Bed-Wetting

 

Toilet training a child takes a lot or patience, time and understanding. Most children do not become fully toilet trained until they are between two and four years of age. Some will be able to stay dry during the day. Others may not be able to stay dry during the night until they are older.

 

Causes

• Nighttime bed-wetting, called enuresis, is normal and very common among preschoolers. It affects about 40% of three-year-olds. All of the causes of bed-wetting are not fully understood, but the following are the main reasons a child wets the bed:

• His bladder is not yet developed enough to hold urine for a full night.

• He is not yet able to recognize when his bladder is full, wake up and use the toilet.

• Most school-age children who wet their beds have primary enuresis. This means they have never developed nighttime bladder control. Instead, they have had this condition since birth and often have a family history of the problem. Children who are older when they develop nighttime bladder control often have at least one parent who had the same problem. In most cases, these children become dry at about the same age that their parent(s) did.

 

My Child Has Been Dry and Is Now Starting to Wet the Bed at Night?

• Often a child who has been dry at night will suddenly start bed-wetting again. When it happens, it is usually due to stress in the child’s life. Such stress could be due to a big change such as a new baby in the home, moving or a divorce. Children who are being physically or sexually abused may also develop enuresis.

• If your child wets the bed after having been dry at night in the past, your doctor should do an evaluation. The bed-wetting may be a sign that stress or a disease is causing the problem.

 

What Are the Signs of a Problem?

• Some parents fear that their child’s bed-wetting is due to a disease or other physical problem. Actually, only about 1% of bed-wetting cases are related to diseases or defects such as :

  • Bladder or kidney infections

  • Diabetes

  • Defects in the child’s urinary system

• With any of these cases there will often be changes in how much and how often your child urinates during the day. Your child may also have discomfort while urinating. Tell your doctor if you see any of the following signs at any age:

  • Unusual straining during urination, a very small narrow stream of urine or dribbling that is constant or happens just after urination

  • Cloudy or pink urine, or bloodstains on underpants or nightclothes

  • Daytime as well as nighttime wetting

  • Burning during urination

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What Will the Doctor Ask Me?

• Is there a family history of bed-wetting?

• How often does your child urinate, and at what times of the day?

• When does your child wet the bed? Is your child very active, upset or under unusual stress when it happens?

• Does your child tend to wet the bed after drinking carbonated beverages, caffeine, citrus juices or a lot of water?

• Is there anything unusual about how your child urinates or the way his urine looks?

• Does your child have a history of constipation or infrequent hard bowel movements?

• Does your child have a history of learning problems or ADD/ADHD?

• Does your child wet himself during the day, even the slightest amount?

• Was there any prior history of urethral instrumentation?

• Is your child on any medications?

 

What Tests Will Be Performed if the Doctor Suspects a Problem?

If your doctor suspects a problem, he/she may take a urine sample from your child to check for signs of infection or other problem. Your doctor may also order tests, such as ultrasound of the kidneys or bladder, if there are signs that wetting is due to more than just delayed development of bladder control. On occasion when a child wets day and night, then a voiding cystouretrogram is performed if it is deemed necessary.

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Tips to Manage Bed-Wetting

Reassure your child that the symptoms of enuresis will pass as he/she gets older. Until that happens naturally, however, the following steps might help the situation:

• Take steps before bedtime. Have your child use the toilet and avoid drinking large amounts of fluid just before bedtime.

• Use a bed-wetting alarm device. If your child reaches the age of seven or eight and is still not able to stay dry during the night, an alarm device might help. When the device senses urine, it sets off an alarm so that the child can wake up to use the toilet. Use this device exactly as directed so that it will detect the wetness right away and sound the alarm. Be sure your child resets the alarm before going back to sleep.

• These alarms are available at most pharmacies and cost about $50. Although they provide a 60% to 70% cure rate, children often relapse once they stop using them. Alarms tend to be most helpful when children are starting to have some bladder control on their own.

• Protect and change the bed. Until your child can stay dry during the night, put a rubber or plastic cover between the sheet and mattress. This protects the bed from getting wet and smelling like urine.

• Let your child help. Encourage your child to change the wet sheets and covers. This teaches responsibility. At the same time it can relieve your child of any embarrassment from having family members know every time he/she wets the bed. If others in the family do have similar chores, though, your child may see this as punishment. In that case, it is not recommended.

• Other treatments. Some doctors recommend bladder-stretching exercises. With these, your child gradually increases the time between daytime urinations so that the bladder can slowly stretch to hold more urine.

Because bed-wetting is such a common problem, many mail-order treatment programs and devices advertise that they are the cure. Use caution: many of these products make false claims and promises and may be overly expensive. Your doctor is the best source for advice, and you should ask for it before your child starts any treatment program.

 

Do Medications Help?

• When no other form of treatment works, your doctor may prescribe medication.

• The use of medications to treat bed-wetting is used once all other treatment modalities are exhausted. The type of medication that will be used varies on the child and the history of bed-wetting. In some cases bed-wetting may respond better to certain medications than to others. We are well aware that no parent wishes to have their child take medications if it can be avoided and we use them only as a last resort.

 

What to Do if Nothing Works

• A small number of children who wet the bed do not respond to any treatment. Fortunately, as each year passes, bed-wetting will decrease as the child’s body matures. By the teen years almost all children will have outgrown the problem. Only 1 in 100 adults is troubled by persistent bed-wetting.

• Until your older child outgrows bed-wetting, he/she will need a lot of emotional support from the family. Support from a pediatrician or a mental health professional can also help.

 

How Parents Can Provide Support

• It is important that parents give support and encouragement to children who wet the bed. They should be sensitive to the child’s feelings about bed-wetting. For instance, children may not want to spend the night at a friend’s house or go to a summer camp. They may be embarrassed or scared that their friends will find out they wet the bed.

• Make sure your child understands that bed-wetting is not his fault and that it will get better in time. Reward him for "dry" nights, but do not punish him for "wet" ones. Remember, your child does not have control over the problem and would like it to stop, too!

• Do not pressure your child to develop nighttime bladder control before her body is ready to do so. As hard as your child might try, the bed-wetting is beyond her control, and she may only get frustrated or depressed because she cannot stop it.

• Set a no-teasing rule in your family. Do not let family members, especially siblings, tease a child who wets the bed. Explain to them that their brother/sister does not wet the bed on purpose. Do not make an issue of the bed-wetting every time it occurs.

• If your child has enuresis, discussing it with your pediatrician can help you understand it better. Your pediatrician can also reassure you that your child is normal and that he/she will eventually outgrow bed-wetting.

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Useful Links

• Dry Nights: a website about bed-wetting designed for both parents and their children

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Bladder Exstrophy and Epispadias

 

What Is Bladder Exstrophy?

• Bladder exstrophy is a congenital birth defect that is the malformation of the bladder and urethra, in which the bladder is turned "inside out." The bladder does not form into its normal round shape but instead is flattened and exposed outside the body. The lower portion of the bladder, a funnel-shaped bladder neck made up of muscles that open and close the bladder, fails to form correctly. The urethra and genitalia are not formed completely (epispadius), and the anus and vagina appear anteriorly displaced. Additionally, the pelvic bones are widely separated (diastasis).

• It is unknown what causes bladder exstrophy. The problem occurs somewhere between 4 and 10 weeks of pregnancy when various organs, tissues and muscles begin to form layers that separate, divide and fold. Bladder exstrophy is NOT inherited and did NOT occur because of anything the mother did or did not do during pregnancy!

• Bladder exstrophy is a surgically correctable birth defect. You must be aware that each child with exstrophy is uniquely different and the care and treatment prescribed by your urologist will be specific to your child’s needs.

  • Bladder exstrophy is noted in 1 of 30,000 to 50,000 live births!

  • Bladder exstrophy is more likely to occur in males than females by approximately 2 to 1.

  • The risk of having a second child with bladder exstrophy is about 1 in 100 and 1 in 70 if one of the parents has bladder exstrophy.

 

How is Bladder Exstrophy Treated?

• Bladder exstrophy requires surgical repair usually involving staged "reconstruction." The primary goals for reconstruction are closure of the bladder and urethra, closure of the abdominal wall, preservation of kidney and sexual function, improved appearance of genitalia, and urinary continence. There are usually three stages of reconstruction (varies for each child and surgical strategy chosen by your surgeon):

  • 1st Stage - Closure of bladder and abdomen (24-48 hours of life)

  • 2nd Stage - Epispadius repair (2-3 years old)

  • 3rd Stage - Achieve urinary continence (4-5 years old)

• Other procedures your child may require are bladder augmentation, reimplantation of ureters or mitrofanoff stoma.

 

Disorders Associated with Bladder Exstrophy

• Epispadius - The urethra, which carries urine out of the body, has not formed completely. In boys, the penis is flattened and is pulled up toward the abdomen with the urethra open on the upper surface of the penis. In girls, the urethral opening is located between a divided clitoris and labia minora.

• Vesicoureteral Reflux - Urine is made by the kidneys and travels down tubes called ureters to be stored in the bladder. Normally urine flows one way. Reflux is a condition where urine can back up from the bladder into the kidneys. Reflux becomes serious when bacteria-infected urine in the bladder travels to the kidneys, which can lead to kidney damage or worse: loss of kidney function. Many children outgrow this condition, but some require surgery to repair this problem. Some children are placed on a daily low-dose antibiotic for a period of time.

• Diastasis - Separation of the front pubic bones which does not allow the bladder to remain inside the body

• Small Bladder Capacity - All exstrophy bladders are small at birth, some smaller than others. The extent to which the bladder will grow cannot be definitely determined. Successful bladder closure and epispadius repair provide conditions for the bladder to grow. Good urethral resistance can help "stretch" the bladder. Time will tell.

• Missing Bladder Neck and Sphincter - The lower portion of the bladder, a funnel-shaped bladder neck and sphincter, consists of muscles that open and close the bladder outlet to control urine flow.

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Will Bladder Exstrophy Affect My Child's Health and Development?

• In the majority of cases the children are healthy with normal intelligence and normal physical and social development. The child may have a waddling gait which will become less obvious as he/she gets older. Extra care will be needed for urinary control.

• A parent of a bladder-exstrophy child described it best: "Your child's future is as bright as any other child's."

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The Normal Urinary SystemThe urinary system consists of two kidneys, two ureters, the bladder, the bladder sphincter (the muscle that acts as a binder to hold urine in the bladder) and the urethra. The kidneys clean waste and remove excess fluids from the blood, as well as help to manage blood pressure. The ureters are the tubes that drain the waste, the urine, into the bladder. The urine is stored in the bladder. When the bladder is full, it contracts, and the sphincter opens allowing the drainage of urine into the urethra to the outside of the body.

 

What Surgeries Will My Child Need?

• Please be aware that each case is different and your doctor will decide which surgery and treatment plan is best for your child. In most cases more than one surgery will be necessary and your doctor will discuss this with you. The following information is generalized and not specific to your child.

• The first surgery is primiary closure of the exstrophied bladder and proper placement of the pubic bones. This is best done within the first seventy-two hours after birth. After the bladder closure the infant will be placed in a position called modified Bryant's traction. This is a position in which the hips have 90 degrees of flexion, the knees and ankles are held together, and the buttocks are slightly elevated off the bed. This traction may be needed for three to four weeks. In some cases more time may be necessary.

• The bladder size may be very small. Surgery will be needed to increase the size of the bladder. This will allow the bladder to hold an ample volume of urine. Most patients will need to empty the bladder of urine with a tube/catheter. The catheter is inserted into the bladder, the urine is drained and then the catheter is removed. This procedure is called clean intermittent urinary catheterization. This will be done several times a day. This will be taught to the patients by the pediatric urology nurse or another qualified professional.

 

The Male Patient

• The male may have a short, curved penis which may appear somewhat flat at the top. The urethral opening is epispadiac (on the upper surface of the penis). There is usually a space between the base of the penis and the scrotum. The patient may have bilateral inguinal hernias. The testes may be undescended (not in the scrotum) or retractile (capable of going back into the scrotum). If hernias are present they will be repaired. Reconstructive surgery will be done to repair the penis. This surgery will result in functional and cosmetically acceptable genitalia.

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The Female Patient

• The female patient usually presents with a normal uterus, fallopian tubes, and ovaries. The vagina may be slightly higher in placement and somewhat narrowed. The clitoris is separated into two parts; the labia and mons pubis (hair-bearing skin) are spread apart. Reconstructive surgery will be performed to bring the clitoris, mons pubis and labia (if necessary) together. This surgery will provide functional and cosmetically acceptable genitalia.

• The adult female patient will be able to have normal sexual intercourse. Almost all females are able to have children. When the female is ready to start a family her doctor should be consulted since she will be prone to prolapse of the uterus. This is not dangerous when monitored carefully. Her doctor will determine if a cesarean section will be necessary.

 

Potential Issues Facing Exstrophy

• Urinary Tract Infections

• Latex Allergy

• Intermittant Catheterization

• Bladder Stones

• Inguinal Hernias

 

What to Expect in the Hospital

• Catheters

• Intravenous (IV)

• NG Tube

• Antibiotics

• ICU

• Traction

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Diaper Rash

 

Diaper Rash affects most babies. It can result in discomfort for your baby and worry for you. However, there are things you can do to try to make your baby feel better if it does occur.
The following information describes the causes of diaper rash, how you can try to prevent it and how to treat this problem. By knowing what to look for, you can keep your baby happy and comfortable.

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What Is Diaper Rash?

• Diaper rash is a term used to describe any skin irritation in the diaper area. The known causes of diaper rash include wetness, not changing diapers often enough and a combination of urine and feces which irritate your baby’s skin. Other known causes include over-cleansing with soaps, antibiotic usage, and yeast and germ infections.

• In many cases, mild diaper rash will appear with no known cause and will heal without any treatment.

 

How Can You Try To Prevent Diaper Rash?

• Avoid harsh soaps and don’t overcleanse. Harsh scrubbing after each diaper change may damage the outer protective layer of the skin. The problem gets worse as the skin becomes more irritated by wetness and bowel movements. You should avoid wipes with alcohol and perfumes because these products can irritate your baby’s skin. Using water alone as a cleanser may be all that is necessary.
  Change diapers immediately after each bowel movement and when necessary to keep your baby dry. Wet skin is easily irritated by bowel movements. Wetness and harsh cleaning could damage and weaken the skin’s protective layer; this often leads to diaper rash.

• Avoid too much drying after a diaper change. Gently pat the diaper area with a soft paper towel. You also should avoid using an electric hair dryer; this may cause “wind burn” on your baby’s sensitive skin.

• Apply a thin layer of ointment for protection against wetness, and avoid perfumed lotions or powders that can irritate your baby’s skin.

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How Can Diaper Rash Be Treated?

• Despite your best efforts, your baby still may get diaper rash. If this happens, there are steps you can take to help eliminate this rash.
  Make sure you change the diapers often and avoid airtight fastening (especially overnight). You can increase air circulation within the diaper by using larger diapers and by loosely attaching diapers. You can also cut the elastic bands on disposables for a loose fit.
  Apply a cream, such as zinc oxide paste, which stays on longer than other any other ointment. This protects the skin by sealing out moisture and the irritants within bowel movements. With each diaper change make sure the skin is clean and ensure that the layer of paste stays on your baby’s skin.

• Instead of wiping your baby’s skin clean, try using a running stream of water from a squeeze bottle. This is gentle on your baby’s skin, and it is an easy way to rinse off bowel movements and urine in the diaper area. To make the job even easier, put your baby in a sink or tub for easy rinsing.

• Call your pediatrician if the rash continues to worsen either on its own or during treatment. A yeast rash, a serious skin irritation or an infection may require special medical treatment that your pediatrician can recommend.

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Are Cloth Diapers or Disposable Diapers Better for Preventing Diaper Rash?

• There are advantages and disadvantages to both cloth and disposable diapers.

• Because diaper rash often occurs when skin is wet and irritated, part of the diaper’s job is to keep the baby dry. Cloth and disposables are both effective as long as they are changed often. Talk with your pediatrician to find out which diaper is best for your baby. Some children may be better suited for one type of diaper. Your pediatrician also can tell which soaps, wipes, lotions and powders may irritate your baby’s skin.

 

Additional Information

• Many parents apply talcum powder to the diaper area during a change; however, routine use of talcum powder is not recommended. If you do use it, be sure to keep the powder away from your infant’s face because inhaling it could cause breathing problems.
  You can prevent choking or suffocation by shaking talcum powder onto your hands-away from your baby’s eyes, nose, and mouth–and then apply it to your baby. Also, make sure that the container is far away from where your baby can reach it; this will keep your baby from accidentally inhaling the powder.

• Remember not to leave your baby alone on the changing table or any surface above the floor. Even a newborn can make a sudden turn and fall to the floor.

• If you change diapers often, your baby can usually avoid the pain and discomfort of diaper rash and you can avoid worry. Talk with your child’s pediatrician if you have questions or concerns about diaper rash.

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Hypospadias

 

What Is Hypospadias?

• Hypospadias is a common congenital anomaly (birth defect) of the penis. The urethral opening (meatus) is at or just below the junction where the glans joins the shaft of the penis. It can, however, be as far back as the scrotum. In addition, boys with hypospadias are often missing the undersurface half of their foreskin so that it forms a hood. There is often a bend (called chordee) in the erect penis.

 

What Causes It?

• Hypospadias results from incomplete development of the urethra. It is sometimes inherited. Other than inherited cases, the cause is usually not known.

 

Why Is It Important?

• Hypospadias may cause deviation of the urinary stream so that the boy is forced to sit to urinate. Additionally, sexual function may be hampered by the location of the urethral opening or by the bend in the penis.

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Can a Circumcision Be Performed?

• No. A circumcision should not be performed during the newborn period. The foreskin may be needed for the repair of the hypospadias.

 

Can It Be Corrected?

• Yes. There is no medicine that will result in correction and the child will not “outgrow” the problem. However, surgery to correct the problem, when performed by a surgeon experienced in genital reconstruction, is usually successful. When possible, these operations are best accomplished between 6 and 18 months of age. Most of the time repair can be achieved in a single operation of one to four hours duration. The child may leave the hospital the same day as the surgery (ambulatory surgery). In some instances it will best to hospitalize the child for several days after the operation. The child often needs a catheter (a tube to drain urine during healing) for several days after the operation. He can still go home the same day as the surgery with the catheter. The catheter and bandage will be removed in the office several days later.

 

What Is the Long-Term Outlook for Boys with Repaired Hypospadias?

• Following surgery most boys have normal function and a good cosmetic result. Long-term studies suggest that these boys do well emotionally as well. Fertility and potency would be expected to be normal after repair.

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Urinary Control

 

Symptoms of Voiding Problems

• Loss of Urinary Control (Enuresis)

• Frequent Urination

• Squatting/Squeezing To Prevent Urination

• Tendency Toward Constipation

• Recurrent Urinary Tract Infections

 

What Causes Incontinence (Enuresis)?

• Enuresis is probably caused by many factors. Most children with enuresis have a developmental delay in their ability to hold urine. Not all children develop this ability at the same rate, and gaining bladder control may take longer in some children. Children who have only night wetting and have never had urinary tract infections rarely have structural abnormalities of the urinary tract to account for wetting. Recent studies suggest that these children produce more urine at night than other children. Some children will have wetting problems during the day and night. They may even have been perfectly dry for some period after toilet training. This is usually very different from night wetting.

• Reasons to explain this are urinary tract infections, structural abnormalities of the urinary tract or problems with bathroom habits. (Such problems include holding urine and bowel movements, infrequent or very frequent urination, insufficient time spent on the commode to empty bladder or eliminate stool, and painful bowel movements with straining.) Many children with severe problems will also be incontinent of stool, causing them to soil themselves.

 

Physician Evaluation

• The initial evaluation should include a thorough history and physical evaluation, a urine analysis and a urine culture to screen for infection.

• Further evaluation may be necessary to help determine the reason for a child’s wetting. Frequently the only test that may be done is a sonogram of the kidneys and bladder. The sonogram is a safe, non-invasive test to screen children for abnormalities in the urinary tract. X-rays are not usually indicated unless there is a history of urinary infections or an abnormality is discovered on the sonogram. Cystoscopy is rarely indicated and urethral stretching (dilatation) is not helpful.

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How Common Is Enuresis?

• Fifteen Percent of all 5-year-olds, 5% of all 10-year-olds, and 1% of all 15-year-old children occasionally wet themselves. This, therefore, represents a common childhood problem.

 

Is There a Cure for Enuresis?

• Yes.

• For children who wet themselves at night and void normally during the day, patience and understanding are most important. A common sense approach includes voiding just before bedtime and encouraging success with a positive reinforcement (reward) program. Punishment should always be avoided. Treatment options that have proven to be effective include the enuresis-conditioning alarm and DDAVP nasal spray or tablets.

• Children with daytime urinary symptoms often respond to medication (bladder muscle relaxants). Many of these children have a tendency toward constipation; this should be treated vigorously with high-fiber diets, stool softeners, laxatives and even enemas if necessary. Timed-voiding by the clock every three to four hours during the day helps encourage regular bladder emptying. Occasionally, for severe problems bladder emptying may be improved by intermittent catheterization or behavior modification.

• Children with anatomic abnormalities will usually show improvement once the cause is addressed. Treatment may include surgery. Children with neurologic dysfunction (spina bifida, spinal cord injury) often require a combination of medication, intermittent catheterization and surgery.

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Overactive Bladder and Voiding Dysfunction

• Children may suffer from “overactive bladder” activity during the day. They will respond to this in a variety of ways. Some will run to the bathroom and be able to stay dry.
  Others may run to the bathroom but will lose urine on the way and dampen their underwear. Others will try to postpone urination in a very different, abnormal way. A normal adult can postpone urination without doing anything. They don’t need to tighten the muscles that hold urine back (the sphincter muscles). They can do this consciously, for example when they are involved in something they want to continue doing and they decide to wait. The bladder remains relaxed and will not try to empty. This postponement can also occur unconsciously. When they are ready to urinate, the bladder contracts and the muscles that hold back urine will simultaneously relax. The emptying of the bladder is low pressure because of the coordinated contraction of the bladder and relaxation of the sphincters.

• Infants urinate in a very healthy way. The bladder will automatically contract, as a reflex, and the sphincters automatically relax. This is very healthy because the bladder pressure needed to empty the urine is low. However, it’s not very sociable! Some children are able to postpone urination in the same way as adults, but many cannot. This can be due to many of the factors mentioned above, but it can also be due to “immaturity” of their nervous system so that they recognize the urge to urinate before they have developed the ability to postpone urination. They feel the sudden need to urinate, but are unable to keep their bladders from trying to empty. They learn to stay dry by blocking the flow of urine because they are unable to postpone urination. Some of these children will dance (“pee-pee dance”), others will stand very still and some girls will even sit down on the heel of their foot in order to put pressure on the urethra and block urine flow (“curtsy sign”). Obstruction and incomplete emptying are bad for the bladder and can lead to an overactive bladder. This pattern of behavior can become the only way these children are able to control their overactive bladders. This is a common cause of what we call voiding dysfunction. Voiding dysfunction is also very frequently associated with constipation. Normal, low-pressure, complete emptying of the bladder is one of the best defenses against urinary tract infection. Because they do not urinate normally, these children have a much higher rate of urinary tract infections. Fortunately, biofeedback training can be used to teach these children how to relax their bladder sphincters during urination and, along with management of their constipation, we can help them become dry and reduce the rate of urine infections.

 

The Role of Constipation in Overactive Bladder and Recurrent UTIs

• There is a close association between constipation or fecal retention and an overactive bladder.

• One of the most important issues in management of overactive bladder is the correction of constipation and fecal retention. An understanding of normal bowel function is essential to understanding problems associated with overactive bladder. The stimulus and desire to have a bowel movement is initiated primarily by rectal distention (overstretching). Distention in the rectal wall will generate nerve impulses that cause relaxation of the muscle (the anal sphincter) that holds a stool in, allowing the stool to come out easily. In many children who have intermittent fecal soiling or fecal marks on their underwear, the involuntary relaxation of the sphincter will allow the stool to reach the anus, causing soiling of their underwear. When they sense the stool at the anal opening, they clamp down on the sphincter and the stool is pushed back in. Continuation of this chronic rectal sphincter tightening may persist during urination and inhibit or obstruct bladder emptying. Children can be taught to relax the pelvic muscles, allowing more normal, low-pressure bladder emptying to occur. The center for bladder control at PUA specializes in the diagnosis and treatment of disorders of urination and bowel control in children. We offer all of the most current means for diagnosing children with disorders of bladder and bowel function, and we are equipped to provide the necessary behavioral, medication and biofeedback methods to successfully treat them.

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Prune Belly Syndrome

 

Management of the child with prune belly syndrome (PBS) has posed a significant amount of trouble to the pediatric urologist.

• There have been calls for conservative management of the urinary tract in these boys by some authors while others have advocated an aggressive approach to the management of these patients, operating on them at ten days of life. At the present time, no definitive timing for therapy has been substantiated one way or the other. What we have been able to see is that prune belly syndrome can present with a spectrum of abnormalities ranging from the stillborn infant with severe urogenital and pulmonary problems to the child with little, if any, urologic abnormalities requiring no therapy other than orchidopexies to correct the undescended testes. It appears that the decision to intervene in the management of the urinary tract of these children should be based on the clinical presentation and not solely on radiographic appearance.

• There is little controversy in the literature as to the present management of the undescended testes in these children. If controversy or confusion arises, it is to the optimal timing for the surgery for the orchidopexy as well the type of orchidopexy to be performed. Similarly, the management of the abdominal-wall abnormalities has several camps, with some going for no surgical reconstruction of the abdominal wall while others advocate surgical reconstruction; this latter group is divided among two separate factions advocating different techniques of abdominal-wall reconstruction.

 

The surgical management of the prune belly patient is not suited for the journeyman pediatric urologist, but it is best left to someone with experience in managing these quite difficult patients. These children can present with a myriad of renal, ureteral and urethral abnormalities.

• Obstruction and/or upper-urinary tract dilatation is not a rare occurrence in these children. Occasionally, the site of obstruction can vary from as high up in the pelvo-ureteral junction area to as far down as the prostatic-membranous urethra. Careful radiologic evaluation of these children is essential before committing one’s self to any type of diverting procedure. Careful observation of urinary output and electrolytes is essential in the early newborn. A rise in BUN and creatinine associated with decreased urine output is an indicator of obstruction. Radiologic studies should be obtained in the newborn period, regardless of whether obstruction is present or not. The first study that should be obtained is a renal and bladder ultrasound which is a non-invasive procedure and can be used later on to follow the child’s progress non-invasively. A contrast voiding cystourethrogram should also be obtained to delineate the prostate-membranous urethra as well as the bladder and the presence of a urachal remnant. Also, vesico-ureteral reflux can be ruled out at this time, thereby indicating that the child should be placed on antibiotic prophylaxis. If there should be any indication at all that there is some upper tract dilatation or obstruction, then the child should have a renal Hippuran or DTPA study performed. Should there be only the presence of megaureter, megacystis and the prostatic abnormalities but no evidence of obstruction and no reflux, conservative management at this point is best indicated and the child should be observed and followed closely.

 

Undescended Testis

• The management of the undescended testis in the patient with prune belly syndrome is something that should be left to the experienced pediatric urologist. In some instances the boys will not require any urologic work and the testis can be brought down using laparoscopic techniques.

• This reduces the morbidity associated with intra-abdominal surgery to bring the testis down. Dr. Franco has reconstructed several boys using this technique with superior results. In other cases the testis can be brought down at the time of open surgery for the reconstruction of the urinary tract.

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Abdominal-Wall Reconstruction

• Abdominal-wall reconstruction is performed in most boys to improve respiratory function as well as for cosmetic reasons. There have been several innovations in abdominal-wall reconstruction over the years.

• The Monfort and Ehrlich variations of Randolph’s operation have improved results with decreased morbidity and the ability to preserve the umbilicus. Firlit and Franco have described a new technique which allows for improved results over these techniques without opening the abdominal cavity. Most recently Franco has modified this technique further to obtain even better results by using laparoscopic guidance to assure that wall tension and cosmetic results will be persistent postoperatively. These recent innovations have reduced the morbidity of abdominal-wall reconstruction significantly.

 

Neurogenic Bladder

• Pediatric Urology Associates has extensive experience helping children who have bladder control issues due to neurological disorders such as spina bifida or spinal cord injury. These are special situations that require intensive consultation with the family and child. Our goals are to have the children be dry and to preserve the function of the kidneys. We also want the children to be able to have regular bowel movements and to achieve overall independence.
  One of the tests that are helpful to achieve these goals is the urodynamics test. Urodynamics testing tells us much about the function of the bladder including its size, its pressure and whether or not the bladder is emptying completely.

• A variety of treatment approaches are available and are tailored to the individual needs of each child. Some of these treatments include medication, clean intermittent catheterization, bowel elimination programs, Botox injections, bladder reconstructive surgery and MACE procedures. Knowing which child needs which treatment is a special expertise of the doctors and nurses at Pediatric Urology Associates.

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Undescended Testis 

 

What Is Undescended Testis (Cryptorchidism)?

• The testicles develop in the abdomen and usually descend into the scrotal sacs by the time of birth. Crytorchidism (undescended testes) is one of the most common malformations in young boys and occurs in about 4 out of every 100 (4%) of newborn boys. Fortunately, most (75%) of these undescended testicles will eventually descend into the scrotal sacs on their own by the first birthday. After the first birthday, however, it is very unlikely for a testicle to descend.

• An undescended testicle must be distinguished from a retractile testis, one which is normal but has temporarily pulled up out of scrotal sac into the groin area. Upon examination the testicle can be pulled into the scrotal sac.

• Your child has been examined and found to have a “cryptorchidism,” or undescended testicle(s). Since the testicles cannot be felt or manipulated down into the scrotum, surgical treatment is recommended.

• An undescended testicle should be brought down into the scrotum as early as possible, preferably before the child is one year old. This is thought to preserve the function of the testicle with regard to fertility. A testicle that has not fully descended into the scrotum by age six months will not do so thereafter. Hormonal manipulation has been found to be ineffective in true undescended testes. Retractile testes are more likely to respond to hormonal treatment. Occasionally, we will use hormonal therapy to differentiate retractile testes from undescended testes.

 

What Problems Can Undescended Testis Cause?

• An undescended testis that remains outside the scrotum throughout childhood may result in impaired or abnormal testicular development which could result in future infertility.

• Another concern is an increased risk of tumor development in the undescended testis during early adulthood. Fortunately, the occurrence is uncommon. Careful periodic examination of the testicles by a physician, and self-examination, is therefore desirable throughout life.

• In addition, most undescended testicles are associated with a congenital (present at birth) hernia and are more prone to injuries than a testicle located within the scrotal sac.

 

What Is the Treatment for an Undescended Testis?

• Operative treatment (surgery) is performed to bring the testicle down into the scrotal sac and to prevent or lessen the likelihood of problems associated with an undescended testicle. In addition, the congenital hernia is corrected at the same time the undescended testicle is placed within the scrotal sac.

• Nonoperative treatment might include a series of hormone shots to stimulate testicular growth and descent into the scrotal sac. Unfortunately, results of hormone therapy have not been predictable and are generally unsuccessful.

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When Should the Surgery Be Done?

• Surgery at the age of one year is now recommended and should allow for maximum preservation of fertility. This may reduce the risk of developing testicular tumors later in life. Furthermore, surgery at this age allows for a normal male appearance before school age.

 

The Surgery

• The goal of surgery is to bring the testicle(s) into the scrotum; the procedure is usually done on an outpatient basis. This means your child may come into the hospital in the morning, have the operation under anesthesia and go home the same afternoon. He may be required to stay overnight if he has other medical problems, such as asthma or diabetes, or if both sides need to be repaired.

• The surgery consists of making a small incision in the groin to locate the testicle. Once located, the testicle is brought down into the scrotum through a small scrotal incision. It is then sutured (stitched) into the scrotum. In some instances the testes are in the abdominal cavity. Laproscopy, looking into the abdomen with a telescope is necessary. In cases where the testes are intra-abdominal, the testes can be brought down using a laproscopic technique, which minimizes the size of the incision and discomfort postoperatively.

• The groin and scrotal incisions are closed with sutures that dissolve and do not have to be removed. Following surgery, the scrotum usually becomes “black and blue” and swollen. This will take several weeks to disappear. If your child experiences pain at home, Tylenol or Tylenol with codeine can be given.

 

Preparing Your Child for Surgery

• If your child is toddler age, you may explain that he will go to the hospital for one day to have an operation. Since he is just beginning to talk and his understanding of surgery is limited, simply tell him that the doctor is going to fix his testicle (use whatever name with which he is familiar).

• Your child will need reassurance that you will be there. He may be frightened by the unfamiliar hospital routines and environment but will be comforted if you reassure him that you are not going to leave him and that he will return home soon.

• Your child may wish to bring a special toy, doll or blanket with him when he comes to the hospital. Of course, your presence is his best source of comfort. You will be able to stay with him as long as possible both before and after surgery.

• Remember: Do not give your child aspirin or Ibuprofen. Your child may be reluctant to walk at first, but encourage him to walk the day after surgery. He may return to school in two or three days and may participate in sports after his postoperative checkup.

• We hope this has answered some of your questions. If you have any additional questions, please contact us for further assistance.

 

Five Easy Steps to Early Detection of Testicular Cancer

• Cancer of the testes is one of the most common cancers in men 15 to 34 years of age.

• The most common type of testicular cancer–seminoma–has a survival rate approaching 100% in cases detected and treated early.

• Men who have an undescended or partially descended testicle are at a higher risk of developing testicular cancer than others.

• If discovered in the early stages, testicular cancer can be treated promptly and effectively.

• Your best hope for early detection of testicular cancer is a simple three minute self-examination. Pubescent boys should be instructed regarding self-examination of their testes even when their undescended testes have been brought down successfully in childhood. Roll each testicle gently between the thumb and fingers of both hands. If you find any hard lumps or nodules or notice any sudden enlargement of your testicles, you should see your doctor promptly. They may not be malignant, but only your doctor can make the diagnosis.

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Urinary Tract Infection (UTI)

 

What Is the Urinary Tract?

• The kidneys filter blood to produce urine. Urine travels from the kidneys down the ureters and into the bladder. The urine is stored in the bladder until urination occurs. The tube through which the urine then passes out of the bladder during urination is called the urethra.

 

What Is a Urinary Tract Infection (UTI)?

• A urinary tract infection is an inflammation of the bladder and the kidneys. It is usually caused by bacteria from the skin outside the urethra moving up the urethra and into the bladder. If the bacteria stay in the bladder, the infection is called cystitis. If the bacteria are in the kidneys, it is called pyelonephritis. These infections are not contagious.

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What Are the Symptoms of Urinary Tract Infection?

• Infants (Less Than two Years Old):

  • Irritability

  • Vomiting and diarrhea

  • Poor feeding

  • Failure to gain weight

• Older Children (More Than two Years Old)

  • Burning with urination

  • Frequent or urgent urination

  • Fever

  • Lower-abdominal pain

  • Wetting episodes

  • Side or back pain

• Regardless of age, bladder infection (cystitis) is not usually associated with fever and generally does not produce any long-term damage to the bladder or kidneys.

• Kidney infection (pyelonephritis), however, is usually associated with a high fever and may produce permanent damage or scarring of the kidney even after only one infection. This is particularly true in the very young child.

 

How Can I Tell if My Child Has a Urinary Tract Infection?

• Your child’s urine will first be evaluated in the office with a microscope. To be certain whether an infection is present, a urine culture will also be obtained. This method is not entirely foolproof, as the urine may be contaminated when voiding by bacteria on the child’s skin. Occasionally, to avoid confusion and to assure greater diagnostic accuracy, a urine sample is obtained by passing a small catheter through the urethra and into the bladder (bladder catheterization).

 

When Should My Child Be Evaluated for Urinary Tract Infections?

• Children who have a culture-proven urinary tract infection should have a radiologic evaluation as soon as possible. This is especially important for infants and small children, since most of them will develop another urinary tract infection. Waiting until a child has had two urinary tract infections before having her/him evaluated increases the risk that permanent kidney damage or scarring may occur.

• Abnormalities of the urinary tract will be detected in one of three children with documented urinary tract infection.

 

What Does the Evaluation Consist Of?

• A physical examination is not sufficiently accurate in evaluating your child’s urinary tract.

• The initial study is the kidney sonogram (ultrasound). This test is done to outline the kidneys and ureters so that a blockage or urinary tract defect can be found. This test does not require radiation and is painless.

• The next study should be a voiding cystourethrogram (VCUG). The (VCUG) is performed by placing a small catheter through the ureter and into the bladder. A fluid (contrast material) is passed through the catheter filling the bladder. A few X-ray pictures are taken during bladder filling and emptying in order to check for reflux of urine. Your child will feel some discomfort but will not need medication for pain.

• Vesicoureteral reflux, or back flow of urine from the bladder into the ureter and up to the kidney, is the most common problem found.

• Reflux is dangerous because it allows bacteria which might be in the bladder to reach the kidney. This can cause a kidney infection and kidney damage.

• A kidney (renal) scan may be done if the above tests are abnormal. This test is used to better demonstrate the actual function and drainage of the kidneys. A kidney scan can also show whether there is kidney damage and scarring.

• A kidney X-ray (IVP) may be done if the anatomy is not clearly shown on a sonogram or if certain abnormalities are suspected.

 

How Are Urinary Tract Infections Treated?

• Prompt and effective treatment followed by adequate evaluation of the urinary tract is essential to minimize your child’s discomfort and risk of urinary tract damage. Your physician will usually prescribe an oral antibiotic for a period of 5 to 7 days to treat a “simple” UTI. To treat a more “complicated” UTI (babies less than two months old, a child who appears ill, a presence of high fevers, poor response to initial oral antibiotic), your physician may decide to hospitalize your child and begin intravenous antibiotics. In a case where a kidney infection is suspected, the course of antibiotics will be 10 to 14 days.

• Unfortunately, it is not uncommon for a urinary tract infection to recur (especially in girls) after adequate antibiotic treatment, even with normal radiologic studies. This may be most perplexing to parents and physicians, but there is little chance of significant damage to the urinary system when the radiologic studies are normal. Further invasive studies such as cystoscopy, urethral dilation or repeat VCUG are not indicated or useful.

• It is important to have your physician perform follow-up urine cultures whether or not another UTI is suspected and routinely every three months for at least one year following treatment. There are children who demonstrate a strong tendency toward recurrent UTIs (more than three per year). Continuous low-dose antibiotic prophylaxis is recommended as a nightly dose for at least three months in these cases.

• Children with UTIs may have poor voiding habits. These children are often helped by encouraging complete bladder emptying every 3 to 4 hours.

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Vesicouretral Reflux

 

What is Vesicouretral Reflux?

• Urine is “waste fluid” excreted by the kidneys. Urine passes from kidneys down the ureters and into the urinary bladder.

• The bladder is an elastic muscle that acts as a storage tank. As the bladder fills, its walls relax to hold more urine, and the control (sphincter) muscle remains tight to prevent leakage of urine.

• Normally the urine is prevented from going back up the ureters toward the kidneys by a valve where the ureters and bladder meet. When the valve is inadequate and allows urine to flow back up into the ureters, this condition is known as reflux.

• About one out of three children who have urinary tract infections are found to have reflux. Reflux is a condition people are born with and it tends to run in families. If your child has reflux, other siblings may have a 7% – 43% risk of having reflux, depending on the age of the sibling. It may suggest that other family members also be checked for reflux.

 

Is Reflux Dangerous?

• Most urinary tract infections stay in the bladder. When a child has reflux, the bacteria have direct access to the kidneys and cause a kidney infection (pyelonephritis). This can result in damage to the kidneys and, in some other children, early onset of hypertension

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How Do I Know My Child Has Reflux?

• The diagnosis of reflux is made by a bladder X-ray called a voiding cystourethrogram (VCUG). During the test a small tube is put into the urethra and a fluid (contrast media or isotope) flows into the bladder. X-ray pictures are then taken to check for reflux. Your child will be awake during the VCUG and may experience some discomfort but will not need medication for pain.

• If your child has reflux:

  • A kidney (isotope renal) scan or X-ray (IVP) may be done to check how well the kidneys are working and to look for kidney damage.

  • A sonogram may be done to check the size of the kidneys and to be able to follow future renal growth and to observe for scarring.

 

How Is Reflux Treated?

• The plan of treatment will vary according to your child’s age, number of urinary tract infections and X-ray findings. Reflux is “graded” on a scale of one through five: one is the mildest and five is the most severe. In children with mild to moderate grades of reflux (grades 1-3) there is an excellent chance that the reflux will disappear as your child gets older. Treatment is aimed at preventing urinary tract infections when reflux and urinary tract infection are both present.

• Children With Grade 1-3 Reflux

  • Most children have a good chance of outgrowing this condition as the ureteral valve matures.

  • Take low dose of an antibiotic nightly for as long as the child has reflux.

  • Have urine cultures done on a regular basis.

  • Undergo VCUG every 12 to 18 months to check if reflux has disappeared.

  • Have a sonogram of the kidneys to check for growth every 1 to 2 years.

• Children With Grades 4-5 Reflux or UTIs While on Antibiotic Medication

  • Have surgery to correct the reflux. This type of surgery is highly successful and safe.

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Sexual Differentiation

What Is This?

• When some children are born, it is impossible by looking at their genitalia to determine what sex they are. This is an uncommon condition but one of the more challenging diagnostic problems that face pediatric urologists. In the past this was called “intersex,” but the conditions are now known as “disorders of sexual differentiation.” These children may be boys whose penis, scrotum, and testes have not developed normally, and they look a little like girls. The opposite can occur in girls who have developed penis-and-scrotum-like structures and look somewhat like boys.

 

How Does It Occur?

• All fetuses begin development in the uterus looking like females. If the fetus is male, the female-like structures will undergo changes that transform (differentiate) them into a penis and scrotum. If this transformation process is not completed in the male fetus, he may have genitalia with both male-and-female-appearing features. In girls, this transformation is not supposed to occur. However, if partial or complete transformation does occur in girls, they will take on the partial or complete appearance of male genitalia with a penis and scrotum. In some instances, transformation will be so abnormal that the infant will look like a normal infant of the opposite sex.

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How Is It Treated?

• The diagnosis of the cause of the child with ambiguous genital development is very complex and best done by multidisciplinary teams of physicians who are experts in this field. The pediatric urologist is a key member of this team. The teams also include geneticists, endocrinologists, bioethicists and pediatricians.

• Treatment is based on several factors. The first is the true genetic sex of the child (XX or XY). The second is the developmental changes that can be expected as the child grows. The third is the potential for the child to be fertile and have children. Finally, the ability to successfully reconstruct the genitalia toward the appropriate appearance is also an important factor.

• The physicians of Pediatric Urology Associates have special expertise in the diagnosis and treatment of children with these developmental abnormalities.

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Varicocele

 

What Is a Varicocele?

• A varicocele is a collection of varicose veins around the testicle. Varicose veins can be seen in other parts of the body. If you have seen someone with large veins on their leg that bulge when they stand up and disappear when they lie down, you have seen varicose veins. Varicocele is the word used to describe varicose veins in the scrotal sac around the testicle. A varicocele can be important because it can be a cause of future infertility. We understand very little about varicoceles other than what we can see on a physical exam.

 

How Does a Varicocele Occur?

• Varicoceles are very common in adolescent and teenage boys and occur in approximately one of every seven or eight boys. We don’t know why a varicocele occurs in one boy and not another. We’re not even sure how they occur or exactly how they lead to infertility. The arteries and veins work differently. The heart pumps blood under pressure to the rest of the body through the arteries. There isn’t a similar pump to get the blood back to the heart. For this reason there are valves in the veins that keep the blood from going backwards when you stand up. If these valves weren’t present, your blood would run back to your feet and you would pass out. We believe that varicoceles occur because the valves in the veins that carry blood back to the heart from the testicle are not functioning properly. Because of this, when a boy with a varicocele stands up, the blood rushes backwards to the scrotum and engorges the veins around the testicle. Most varicoceles occur only on the left side, though some occur on both sides.

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What Problems Do Varicoceles Cause?

• The only significant problem that a varicocele may cause is infertility – the inability to father children. Approximately two or three men out of ten with a varicocele will be infertile at a time when they want to have children. We are not sure how the varicocele causes the infertility. What we do know is that the effect on fertility appears to worsen with time. However, in most men the effect may occur so late in life (e.g., 60 or 70 years old) that they don’t even know it has happened or are not concerned with fertility.

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Who Needs Treatment?

• The only significant problem that a varicocele may cause is infertility – the inability to father children. Approximately two or three men out of ten with a varicocele will be infertile at a time when they want to have children. We are not sure how the varicocele causes the infertility. What we do know is that the effect on fertility appears to worsen with time. However, in most men the effect may occur so late in life (e.g., 60 or 70 years old) that they don’t even know it has happened or are not concerned with fertility.

 

How Are Varicoceles Treated?

• The object of treatment of a varicocele is to interrupt or block the vein that has been allowing the blood to go backward when a boy stands up. This prevents the veins around the testicle from becoming enlarged any more. The most common way a varicocele is corrected is by surgical division of the blood vessel somewhere above the scrotum. This is an outpatient procedure done either by an incision in the groin or lower abdomen or by laparoscopic surgery. In some instances, parents will elect to have the varicocele treated by having a catheter placed into the main vein to the heart (the inferior vena cava). The catheter is then fed back down the “bad” vein and solid material is injected down the vein to block it. Both of these are very effective at correcting the varicocele.