Pediatric Urinary Tract Infections

One of the most common problems I see in my practice is a child who has had one or more urinary tract infections.
The most important question to ask when someone is having urinary tract infections is whether the infections happen with fever. This is referred to as a febrile UTI. The workup and management of a febrile UTI is completely different than that of a non-febrile UTI. Failing to make this distinction usually results in unnecessary radiologic testing.
A child with a febrile UTI has a temperature of more than 101.5, looks like he has the flu, and often needs to be admitted to the hospital for IV fluids due to nausea and vomiting. He may also have burning and pain with urination, but not always.
A child with a non-febrile UTI feels well overall but hurts terribly when voiding. He may also void frequently in small amounts or instead hold his urine and then have accidents. Some children may have no symptoms, though parents report a strong smell in the child’s urine.
FEBRILE UTI (UTI with fever)
Febrile UTI’s are usually due to anatomic problems like urine going backwards from the bladder to the kidneys (vesicoureteral reflux), or a blockage in the kidney, ureter, or urethra.
The American Academy of Pediatrics (AAP) recommends obtaining a renal and bladder ultrasound after the first febrile UTI mainly to rule out blockage or obstruction in the urinary tract. A renal ultrasound is well tolerated by most children, is non-invasive, and there is no risk of radiation.
After the second febrile UTI, the AAP recommends a more invasive test, disliked equally by parents and children: the voiding cystourethrogram (VCUG). The VCUG is done mainly to detect vesicoureteral reflux, a condition associated with recurrent febrile UTI’s. Surgery for vesicoureteral reflux can decrease the chances of recurrent febrile UTI’s by more than half, however, it does not affect the risk of recurrent non-febrile UTI’s.

NON-FEBRILE UTI (UTI without fever)
Non-febrile UTI’s are usually due to infrequent voiding, incomplete voiding, bad hygiene, or constipation. Children with non-febrile UTI’s usually have normal anatomy. The treatment for recurrent non-febrile UTI’s is:
 voiding frequently (every 2 hours)
 double voiding (the child counts to 10 after voiding and then tries to void again)
 proper hygiene (sometimes using moist toilettes, wiping from front to back, etc.)
 treatment of constipation (which should be continued indefinitely, usually into adulthood)
DYSFUNCTIONAL ELIMINATION SYNDROME
A small subset of children with non-febrile UTI’s have what we call dysfunctional elimination syndrome, which is a failure to relax the urinary or anal sphincters when voiding or defecating. These patients usually don’t empty their bladders completely, which results in infections and/or incontinence. They also suffer from constipation and soiling. These patients might benefit from medications or pelvic muscle training (biofeedback) when simpler maneuvers like timed voiding, double voiding, and treatment of constipation fail to solve the problem.

Leave a comment

Filed under Urinary tract infections

Undescended Testis (UDT) versus Ascending Testis (AT)

Undescended Testis (UDT)

The most common congenital urologic problem is undescended testis (UDT).  This occurs in about 3% of newborns.  By six months of age, only 1% of those born with UDT still have it.  In other words, two-thirds of UDT come down to the scrotum on their own by six months of age.  The 1% of UDT that remain undescended by six months of age will almost never come down on their own and will need surgery.

Medical concerns related to UDT include:

  1. Infertility

Paternity rates for men with unilateral (one) UDT that has been operated on previously are similar to those of men with two normal testicles.  So, having one UDT is usually not a concern as far as fertility goes.  On the other hand, paternity rates for men with bilateral (two) UDT are considerably lower at around 60%.

  1. Cancer

The risk of cancer was overestimated in the past, where biased studies were used to make the calculations.  The best estimate we have now about cancer risk comes from a study done in Sweden that looked at more than 16,000 patients that had UDT surgery, of which only 56 developed testicular cancer (0.3%) (Pettersen, et al 2007, NEJM).  Compared to the Swedish general population, when surgery was done before the age of 13 years, the risk of cancer was twice as high.  And when the surgery was done after the age of 13 years, the risk of cancer was about five times higher.  Although “twice the risk” sounds scary, the absolute numbers are not (0.3%).

  1. Cosmesis and comfort

I think this should be obvious.

Ascending Testis (AT)

The ascending testis (AT) refers to a patient that at birth, had a documented physical exam by an experienced provider in which both testicles were found to be in the scrotum, but on subsequent medical check-ups, one or both testicles are found to be out of the scrotum (undescended).

Some prepubertal boys have an underdeveloped scrotum where the pubic fat, penis, and scrotum all mix into one unit, whereas in the adult, the scrotum is completely separate from the body and “hangs out”.  Prepubertal boys also have very small testis (less than 2 cm in length) compared to adult testis (4-5 cm in length).  The cremasteric muscles surround the blood vessels going to the testicles and when they contract, they pull the testicles up into the groin (for instance, when cold, etc.).  The cremasteric muscles are well developed in prepubertal boys and can easily pull up a small testicle into the groin.  These characteristics may make prepubertal boys appear to have ascending testicles when in fact all they have is a retractile testicle.  Retractile testicles do not require treatment.

Only an experienced examiner can distinguish between a retractile and an ascending testicle (retractile testicles can still be manipulated into the scrotum without tension, whereas the true AT testis cannot be manipulated down).  Only birth medical records can distinguish an ascending from an undescended testicle.

Is there a difference between Undescended Testicles (UDT) and Ascending Testicles (AT)?

Yes. The health consequences of undescended testicles that I described above have been well studied. We know nothing about the health consequences of ascending testicles (Cancer? Infertility?).

There is one good study done in the Netherlands where patients with documented ascending testicles were followed without surgery until puberty.  They found that in 75% of the cases, the testicles descended spontaneously (without surgery) by the time the boy reached puberty.  (Sijstermans 2006, International Journal of Andrology).

Leave a comment

Filed under Hernia and Undescended testis

Antenatal hydronephrosis (kidney swelling)

With ultrasounds being done so commonly during pregnancy, one of the most common congenital abnormalities encountered is accumulation of urine inside the kidney, or in medical terms, hydronephrosis. This happens in 1-5% of pregnancies. Most cases of antenatal hydronephrosis (more than 50%) are inconsequential and transient, but on the other side of the spectrum there are cases of real urinary tract obstruction which, if untreated, could lead to infections, stones and loss of the kidney.

A well done study to determine which cases of antenatal hydronephrosis are transient versus potentially dangerous has not been done. Most of the studies to date are retrospective in nature and with substantial biases.

Capture

Measurement of the diameter of the renal pelvis (see picture) has been used to classify cases into mild, moderate, and severe.  Several researchers have come up with different thresholds, some categorizing greater than 15mm as severe, others categorizing greater than 10mm as severe.  Choosing a specific threshold to determine normal from abnormal has its consequences. We understand that the higher the measurement the more likely the kidney will have problems. So say you have 10 real cases: 5 are significant and their measurements are 8,9,14,16, and 18.  Five are not significant and their measurements are: 7,6,8,9, and 11.  If you chose 10mm as your threshold then 2 significant cases and 1 insignificant case would have been incorrectly diagnosed.  If you chose 15 as your threshold, 3 significant cases and no insignificant cases would have been incorrectly diagnosed.

So what are the most common causes of antenatal hydronephrosis?

1. Transient/Physiologic:This just means that the hydronephrosis is a normal anatomic variant with no clinical consequences. This accounts for roughly 40-88% of the cases.

2. Ureteropelvic Junction Obstruction. This refers to an obstructive process happening  between the renal pelvis and the ureter (see picture above). This accounts for 10-30% of the cases of antenatal hydronephrosis. Only 10-25% of children with ureteropelvic junction obstruction will eventually need an operation. The rest don’t develop an obstruction significant enough to damage the kidney, cause infections or symptoms.

3. Vesicoureteral Reflux: This means that urine will go back to the kidney from the bladder. It occurs in about 10-20% of antenatal hydronephrosis cases. The incidence of reflux is not different among children with or without antenatal hydronephrosis. In recent years, reflux has become one of the most controversial topics in pediatric urology. Some U.S. centers are aggressive at the diagnosis and management of reflux, whereas more and more centers are taking a very conservative approach at diagnosing and managing reflux. The main reason for the latter is that recent well conducted studies have failed to show much benefit in diagnosing and treating reflux, in terms of preventing renal damage, hypertension, or infections with either antibiotics or surgery.

4. There are other causes of antenatal hydronephrosis that are not common which I won’t cover in this post.

Which patients require further evaluations?

Most patients with antenatal hydronephrosis diagnosed during the second trimester will have their hydronephrosis resolved by the third trimester. If the hydronephrosis persists through the third trimester and especially if the diameter of the pelvis is greater than 10 mm, further postnatal evaluation with a renal bladder ultrasound is recommended.

Leave a comment

Filed under Hydronephrosis

Bedwetting (Enuresis)

Bedwetting is a common problem seen by Pediatric Urologists. Some children who wet the bed also have accidents or urgency/frequency during the day. In this post, I want to focus on the patients that are okay during the day, but  wet the bed at night. So from now on, when I mention bedwetting, I refer to patients that only have problems at night.

Bedwetting occurs in around 15% of 6 year olds, but is  present in less than 1% of adults. This means that most children with bedwetting get better on their own. It is common for children with bedwetting to have 1 or 2 parents that wet the bed as children. Usually it is predicted that the child will stop wetting the bed around the same time their parents did (that is, of course, without treatment).

Bedwetting can be treated with medications, with non-pharmacologic interventions, or with both.

Medications do not cure bedwetting. Not only that, but medications are only temporarily effective in around 20-30% of patients taking them. Most people resume bedwetting when these medications are stopped. Medications can be useful for special occasions such as sleepovers, camp, etc.

Bedwetting alarms do cure bedwetting in up to 80% of children. Alarms are worn on the child’s pajamas and they have a humidity sensor that attaches to the child’s underwear. The alarm will go off as soon as the child starts voiding and initially will wake up at least the parents (most bedwetters are deep sleepers), who would then take the child to the bathroom to help him finish voiding, and then change the bed as needed. With time the child’s brain starts associating the sensation of a full bladder with the alarm and the child starts waking up on his own to go to the bathroom. Bedwetting alarms require cooperation from the parents and some maturity from the child, and thus might not be appropriate for all social situations or for children 5 years old or younger . It may take up to 3 months of daily use for the alarms to fully work.

Lastly, the following measures can be tried on all children regardless of the age to manage bedwetting:

  • Distribute fluid consumption evenly throughout the day (some kids don’t drink anything during the morning and then come back from school and drink all their fluids in the late afternoon and evening)
  • Have your child void before going to bed.
  • Take your child to the bathroom (either awake or asleep) before you go to bed.
  • Ensure that your child voids at least 4-7 times during the day.
  • Avoid caffeinated beverages and milk towards the end of the day.
  • Avoid punitive measures for times when your child wakes up wet. Bedwetting is not due to laziness or child misbehavior. Bedwetting is involuntary.

Leave a comment

Filed under Bedwetting

Hidden Incision Endoscopic Surgery or “HIDES”

HIDES was developed by one of my mentors in Dallas, Dr. Gargollo. HIDES is just a different technique of placing the laparoscopic ports during laparoscopic surgery in order to ‘HIDE” all visible scars. During traditional laparoscopic surgery, some ports are placed above the belly button in areas that would be visible when wearing a swimming suit for example. With HIDES, one laparoscopic port is placed inside the belly button and the others are placed at or below the bikini line, thus hiding the incisions.

The patient below had a robotic pyeloplasty, using the traditional port placement. As can be seen, the most superior port scar would be visible when wearing a swimming suit.

NO hides

In contrast, the following picture shows a patient that had a robotic pyeloplasty using the HIDES technique, showing all the scars are hidden.

Gargollo Fellows Talk 2012

Leave a comment

Filed under Surgical Innovation