Most frequent pediatric urological pathologies

What is Congenital Obstructive Uropathy (congenital hydronephrosis)?

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

Hydronephrosis maintained over time causes renal parenchymal lesions just above the obstruction, secondary to increased pressure in the urinary tract and decreased blood flow. The persistence of hydronephrosis increases the risk of chronic childhood nephropathy, urinary tract infections and lithiasis formation in the upper urinary tract.

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

Symptoms of Congenital Obstructive Uropathy

How is Congenital Obstructive Uropathy diagnosed?

Treatment for congenital hydronephrosis

Mild or severe unilateral dilatations can be monitored ultrasonographically during pregnancy until delivery. Some never need to be treated, but if an obstructive pattern is demonstrated, surgical intervention is necessary.

What is vesicoureteral reflux (VUR)?

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

The cause or causes are not completely clear. Basically it has 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 demonstrating an association between reflux and various types of bladder function disorders 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 predictors for resolution of reflux.

How is Vesicoureteral Reflux diagnosed?

What is Enuresis?

Enuresis is defined as the presence of involuntary urination that occurs during nighttime sleep in children over 5 years of age.

The importance of enuresis lies in its high prevalence. This is particularly significant in the preschool age, so it represents a very frequent reason for consultation during the pediatric age. On the other hand, it is also important to highlight the psychological impact 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 presented a period of nocturnal continence (dry) equal to or longer than 6 months, relapsing

Epidemiology of Enuresis

The incidence is higher in boys than in girls, approximately in a 2:1 ratio. It is estimated that the prevalence of enuresis ranges between 10-15% by the age of 5 years, with about 80% of these cases belonging to the primary type of EMS. Generally, it is a self-limited disease, and in most patients it disappears with age.

Enuresis is probably not due to a single mechanism of production, but several of them must concur in the participation for the clinical fact of urine loss in bed to occur.

Enuresis is often associated with the presence of psychological disorders such as: low self-esteem, feelings of stigmatization, guilt, behavioral disorders or learning and cognitive disorders, derived from poor quality sleep. These disorders represent a problem of added concern for both the patient and his family. Enuresis must be treated. This decision must be made on an individual basis and will be made according to the presence of emotional involvement, alteration in the 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:Anomalous urethral opening. The distal urethra is open (urethral plate).

• Abnormal 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 dorsally
• 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.

Hypospadias classification

Distal hypospadias: The urethral meatus is located on the glans penis, balanopreputial sulcus 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 in the penoscrotal junction, scrotum or perineum (10-15%).

How is Hypospadias treated?

The optimal time for surgical treatment is between 6 and 18 months of age. Early surgery has many advantages: The child will not remember the surgical intervention and will join school with the malformation corrected. Post-surgical care is easier at this age. Emotional disturbances are less.

The objective is the correction of all defects associated with the malformation. The incurvation 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 foreskins can be retracted, and less than 1% of males have phimosis by the age of 17. Early forced retraction is not recommended (de-epithelialization and secondary phimosis).

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

What is cryptorchidism?

Cryptorchidism, etymologically "hidden testicle", defines testicular absence in the scrotum. Absence of the testicle in the scrotum can signify 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 testis.

• Congenital undescended testicle: testicle that is located outside the scrotum somewhere in 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 located in a suprascrotal position that spontaneously or with manual maneuvers descends to the scrotal cavity. This situation is due to the activity of the cremasteric reflex, 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 term infants and 30% of preterm infants.

Seventy percent of congenital undescended testes descend spontaneously in the first months of life. The prevalence at one year of life is 1%, similar to the adult population. Eighty-five percent of cryptorchidism are unilateral and in 80% of them the testicle is located in the inguinal tract.

Diagnosis of Cryptorchidism