Hydronephrosis (PUJ)

This section discusses about blockage caused by PUJ obstruction. In this condition there is a blockage of urine at the junction of kidney and the pipe draining (ureter) – pelvi ureteric junction (PUJ). Because of this the kidney stretches. Often it affects one side alone although it can involve both kidneys.

i-20x20What are the symptoms of hydronephrosis?

i-20x20How is hydronephrosis diagnosed?

i-20x20How can hydronephrosis be treated?

i-20x20What does a pyeloplasty involve?

i-20x20What is the outlook for children with hydronephrosis?

bullet_purpleDetected before birth (Antenatal Scans): The condition should not cause the mother to have any symptoms. Hydronephrosis should not cause the baby to have any problems before birth, but he or she needs close monitoring after birth to keep an eye on the condition.

bullet_purpleColic or Pain abdomen: This can be a feature in older children. This is because of the urine in the kidney trying to push and overcome the blockage.

bullet_purpleUrinary Infection (UTI) Whenever there is any blockage to urine flow, the system can easily catch infection. These children may have fever, frequent painful urination etc.

bullet-yellowUltrasound Scan: Hydronephrosis is diagnosed using an ultrasound scan. It helps to determine the severity of blockage; reflected by the amount of dilatation.

bullet-yellowNuclear Scan: For this test a small dose of medicine is injected in to the vein; pictures are taken with a gamma camera (like x-ray) every few minutes; this shows how fast the kidneys take up the medicine and how fast it leaves the kidney. When there is a blockage, the medicine stays in kidney for a long time. When the kidney function is poor; very little medicine is taken up by the kidney.

bullet-yellowMCU: This is mainly to exclude problems like reflux or a valve.

bullet-greenIf the hydronephrosis is diagnosed during pregnancy, early treatment will consist of monitoring with ultrasound, to check that the baby is growing normally and the kidneys are not getting too large. The baby will usually be born by a routine delivery.

bullet-greenAfter the baby is born, the hydronephrosis will be monitored using ultrasound scans and Nuclear scans.

bullet-greenWhen the hydronephrosis is getting worse or the kidney function is reducing surgery called pyeloplasty is recommended.

Under general anaesthesia, a small cut is made in the kidney region. The blocked portion is removed and reconnected. A small tube called stent may be kept to protect the sutures. It may be kept fully inside (needs removal under a second anaesthesia) or partly out (bedside removal after 7 days). The hospital stay is between 4-8 days. Children recover very well and it is not very painful as medicines will be given to take care of it. They can have normal feeds within 24 hours of operation.

bullet-yellowIf the cause of the hydronephrosis is an obstruction and this is removed shortly after birth, kidneys will be able to work properly.

bullet-yellowThe earlier the hydronephrosis is discovered, the better the outcome

Hydronephrosis & Antenatal Counselling

Currently most pregnant women undergo one or two ultrasound scans during their pregnancy. When the fetus is scanned, kidneys and the urinary tracts are analyzed, In addition the volume of liquor (amniotic fluid) also helps to suspect kidney problems. Of late stretching of the kidney (Hydronephrosis) is detected very frequently.

i-20x20Kidney Stretching (Hydronephrosis)

i-20x20Single Kidney Stretching (Unilateral Hydronephrosis)

i-20x20Both Kidneys Stretching (Bilateral Hydronephrosis)

i-20x20Consultation before birth (Antenatal Counseling)

During scanning of 100-200 pregnant ladies, one fetus is found to have this abnormality. This usually happens because of a blockage in the urinary tract. Before proceeding further it is essential to describe the normal arrangement of the kidneys. In human body there are two kidneys, one on either side of belly. From each kidney urine drains out via a tube called ‘ureter’ into a common urinary bladder. The bladder is located in the lower most part of belly. Once enough urine accumulates, it empties via a tube called ‘urethra’. Whenever there is a block in any of these tubes, kidney stretching results.
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When only one kidney (right or left) stretches, blockage is suspected only on that side. When kidneys only stretch, the blockage is suspected at a higher location (PUJ obstruction). When the pipe draining the kidney also stretches, blockage is suspected at a lower location (VUJ obstruction). Newborns with this problem need to be scanned on the third day after birth. In general very mild stretching is likely to settle spontaneously. Huge stretching requires surgery urgently to prevent loss of kidney function (renal failure). Children with moderate stretching need close monitoring with repeat scans and further tests. It is essential to consult a pediatric urologist to determine what tests are required and when a surgery could be avoided. Also it is essential to prevent urinary infection by taking a small dose of antibiotic once at night.

When both kidneys stretch, they can be blocked separately. But usually they are blocked as urine exits the bladder in the ‘urethra’. In boys a valve like blockage can result in stretching of both kidneys (posterior urethral valve – PUV). Immediate endoscopic intervention after birth is essential to prevent urine infection and kidney failure.

When there is a fetal kidney problem, there could be a lot of anxiety among parents. Consulting a paediatric urologist can relieve the anxieties and also provide answer to many questions. It will help to plan the type of delivery, place of delivery (where the treatment is available to the baby after birth), the type of tests required after birth. Also it helps to find out more about what is expected in the long run (prognosis) and whether the problem can occur again in future children (familial incidence).


bullet-redIt is possible to determine kidney problems in the baby before birth.

bullet-redMost of the kidney problems correct spontaneously, although it is essential to confirm this by consulting a Paediatric Urologist

bullet-redA small proportion of babies require corrective surgery after birth.

bullet-redBy consulting before delivery, parents can relieve their anxieties.

Intersex

The first question asked by grandparents after a baby is born is ‘is it a boy or girl’. This is often determined by looking at the genitalia. Intersex is a condition where the sex of the child could not be determined looking at the genitalia.

i-20x20What are the causes of intersex?

i-20x20How to deal with this at birth?

i-20x20Can the appearance be improved by an operation?

The causes of intersex are many however it can be simplified as follows

bullet-green A Hypervirilised Girl:chromosome is XX but genitals are masculanised due to exposure to male hormones

bullet-greenUndervirilised Boy: Chromosome is XY but the genitals are not well masculanised due to deficiency or failure of action of male hormones

bullet-greenMixture of problems: Mixture of problems: This can be at various levels; both XX and XY chromosomes or both testicular and ovarian tissues or multiple patterns

It is essential to do the tests like chromosomes and harmonal tests soon after the birth to identify the problem. It is also essential not to name or fix gender for the baby before diagnosis. Once the problem is assessed doctors and parents should sit together and decide what is the best sex of rearing for the baby. If the sex is assigned by appearances without proper testing, it becomes socially very difficult to change gender once the child becomes old.

Hypospadias

Little baby boys pass urine like a fountain. Small lads can stand and pass urine straight with an ability to point the stream where they want, like a fire-man’s hose. This is possible because the urine comes out of the opening at the tip of the penis. In boys with hypospadias, the opening is located on the under surface of penis. Because of this the urine is deviated downwards towards their feet. The picture shows normal arrangement and hypospadias.

i-20x20How is hypospadias detected?

i-20x20What are the consequences of Hypospadias?

i-20x20Do they have other birth defects? Can the same problem recur in future children?

i-20x20What is the right time to correct hypospadias?

i-20x20What are the chances of fertility after operation?

Hypospadias occurs in one in 300 male newborns. When the paediatrician checks out the baby, or when the parents bath the baby, the following features can make one suspect hypospadias

bullet-yellowUrine opening on the under surface of the penis

bullet-yellowPenis being slightly bent downwards

bullet-yellowExcess foreskin on the top of the penis

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When hypospadias is left uncorrected, the following consequences can develop

bullet-greenUnlike the normal lads who can stand and pass urine, hypospadiac lads have to sit; if they stand and pass urine, it goes down the leg.

bullet-greenWhen they get older, because of the bent in penis, sexual activities become difficult. Also they have much lower chance to have children, as they can’t deposit the sperm normally. The sperm leaks out through the opening located underneath.

bullet-greenSometimes the urinary opening is also small, leading to blockage in urine stream. This leaves them at a risk of urinary infection.

In general, hypospadiac children do not have other kidney abnormalities. However in 10% of these kids, the testis may not be descended normally. When both testes have not come down normally, they can have associated hormone defects. When the first child or the father has hypospadias, there is a slightly higher chance (7-10%) for the future boys in the family to have the same birth defect.

From 6 months onwards, hypospadias can be corrected by an operation. By completing the operation before 2-3 years of age, these children can be toilet trained normally like any other child. Not having an appearance like other boys at school, can lead to emotional problems in these children.

Most of the hypospadias belong to the mild variety and can be operated by a single stage operation. When the opening is too far down from the tip, they might require two-stage operation. The operation is usually done under general anesthesia and a catheter/ dressing is left for 5-7 days. Three things are corrected during the operation.

bullet_purpleThe opening is brought to the tip

bullet_purpleThe penis is straightened

bullet_purpleExcess foreskin is removed (circumcision).

Optical magnification (microscope) and fine suture materials are essential for a successful result. When extra care is taken there is a very good (95%) success rate. In 5% the following complications can occur.

bullet_purpleThe new opening gets small gradually (meatal stenosis)

bullet_purpleUrine leaks at the original site (Fistula)

Both these can be corrected by another minor operation; so the parents need not have undue concern about this.

bullet-redIn children with hypospadias, the opening is on the under surface of penis.

bullet-redBecause of this, these lads can’t stand and pass urine like normal children.

bullet-redThey can have infertility in later life, if left uncorrected.

bullet-redBy performing a corrective surgery at the right age, these can be avoided.

Inguinal hernia / hydrocele Undescended Testis

The testis is responsible for sperm production in men. The general body temperature is 36.9o C. But sperm production is best at a temperature 2o less than this level. This is the reason why the testes are located outside the body. When the baby is formed in the womb, the testis is initially formed inside the baby’s belly. As the fetus (baby in the womb) grows, the testes gradually descend out of the body and reach the sac (scrotum). When this does not happen, or is arrested half way, the result is ‘Undescended Testis’ (UDT).

i-20x20How common is Undescended Testis? Is it possible for the testis to descend by itself?

i-20x20How is it detected?

i-20x20What happens when Undescended Testis is not corrected?

i-20x20What is the right time to operate and bring down the testis (Orchidopexy)

i-20x20What are the complications of Orchidopexy?

i-20x20What are the chances of fertility after operation?

i-20x20What is a retractile testis?

i-20x20Can a normally descended testis go back up?

Undescended Testis is seen in 30% of boys born before date (preterm). In such cases it is very likely that testis can descend by itself in 3-6 months time. Among full term boys 1-3% are found to have Undescended Testis. They also have a small chance to correct this problem by themselves. But this possibility becomes much less after 6 months of age, after this age surgery is required to correct it.

When the newborn baby is examined by the paediatrician, by feeling with hands one can find out that the testis is missing. When the sac (scrotum) is poorly formed, one can suspect this. Also parents can detect it in a similar way when bathing the child. When the testis is not there, one can wait for 3-6 months for spontaneous descent. If this does not happen, it is essential to consult a Paediatric Urologist.

bullet-blueInfertility: As mentioned before, sperm production takes place at a lower temperature than body temperature. When testis is not descended, it is exposed to higher body temperature, and sperm production is affected. In later life these patients have much reduced sperm count and chance to father (50-70% less than normal).

bullet-yellowTwisting of Testis (Torsion): When the testis is not descended, it is very free to move around itself. This makes it easy to twist and cut off its own blood supply; the result being loss of testis.

bullet-yellowTesticular Tumor: There is a small risk of tumor development in Undescended Testis. By doing an operation to bring it down this can be easily checked out. If the testis is not brought down, tumor can develop without being noticed and can become advanced before treatment.

For the children with Undescended Testis, it is recommended to have surgical correction within one year to prevent infertility in later life. During this operation, the testis is found at the lower part of the belly and fixed to the testis after achieving enough length. When the testis is developed poorly, it may need to be removed. Some times the testis is absent by birth. Laparoscopy is essential in such situations. Also when the testis is too high, two-stage operation may be needed. During the first stage the blood supply to the testis is cut off using a laparoscope. As the testis develops new blood supply, it is brought down at a second stage. All these need to be carefully decided by the Paediatric Urologist.

In general in 95% of such operations there is a successful outcome. In 5% the following complications can occur.

bullet-greenTestis being small (Atrophy): This can result because of damage to the blood supply during the operation. This can also be a result of testis being small by birth.

bullet-greenTestis going back up (Ascent): When the length is not enough and the testis is under tension, testis can go back high again.

When only one testis is affected, and surgery is performed at the right time, there is 80% chance for fertility and paternity. When both testis are affected, if the surgery is performed at the right time, there is still 50% chance for fertility and paternity.

Sometimes the testis intermittently disappears upwards. This phenomenon is called ‘retractile testis’. In this situation one can wait for the boy to grow, however a careful followup is essential. On regular followup checks if the testis prefers to stay higher or if the testis is under tension when brought down, surgical correction is recommended.

In some boys who had normal testis at birth, at a later age the testis can go back up. This is called ‘ascending testis’. This is due to increased activity of a muscle around the cord. Although it can be an intermittent phenomenon, in some boys, the testis preferentially stays higher exposing them to high temperature. These patients need to be carefully selected for surgery.

bullet-redUndescended Testis is found in 3% of term boys and 30% of preterm boys.

bullet-redWhen the testis does not come down by it self by 6 months, it is essential to consult a Paediatric Urologist with a view to correct.

bullet-redWhen left uncorrected, complications like infertility and torsion can result.

Phimosis / Circumcision

The term ‘Phimosis’ derived from Greek word for ‘muzzling’ has been widely applied to narrow foreskin. It is essential to understand normal appearance in a newborn child to know when Phimosis is abnormal or when it will require surgery

i-20x20What is a normal foreskin?

i-20x20Is it normal to have a non-retractile foreskin?

i-20x20Is it advisable to practice retraction to make it better?

i-20x20When is Phimosis a true problem?

i-20x20What is Circumcision?

i-20x20What does a circumcision involve? Are there any complications?

i-20x20Are there any alternatives to circumcision?

The skin over the tip of penis normally folds on itself as a sleeve and attaches to the head of penis. This extra skin is called foreskin. In newborn babies the under surface of the foreskin is fused to the head of penis. Because of this in 95% of newborn babies the foreskin can not be pulled back. This is referred to as ‘physiological phimosis’ or ‘non retractile foreskin’. However as they gets older it separates slowly; upto 1-2 years of age, 50% of boys have a foreskin that can be pulled back; and by 15 years almost 90% have normal adult pattern.

Up to 1-2 years of age there is a variable proportion of foreskin adherence to the penis. Sometimes there can be accumulation of white discharge called ‘smegma’ giving the appearance of ‘white pearls’ under the skin. Some times the foreskin balloons as the boy passes urine but there is no other problem. These are entirely with in the normal limit and should not be a cause of concern.

If parents resort to the practice of retraction exercises, they might overdo and can cause soreness and bleeding. Also excessive retraction with damage heals with scarring leading to real phimosis. Boys older than 7 years of age can attempt self retraction at bath. However it is essential to put it back after retraction, as skin left retracted can result in swelling called ‘paraphimosis’.

bullet-greenScarring of the skin at the tip

bullet-greenRecurrent infections

bullet-greenStraining and only dribbling when passing urine

bullet-greenPara phimosis (swelling and inability to put back the pulled foreskin)

Circumcision is one of the oldest operations known to mankind. It basically involves removing the excess skin at the tip of the penis. There are several reasons for doing circumcision

bullet_purpleAs a treatment: in true Phimosis

bullet_purpleAs a preventive step: In children with recurrent urine infections (circumcision reduces the risk of cancer penis, sexually transmitted disease)

bullet_purpleFor religious reasons: in Muslims and Jews

bullet_purpleSocial reasons: ‘to look like Daddy!’; ‘to look like brother’

bullet_purpleAs a routine: in some countries circumcision is performed routinely

Circumcision in children is usually done under general anesthesia, as a day case procedure. The operation lasts for around 30 minutes. The stitches are dissolvable and need not require removal. There can be a variable degree of swelling and the penis may look ugly for 2 weeks. As the head of penis has not been exposed, it undergoes drying and scabbing over it. Bleeding is a rare complication and usually settles spontaneously. The urinary opening on the penis can become narrow, especially if there is a skin problem called BXO. If this develops, it might require dilatation under general anesthesia.

In an operation called ‘prepucioplasty’ the narrow ring of skin is divided across and sutured along. This widens the narrowing without removing the foreskin. For this operation to be successful, the boys need to self retract after the operation for 2-3 months

bullet-redNon-retractile foreskin can be a normal developmental process in boys under 1 years of age.

bullet-redCircumcision is indicated if there are recurrent infections, or if there is narrowing with scarring.

bullet-redCircumcision is a safe operation that can be performed with out the need for over-night stay.

bullet-redFor a good cosmetic result, and minimal complications, it has to be performed by a well trained surgeon

Emergencies

The testis can go for a twist inside the sac it is held. This results in loss of blood supply. If left untreated for more than 6 hours the testis loses function. Typical presentation is a 14 year old boy who develops severe pain, red ness and swelling of the sac of testis suddenly. It is very tender to touch. It is necessary to do a surgery immediately. There is no point in wasting crucial time on different tests. Surgery is diagnostic and also curative; if blood supply returns after untwisting the testis is preserved. If the blood supply is lost the testis may have to be removed. In either case opposite testis has to be fixed to prevent twisting on that side.

Children can sustain injury to kidney when there is blow to the loin either during a road traffic accident or a handle bar injury during cycling. The damage to the kidney can very from mild to serious type. There may be pain, blood in urine etc. CT scan is often required to confirm the extent of damage. Often the treatment is bed rest. Surgery is required only if there is continuous blood loss.

When boys fall on to a branch of a tree while climbing, or on cycle bar during cycling, the urethra located in between the legs is injured. When there is severe injury there will be blood from the tip of the penis and the child might not be able to pass urine; with urine accumulating in the bladder. A temporary diversion of urine directly from the belly may be required.

This term refers to pus in the kidney. This can be a result of obstruction to the urine flow and infection developing in it. It is a very serious problem requiring admission, IV fluids and IV antibiotics. In addition prompt relief of pressure has to be done to prevent complete loss of function in that kidney. The conditions that can lead to this include

bullet-blueBlockage at the upper end of ureter (PUJ obstruction)

bullet-blueBlockage at the lower end of ureter (VUJ obstruction)


If both kidneys are blocked then it can rapidly lead to renal failure. There can be very low to absent urine output (anuria). The conditions that can lead to this serious problem, even in the newborn period, include

bullet-bluePosterior Urethral Valves

bullet-blueUreterocele blocking bladder outlet

They need to be carefully treated by experts in the field. Some times a simple catheter can revert the situation. Dialysis may be required before planning definitive surgery. Both of these problems can be tackled by a simple endoscopic surgery, relieving the blockage.

Appendicitis

i 20x20What is Appendicitis?

i 20x20What are the symptoms?

i 20x20How is it diagnosed?

i 20x20What is the treatment?

i 20x20What is the outcome?

In this condition there is infection followed by inflammation of the appendix. Appendix is a tail like structure found at the junction of small and large bowel. It is a rudimentary organ (not necessary for normal function of gut), only useful in animals.

Typically there is pain in the right lower part of tummy. This is sudden onset with sometimes vomiting and fever associated. Any movement or cough will aggravate the pain. The pain to start of is in the centre of tummy, but with time localises to right lower part where the appendix is situated.

Often the diagnosis is by clinical examination. Typical location of pain is there. On pressing the right lower part, the child winces in pain. Blood counts may show elevated white cells. Ultrasound is often performed, not to look for appendix, but to exclude other causes of abdominal pain like kidney stones or ovarian cyst.

The treatment is emergency surgery to remove the infected appendix. Laparoscopic operation can be performed to minimise scar and hasten recovery.

If not operated in time, rupture of appendix can lead to a life threatening complication called peritonitis, where pus is spread all inside the abdomen. Operation and recovery after peritonitis are complicated. However for simple appendicitis, a quick recovery is the norm.

Common Paediatric Surgical Problems

Congenital Diaphragmatic Hernia (CDH)

Oesophageal atresia/sTracheo oesophageal fistula (TOF)

Small Bowel Atresia

Hirschsprung’s Disease

Anorectal malformation,

Exomphalos

Gastroschisis

Congenital Cystic Adenomatoid Malformation (CCAM)

Necrotising enterocolitis (NEC)

Pyloric stenosis

Intusussception

Appendicitis

Paediatric Laparoscopic Surgery (Key Hole Surgery)

i 20x20What is a laparoscope? What is key-hole surgery?

i 20x20What are the advantages?

i 20x20Is it safe in children?

i 20x20What problems can be treated with laparoscopic surgery?

Laparoscope is a telescope like instrument to visualise organs inside. In key hole surgery there is no cut made; but surgery is performed through camera and instruments inserted via tiny holes.

bullet-blueAs there is no cut, there is no big scar

bullet-blueThe pain is almost nil as there is no cut

bullet-blueThe healing is fast

bullet-blueComplications of wound healing are much less

bullet-blueChildren recover quicker and can be discharged quicker

bullet-blueThis helps to reduce the cost

bullet-blueAs they recover quicker can return to school quicker

Laparoscopic surgery has been performed safely in children. There are no disadvantages. However one has to be prepared for open surgery in case there is instrument failure or technical difficulty.

bullet-blueAppendicitis

bullet-blueGall stones; spleen surgery

bullet-blueKidney surgery

bullet-blueVaricocele

bullet-blueUndescended testis

bullet-blueEmpyema (pus in chest)

bullet-blueOvarian problems

Incontinence, Neuropathic Bladder

i 20x20What is urinary incontinence?

i 20x20What are the causes of neuropathic bladder?

i 20x20What are the features of neuropathic bladder?

i 20x20What are the risks faced by these children?

i 20x20What are the tests required?

i 20x20What are the treatments available?

i 20x20When is surgery required?

The term ‘Incontinence’ means lack of control. Urinary incontinence refers to the leakage of urine with no control over it. A large proportion of children who suffer from bed wetting or day time wetting do not have any major medical problem. They belong to a group called ‘Bladder Dysfunction’ which settles in course of time by itself or with the help of some medication. In children born with birth defects of the spine the incontinence is constant and can be a considerable problem. This is referred to as ‘Neuropathic Bladder’ or ‘Neurogenic Bladder’

In the condition called ‘Meningocele’ the spine is not closed fully and the baby is born with open spinal cord or a swelling in the back. These children undergo a neurosurgical correction at birth and present later with urinary incontinence by 4-5 years of age. In some children the back is normal to look but the spinal abnormality is hidden. Only on evaluation with further test like MRI scan a defect like spina bifida or tethered cord is detected. Spine injuries or injury to the nerves during an operation on the bowel within pelvis [‘pull through’ operation] also can cause damage to the bladder nerve supply.

These children suffer from constant dribbling of urine and very severe leakage of urine. They may suffer from recurrent urinary infection. The may also have very poor control of bowel. This may be in the form of constipation or severe soiling of liquid stools. Some of them might also have associated problems like leg spasticity or deformity.

The nerve supply of the bladder and muscles that control urine are affected. The storage capacity as well as emptying capacity is impaired because of this. Stagnation of urine can predispose to recurrent urine infection. The bladder muscle generates high pressures during filling or emptying. The urine might go upstream towards the kidneys (reflux). The pressure and recurrent infections might damage the kidney and cause kidney failure.

Initial assessment of these children begins with an ultrasound scan to see whether the kidneys are affected and whether the bladder empties fully. A test called MCU identifies the shape of bladder and the presence of reflux. A more detailed assessment of bladder pressure and storage capacity can be done with a test called urodynamics. In this a computer records the bladder pressure during filling with saline.

If the bladder pressures are high, a medicine is prescribed to relax the bladder. Constipation if present has to be treated effectively with medicine or enemas. When emptying of urine is a problem, these children need to use a small tube (catheter; pronounced ka- thee- ter) to empty the bladder. This procedure called ‘clean intermittent catheterisation’ is essentially passing the tiny tube via naturalis to empty the bladder using clean hands. Initially the parents may have to do this and once older the children learn how to do it. The very idea of passing a tube down the penis is worrying to the parents, however, worldwide a large proportion of children and adults have learnt this procedure and have prevented kidney failure and transplantation successfully. Initially there might be some reluctance, but once learnt this can be easily done as a routine. Often people worry about introducing infection as they pass tubes. In fact more people are saved from urine infection by regular emptying of bladder with a catheter.

Sometimes the bladder is too small and does not store enough urine. It may also generate high pressure and can cause kidney damage. In such a situation, the bladder is enlarged by an operation using a piece of bowel. This procedure called bladder augmentation increases the bladder capacity and reduces the pressure. Once this procedure is done, the bladder needs to be regularly emptied with catheterization. If catheterization via natural route is not possible because of pain or some other defect, they need a surgery called ‘Mitrofanoff’. In this procedure the appendix is used to create a tunnel between the belly and bladder. Through this a tube can be passed more easily without pain to empty the bladder.

bullet-redConstant leakage of urine and a bad urine odour can affect the child’s self image if left untreated.

bullet-redIn modern medicine childhood urinary incontinence can be effectively treated.

bullet-redPrompt treatment can prevent multiple urine infections as well as kidney failure.

Bedwetting

Bedwetting (nocturnal enuresis) is involuntary voiding of urine during sleep at least three times a week in a child aged 5 years or older. It is a common worldwide problem affecting both boys and girls below 16 years. It can be a distressing experience for the child and may lead to loss of self-esteem and isolation. Children fear being discovered and are afraid to go to relatives’ or friends’ house. Although most parents are supportive, up to 30% parents become intolerant towards their child.

i 20x20How common is bedwetting? Can it correct itself?

i 20x20Why does bedwetting happen? Is it anyone’s fault?

i 20x20Is it caused by any underlying problem?

i 20x20What treatment is available? Can any dietary modification help?

i 20x20Do’s

i 20x20Don’ts

At 5 years of age, around 1 in 6 children still wet the bed. This means that in a school class of thirty there will be five who wet the bed regularly. Because the children and their parents are too embarrassed to talk about the problem it is unlikely that they will be known to each other. Most of these children spontaneously grow out of it. By the age of 10 only one in 15 still wet the bed. Even in adulthood 1 in 100 still suffers from the problem.

It is important to remember that it is not the child’s fault. Parents must also not blame themselves. Getting angry or punishing the child could make the problem worse. Supporting and praising the efforts of the child to stay dry will help the child to become dry sooner. Getting medical help relieves the anguish for the family. The cause of bedwetting is usually a combination of three factors.

bullet-blueOver production of urine at night

bullet-blueHyperactivity of the bladder

bullet-blueLack of arousal from sleep

Stressful early life events can trigger bedwetting in those who have previously been dry for a long period.

Children with isolated bedwetting usually do not have any underlying problem. However if a child has been wet right from birth, always wet day and night, or never achieved toilet training, then it is essential to see a Paediatric Urologist to make sure that there is no associated medical problem like ectopic ureter, where one kidney drains not into the bladder but, outside the body directly.

Often simple methods like waking up the child (alarms) and giving awards for a dry night (star chart) are undertaken. If bladder over activity is suspected, a bladder relaxing medication is prescribed. If night time alone is a problem, a medicine to reduce the volume of urine in the night is prescribed. When urine infection is suspected, an antibiotic is prescribed. It is essential to avoid bladder irritants as black current, coffee or coke. Constipation can make bladder problems worse. Taking plenty of fruits and vegetables can help to prevent this. Often parents restrict children’s water intake. This is not necessary; in fact these children need plenty of water and regular toilet visits during the day.

bullet_purpleStay calm, be prepared and try not to worry

bullet_purpleEncourage your child for staying dry; give awards for dry nights

bullet_purpleEncourage the child to drink plenty; it is important that they recognize the feeling of full bladder

bullet_purpleAvoid fizzy drinks, tea, coffee, chocolate; these can irritate bladder and can cause more urine production

bullet_purpleEnsure that the child goes to toilet before bed

bullet_purpleMake sure that easy access to toilet is available at night

bullet_purpleAllow the child to help with changing the bed; this helps them to understand the problem and overcome it.

bullet_purpleMake sure that the child has a bath each morning. This removes the smell of urine and avoids the child being teased at school.

bullet-blueDo not get cross with your child; it is not their fault

bullet-blueDo not use waking the child as a long term strategy to overcome bedwetting; instead get help from a doctor.

bullet-blueDon’t give up. 99% of these children get better by adulthood.

Kidney Stones in Children

There is a wide misconception that only adults develop stones. On the contrary kidney stones are very common in children living in hot climates.

i 20x20How is a stone formed in urine?

i 20x20What are the symptoms of urine stones?

i 20x20How is a stone detected?

i 20x20What are the treatments available to remove the stones?

i 20x20What is Endoscopic treatment?

i 20x20What is Breaking Stones?

i 20x20Can stones come back? How can we prevent this?

i 20x20What are the dietary restrictions in children with stones?

Urine is basically made of unwanted salts in the body. Presence of a reasonable amount of water is essential to prevent stone formation. When the the water content is less, the urine becomes concentrated and favours stone formation. Also stagnation to urine flow promotes stone formation. Some children with stones have birth defects that make them pass more calcium and less citrate in urine. Children with recurrent urine infection are more prone to develop stones; stone in turn promotes urine infection.

bullet-blueThere can be no symptoms when a stone is present.

bullet-blueWhen a stone is blocking urine passage in the kidney or urinary tubes, severe loin pain results.

bullet-blueWhen there is a stone in the urinary bladder, there will be pain at lower part of belly or the penis.

bullet-bluePain when passing urine, blood in urine or even passing small stones or gravel can be present.

bullet-blueSmall babies cant tell these. When children cry while passing urine or when there is urine infection, it is essential to rule out a stone.

When children experience the above symptoms, urine is tested in the lab. Presence of excess red cells or white cells; and presence of crystals in the urine suggests urinary stone disease. Ultrasound scan helps to find out whether there is a stone, the position, size and number of stones. In addition special tests like IVP, X-Ray, or CT scan may be required.

There is a general misconception that childhood stones always require open surgery. Like adults children also can be treated without open surgery. In modern medicine facilities are available to break stones and 80% are removed without open surgery. For this it is essential to consult a pediatric urologist trained in this field.

When stone is present in the bladder, it can be removed with the help of an endoscope. Endoscope is a small tube with a camera that is passed up via the urinary passage. The stones are grasped with small grabbers. Bigger stones can be broken with the help of a technique called lithotripsy. As children won’t stay still, they need a general anesthesia. To prevent blockage by broken stone pieces, a small tube called stent is left in for 2-3 weeks.

A technique called ESWL uses sound waves to break stone. With the help of an x-ray or a scan the stone is focused. ESWL machine breaks the stone in less than an hour. Sometimes a second sitting may be required for complete stone clearance. With this treatment, children can return home with a couple of days. Small children need general anesthesia, as they have to lay still for this.

Children have a 20-50% higher chance for the stone recurrence. Problems like passing excess calcium in urine can be there. It is essential to identify this to prevent further stone formation. Regular toileting and drinking plenty of water are essential to prevent stones and urine infection.

bullet_purpleIn general drinking plenty of water (10-20 cups) helps to reduce stone formation.

bullet_purpleSalt should be restricted in diet.

bullet_purpleNon vegetarian foods and milk products need to be reduced.

bullet_purpleCabbage, spinach, cashew, walnut etc need to be avoided.

bullet_purpleCoffee, tea, cola, apple and grape juices need to be restricted.

bullet_purpleOrange and lime juices are good.

bullet_purpleVitamin D and calcium tonics should be avoided.

bullet-redLike adults children can also develop urinary stones.

bullet-redChildren can have underlying medical problems that make them prone to develop stones.

bullet-redIt is essential to identify and treat these to prevent stone recurrence.

bullet-redWith the advent of newer facilities, 80% of stones in children can be removed without open surgery.

bullet-redIt is essential to consult a paediatric urologist trained in this area to obtain the appropriate treatment.

Urinary infection/Vesico Ureteric Reflux

A child is considered to have urinary tract infection (UTI) when the urine of the child grows bacteria during a microbiological test and the amount is significantly high (more than one lakh per ml). During childhood 5% of girls and 2% of boys get UTI. In the new-born period more boys get UTI than girls. Among the girls half can get a second UTI within a year.

i 20x20Why is UTI important in children?

i 20x20How do we suspect urinary infection?

i 20x20How is UTI diagnosed?

i 20x20How is UTI managed?

i 20x20What is Vesico Ureteric Reflux (VUR)?

i 20x20How do we diagnose VUR?

i 20x20Can it be familial?

i 20x20What is the treatment for VUR?

i 20x20Is it safe to give a child long term antibiotics? Will it reduce the immunity?

i 20x20When is operation required for VUR? What does it involve?

i 20x20What are the other problems that might require operation?

i 20x20What are the general measures one should take to prevent urine infections?

The incidence of underlying kidney problem is far higher in children compared to adults. 30-50% of children with UTI can have a kidney problem. If left untreated, they can lead to multiple infection, kidney scarring and in the long term hypertension and renal failure.

When the UTI involves bladder alone, one experiences frequency, pain and burning sensation while passing urine. When the kidneys are also affected, high fever, vomiting, tummy pain and feeling unwell, can be the features.

Initial urine tests with microscope can help to identify presence of UTI. However it is confirmed only after growing organisms in a large number when tested in micro lab.

After confirming the diagnosis, it is usually treated with a course of oral antibiotics. If kidney infection is suspected, the child may require hospitalization for IV fluids and antibiotics via IV route. Once UTI is treated, an ultrasound scan is requested to look for any underlying abnormalities.

In normal state, the urine travels in a one-way direction from kidneys to the bladder via the ureter. Once in bladder, the urine does not go back up either during storage or emptying. But in children with Vesico Ureteric Reflux (VUR), the urine goes upstream towards the kidneys. Because of this the kidneys are exposed to serious infection and scarring during any urinary infection.
VUR

A test called MCU is done to diagnose VUR. In this a special radio opaque dye is injected via a catheter into the bladder. X-rays are taken while the child passes urine. Normally urine should not go up towards kidneys. But in children with VUR it goes up.

There is a slightly higher chance in future kids to have VUR when there is a kid with this problem in the family.

When VUR is present the usual treatment is to put them on long term low dose antibiotics (sometimes up to 4-5 years). This prevents the kidney getting infected. Most of them do not require surgery.

Long term antibiotics are only to protect kidneys. They are found to be safe and they do not cause reduction in immunity.

When a child gets recurrent urine infections despite being on antibiotics, or when the reflux is very high grade with kidney scarring, then surgery is recommended. In this the length of ureter inside the bladder is increased, thereby creating a one-way valve. This prevents urine going back upstream. It is done under general anesthesia and involves 5-7 days hospital stay. The success rate is above 95%.

In boys, circumcision has shown to reduce UTI significantly. If there is a blockage to the urinary tract, it will need correction. If urinary stones are present, they need to be removed. If there are congenital abnormalities of kidneys predisposing to UTI, they may need correction

bullet-blueEncourage your child to drink plenty of water

bullet-blueAsk them to go to toilet regularly

bullet-bluePrevent constipation by giving plenty of vegetables and fruits

bullet-blueAvoid bladder irritants like coffee, tea and coke.

bullet-blueAvoid exposing genitalia to soap, or shampoo, or bubble baths.

bullet-blueBio-yoghurts, curd etc have been shown to reduce UTI.

bullet-redUTI in children need to be properly diagnosed and treated.

bullet-redChildren are more likely to have underlying kidney abnormalities than adults.

bullet-redSome of them require surgery to prevent long term damage to the kidneys.

Posterior Urethral Valves (PUV)

Posterior urethral valves (PUV) is a condition found only in boys. PUV occurs in one in every 8000 boys born. It affects the urethra (the tube which runs from the bladder to the outside). In boys with PUV, the urethra has a blockage in it near the bladder. This makes it difficult for them to pass urine. As the bladder pushes hard to get the urine out, it causes pressure which may result in urine being pushed back from the bladder into the ureters and kidneys (reflux). This causes the kidneys and bladder to swell. This also may lead to kidney damage.  

i 20x20What are the symptoms of PUV?

i 20x20How is it diagnosed?

i 20x20How can PUV be treated?

i 20x20What is the outlook for children with PUV?

There are various symptoms associated with PUV, but they may not affect every child in the same way. The degree of blockage affects the severity of the symptoms. These boys can have

bullet-blueurinary tract infections (UTIs)

bullet-bluedifficulty urinating

bullet-bluea weak stream of urine

bullet-blueunusually frequent urination

bullet-bluebedwetting after toilet training has been successful

bullet-bluepoor weight gain

bullet-bluean enlarged bladder, so that it can be felt through the abdomen as a lump

PUV can be diagnosed by a routine ultrasound scan during pregnancy if the bladder, ureters or kidneys are swollen. It can also be diagnosed in a newborn baby if the bladder is swollen and urine dribbles constantly. If the blockage is not severe the condition can remain undetected until the child has symptoms as above.

bullet_purpleUltrasound of abdomen – this is very similar to the ultrasound scan that most women have during pregnancy. It creates a picture of the organs inside the body and shows how well they are working.

bullet_purpleMicturiting cystourethrogram (MCU) – this test shows urine passing from the bladder to the urethra and then to the outside. It will also show if the urine is flowing backwards towards the ureters and kidneys (reflux).

bullet_purpleBlood tests – these will show how well your child’s kidneys are working and check that there is enough fluid inside the body.

Other tests and scans may be needed to check that other parts of the urinary system are working properly. These can include kidney and bladder function tests.

There are several options for treatment, depending on how severely the symptoms are affecting your child:

bullet-blueThe first course of action usually deals with the symptoms and includes putting a catheter (thin, plastic tube) into the bladder to drain away the urine. Any UTIs and fluid imbalance will also be treated with antibiotics and intravenous (IV) fluids, which are delivered directly into a vein.

bullet-blueFollowing this the valves are destroyed with the help of a cystoscope (a tube with a light on the end) – called Cystoscopic fulgration. This is a delicate procedure and needs to be done under general anaesthesia. Following this a catheter is left in for a few days. Some times a second sitting is required after a few months.

The outlook depends on how much damage has already occurred in the kidneys. Your doctors will be able to give you a better idea once they have all of your son’s test and blood results. It is essential to keep up with the follow up appointments as they need long term monitoring; some time for years together.

Inguinal hernia / hydrocele Undescended Testis

The testis is responsible for sperm production in men. The general body temperature is 36.9o C. But sperm production is best at a temperature 2o less than this level. This is the reason why the testes are located outside the body. When the baby is formed in the womb, the testis is initially formed inside the baby’s belly. As the fetus (baby in the womb) grows, the testes gradually descend out of the body and reach the sac (scrotum). When this does not happen, or is arrested half way, the result is ‘Undescended Testis’ (UDT).

i 20x20How common is Undescended Testis? Is it possible for the testis to descend by itself?

i 20x20How is it detected?

i 20x20What happens when Undescended Testis is not corrected?

i 20x20What is the right time to operate and bring down the testis (Orchidopexy)

i 20x20What are the complications of Orchidopexy?

i 20x20What are the chances of fertility after operation?

i 20x20What is a retractile testis?

i 20x20Can a normally descended testis go back up?

Undescended Testis is seen in 30% of boys born before date (preterm). In such cases it is very likely that testis can descend by itself in 3-6 months time. Among full term boys 1-3% are found to have Undescended Testis. They also have a small chance to correct this problem by themselves. But this possibility becomes much less after 6 months of age, after this age surgery is required to correct it.

When the newborn baby is examined by the paediatrician, by feeling with hands one can find out that the testis is missing. When the sac (scrotum) is poorly formed, one can suspect this. Also parents can detect it in a similar way when bathing the child. When the testis is not there, one can wait for 3-6 months for spontaneous descent. If this does not happen, it is essential to consult a Paediatric Urologist.

bullet-blueInfertility: As mentioned before, sperm production takes place at a lower temperature than body temperature. When testis is not descended, it is exposed to higher body temperature, and sperm production is affected. In later life these patients have much reduced sperm count and chance to father (50-70% less than normal).

bullet-blueTwisting of Testis (Torsion): When the testis is not descended, it is very free to move around itself. This makes it easy to twist and cut off its own blood supply; the result being loss of testis.

bullet-blueTesticular Tumor: There is a small risk of tumor development in Undescended Testis. By doing an operation to bring it down this can be easily checked out. If the testis is not brought down, tumor can develop without being noticed and can become advanced before treatment.

For the children with Undescended Testis, it is recommended to have surgical correction within one year to prevent infertility in later life. During this operation, the testis is found at the lower part of the belly and fixed to the testis after achieving enough length. When the testis is developed poorly, it may need to be removed. Some times the testis is absent by birth. Laparoscopy is essential in such situations. Also when the testis is too high, two-stage operation may be needed. During the first stage the blood supply to the testis is cut off using a laparoscope. As the testis develops new blood supply, it is brought down at a second stage. All these need to be carefully decided by the Paediatric Urologist.

In general in 95% of such operations there is a successful outcome. In 5% the following complications can occur.

bullet-blueTestis being small (Atrophy): This can result because of damage to the blood supply during the operation. This can also be a result of testis being small by birth.

bullet-blueTestis going back up (Ascent): When the length is not enough and the testis is under tension, testis can go back high again.

When only one testis is affected, and surgery is performed at the right time, there is 80% chance for fertility and paternity. When both testis are affected, if the surgery is performed at the right time, there is still 50% chance for fertility and paternity.

Sometimes the testis intermittently disappears upwards. This phenomenon is called ‘retractile testis’. In this situation one can wait for the boy to grow, however a careful followup is essential. On regular followup checks if the testis prefers to stay higher or if the testis is under tension when brought down, surgical correction is recommended.

In some boys who had normal testis at birth, at a later age the testis can go back up. This is called ‘ascending testis’. This is due to increased activity of a muscle around the cord. Although it can be an intermittent phenomenon, in some boys, the testis preferentially stays higher exposing them to high temperature. These patients need to be carefully selected for surgery.

bullet-redUndescended Testis is found in 3% of term boys and 30% of preterm boys.

bullet-redWhen the testis does not come down by it self by 6 months, it is essential to consult a Paediatric Urologist with a view to correct.

bullet-redWhen left uncorrected, complications like infertility and torsion can result.