Posterior Urethral Valve (PUV) PUV is a type of tissue fold that is seen in male children and blocks the bladder outlet. Since the urination from the bladder is not sufficient, high pressure in the kidneys is caused. VUR may be seen. Bladder wall thickens. Urinary channel expands (posterior urethra dilatation). Since the urination reduces […]
Posterior Urethral Valve (PUV)
PUV is a type of tissue fold that is seen in male children and blocks the bladder outlet. Since the urination from the bladder is not sufficient, high pressure in the kidneys is caused. VUR may be seen. Bladder wall thickens. Urinary channel expands (posterior urethra dilatation). Since the urination reduces in the uterus, amnion liquid (the liquid in the uterus during pregnancy) also diminishes. This poses a great risk for the child.
Antenatal ultrasound examination may help for the diagnosis. This valve should be cut endoscopically and ensure normal bladder function as soon as possible after the children with this problem are born prematurely or on time. First, a catheter should be used for these children with difficulty in urination. After the stable condition is achieved, these valves are cut endoscopically as soon as possible. After these valves are cut, the child continues to live on the catheter for a while. After the catheter is taken out, better urination is observed. These children should be monitored for a long period. Endoscopic surgery might be required for more than once. This disease causes chronic kidney disease when diagnosed and treated late. If swollen kidneys are spotted during the ultrasonography conducted on the mother’s abdomen; these kids should start being monitored by a pediatric urologist or a pediatric surgeon as right after being born.
Hypospadias which is known as half circumcision is the situation where the urinary meatus is opened not on tip of the penis but below. External urinary canal can’t be formed completely and can’t move towards the tip of glans penis due to disorder in the sexual development stages in the fetus. Hypospadias has various grades. If the external urinary canal completed its development up to a point very close to the tip of the glans penis and stayed at that point, it’s called glandular hypospadias. This is the mildest version of hypospadias. Urinary meatus can be opened in the middle or lower part of the penis. These are called “penile hypospadias” and are considered as the mild low grade. In the most severe hypospadias cases, urinary meatus is opened on the bottom part of in the middle of the scrotum. This type which is known as penoscrotal hypospadias is generally caused by significant hormonal problems in the early sexual development of the embryo. The main disease that causes this type of hypospadias is “pseudohermaphroditism” which is also known as androgyny. Testosterone production in the first three months of embryo’s sexual development is significant. If enough testosterone can’t be found during this period, male genital organs can’t complete their development and hypospadias occur. Treatment: Surgery. Operation type is determined according to the hypospadias grade.
Hypospadias surgery is conducted with special glasses and stitches that are thin as a cup. When the hypospadias which is seen one in every 300 male children, it may cause infertility. Since the urinary meatus is not on tip of the glans penis, semen can’t be sprayed forward and come out of the vagina. Therefore the sperms can’t the tubes where they are supposed to reach and can’t fertilize the egg. Since the urinary meatus is quite narrow in the children with hypospadias, urination problems are also seen. Hypospadias should be surgically treated between the ages of 1 and 2 at the latest before the sexual identity is formed. The most important purpose of the surgical operation is to move the urinary meatus on top of the glans penis. Penis curvature which typically is concomitant should also be fixed during the same session. This way, bot urine, and sperm can be discharged normally. One session is generally not enough for severe hypospadias cases and multiple surgeries are needed. In severe cases, in other words, penoscrotal hypospadias cases, hormonal treatment may also be needed to enlarge the penis. Results are generally successful. Almost all the children could have normal and functional penises after surgeries and treatments in early ages.
Normally there are mechanisms that allow one-sided discharge of the urine from the bladder. When the urine goes to ureter and/or kidneys during urination in case of any disruptions in this mechanisms due to any reasons, it’s called vesicoureteral reflux.
Still, the most common reason for kidney failure in World is the urinary tract infections due to vesicoureteral reflux.
How is VUR diagnosed?
VUR typically shows the symptoms of feverish urinary tract infection or prenatal hydronephrosis. Diagnosis is established during the examination due to urinary tract infection. The first examination to be conducted on a child with urinary tract infection is urinary ultrasonography. The best test for the children with the possibility of having VUR is the x-ray of the bladder during injecting a colored fluid through a catheter to a urinary tract called urine cystourethrography or voiding cystourethrography.
In the figure, movement of the opaque substance from ureter till kidney injected from the bladder during voiding cystourethrography is seen from the 1st stage to 5th (left-to-right).
The method preferred to determine the kidney functions and damage in renal tissue is DMSA, or kidney scintigraphy in other words. With the combined use of voiding cystourethrography (urine cystourethrography) and DMSA, an estimation of the natural course of reflux can be made.
Who gets VUR and what is the prevalence?
Only 1-2% of the children get VUR, however, 25-40% of the children who had nephritis get VUR. Concomitant reflux is the case with 17-37% of the swollen kidneys (hydronephrosis) before birth. Therefore, any child who had feverish urinary tract infection should be tested for reflux.
Vesicoureteral Reflux Grading:
1st Stage: Contrast substance filling the bladder can only reach until the distal part of the ureter. This VUR stage consists of 8% of all cases.
2nd Stage: Contrast substance goes up until renal calyxes. However, there is no dilatation in the urinary system. 37% of the cases are on this stage.
3rd Stage: Despite the mid-level dilatation in ureter, renal pelvis and calyxes, renal calyxes still haven’t blunted. 25-37% of the cases are included in this group.
4th Stage: In addition to dilatation in ureter, renal pelvis and calyxes, renal calyxes are blunted. 14-24% of the cases are included in this group.
5th Stage: Advanced hydroureteronephrosis and a curved ureter are present on the side where reflux occurs. 5% of the cases are included in this group.
The basis of the treatment is based on early diagnosis and a close follow-up and this way the protection of renal tissue is aimed. Since the reflux can heal itself as the child grows up, the first step of the treatment is to encourage them for a high level of fluid intake up to a certain age, ensuring that their bladder is fully emptied and monitoring while preventing infection through low dose antibiotic. Circumcision of male babies is recommended in order to protect them from infections.
VUR can heal itself in the first 2 years with a fifty percent chance. When conducted by specialists, VUR treatment can be achieved by 85% through the injection of some filling substances special to urinary tract endoscopically when needed. However, the situation is different for the children with feverish urinary infection. Stage of the reflux, age of the child and kidney damage level is significant for the determination of the treatment. Damage level in the kidney can be measured numerically and visually via nuclear medicine studies (static renogram – DMSA). Ours typically heals itself until the age of 5 depending on the stage. Monitoring and treatment can accelerate this process in case of voiding dysfunction.
When is the surgical treatment needed for VUR?
- Bacteriuria continues despite stage IV and stage V reflux antimicrobial treatment
- Presence of diseases causing secondary VUR (bladder diverticula, ureterocele, ureter duplication etc.)
- Nephralgia (reflux-associated side pain)
- Cease of kidney growth, kidney damage and/or increase in scarring
- Insufficient medical treatment
- Refluxees in later ages
- Children with damaged kidneys, advanced stage reflux and over the age of 5 generally need surgical treatment.
Phimosis – Paraphimosis
Phimosis is a condition of the penis where the foreskin cannot be fully retracted over the glans penis. It can be very common among male children. In most of the newborns, natural phimosis exists due to natural bonds between the foreskin and glans penis. Foreskin can’t be fully retracted and looks like a blooming flower. In pathological phimosis, the hole of the foreskin is scarred and therefore there are narrowness and swelling due to edema in some cases. While the necessity of treating natural phimosis through circumcision, pathologic one should definitely be treated this way.
The fact that preputium can’t retract is not enough for the diagnosis of phimosis. The openness of the foreskin should be less than 0.5 cm and symptoms as aneurysm of the foreskin during urination occur. Urination of the child is typically dripping. Treatment is circumcision. However, creams containing steroid can also be recommended for the families that don’t consider circumcision as an option.
The method for opening the phimosis is stretching. However, it’s very unfavorable. The child would have as much pain as in circumcision, the skin would stick again, fear is caused since it’s conducted without anesthesia and the circumcision becomes more difficult. Sometimes families apply with the symptoms of a swollen penis or inflammation coming out of the penis of the child. These are the white, dense and pearl-like accumulations called smegma. Families get worried about this situation, however, it’s a totally normal situation. There is no obligation as cleaning the accumulation called smegma. These will be discharged in time while the glans penis fissures from the foreskin.
It’s the condition where foreskin goes back to its original state after the foreskin in stretched down from the glans penis. A circle, the astringent band is formed and tight preputium openness can clinch the glans penis. It causes immediate swelling and pain by preventing the blood from going back to the glans penis. In the case of paraphimosis, the patient should immediately go to a hospital and see a doctor. If not treated immediately, blood flow of the glans penis can be disrupted and this may prevent urination. The condition can be reversed under local or general anesthesia. In case of not healing, circumcision may be needed. It’s an emergent and acute condition when compared to phimosis.
Pediatric Urinary Incontinence Problem
Wetting yourself at inconvenient times during childhood is a common condition and consists of 40% of the cases in the pediatric urology clinic. This situation can be only as bed-wetting or as urinary incontinence both day and night.
Normally children have urinary control when they are 4 years old, day control is gained before that. As the studies in Turkey and abroad show, 15% of the 5-year-old children, 1% of 15-year-old children have urinary incontinence. Every year, 15% of bed-wetting children recover without any treatments, however, the necessity of treating the problem is obvious when social and psychological problems both in the family and in child’s life considered.
Primary Enuresis Nocturnia:
It’s the bed-wetting problem without the presence of urinary incontinence during the day.
This condition has multiple factors and positive family history, lack of functional bladder capacity, ADH deficiency and waking in the night are the main ones.
- Dysfunctional Urination: It’s the problem where the child urinates using sphincter and pelvic floor muscles which help to hold the urine during the bladder emptying phase as a result of getting a wrong toilet training and the periodic urination and inability to completely empty the bladder occurs due to the bladder dynamics disorder caused by this Situation. Constipation is also common in terms of this problem.
- Urge Syndrome: This is the condition where involuntary contraction of the bladder occurs before the full capacity is reached during the filling phase of the bladder and urinary incontinence is caused due to the pressure rise arising from these contractions.
- Less Active Bladder: It’s the least common condition in this group and is the situation where bladder can’t empty the urine by not being able to contract enough and the Situation occurs when the urine remains in the bladder after urination.
Urinary Incontinence While Laughing:
While it’s mostly seen in the girls in their puberty, it’s a situation where the control of urination is lost while laughing and can be seen in boys as well. It’s suggested that this situation is caused by the fact that laughing and bladder control center in the brain is very close to each other and that this is a developmental problem. It’s a disease that heals itself and sometimes can be treated with medication as well.
The success of the treatment depends on the correct treatment according to the classification above and planning of the treatment. Treatment alternatives according to the classification are as follows:
Primary Enuresis Nocturnia
Restriction of fluids before going to bed: It’s a method where fluid intake during the 1-2 hours of the period before going to bed is decreased and sugary, caffeinated drinks aren’t consumed considering the fact that they increase the bladder contractions.
Making the child urinate by waking up periodically during the night: This method which is used by many families without consulting to a doctor is not a very beneficial one in the long-term, however, it can be used together with the fluid restriction as part of the treatment.
Alarm devices: It’s based on waking up the children for urination through an alarm that warns when the urine reaches the device and it’s a very successful method in the long-term. The constant need for parent monitoring is, however, a disadvantage. There are two types. The first one can be mounted in the underwear, and the second one can be laid under the bed sheet.
Oral Desmopressin Acetate-(Minirin): It’s a frequently preferred one since it shows its effects rapidly and has a little side effect, and its early stage success rate is 70% while this rate can go down to 30% following quitting the use after 3 months of use.
Imipramine: Although the effect mechanism is not known completely, it loses its popularity more and more every day due to its side effects.
Other: Although Oxybutynin and other anticholinergics are used in some cases, these are the medications that are mostly used for children with day-night urinary incontinence and urge syndrome.
It’s been reported that acupuncture and natural medications also help in some cases.
The purpose of this disease is to prevent the bladder from contracting involuntarily. Most medical treatments are used for this one.
Oxybutynin chloride: It’s a medication that shows its effects on the muscarinic receptors and helps bladder relax. It’s taken 3 times a day. Although it’s an important medication for the urge syndrome, it has many side effects and these are the possibilities of xerostomia, constipation, blurred vision and urinary retention.
Tolterodine: It’s an anti-muscarinic medication that helps bladder smooth muscles relax and has fewer side effects compared to Oxybutynin chloride. 1-2 mg is applied 2 times a day depending on the age.
Trospium Chloride: It’s both an antimuscarinic and gangliaları effecting medication. It operates by preventing bladder contractions.
Intravesical BOTOX: It’s a treatment type conducted to eliminate involuntary contractions of the bladder in the cases resistant to medication. While effective in the early stages should be repeated with 8-11 month intervals due to loss of effects.
It’s the treatment type that aims to fix toilet training and diet if needed in the children with urinary incontinence.
It’s a treatment method that aims to teach the body activities that the patient doesn’t know normally and are physiological from scratch through the computer and similar devices. The purpose of this method is to fix the incorrect behaviors that are the reasons for urinary incontinence and disrupting the bladder dynamics for years and to prevent urinary incontinence.
Especially in the cases where children have problems with contraction of the bladder for urination and relaxation fo sphincter, it helps to learn the normal physiology completely after 4-6 sessions. In the patients for whom biofeedback is selected, the purpose is to fix urination dysfunction and other complications without the need for complex procedures as surgeries.