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.
Detected 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.
Colic 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.
Urinary 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.
Ultrasound Scan: Hydronephrosis is diagnosed using an ultrasound scan. It helps to determine the severity of blockage; reflected by the amount of dilatation.
Nuclear 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.
MCU: This is mainly to exclude problems like reflux or a valve.
If 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.
After the baby is born, the hydronephrosis will be monitored using ultrasound scans and Nuclear scans.
When 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.
If the cause of the hydronephrosis is an obstruction and this is removed shortly after birth, kidneys will be able to work properly.
The 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.
It is possible to determine kidney problems in the baby before birth.
Most of the kidney problems correct spontaneously, although it is essential to confirm this by consulting a Paediatric Urologist
A small proportion of babies require corrective surgery after birth.
By consulting before delivery, parents can relieve their anxieties.
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.
A Hypervirilised Girl:chromosome is XX but genitals are masculanised due to exposure to male hormones
Undervirilised Boy: Chromosome is XY but the genitals are not well masculanised due to deficiency or failure of action of male hormones
Mixture 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
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.
Urine opening on the under surface of the penis
Penis being slightly bent downwards
Excess foreskin on the top of the penis
Unlike 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.
When 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.
Sometimes the urinary opening is also small, leading to blockage in urine stream. This leaves them at a risk of urinary infection.
The opening is brought to the tip
The penis is straightened
Excess foreskin is removed (circumcision).
The new opening gets small gradually (meatal stenosis)
Urine leaks at the original site (Fistula)
In children with hypospadias, the opening is on the under surface of penis.
Because of this, these lads can’t stand and pass urine like normal children.
They can have infertility in later life, if left uncorrected.
By 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).
Infertility: 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).
Twisting 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.
Testicular 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.
Testis 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.
Testis going back up (Ascent): When the length is not enough and the testis is under tension, testis can go back high again.
Undescended Testis is found in 3% of term boys and 30% of preterm boys.
When 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.
When 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
Scarring of the skin at the tip
Straining and only dribbling when passing urine
Para phimosis (swelling and inability to put back the pulled foreskin)
As a treatment: in true Phimosis
As a preventive step: In children with recurrent urine infections (circumcision reduces the risk of cancer penis, sexually transmitted disease)
For religious reasons: in Muslims and Jews
Social reasons: ‘to look like Daddy!’; ‘to look like brother’
As a routine: in some countries circumcision is performed routinely
Non-retractile foreskin can be a normal developmental process in boys under 1 years of age.
Circumcision is indicated if there are recurrent infections, or if there is narrowing with scarring.
Circumcision is a safe operation that can be performed with out the need for over-night stay.
For a good cosmetic result, and minimal complications, it has to be performed by a well trained surgeon
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
Blockage at the upper end of ureter (PUJ obstruction)
Blockage 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
Posterior Urethral Valves
Ureterocele blocking bladder outletThey 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.
Common Paediatric Surgical Problems
Congenital Diaphragmatic Hernia (CDH)
Oesophageal atresia/sTracheo oesophageal fistula (TOF)
Small Bowel Atresia
Congenital Cystic Adenomatoid Malformation (CCAM)
Necrotising enterocolitis (NEC)
Paediatric Laparoscopic Surgery (Key Hole Surgery)
As there is no cut, there is no big scar
The pain is almost nil as there is no cut
The healing is fast
Complications of wound healing are much less
Children recover quicker and can be discharged quicker
This helps to reduce the cost
As they recover quicker can return to school quicker
Gall stones; spleen surgery
Empyema (pus in chest)
Incontinence, Neuropathic Bladder
Constant leakage of urine and a bad urine odour can affect the child’s self image if left untreated.
In modern medicine childhood urinary incontinence can be effectively treated.
Prompt treatment can prevent multiple urine infections as well as kidney failure.
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.
Over production of urine at night
Hyperactivity of the bladder
Lack of arousal from sleep
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.