Back To Basics Pediatric Urology
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Transcript of Back To Basics Pediatric Urology
Dr. Michael P. Leonard MD, FRCSC, FAAPDr. Michael P. Leonard MD, FRCSC, FAAP
Professor of SurgeryProfessor of Surgery
University of OttawaUniversity of Ottawa
Caused by gut bacteria
E. coli most common Ascend via urethra to bladder and kidneys
Presentation varies with age: Infants – fever, lethargy, diminished feeding,
failure to thrive, diarrhea, vomiting Children – frequency, urgency, dysuria, wetting,
gross hematuria, abdominal pain, fever
Urinary Tract Infections
Incidence
< 1 yr – more common in males (peak 6 months) Increased in uncircumcised males (10x)
> 1 yr – more common in females (peak 2-3 years)
School age children: 1.2% males 5% females
Urinary Tract Infections
Obtain urine sample for urinalysis / culture Methods of obtaining urine:
Infant = bag urine, catheterized urine Child = midstream urine, catheterized urine Beware contamination!
Urinalysis: +ve nitrite, leucocyte esterase, RBC
Culture: > 108 CFU/l of one organism
Urinary Tract Infections
Diagnosis
Antibiotics
IV ± hospital admission if systemically unwell (especially infants) IV ampicillin / cephalosporin and gentamicin initially
Oral if reasonably stable and not toxic Trimethoprim, TMP-SMX, nitrofurantoin,
cephalosporin Broad spectrum to cover gram negative and some
gram positive (Staph, Enterococcus) No worry regarding anaerobes Duration of treatment 7-14 days depending on
clinical scenario
Urinary Tract Infection
Treatment
AAP Guidelines 2011
First febrile UTI 2-24 months = renal ultrasound VCUG only if abnormal US or second febrile UTI
“Top down approach” DMSA scan to document evidence of APN VCUG only if findings APN on DMSA
Urinary Tract InfectionInvestigation
Consider referring the following to specialist:
GU anomalies on US and/or VCUG VUR, hydronephrosis, ureterocoele
Concern regarding neurogenic features Abnormal lower back exam VACTERL syndrome
Recurrent UTI in the otherwise normal child if not responsive to timed voiding and management of constipation
Urinary Tract Infection
Referral ?
Urine washing back to kidneys from bladder =
VUR Increases risk of renal infection if UTI
Renal infection may lead to scarring Associated with renal dysplasia ± renal scarring More common in males < 1 yr and females > 1
yr Seen in 35-50% of children with UTI Diagnosed by VCUG
Vesicoureteric Reflux (VUR)
VUR - Grading
Prevent UTI by antibiotic prophylaxis
Follow at intervals for resolution Follow-up comprises US and Cystogram
Surgical intervention: Breakthrough UTI New scarring Parental preference
Surgical options: Minimally invasive (STING) Open ureteric reimplantation
VUR - Management
VUR - Surgery
If child wets bed at ≥ 5 years of age = NE Common developmental issue:
15% of 5 year olds 1% of 15 year olds 15% spontaneously resolve annually
Family history common (genetic component) Several theories abound:
Developmental delay of normal maturation Deep sleep patterns Bladder over-activity at night Lack of nocturnal ADH production
Nocturnal Enuresis
Primary nocturnal enuresis (PNE)
No day time symptoms No dry interval 6 months or longer
Secondary nocturnal enuresis As above but with dry interval > 6 months at
some time in past Complicated nocturnal enuresis
Day time symptoms ± UTI
Nocturnal EnuresisClassification
Nocturnal EnuresisEvaluation (Rushton, J Pediatr)
- ve
+ ve
**
** m ino rity o f p a tie n ts
N o fu rth er s tud ies
U rin a lys is / cu ltu reP h ys ica l e xam
U N C O M P L IC A T E DP rim a ry o n se t
N o rm a l d a ytim e h a b its
U ro d yn a m icsN e u ro su rg e ry co n su lt
R e n a l U SV C U G
C O M P L IC A T E DD ys fu nc tio n a l e lim in a tion
U T I
N O C T U R N A L E N U R E S ISE va lu a tion
Nocturnal Enuresis:
Treatment
Three primary treatment modalities: Observation:
fluid restriction, double void at night, star charts Conditioning therapy:
bedwetting alarm system Pharmacotherapy:
DDAVP
Daytime Wetting
Toilet training complete at 2-3 years 5% of 5 year olds experience occasional
daytime wetting Causes:
anatomical (ectopic ureter, epispadias) pseudo-incontinence (vaginal voiding) neurogenic (spina bifida) dysfunctional elimination (DE)
Daytime wetting - DE
Bladder problems: overactive bladder (OAB) hypoactive bladder detrusor / sphincter incoordination
Bowel problems: fecal impaction colonic distension hypotonicity pelvic floor / sphincter tone
Daytime wetting -Rx
Anatomical: surgery (i.e. hemi-nephrectomy)
Pseudo-incontinence: change of voiding posture
Neurogenic: improve storage (anti-cholinergics) improve emptying (IMC)
Daytime wetting -Rx
Dysfunctional elimination: improve bowel function (diet) timed voiding (q 2-3h) biofeedback medication:
anti-cholinergics -blockers
psychotherapy
NORMAL SCROTAL NORMAL SCROTAL ANATOMYANATOMY
Acute Scrotum
Case study #1: 14 year old boy with right hemi-scrotal pain Duration of pain = 6 hours No history of trauma or LUTS What else do you need to know?? What is your differential diagnosis?? Are any ancillary investigations useful??
TESTIS TORSIONTESTIS TORSION
• Clinical Presentation:Clinical Presentation:– pubertal boy (12-16 years)pubertal boy (12-16 years)– abrupt onset lower abdominal / abrupt onset lower abdominal /
testicular paintesticular pain– pain usually severe, unrelentingpain usually severe, unrelenting– associated with nausea, vomiting, associated with nausea, vomiting,
anorexiaanorexia– prior history of trauma (minor)prior history of trauma (minor)– previous episodes which resolvedprevious episodes which resolved
TESTIS TORSIONTESTIS TORSION
• Physical Findings:Physical Findings:– elevated testis with abnormal lieelevated testis with abnormal lie– ““knotting” of spermatic cordknotting” of spermatic cord– absent cremasteric reflexabsent cremasteric reflex– scrotal erythema / edemascrotal erythema / edema– reactive hydrocoelereactive hydrocoele– ““bell clapper” contralaterallybell clapper” contralaterally
TESTICULAR TORSION
DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
• Emergent:Emergent:– Testicular torsionTesticular torsion– Traumatic testicular ruptureTraumatic testicular rupture– Incarcerated inguinal herniaIncarcerated inguinal hernia– Peritonitis with patent processus Peritonitis with patent processus
vaginalisvaginalis– Fournier’s gangreneFournier’s gangrene
DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS
• Non-emergentNon-emergent– Torsion of testicular or epididymal Torsion of testicular or epididymal
appendageappendage– Acute epididymo-orchitisAcute epididymo-orchitis– Idiopathic scrotal edemaIdiopathic scrotal edema– Henoch-SchHenoch-SchÖÖnlein purpuranlein purpura– Hydrocoele / herniaHydrocoele / hernia– Acute hemorrhage into testicular Acute hemorrhage into testicular
neoplasmneoplasm
TESTIS TORSIONTESTIS TORSION
• Laboratory Studies:Laboratory Studies:– urinalysis typically negative, but may urinalysis typically negative, but may
contain WBC’scontain WBC’s– CBC and differential not useful CBC and differential not useful
discriminatordiscriminator
• Radiographic Studies:Radiographic Studies:– notnot indicated if typical clinical case indicated if typical clinical case
with duration of pain < 12 hours!with duration of pain < 12 hours!
TESTIS TORSIONTESTIS TORSION
• When should radiographic studies When should radiographic studies be considered?be considered?– duration of pain > 12 hours duration of pain > 12 hours and / orand / or
diagnosis is uncertain diagnosis is uncertain
• Which study is indicated?Which study is indicated?– Color Doppler ultrasonographyColor Doppler ultrasonography
TESTIS TORSIONTESTIS TORSION
• Color Doppler ultrasoundColor Doppler ultrasound– readily available in most localesreadily available in most locales– positive finding = no or decreased positive finding = no or decreased
flow in affected testisflow in affected testis– sensitivity 91% (range 82-100%)sensitivity 91% (range 82-100%)– pitfalls:pitfalls:
•small (infant) testis = no flow small (infant) testis = no flow
•peri-testicular flow due to inflammation peri-testicular flow due to inflammation around torted testisaround torted testis
TESTIS TORSIONTESTIS TORSION
TESTIS TORSIONTESTIS TORSION
• Time is of the essence!Time is of the essence!– salvage is usually successful within 6-salvage is usually successful within 6-
8 hours after onset of pain8 hours after onset of pain– salvage possible up to 24 hours, but salvage possible up to 24 hours, but
rate declines exponentiallyrate declines exponentially– pain > 24 hr invariably = necrotic pain > 24 hr invariably = necrotic
testis (very rare exception!)testis (very rare exception!)
TESTIS TORSIONTESTIS TORSION
• Surgical Results:Surgical Results:– salvage rates approximate 60-70%salvage rates approximate 60-70%– factors contributing to missed torsion:factors contributing to missed torsion:
•patient delay in presentation = 80%patient delay in presentation = 80%
•physician mis-diagnosis = 20%physician mis-diagnosis = 20%
– suggests need for education through suggests need for education through school health / physical education school health / physical education programsprograms
TESTIS TORSION
EXTRA-VAGINAL TESTIS EXTRA-VAGINAL TESTIS TORSION (NEONATAL)TORSION (NEONATAL)
• Occurs ante-natally (in utero) or in Occurs ante-natally (in utero) or in the first week post-natallythe first week post-natally
• Testis and tunica vaginalis rotate Testis and tunica vaginalis rotate together (inadequate scrotal wall together (inadequate scrotal wall fixation)fixation)
• Presents as painless scrotal Presents as painless scrotal swelling with scrotal erythema / swelling with scrotal erythema / bluish discolorationbluish discoloration
• Testis rarely viable - ? need for Testis rarely viable - ? need for surgerysurgery
TORSION OF TESTICULAR APPENDAGE
Case study #2: 8 year old boy 2 day history right hemiscrotal pain
Anything else you want to know??
TORSION OF TESTICULAR TORSION OF TESTICULAR APPENDAGEAPPENDAGE
• Clinical presentation:Clinical presentation:– 7-12 year old (pre-pubertal) boy7-12 year old (pre-pubertal) boy– pain more indolent, not as severe as pain more indolent, not as severe as
testis torsiontestis torsion– pain may resolve with restpain may resolve with rest– usually no accompanying nausea or usually no accompanying nausea or
vomitingvomiting
TORSION OF TESTICULAR TORSION OF TESTICULAR APPENDAGEAPPENDAGE
• Physical Exam:Physical Exam:– earlyearly
•testis has a normal lietestis has a normal lie
•maximal tenderness at upper polemaximal tenderness at upper pole
•tender nodule may be seen (“blue dot”) tender nodule may be seen (“blue dot”) or feltor felt
– latelate•progressive scrotal erythema and edemaprogressive scrotal erythema and edema
•reactive hydrocoelereactive hydrocoele
•more difficult to differentiate from testis more difficult to differentiate from testis torsiontorsion
TORSION OF TESTICULAR TORSION OF TESTICULAR APPENDAGEAPPENDAGE
• Laboratory investigations:Laboratory investigations:– urinalysis usually negativeurinalysis usually negative
• Radiographic evaluation:Radiographic evaluation:– Color Doppler ultrasound shows Color Doppler ultrasound shows
increased flow to upper pole testis / increased flow to upper pole testis / epididymis. May also see small epididymis. May also see small hypoechoic torted appendage.hypoechoic torted appendage.
– Radionuclide scan shows increased Radionuclide scan shows increased blood flow to the affected hemi-blood flow to the affected hemi-scrotumscrotum
TORSION OF TESTICULAR TORSION OF TESTICULAR APPENDAGEAPPENDAGE
• Treatment:Treatment:– limit physical activitylimit physical activity– analgesiaanalgesia– expect an initial increase in swelling / expect an initial increase in swelling /
redness with resolution over 7-10 redness with resolution over 7-10 daysdays
– surgery only necessary if diagnosis in surgery only necessary if diagnosis in doubt and / or pain not well managed doubt and / or pain not well managed by analgesicsby analgesics
– no long term sequelae re: testicular no long term sequelae re: testicular functionfunction
EPIDIDYMITIS
Case study #3: 10 year old boy 2 day history left hemiscrotal pain and swelling LUTS for 3 days Febrile (39.5C) Any further investigations / information
required??
EPIDIDYMITISEPIDIDYMITIS
• Bacterial or chemical inflammation Bacterial or chemical inflammation of epididymisof epididymis
• Rare in pre-pubertal boysRare in pre-pubertal boys– if occurs, consider urinary tract if occurs, consider urinary tract
abnormality such as ectopic ureter, abnormality such as ectopic ureter, PUV, stricturePUV, stricture
• Common in sexually active Common in sexually active adolescentsadolescents– usually Chlamydia, rarely gonococcususually Chlamydia, rarely gonococcus
EPIDIDYMITISEPIDIDYMITIS
• Clinical presentation:Clinical presentation:– pain insidious in onsetpain insidious in onset– irritative lower urinary tract irritative lower urinary tract
symptoms may precede onset of painsymptoms may precede onset of pain– urethral discharge if STDurethral discharge if STD– may be septicmay be septic
EPIDIDYMITISEPIDIDYMITIS
• Physical examination:Physical examination:– elevated temperatureelevated temperature– scrotal edema, erythema, tenderness, scrotal edema, erythema, tenderness,
reactive hydrocoele, tender prostatereactive hydrocoele, tender prostate– early on epididymis may be increased early on epididymis may be increased
in size and exquisitely tenderin size and exquisitely tender– in later stages, loss of anatomical in later stages, loss of anatomical
landmarks with diffuse tendernesslandmarks with diffuse tenderness– Prehn’s sign unreliable!Prehn’s sign unreliable!
EPIDIDYMITISEPIDIDYMITIS
• Laboratory investigations:Laboratory investigations:– urinalysis may show pyuria, urinalysis may show pyuria,
hematuria, bacteriahematuria, bacteria– urine culture may be positiveurine culture may be positive
• Radiographic evaluationRadiographic evaluation– only necessary in pre-pubertal child only necessary in pre-pubertal child
with concurrent UTIwith concurrent UTI– renal ultrasound and VCUG renal ultrasound and VCUG
recommendedrecommended– if Color Doppler US obtained will show if Color Doppler US obtained will show
increased blood flow to affected sideincreased blood flow to affected side
Scrotal Mass
Need to distinguish where mass is coming from: Processus vaginalis:
Indirect inguinal hernia Communicating or non-communicating hydrocoele
Testicular adnexae: Epididymal cyst / spermatocoele Varicocoele
Testis Testicular tumour
Scrotal mass in children
Hernia - Hydrocoele
Embryology
As testis descends through inguinal canal into scrotum: carries along a tongue of peritoneum (processus
vaginalis) normally communication of processus with
peritoneum closes leaves potential space (tunica vaginalis) over
antero-lateral testis
Hydrocoele - Hernia
Anatomy
Hernia - Hydrocoele Management
Communicating hydrocoele: may resolve spontaneously < 2 yr. if persists > 2 yr. repair
Indirect inguinal hernia: repair at any age risk of incarceration small but real
Non-communicating Hydrocoele
Localized collection of fluid in tunica vaginalis May be secondary to:
inflammatory process trauma, infection, torsion
tumor If concern re: testis ultrasound Surgical intervention is option
Hydrocoele - US
Epididymal cyst common in pre-pubertal boys
Usually seen on scrotal US (non-palpable) Benign course May grow and become palpable
Spermatocoele seen in post-pubertal boys Blow out of efferent duct encysted collection
of spermatozoa Both conditions may cause cosmetic concerns
and mandate surgical excision
Epididymal Cyst / Spermatocoele
Varicocoele
15% of adolescents have varicocele: rare to have onset prior to adolescence >90% left sided not likely to spontaneously regress
Clinical conundrum: how can we predict which patients will suffer
gonadal damage from varicocele?
Varicocoele - Anatomy
Varicocoele
Indications for surgery: absolute
volume difference > 20% on affected side caveat re: differential growth and need for more
than one measurement relative
pain cosmesis
VaricocoeleAblation Outcomes
Testicular Tumour
Rare 0.5-2/100,000 children
Presents as painless scrotal mass Mass is firm and non-transilluminating Caveat re: hydrocoele and inadequate
testicular exam
Testis Tumour
Histology
Testis Tumour
Obtain serum markers: -fetoprotein HCG
Ultrasound of testis: confirm diagnosis treatment planning
Imaging - Testis Tumour
Surgical Management
Testis Tumour
Radiological Staging
CXR CT abdomen / pelvis Bone scan (RMS)
Management - Non RMS
Orchiectomy and surveillance: teratoma / dermoid cyst stage I yolk sac tumour gonadal stromal tumour (Leydig, Sertoli)
Chemotherapy (BEP) for yolk sac if: stage II-IV disease relapse stage I
Limited role for RPLND in yolk sac
Management RMS
Radical inguinal orchiectomy Children > 10 yr. undergo ipsilateral RPLND
before chemotherapy Chemotherapy in all age groups Radiotherapy in addition to RPLND in children
> 10 yr. Higher risk of relapse / spread
Neonatal Abdominal Mass
Abdominal mass (75% arise in the GU tract) #1-Hydronephrosis (UPJO, VUR, UVJO, PUV) #2-Multicystic dysplastic kidney (MCDK) #3-Tumours account for 12 %
Neuroblasoma, CMN and teratoma (sacrococcygeal)
Hydronephrosis MCDK
Neonatal Abdominal Mass
Neuroblastoma is the most common malignancy in the neonate
Wilms’ tumour is extremely rare in this age group
Abdominal mass + hematuria = renal vein thrombosis
Girl with abdominal mass + interlabial bulging = hydrocolpos
Congenital Mesoblastic Nephroma (CMN) is the most common renal tumour
Abdominal Mass After Neonatal Period
From 1 month to 1 year of age: Hydronephrosis – 40% Solid masses and tumour – 40%
Older than 1 year of age: Tumour is the most common cause of abdominal
mass
Neuroblastoma (NB)
Most common malignant tumour of infancy 8% to 10% of all childhood cancers Annual incidence 10 cases per 1 million Median age at diagnosis: 22 mo 50% of cases < 2 years of age (75% <4yrs)
(Fortner et al, 1968)
NB - What and Where?
Tumours of neural crest cell origin: Cells that form the adrenal medulla and
sympathetic ganglia 75% are retroperitoneal
50% adrenal 25% sympathetic chain (from neck to
pelvis)
NB - Presentation
Often has systemic symptoms (different from WT) Fever, abdominal pain or distension, abd mass,
weight loss, anemia, bone pain, proptosis and periorbital ecchymoses (retro-orbital metastasis)
Metastases are present in 70% at diagnosis VMA (vanillylmandelic acid), HMA (homovanillic
acid) Elevated in > 90% of the neuroblastomas 24 hr urine collection (catecholamine metabolites)
NB - Imaging
US is usually the first exam in child with abdominal mass
CT or MRI Both detect extension beyond midline and
hepatic involvement MRI: better displays the relationship with
great vessels and detects intraspinal extension (tumor of sympathetic chain)
CT may show calcifications (rare in Wilms tumor)
NB - Treatment
Generally based on risk assessment Tumour stage Grade Biochemical risk factors Genetic risk factors
Low-stage favorable Surgery alone Higher risk tumor Adj chemo +/- RT Very aggressive tumor Autologous bone
marrow transplantation
Wilms' Tumor
Most common primary malignant renal tumour of childhood
Embryonal tumour develops from remnants of immature kidney
Annual incidence 7 to 10 cases per million Median age 3.5 yrs 80% diagnosed < 5 yrs of age Worldwide sex ratio is close to 1
(North American girls slightly > boys)
Congenital Anomalies and WT
Genitourinary anomalies in 4.5% of WT Renal fusion anomalies Cryptorchidism Hypospadias (Breslow et al, 1993)
These are common disorders and screening for WT is not necessary in most children with genital anomalies
Syndromes and WT
Without overgrowth: Denys-Drash syndrome (DDS)
Male pseudohermaphroditism, renal mesangial sclerosis and WT ( Drash et al, 1970)
Aniridia (Found in 1.1% of patients with WT) WAGR syndrome
Wilms' tumor, Aniridia, Genital anomalies, mental Retardation
(Clericuzio , 1993)
Horseshoe kidney (NWTSG found 7 times incidence of WT)
With overgrowth
Hemihypertrophy May occur alone or with syndromes
Beckwith-Wiedemann (BWS) Perlman Soto Simpson-Golabi-Behmel
Syndromes and WT
Imaging in WT
Ultrasound is the first study performed in most children with an abdominal mass Solid nature of the lesion
CT shows the relationship with other organs MRI is the study of choice if extension of tumour
into the inferior vena cava cannot be excluded by ultrasound (Weese et al, 1991)
Treatment of WT
Surgical Radical nephrectomy Accurate staging to determine need RT +/-
chemo Exploration of the abdominal cavity
Liver, nodal metastases, peritoneal seeding Formal exploration of the contralateral kidney
Not necessary with modern imaging Formal retroperitoneal lymph node dissection
not recommended