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Urological Problems explained

 

Antenatally Diagnosed Renal Anomalies(diagnosed in Pregnancy)
 
Consultation and counseling by a Pediatric Urologist is very important for these disorders as the parents are very anxious and worried. They would want to know about the eventual outcome and the problems the baby is about to face after birth. A Pediatric Urologist given his expertise in the field is ideally suited for this counseling and he also provides a continuum of care right from antenatal diagnosis and its proper interpretation to management after birth.
 
Antenatally Diagnosed Hydronephrosis: Hydronephrosis refers to Swelling of the kidney. Hydronephrosis is the most common structural abnormality seen on antenatal sonogram, occurring in 1% of all pregnancies. Many of these mild hydronephrosis subside during the course of the pregnancy while others may be diagnosed to have various disorders as detailed below.
 
a) Pelviureteric junction (PUJ) obstruction: There is a partial blockage where the pelvis of the kidney joins the ureter. As a result the urine collects under pressure and produces swelling of the kidney. During pregnancy estimation of the diameter of the pelvis can give a rough idea of the chances of requirement of surgery after birth. These kids are best investigated after birth with ultrasonogram (at one week of age) and a renal scan at 4-6 weeks of age. On the average about 50% of these may require surgery after birth.
 
b) Vesicoureteric Reflux (VUR): In this condition the urine goes back to ureter and kidneys from the bladder when pressure rises and the ureter is also swollen along with kidney so called Hydroureteronephrosis. In children with VUR hydronephrosis is generally mild and variable between different scans. After birth, these kids are put on low dose antibiotics to prevent infections which can cause kidney damage. An ultrasonogram and a special test called Micturating Cystourethrogram (MCU) is performed at one month of age to confirm or rule out VUR.
 
c) Posterior urethral valves (PUV): In this condition there is a block in the urethra, as a result urine is stored in bladder at high pressures which is not able to empty properly. The bladder becomes thick and distended. Both the ureters and kidneys may be swollen. This is a very serious condition as upto 30% of the children will have eventual renal failure at some point after birth even after adequate therapy. This is especially true for those cases where oligohydramnios sets in during pregnancy. Oligohydramnios signifies severe obstruction and decreased urine production by the developing child. These children are to be investigated as soon as possible after birth may be on day 1 of life as this is a semi emergency situation to treat them. An ultrasonogram and a special test called Micturating Cystourethrogram (MCU) is performed to confirm or rule out PUV.
 
d) Vesicoureteric junction (VUJ) obstruction: There is a block at the point where the ureter joins the bladder. As a result, the ureter and the kidney get swollen up- Hydroureteronephrosis. This can be evaluated after birth with a USG and a renal scan. A MCU is also recommended to rule out VUR. 
 
e) Duplex system: There is double collecting system of the kidney and generally the upper pole may be swollen due to abnormal junction of the ureter with the bladder.
 
Absent Kidney
 
Also called Renal Agenesis. If both kidneys are absent- the child will be born with renal failure and will soon succumb to it. Unilateral or one sided renal agenesis is a fairly common condition and does not have many long term issues in most children. After birth, these children should be investigated to rule out problems in other kidney like VUR or PUJO, which are seen in upto 20-30% of children. Abnormalities of female reproductive organs are also fairly common in girls and these kids merit further investigation after birth. 
 
Polycystic kidney
 
In this disease, there are multiple fluid filled cysts in the kidney generally on both sides. There are further two types of this disease. Infantile variety which generally presents soon after birth as renal failure and Adult Variety which is diagnosed later in life. Infantile variety can be diagnosed easily during pregnancy and a therapeutic termination of pregnancy should be recommended for these babies.
 
Multicystic kidney disease (MCKD)
 
In this disorder there are multiple non-communicating cysts in the kidney. This disease generally occurs on one side and the other kidney is usually normal. The side having MCKD is generally non-functioning in nature and may require surgery after birth once the diagnosis is established. Some of these kidneys may disappear automatically during pregnancy or first 2-3 years of life, thus a surgery to remove such kidneys may not be required in all the cases. But the diagnosis must be confirmed with a USG and a renal scan after birth and also to see that the other kidney is normal. Sometimes it may be difficult to distinguish a severe hydronephrosis from MCKD even after renal scan, then a Cystoscopy and retrograde pyelogram may be required to confirm the diagnosis and proceed with appropriate surgery.
 
Oligohydramnios
 
Inadequate renal function in a fetus may lead to shortage of amniotic fluid or oligohydramnios. Oligohydramnios is the single most important prognostic indicator for renal anomalies during pregnancy. Fetuses with oligohydramnios tend to develop renal failure soon after birth. Some of these may even have inadequate lung development and difficulty in breathing soon after birth. Most common condition causing oligohydramnios is PUV followed by bilateral renal agenesis and infantile variety of polycystic kidney disease.
 
Pain while passing urine(Dysuria)
 
Common causes for Dysuria in children are
1) Urinary tract infection (UTI)
2) Calculus disease
3) Balanoposthitis
 
Thin stream/Straining to pass urine/Urinary retention/Failure to pass urine
 
Newborn babies: Most common cause is Posterior Urethral valves and newborn should be admitted and investigated immediately. Sometimes a Ureterocele which is jutting out into urethra can cause similar symptoms. We have also seen a newborn who had out pouching of the bladder called diverticulum leading to these symptoms. All these can be easily diagnosed on a MCU and a USG.
 
Older children: may have thinning of stream and the above symptoms due to
 
1) Phimosis: Very tight foreskin can sometimes cause this problem. This can be easily diagnosed on examination by a Pediatric Urologist.
2) Meatal stenosis: Tight urinary opening can cause these symptoms. This condition can be easily diagnosed on clinical examination and treated by a minor surgery.
3) Urethral stricture: Sometimes, there is narrowing of urethra due to infection, injury or after catheterization. This can be very well seen on X-ray study called retrograde urethrogram and if possible a MCU. 
4) PUV: Rarely, older children may present with a variant of PUV called Mini-valves where small fold of tissue in urethra cause mild obstruction to urine flow. These can be diagnosed on MCU and treated easily cystoscopically.
5) Stone impacted in urethra or bladder neck.
 
 
Frequent passage of urine( Frequency)
 
Frequency signifies irritation or small bladder capacity. Common causes are:
1. Urinary tract infection
2. Urinary calculi or stones
3. Overactive bladder
4. Small bladder capacity
 
A good chat with the patient, a thorough examination and a few investigations can sort this issue. 
 
Hematuria or blood in urine
 
Blood in urine can come either from the kidneys, ureters, bladder or urethra. Generally blood which comes from kidneys makes the urine look like cola (brownish) and is well mixed with urine, there are no symptoms of irritation like frequency. There may be clots also if the bleeding is occurring from the kidneys. Common causes of such an occurrence are Nephritis, calculi (stones) or malignancies and these can be differentiated by certain tests. Patients who have nephritis are further treated by Nephrologists while others by Pediatric Urologists. Blood in urine from bladder occurs commonly due to infection or stones. Generally there are associated symptoms like fever, pain in lower abdomen, Pyuria, frequency etc when there is either of these. Bladder tumours are very rare in childhood. Further work-up like Ultrasonogram, X-rays may be required to deal with such problems.
 
Pus in Urine or Pyuria
 
Pyuria signifies urinary tract infection and a Pediatric urologist should be consulted immediately as this is potentially serious condition. 
 
Bed wetting
 
Bed wetting or Nocturnal enuresis is a very common problem and affects upto 10% of normal children. Classically, the child has no daytime symptoms and wets the bed at night. Such kids do not need further investigation once a Pediatric Urologist has seen and examined the patient in detail. Generally, some behavioral modification and adjustments in life style are enough to help these children. In 1% of these children, especially if the wetting continues beyond 7 years of age a proper re-evaluation and therapy is recommended. It is important to remember that bed wetting though may be very common and not harmful to the child as such, but it exerts a harmful psychological effect on the developing children. These children may have a lowered self esteem because of bed wetting and may be afraid to go to a relatives place or a friend's place to stay overnight. There is other group of children who have bed wetting at night along with some day time symptoms like urgency, frequency with occasionally wetting the undergarments. Some of these children try to assume a squatting posture with heel pressed into the perineum- this phenomenon is called Vincent's Curtsy. These are all signs of an overactive bladder and such children need proper evaluation and therapy by a Pediatric Urologist.
 
Incontinence of Urine(Lack of Control)
 
If the child is continuously wetting his clothes and lacks control over the urination, the condition is called incontinence of urine. This is a very distressing condition for the family as well as for the child. Common causes are:
1. Neurogenic bladder
2. Exstrophy bladder
3. Overactive bladder
4. Non-Neurogenic Neurogenic bladder
5. Epispadias
 
A Pediatric Urologist would be able to differentiate these conditions based on a good examination of the patient. Nowadays we have newer therapies and approaches to these conditions. The prime goal is to offer dryness to the patient by medical or surgical means and is a very much attainable goal. The family and the treating Pediatric Urologist have to be committed to spend time and energy in arriving at correct formula which works for the patient. This means a very individualized approach and frequent visits. 
 
Fever 
 
Fever generally signifies upper tract or kidney involvement in the presence of other symptoms of urinary infection in a child. In newborn babies and infants, fever may be the only symptom of a severe urinary tract infection as other symptoms like frequency, urgency or Dysuria may be absent or missed in a small child who passes urine in a diaper. If clinically, the other systems are not involved and the child had fever, it may be worthwhile to rule out a urinary tract infection by submitting a urine examination.
 
Abdominal Pain 
Abdomen or tummy houses a lot of organ systems like stomach, intestines, liver, spleen, kidneys, pancreas and other glands. Resultantly, abdominal pain can arise from any of these organ systems. Though the causes are diverse, still there are some generalizations. Pain arising from the kidneys is generally in the flank, is deep seated, may be associated with some urinary symptoms (like frequency, dysuria, Hematuria) and there may be no vomiting or diarrhea (associated with stomach or intestinal problems). Jaundice is commonly associated with diseases of liver.
Common causes of pain arising from the kidneys:
1. Acute Pyelonephritis: Urinary infection which has involved the kidney.
2. Abscess: Pus collection inside or outside the kidney.
3. Pelvi-ureteric junction obstruction: There is an obstruction to urine flow from the kidney to the ureter and bladder leading to swelling and pain. 
4. Stones: Renal or ureteric calculi generally present with pain in the flank. Classical pain in such cases is Colicky in nature- meaning which comes and goes. 
 
A detailed history and examination would be recommended for any child for such symptoms.
 
Abnormal looking Penis or Genitalia
 
The Common causes are:
1. Hypospadias: Birth defect in which the urinary opening is not present at the tip of the penis but on the underside anywhere along the midline. These can be corrected with surgery at 9 months- 1 year of age. Some of these babies with severe defects may require further investigation to rule out other abnormalities. 
2. Epispadias: This is reverse of Hypospadias and the urinary opening is present on the top of the penis. These can also be easily corrected with surgery. 
3. Intersex: This should be suspected is there is any doubt about the sex of the baby or so called "Ambiguous genitalia". Other situations are severe Hypospadias, Hypospadias with undescended testis, both sided undescended testes, a young girl with a large clitoris or bilateral inguinal hernias. If there are any of the above conditions then these patients should be thoroughly investigated to learn more about their reproductive organs and sex of rearing. The investigations are karyotype (tells about chromosomes and DNA), Ultrasound, Genitogram and hormonal analysis.
 
Undescended Testis
 
Undescended testis is one of the most common congenital anomalies in newborn males and can be seen in upto 3-5% of these babies. Some of these will descend to scrotum in first 3-4 months of life, so it is wise to wait for this time before any decision is made. The further planning depends whether the testis can be felt clinically or not. The testis which can be felt clinically can be easily operated on outpatient basis by a surgery called orchidopexy. The ones which can not be felt clinically are called Non-palpable undescended testis and they may require laparoscopy to find their position and also to facilitate their placement in the normal position. It is important to mention here that in such babies' upto 10-15% may have an absent testis on laparoscopy. This is where laparoscopy is better than USG or MRI scan as it is 100% diagnostic when compared to USG and MRI where chances of missing a small testis are always there. So personally, we don't recommend any imaging for such babies and prefer to do laparoscopy to decide and counsel for once and all. This is important as the testis left inside the tummy can develop into a cancer at a later date. 
 
Testicular swelling or pain
 
Common causes of testicular swelling are:
 
1. Hernia- out pouching of intestine from the abdomen into the scrotum
2. Hydrocele- collection of fluid around the testis
3. Cyst
4. Tumors
5. Infections- epididymo-orchitis
 
Common causes of pain in testis are
1. Testicular torsion: The testicle twists on itself and as a result the blood supply is interfered with. This is an absolute emergency as delay in diagnosis and surgery may result in loss of testis due to total stoppage of blood supply. Classically, the child with testicular torsion has sudden onset of pain in scrotum which is severe and there is associated nausea. There is no fever or urinary symptoms. An emergent surgery may be able to salvage the testis.
2. Epididymo-orchitis: This refers to infection of the testis. There may be associated symptoms of burning micturition, frequency or urgency or fever due to underlying urinary infection. 
3. Trauma: injury to testis can result in swelling and pain.
4. Torsion of testicular appendage: Testicular appendages are small nonfunctional nodules which are located near upper part of testis. They can undergo a twist and present with symptoms quite similar to testicular torsion. In early stages, it is fairly easy to distinguish the two but it may not be so in late stages when swelling sets in. While testicular torsion requires emergency surgery, torsion of the appendage can be managed no-surgically if diagnosed with surety.

 

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