctor. If the history is typical of torsion, the patient may be scheduled for elective fixation of the testis. This is necessary to prevent an episode of torsion which will not spontaneously resolve leading to testicular damage.
- URINARY TRACT INFECTION IN CHILDREN
For Urinary Tract Infection
Treatment of VUR is important to protect the kidneys, by preventing possible infections and kidney damage. There are 3 options for managing or treating VUR:
- Medical Treatment: Antibiotics are prescribed and are administered either orally or through injection, depending upon the condition of the child. If the child is very ill, the antibiotics are administered through injections. Otherwise, the medicine is orally administered.
Urinary tract infection is quite common in children. Surprisingly, it is as commonly, not diagnosed. Infection of the urinary tract occurs both in normal children and in those with some urinary tract abnormality.
The reason why so much of importance is placed upon the diagnosis and management of this problem is because, firstly, unlike other diseases, infants who have urinary tract infection may not have any symptoms pertaining to the urinary tract at all. The common belief that most parents have is that an infant with urinary tract infection should have symptoms such as a burning sensation while urinating, blood in the urine, difficulty in passing urine and so on.
This belief is incorrect. Infants who are less than one year of age may only not feed well and may have fever, loose stools, vomiting, etc. Unless one has a high degree of suspicion about the presence of a urinary tract infection, it can be missed.
The second reason is, if urinary tract infection is missed, it can cause disastrous results. If the kidneys are affected because of urinary tract infection, it can result in irreversible kidney damage and have negative long-term consequences. These are renal scarring, blood pressure, protein in the urine or ultimately, chronic renal failure. When these have set in, no matter what is done at a later stage, the problems cannot be set right.
Infection commonly occurs as a result of bacteria ascending from the genital area. Girls have a higher incidence in their early years because of their short urethra. There may be numerous other causes contributing to the incidence of infection, in which either the urine flowing down from the kidney may be blocked at different levels, or the normal flow of urine out of the bladder is disturbed, with urine flowing backwards into the kidney. Kidney scarring, the most serious long-term result, occurs due to the urine flowing backwards into the kidney, or because pressure in the kidney is increased by the block and there is added infection. This, in turn, leads to decreased kidney function and even blood pressure. Those who had infection very early in their life and who had severe scars in the kidney are more prone to hypertension and nephropathy.
For Further Information: Please go to Urinary Tract Infection in Children
- VESICOURETERAL REFLUX (VUR) IN CHILDREN
Treatment of VUR is important to protect the kidneys, by preventing possible infections and kidney damage.
There are 3 options for managing or treating VUR:
- Antibiotics: may be used to prevent infections until VUR goes away by itself. Children must take the medications every day, and be re-tested for VUR on a regular basis.
- Surgery: can fix the ureters to stop VUR. This type of treatment cures most children. Surgery may be favoured if VUR is severe or if there are other related medical conditions.
- Endoscopic treatment: In endoscopic treatment, a substance is injected where the ureter joins the bladder.
Treatment VUR is important to protect the kidneys, by preventing possible infections and kidneu damage. There are 3 options for managing or treating VUR. Regular follow-up visits according to protocol are mandatory. This should be discussed with your doctor.
Some families find it hard to ensure that the child has his or her routine x-ray test performed,and takes the daily medications required for antibiotic treatment. Your concerns or beliefs matter. It is therefore important to discuss them with your doctor.
Please make sure that you understand the risks and benefits of each treatment, as well as the follow-up required for each treatment.
Diagram Demonstrating How Urine Normally Flows without the Presence of VUR
About 1% of children in the world have VUR. It results when the connection between the bladder and the ureter is not normal. The lower part of the ureter tunnels through the muscle of the bladder (valve mechanism). If this tunnel is too short, VUR occurs. Behaviors such as infrequent or incomplete urination and related constipation are also associated with VUR.
Urine is made in the kidneys. Normally, it only flows one way – down the ureters and into the bladder. VUR occurs when urine flows back to a kidney from the bladder, through the ureters. This can happen on either or both sides.
Your doctor can tell you how serious your child’s VUR is, with a grading scale obtained by conducting an MCU. This scale ranges from Grade 1 (mild) to Grade 5 (severe). Most of the time, mild VUR will go away by itself. However, the more severe the VUR, the less likely is the possibility that it will go away on its own.
Table Showing the Different Stages in the Progression of VUR
VUR can have serious consequences. Kidney infections can occur when infected urine flows back into the kidneys. The risk of kidney damage is greatest during the first 6 years of life. The goal is to find VUR early and prevent infection that could result in kidney damage.
VUR tends to run in families. As many as one-third of siblings will have VUR. If a parent has VUR, about half of his or her children will also have it.
For Further Information: Please go to Vesicoureteral Reflux in Children VUR