Urology Pediatric

Pediatric urology

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Most frequent pediatric urology pathologies

What is Congenital Obstructive Uropathy (congenital hydronephrosis)?

Hydronephrosis is a dilation of the renal collecting system due to an alteration in the mechanism of urine transport from said kidney to the bladder. It may be due to alterations of type functional or mechanical. The severity of dilation is not always proportional to the degree of obstruction.

The sustained hydronephrosis in time it causes parenchymal lesions kidneys just above the obstruction, secondary to increased pressure in the urinary tract and decreased blood flow. Persistent hydronephrosis increases the risk of childhood chronic nephropathy, urinary infections and stone formation in the upper urinary tract.

It becomes essential evaluate the specific cause and administer the appropriate treatment for each case.

Symptoms of Congenital Obstructive Uropathy

The clinical presentation is variable, many remain asymptomatic, especially if the obstruction is partial. In those cases in which symptoms appear, the most frequent are: abdominal mass palpable during lactation, abdominal pain, presence of blood in the urineUrinary infections and stunted growth.

How is Congenital Obstructive Uropathy diagnosed?

It is essential to have a correct diagnosis as early as possible to avoid the potential risk of developing obstructive nephropathy (a common cause of chronic kidney disease in childhood). In this regard, the widespread use of ultrasound In the prenatal period, it allows both kidneys to be identified from the 16th week of gestation.

Treatment of congenital hydronephrosis

Mild or severe unilateral dilations can be ultrasound controlled during pregnancy until birth. Some never need to be treated, but if an obstructive pattern is demonstrated, treatment is necessary. surgical intervention.

What is vesicoureteral reflux (VUR)?

Vesicoureteral reflux (VUR) is the retrograde urine flow from the bladder to the ureter and renal pelvis. It can be unilateral or bilateral. It is both an anatomical and functional disorder with consequences such as urinary tract infections, the hypertension and the appearance of kidney scarring that can lead to disturbance of kidney function. The main objective of its treatment is to prevent the appearance of these complications.

The cause or causes are not totally clear. It has basically been accepted as a congenital alteration in the development of the vesicoureteral junction.

Reflux can also be an acquired pathology and there is sufficient scientific evidence that demonstrates an association between reflux and various types of bladder function impairment such as neurogenic overactive bladder.

The prevalence of VUR in asymptomatic children is estimated to be 0.4-1.8%. The natural history of primary VUR is spontaneous resolution, which explains its high incidence in children compared to adults. Spontaneous resolution of VUR depends on age at presentation, sex, grade, laterality, mode of presentation, and anatomical factors. It is more likely before the first year of life, in low grades, asymptomatic patients with antenatal ureterohydronephrosis (UHN) or VUR in siblings.

The presence of renal cortical abnormalities, bladder dysfunction, or febrile urinary tract infections are negative predictive factors for resolution of reflux.

How is Vesicoureteral Reflux diagnosed?

The imaging tests They are the basis of the diagnosis and management of reflux. For this, imaging tests such as ultrasound, cystography, etc. are performed.

What is Enuresis?

Enuresis is defined as the presence of involuntary urination that are produced during night sleep, in children over 5 years old.

The importance of enuresis lies in its high prevalence. This is particularly significant in preschool age, which is why it represents a very frequent reason for consultation during pediatric age. On the other hand, we must also highlight the psychological impact that it can have on the child and/or the family.

Classification of Enuresis

  • Primary: That in which the child at no time in his life has remained without enuretic episodes for a period of more than 6 months.
  • Secondary: When they have had a period of nocturnal continence (dry) equal to or greater than 6 months, relapse

Epidemiology of Enuresis

The incidence is higher in children than in girls, approximately in a ratio of 2:1. It is estimated that the prevalence of enuresis ranges between 10-15% when reaching the age of 5 years, belonging to close to the 80% of these cases to the type of EMS primary. It is generally a self-limiting disease over time, and in most patients it disappears with age.

Enuresis is probably not due to a single production mechanism, but rather several of them must participate in order for the clinical event of urine loss in bed to occur.

Enuresis is associated in many cases with the presence of psychological alterations such as: low self-esteem, feelings of stigmatization, guilt, behavioral alterations or learning and cognitive disorders, derived from poor quality sleep. These disorders pose a problem of added concern for both the patient and their family. Enuresis must be treated. This decision must be made on an individualized basis and will be made based on the presence of emotional affectation, alteration in quality of life and/or demand for treatment by the parents.

What is Hypospadias?

Hypospadias is a congenital defect caused by incomplete fusion of the urethral folds and presents as: Abnormal opening of the urethra. The distal urethra is open (urethral plate).

  • Anomalous opening of the urethra. The distal urethra is open (urethral plate)
  • The corpus spongiosum is divided and hypoplastic on each side of the urethral plate.
  • Ventral preputial defect with excess skin on the dorsal part
  • Ventral curvature of the penis.

Hypospadias is the most common congenital anomaly of the penis. Cryptorchidism and inguinal hernia are the anomalies most frequently associated with hypospadias.

Classification of Hypospadias

Distal hypospadias: The urethral meatus is located in the glans penis, balanopreputial groove or distal part of the penis (60-65%).

Middle hypospadias: The meatus is located in the middle or proximal part of the penis (20-30%).

Proximal hypospadias: The meatus is located at the penoscrotal junction, the scrotum, or the perineum (10-15%).

How is Hypospadias treated?

The optimal moment of surgical treatment is between 6 and 18 months of life. Early surgery provides numerous advantages: The child will not remember the surgical intervention and will go to school with the malformation corrected. Post-surgical care is easier at this age. The emotional disturbances are minor.

The objective is the correction of all defects associated with the malformation. The curvature will be corrected, a urethra of adequate length and caliber, glanduloplasty and adequate skin coverage will be performed.

What is phimosis?

By the third year of life, 90% of the foreskins can be retracted, and less than 1% of males have phimosis at 17 years of age. Forced and early retraction is not recommended (de-epithelialization and secondary phimosis).

It is recommended the application of corticosteroid creams topical from 4 – 5 years of life. In our opinion, only non-physiological phimosis, secondary to other processes or that which produces disorders (urination, pain and/or local infections) must be treated surgically.

What is Cryptorchidism?

Cryptorchidism, etymologically “hidden testicle”, defines the absence of the testicle in the scrotum. The absence of the testicle in the scrotum can mean the following entities:

Testicular anorchia or absence: Due to testicular agenesis or atrophy secondary to intrauterine vascular compromise, a situation defined as testicular regression syndrome or evanescent testicle.

  • Congenital undescended testicle: Testicle that is located outside the scrotum somewhere along the normal path of descent: abdomen, inguinal canal, or scrotal root.
  • Ectopic testicle: Testicle that is outside the normal path of descent.
  • Retractile testicle or cremasteric hyperactivity: Testicle that is located in a suprascrotal position and that descends spontaneously or with manual maneuvers into the scrotal cavity. Situation due to the activity of the cremasteric reflex, it involves normal testicles and does not require treatment.
  • Acquired undescended testicle: Situation that defines the testicle with normal descent and subsequent ascent to suprascrotal positions.

Cryptorchidism occurs in 2-5% of children born at term and in 30% of those born preterm.

70% of congenital undescended testes descend spontaneously in the first months of life. The prevalence at one year of age is 1%, similar to the adult population. The 85% of the cryptorchids are unilateral and in the 80% of them the testicle is located in the inguinal tract.

Diagnosis of Cryptorchidism

Although cryptorchidism usually presents as an isolated entity, a general examination must be performed to rule out the presence of endocrine, genetic or metabolic alterations that may be associated. It will be essential to differentiate palpable from non-palpable testicles, the presence of other associated alterations, as well as the time of diagnosis.

Treatment of Cryptorchidism

The goals of treatment are place the testicle in a normal scrotal position and fix it if it is viable, or to remove the remaining tissue if it is not. The benefits of placement in a correct location are based on the improvement of testicular function, the possible reducing the risk of malignancy, as well as the ease of diagnosis if it occurs, for aesthetic reasons and in the prevention of complications such as the development of a hernia or a torsion. Likewise, it can improve body self-image.

If spontaneous descent does not occur at 12 months of age, it is recommended surgery, since it is unlikely to resolve spontaneously after that time and it does not seem that hormonal therapy will be effective.

Medical (hormonal) treatment of cryptorchidism is controversial, and is not recommended by all groups, due to its poor effectiveness and lack of evidence of long-term effects.

Patricia ramirez urologa2

"The vision of a specialist in pediatric urology allows for diagnosis and timely treatment"

Dr. Patricia Ramírez

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