Urology-basics lecture

1. Evaluation of the Pediatric
Urology Patient

2. I. Chief Complaint and History of Present
Illness
II. Past Medical and Surgical History
III. Medications and Allergies in the Pediatric
Patient

3. I. Chief Complaint and History of
Present Illness
• First question: “why is the child here?”
– ask the child a few questions directly
– Interview adolescents separately from their
parents when asking sensitive questions

4. Chief Complaint and History of Present
Illness
1. Abdominal Complaints
– Children with acute abdominal pain should be seen
immediately. An accurate history of the character of
the pain may be the best indicator of the source of the
pain.
– Details about the character of the pain, timing,
acuteness of onset, radiation, and migration are
important
– Associated symptoms
• loss of appetite, nausea, vomiting, or a change in bowel
pattern may help to distinguish gastrointestinal from
genitourinary sources.

5. • Intra-abdominal causes in children
– pyloric stenosis, midgut volvulus, appendicitis, and
intussusception.
• Non- abdominal sources
– sickle cell crisis, streptococcal pharyngitis, or
pneumonia

6. • children should be evaluated for
– urinary tract infection (UTI),
– constipation (abdominal series shows - considerable amounts of stool
throughout the colon)
– spermatic cord torsion (Occasionally, some children with spermatic cord
torsion complain of abdominal pain and have surprisingly few complaints
referring to the scrotum)
• Most abdominal masses originate in genitourinary organs and should be
evaluated immediately (Chandler et al, 2004) (Table 115–1).
– The most common malignant abdominal tumor in infants is neuroblastoma,
followed by Wilms tumor (Golden and Feusner, 2002).
– neuroblastoma - more constitutional symptoms than children with Wilms
tumor.
– If an abdominal mass is suspected  abdominal ultrasound evaluation  If
the mass is solid  computed tomography (CT) .

8. 2. Scrotal Symptoms
– A child with acute scrotal pain must be presumed to have spermatic
cord torsion regardless of age until proven otherwise.
– The differential diagnosis of the acute scrotum:
• testicular torsion,
• torsion of the appendix testis or epididymis,
• epididymitis/orchitis,
• hernia/hydrocele,
• trauma, s
• exual abuse,
• umor, idiopathic scrotal edema,
• dermatitis, cellulitis, and
• vasculitis, such as Henoch-Schönlein purpura

9. • Gradual onset of the pain is more consistent with epididymitis,
whereas abrupt pain suggests spermatic cord torsion or torsion of
one of the testicular appendices. Associated scrotal wall swelling,
erythema, or superior displacement of the testis with an absent
cremasteric reflex is suggestive of spermatic cord torsion. Yet, the
absence of edema or erythema or the presence of a cremasteric
reflex does not rule out the possibility of acute testicular torsion,
especially if the onset of pain was recent. The classic presentation
of testicular torsion is the sudden onset of severe, unilateral pain
that is often associated with nausea and emesis. A history of similar
intermittent episodes may suggest intermittent testicular torsion.
Traditionally, significant ischemic damage is believed to occur after
4 to 8 hours. Therefore testicular torsion represents a true surgical
emergency. Patients presenting after 8 hours should still be
explored, because the viability of the testis is difficult to predict
(Beard et al, 1977; Bartsch et al, 1980).

10. • If there is history of inguinal or scrotal pain, infants and chil- dren with an
inguinal hernia or a hydrocele that changes in volume should be seen
within 24 hours or sooner. Not all of these children will need emergency
surgery, but a few will require surgi- cal intervention within a short period.
If there is a history of scrotal or inguinal pain, the child’s parents should be
taught to recognize the signs of an incarcerated inguinal hernia and
instructed to go to the emergency department if symptoms occur before
the planned surgical correction. Infants with asymp- tomatic hydrocele
rarely require surgery initially. In most cases, the hydrocele will resolve in
the first year of life. The authors make an exception if the hydrocele is
particularly large or palpable in the inguinal region. A large hydrocele with
a palpable inguinal component or one that is enlarging may indicate the
presence of an abdominoscrotal hydrocele. These do not sponta- neously
resolve and usually enlarge. These should be corrected, usually at 6 to 12
months through an initial scrotal incision that will decompress the
hydrocele (Luks et al, 1993; Belman, 2001).

11. • Boys with undescended testes are one of the most common
referrals to the pediatric urologist. Undescended testes are present
in 30% of preterm neonates and are present in 3% of full-term male
infants at birth (Ghirri et al, 2002; Boisen et al, 2004). Unde-
scended testes do not represent a surgical emergency. We operate
on patients with undescended or absent testes at about 6 months
of age. Very few of these testes will descend after 3 months of age
(Berkowitz et al, 1993). Some infants with impalpable testes may
require laparoscopic evaluation, and this examination may be done
at 6 months as well. In prepu- bertal boys, concerns of an
undescended testis often reflect a retractile testis that results from
a brisk cremasteric reflex and does not require surgical intervention.
A retractile testis must be dif- ferentiated from an ascending testis,
which may require an orchidopexy.

12. • Varicoceles are uncommon in prepubertal boys and
increase in incidence to around 15% by 15 years of age
(Schiff et al, 2005). We normally try to document the
size of the testis with an ultra- sound examination.
From the three-dimensional measurements on
ultrasonography, the relative testicular volumes may be
calcu- lated and used to guide further treatment
(Diamond et al, 2000). Varicoceles are 90% left-sided
and 10% right-sided (MacLellan and Diamond, 2006). A
right-sided varicocele in the absence of a left- sided
varicocele should prompt an evaluation for a
retroperitoneal process.

13. • Testicular masses should be evaluated immediately. Prepubertal testicular and
paratesticular tumors should
• be considered in the differential diagnosis of a scrotal mass. Although much less
common than epididymal cysts or spermatoceles, a complaint of a painless
testicular or paratesticular mass should be addressed urgently. A physical
examination and scrotal ultrasonography should determine if the mass is concern-
ing for neoplasia. In a contemporary series from a tertiary center, the most
common prepubertal testis tumor was a teratoma, fol- lowed by
rhabdomyosarcoma, epidermoid cyst, yolk sac tumor, and germ cell tumor,
respectively (Metcalfe et al, 2003). This his- tologic distribution was corroborated
by a multicenter review, including four tertiary pediatric hospitals, demonstrating
that 74% of tumors were benign, with 48% being teratomas (Pohl et al, 2004).
Testicular tumors occur in the newborn and in early child- hood as well as after
adolescence. It is important to recognize that the peak incidence of testicular
tumors in young children and infants occurs at age 2. In this population, yolk sac
tumors are most common, and approximately 75% of tumors are malignant (Levy
et al, 1994; Ciftci, 2001). Tumors of nontesticular origin, such as leukemia and
lymphoma, must also be considered in the pediatric population.

14. • 3. Male Penile or Urethral Symptoms
• Boys with painful priapism must be evaluated
immedi- ately. Pain may suggest ischemia of the
corporeal bodies, which may progress to corporeal
fibrosis if untreated. Children with sickle cell anemia
are especially at risk for priapism, with 75% of
patients experiencing their first episode by the age of
20 years (Mantadakis et al, 1999; Adeyoju et al, 2002).
Outpatient treatment with penile aspiration and
epinephrine irrigation has successfully been used in the
treatment of this condition (Manta- dakis et al, 2000).

15. • Paraphimosis also requires immediate attention and
manual reduction. In children, this procedure may require
some level of sedation. Conversely, phimosis is physiologic
in young infants and attempts to manually retract the
foreskin in boys less than 2 years of age should be avoided.
Phimosis in older children is typi- cally treated with one or
two courses of low-dose steroid cream and circumcision if
necessary (Ashfield et al, 2003).
• Boys with hypospadias are seen routinely. Normally, we
initiate the evaluation as a newborn because most parents
of with a child with a birth defect, even a relatively minor
one such as hypospa- dias, desire an early opportunity to
speak with a specialist.

16. • We evaluate children who have developed a complication after
circumcision at the convenience of the family as long as there is no
active bleeding, the child is voiding normally, and there is no injury
to the penile shaft or shaft skin. Narrowing of the preputial ring
after circumcision may result in a trapped penis (Casale et al, 1999;
Gillett et al, 2005). These infants can usually be managed with
application of petroleum jelly to the penis for 4 to 6 weeks as
healing continues. As long as voiding remains normal during this
period, the revision of the circumcision may be postponed until age
4 to 6 months when an outpatient surgical procedure can be
performed. A more common complication, urethral meatal stenosis,
may be present as early as 6 months of age in circumcised infants
(Upadhyay et al, 1998; Ahmed et al, 1999). This problem may be
easily corrected in the office (Smith and Smith, 2000).

17. • 4. Female Genital Symptoms
• Infant girls with introital masses commonly present to the pedi- atric urologist’s outpatient office.
Vaginal masses may be palpable or may protrude from the introitus. The differential diagnosis of
• Figure 115–1. Urethral prolapse. (Courtesy of Pasquale Casale, MD.)
• these masses includes benign periurethral cysts, skin tags, urethral prolapse, imperforate hymen,
prolapsed ureterocele, or, rarely, malignancies such as a rhabdomyosarcoma. Bladder outlet
obstruction may result from a prolapsed ureterocele. The majority of these lesions are
differentiated by physical examina- tion, but historical information, such as pain, bleeding, or
voiding difficulties, help solidify the diagnosis.
• Urethral prolapse is relatively common, particularly in young African-American girls. Figure 115–1
demonstrates urethral prolapse in a young girl. A urethral catheter demonstrates the
circumferential prolapsed urethral tissue. The prolapse is through the meatus, forming a
hemorrhagic, often sensitive mass that bleeds with palpation or when in contact with the undergar-
ments. Girls may have difficulty with urination depending on the size of the prolapse and whether it
compromises the urethral meatus. Urethral prolapse may respond to topical application of estrogen
and may be managed expectantly as long as voiding is normal (Redman, 1982).

18. • Benign and malignant tumors of the vagina should be considered when
vaginal bleeding occurs in young girls. A broad spectrum of entities
ranging from capillary hemangioma, rhabdomyosarcoma, or carcinoma
may be associated with vaginal bleeding. Labial masses may be associated
with hernia or hydro- cele of the canal of Nuck (Kizer et al, 1995).
Adhesions of the labia minora are common. In most cases, they are not
symp- tomatic. Occasionally, a girl with labial adhesions will complain of
vaginal irritation from pooled urine. In this case, if the labial adhesions are
not separated, the irritation may progress to irregu- lar voiding that may
exacerbate the problem of frequency and urgency. In some girls, a short
course of estrogen cream applied to the labia may be effective. In many,
however, separation of the adhesions in the office with local anesthetic
cream may be required. Labial fusion may be associated with congenital
adrenal hyperplasia (CAH), gonadal dysgenesis, or cloaca (Powell et al,
1995). A genitosinogram may be indicated in cases where the urethra
cannot be distinguished from the vaginal orifice and a urogenital sinus is
suspected.

19. • The authors evaluate adolescent girls who have not
menstru- ated and in whom there is concern about a
ureteral or vaginal anomaly within 3 days. Patients with
complete androgen insensi- tivity (CAIS) can also
present with primary amenorrhea. Many of these girls
have an imperforate hymen or uterine anomaly that
results in poor uterine drainage that may be
uncomfortable. If left untreated, retrograde drainage of
the uterus may place these
• patients at risk of endometriosis and infertility (Rock et
al, 1982). Pelvic ultrasonography or magnetic
resonance imaging (MRI) can further delineate the
anatomy and guide intervention if necessary.

20. • 5. Voiding Symptoms
• Like most teams, we see a large number of children of both sexes with voiding complaints and
incontinence. Incontinence is clas- sified as diurnal (daytime), nocturnal (nighttime) or both. If a
child has never been dry, the incontinence is primary. If the child is wet after a dry interval greater
than 6 months, the incon- tinence is secondary. The ability to place children in catego- ries based
on the voiding history will help to focus the rest of the evaluation and guide further therapy. The
time and duration of the voiding disorder must be identified early in the interview. A thorough
history obtained from both the parents and the child is important to determine the actual pattern
of voiding, which may differ from parental perceptions. Did symp- toms begin before or after potty
training? Is wetting associated with pain, urgency, or frequency? What is the character of the
voiding? Is the urinary stream steady from beginning to end or is it a “staccato” or stop and start
pattern suggestive of dysfunctional voiding? Are the symptoms worse at a particular time of the
day? Does the child void frequently during the day yet sleep through the night without wetting? Is
wetting confined to the night, suggestive of primary nocturnal enuresis? Additionally, behavioral
signs can be used to further understand the etiology of functional incontinence. Episodes of
urgency in children are often suggested by holding maneuvers, such as squatting, crossing legs, and
sitting on heels (Ellsworth et al, 2008). Poor potty habits may result in incomplete voiding or vaginal
voiding. Giggle inconti- nence is encountered in young girls and describes large-volume
incontinence that occurs only with laughter. In this situation, the incontinence is associated with a
complete emptying of the bladder and should be distinguished from stress urinary inconti- nence in
adults because the treatment differs significantly (Berry et al, 2009).

21. • The voiding history is incomplete without a record of the child’s eating and drinking pattern. Does
the child consume small amounts of water during the day and large amounts of alternative liquids,
such as soft drinks and juices, which tend to be laden with salt and sugar and low in free water?
What is the stooling pattern? Does the child have firm, chunky, or pebble-like bowel move- ments
suggestive of a retentive pattern of stooling, or does the child have soft, well-formed bowel
movements more suggestive of a normal stooling pattern? Very few children hold the urine and not
the stool. Conversely, children who retain stool nearly always retain urine. All of these are indicators
of a dysfunctional voiding pattern, which may lead to UTI. Referencing a standardized stool chart,
such as the Bristol stool form scale (http://en.wikipedia.org/ wiki/Bristol_Stool_Scale; Lewis and
Heaton, 1997) may be helpful to further clarify the stooling pattern (Koh et al, 2010).
• Children with day or nighttime wetting are evaluated routinely in the absence of other
complicating problems. The care of children with nocturnal enuresis is individualized. Although
some recommend treatment in children after age 5, the authors often wait to treat until the child
seems bothered by the problem. If the child does not perceive nighttime wetting as a problem,
there is usually little advantage to treatment with medi- cations or alarms. In our experience, only a
few children younger than age 6 or 7 are bothered emotionally by nocturnal enuresis.

22. • Wetting during the day causes more concern and may indicate incomplete or
infrequent voiding. Incomplete or infrequent voiding may lead to UTI, which may
exacerbate wetting.
• Although the majority of voiding symptoms are sec- ondary to voiding habits, it is
important to remember that more serious pathophysiology may present with
similar complaints. After a careful history, any concerns regard- ing a structural
etiology for voiding dysfunction should be inves- tigated. Continuous leakage in
between normal voiding patterns in a girl should raise concerns of an ectopic
ureter. Symptoms suggestive of detrusor-sphincter dyssynergia may represent
occult spinal dysraphism. Urinary retention and stranguria may be caused by
posterior urethral valves in a boy or a bladder mass, such as a polyp, ureterocele,
or rhabdomyosarcoma, in either sex. Uroflow, postvoid residual urine, and
ultrasound studies are usually appropriate first steps in the evaluation of voiding
dys- function and investigation of potential structural anomalies. Addi- tional
testing may include a voiding cystourethrogram (VCUG), retrograde urethrogram,
spinal MRI or ultrasound (USG), and an urodynamic evaluation.

23. • 6. Sexual Abuse
• Although genital injuries may be accidental, the possibility of physical or sexual abuse must be
considered in all cases of genital trauma in females or males. Sexual abuse is surprisingly common
and includes any activity with a child before the age of legal consent that is for sexual gratification
of an adult or a significantly older child. Sexual intercourse includes vaginal, oral, or rectal
penetration, which is defined as entry into an orifice with or without tissue damage. Sex acts per-
petrated by young children are learned behaviors and are associ- ated with experiencing sexual
abuse or exposure to adult sex or pornography. In 2007, there were more than 740,000 reported
cases of child maltreatment. Included in this number were 56,460 victims of sexual abuse in the
United States. Of these children, 18% were less than 4 years of age, 23% were 4 to 7 years of age,
24% were 8 to 11 years of age, and 35% were 12 to 15 years of age. The perpetrators of the sexual
abuse are most commonly a friend or neighbor, followed by a relative or daycare worker (U.S.
Department of Health and Human Services, 2009). In a recent review, the peak incidence of
sexually transmitted diseases was seen in the 10- to 14-year age group (Pandhi et al, 2003). In one
study of women presenting to an urban sexual assault clinic, 43% were adolescents (Jones et al,
2003). Pelvic inflammatory disease rates are highest in females age 15 to 25 with 33% of those
infec- tions in females younger than age 19 (Jenkins, 2000). Any pediat- ric patient with a sexually
transmitted infection should be evaluated for sexual abuse. Although the mode of transmission of
human papillomavirus (HPV) and herpes simplex virus (HSV) is often unclear, Neisseria gonorrhoeae
or Chlamydia trachomatis infec- tions in a prepubertal child should be reported to child protective
services (Bechtel, 2010).

24. • The possibility of sexual abuse should be considered a result of associated
physical symptoms, including (1) vaginal, penile, or rectal pain, discharge, or
bleeding or (2) chronic dysuria, enuresis, constipation, or encopresis. In one
study, 74% of pediatric patients with documented sexually transmitted diseases
had histories or signs of abuse (Pandhi et al, 2003). Sexual abuse should be
considered when the vaginal mucosa is bruised or injected, the vaginal opening is
dilated, or the hymen is damaged, showing a V-shaped notch or cleft (Walker,
1998). Despite these guidelines, the diagnosis of sexual abuse is
• CHAPTER 115 l Evaluation of the Pediatric Urology Patient 3071
• often made by the history and not by the physical examination. In a review of 506
girls with a history of penetrative abuse referred to a sexual abuse clinic, only 11%
had examination findings sug- gestive of sexual abuse (Anderst et al, 2009).
Investigating the possibility of sexual abuse requires supportive, sensitive, and
detailed history taking. Many hospitals have a sexual abuse team that can be
consulted if sexual abuse is suspected. The key is to be aware of the possibilities
when they might exist and to invite the team in early. The pediatric urologist will
likely be asked to evaluate the abdomen and perineum (Johnson, 2000). If abuse is
suspected, it must be reported to the police. Furthermore, if the perpetrator is a
caregiver of the child, or a parent, the state child welfare team must be contacted.

25. • 7. UTI
• Febrile UTIs in the newborn are treated emergently, because newborns are particularly susceptible to signifi-
cant renal damage if the infection is not treated promptly. A urine culture should be obtained, and these infants
require intravenous antibiotics as early as possible after a urine culture has been obtained, because they have a
higher prevalence of concomitant bacteremia (10% to 22%) (Pitteti and Choi, 2002). Appropriate antibiotic therapy
administered without delay has been shown to reduce the incidence of scarring (Ransley and Risdon, 1981;
Hiraoka et al, 2003). Some authors suggest this decreased incidence of scarring reflects a decreased likelihood of
renal involvement rather than a true prevention of scar formation (Doganis et al, 2007).
• Febrile UTIs in children older than newborns should be treated acutely. Children of all ages with a severe urinary
tract infection may be subject to renal scarring (Ransley and Risdon, 1981; van der Voort et al, 1997) and should
be seen within 24 hours or sooner. Children older than newborns with nonfebrile UTI should be seen
semiurgently. In practice, many of these patients are seen by their pediatrician and are seen in follow-up by the
pediatric urologist. Nearly all children with culture-proven UTI should be evaluated with ultrasonography and
VCUG, although some groups are re-evaluating the role of renal nuclear scans in these children.
• The evaluation for UTI is completed at the parent’s convenience after the initial infection has been treated. In
most cases, radio- logic studies after UTI in a child include VCUG to detect vesico- ureteral reflux. However, a
substantial number of cortical defects on dimercaptosuccinic acid scintigraphy (DMSA) scan occur in the absence
of identifiable reflux (62% to 82%) (Majd and Rushton, 1992; Benador et al, 1997; Ditchfield and Nadel, 1998;
Biggi et al, 2001; Ditchfield et al, 2002). This has led to a re-evaluation of the role of VCUG as the initial
investigation in a child with a UTI. It is important to recognize that infants less than 6 months of age and
uncircumcised male infants are at increased risk for recurrent UTI (Wiswell and Roscelli, 1986).

26. • 8. Hematuria
• A practical approach to the evaluation of hematuria in
children is presented in Chapter 112. The authors’
recommendation for patients with microscopic
hematuria with unrelated clinical symp- toms is to treat
the affiliated illness (e.g., pulmonary or immuno- logic
conditions, glomerular and interstitial disease, lower
urinary tract disease, stones, tumors, vascular disease,
or acute abdominal conditions) and ignore hematuria
until the treatment for the underlying illness is
underway. Transient microhematuria is also

27. • common in healthy children (Vehaskari et al, 1979). The large majority of children with
microscopic hematuria are evaluated, and the source of the hematuria is never iden- tified (Diven
and Travis, 2000). Notably, the most commonly identified etiology of asymptomatic microhematuria
and gross hematuria in children is hypercalciuria (Parekh et al, 2002; Berg- stein et al, 2005).
Microscopic hematuria in the absence of other symptoms is not an emergency in children.
• Gross hematuria in children is less common than microscopic hematuria, with an estimated
prevalence of 1.3 per 1000 (Ingelfinger et al, 1977). The most common diag- noses are UTI (26%),
perineal irritation (11%), trauma (7%), meatal stenosis with ulceration (7%), coagulation
abnormalities (3%), and urinary tract stones (2%). The most common glomerular causes of gross
hematuria in children are poststreptococcal glomerulone- phritis and IgA nephropathy. An
antecedent sore throat, pyo- derma, edema, or red blood cell casts suggest glomerulonephritis. IgA
nephropathy can cause recurrent gross hematuria with flank or abdominal pain and may be
preceded by an upper respiratory tract infection (Meyers, 2004). Adenoviral infection, hypercalci-
uria, and hyperuricosuria are other sources to consider. In peripu- bertal boys, benign
urethrorrhagia can present with terminal gross hematuria. The authors perform ultrasonography of
the kidneys, ureters, and bladder in children with gross hematuria, although the yield is low
(Fernbach, 1992). In contrast with the adult patient, cystoscopic examination in children rarely
reveals a cause for hematuria but should be performed when bladder pathology is a consideration.

28. • Gross hematuria in the newborn is an emergency because it may indicate
renal venous thrombosis or renal arterial thrombosis. Both may be life-
threatening. Renal venous thrombosis affects boys twice as often as girls,
with a left- sided predominance. These infants require resuscitation and,
occa- sionally, anticoagulant or operative therapy (Kuhle et al, 2004).
Gross hematuria outside the newborn period, although not life-
threatening, should be evaluated without delay. Many children have an
easy-to-recognize source such as UTI, ure- thral prolapse, trauma, and
meatal stenosis with ulceration, coagu- lation abnormalities, or urinary
tract stones. Less obvious sources include acute nephritis, ureteropelvic
junction obstruction, cysti- tis cystica, epididymitis, or tumor (Diven and
Travis, 2000; Meyers, 2004). As with adult patients, a thorough history
including a specific description of the color of the urine, the presence of
clots, and timing of hematuria, such as terminal hematuria or hematuria
upon initiation of micturition, should facilitate the diagnostic process. A
directed history should include medications, exercise habits, propensity
for bleeding diathesis, and a travel history to rule out exposure to
infectious diseases such as schistosomiasis or tuberculosis.

29. • 9. Renal Trauma
• The pediatric trauma patient usually presents to the
emergency department and is evaluated by the emergency
medicine and trauma teams, often with the assistance of
the urology service. Blunt force trauma is the primary
mechanism for major renal trauma (Mohamed et al, 2010).
The pediatric kidney is particularly susceptible to trauma
due to the limited visceral adipose tissue, limited chest wall
protection, relatively increased renal size, and increased
mobility of the kidney (Brown, 1998). The mechanism of
injury should be determined and a thorough history
obtained from the patient and caregivers or observers.
Epidemiologic data demonstrate that the majority of renal
injuries

30. • result from motor vehicle accidents, falls, or high- velocity activities, such as sledding, skiing, all-
terrain vehicle accidents, and skateboarding (Margenthaler et al, 2002; Rogers, 2004). Therefore
injuries of this nature should alert the clinician to potential renal damage. The history should
include any congenital renal anomalies, such as an ureteropelvic junction obstruction, a solitary
kidney, or renal ectopia. Finally, evaluation of associated injuries must be undertaken. Any
abdominal injury in a toddler or young child without an antecedent history of blunt force trauma
should be evaluated for physical abuse (Barnes et al, 2005).
• Blunt force renal trauma represents a urologic emergency that requires immediate attention but
does not necessarily require operative intervention. It is well accepted that low-grade blunt renal
injuries are managed conservatively. More recently, the con- servative treatment of high-grade
blunt renal injuries have been successfully described in children. A consecutive series of 101
patients from The Children’s Hospital of Philadelphia (CHOP) with blunt renal injury demonstrated
that a nonoperative man- agement strategy was advantageous and successful in 94.7% of pediatric
blunt renal injuries (Nance et al, 2004). The children with high-grade injuries at risk for failure of
conservative manage- ment include those with major vascular avulsion or extensive urinary
extravasation, especially in the setting of ureteropelvic junction disruptions (Henderson et al,
2007). These patients deserve close urologic observation and repeated examinations. The authors
recommend conservative management and recognize that a complete evaluation is necessary to
accurately determine which patients require further intervention.

31. • 10. Ambiguous Genitalia
• Infants with ambiguous genitalia also require immediate evalua- tion.
Many will require direct transfer from a referring hospital. Because CAH
may result in salt wasting, which may be life threatening, infants with
ambiguous genitalia must be evaluated quickly and stabilized (Forest,
2004). If CAH is suspected, the infant should not be discharged home
from the nursery before appropriate testing is complete. In some cases, a
genotypic female neonate with CAH may be incorrectly identified as a
male neonate. The correct diagnosis should be made as quickly as possible
to establish the appropriate sex of rearing. Infants with ambiguous
genitalia may also have other syndromes and may require further
evaluation (Tables 115–2 and 115–3). A history of a discordant karyotype
from an amnio- centesis and infant phenotype should prompt an
evaluation. The parents should be asked about a family history of
infertility, amen- orrhea, and infant mortality. The complete evaluation of
infants with ambiguous genitalia should include urology, neonatology,
endocrinology, genetics, and radiology.

32. • 11. Antenatal Hydronephrosis
• In neonates with prenatally detected hydronephrosis and a
normal bladder, the authors begin the postnatal evaluation
of the hydro- nephrosis within the first few days of life.
Families are usually concerned about the diagnosis and
anxious to establish a manage- ment plan. The postnatal
evaluation can be scheduled at the fam- ily’s convenience
for most infants. This classification includes infants with a
history of prenatal hydronephrosis who are not suspected
of having bladder outlet obstruction on the postnatal
ultrasonography. Additionally, the ultrasonogram must not
dem- onstrate bilateral hydronephrosis, a solitary kidney, or
a thickened

33. • bladder wall. The infant must be thriving and have normal elec- trolytes and normal blood urea
nitrogen (BUN) and creatinine levels.
• The postnatal history should also include the sex of the infant, laterality of the hydronephrosis, the
level of obstruction (i.e., ure- teropelvic junction [UPJ], ureterovesical junction [UVJ], urethra), the
presence or absence of oligohydramnios, and any other associ- ated anomalies. The additional tests
to be scheduled can include a repeat ultrasonogram, a renal scan, or a voiding cystourethrogram to
evaluate the relative drainage and percentage of function of the kidneys, as well as to evaluate for
vesicoureteral reflux. Until this postnatal evaluation is completed, most infants are maintained on
amoxicillin prophylaxis. The utility of specific testing remains controversial. The differential
diagnosis for antenatal hydrone- phrosis most commonly includes UPJ obstruction, vesicoureteral
reflux, ectopic ureter, ureterocele, megaureter (UVJ obstruction), multicystic dysplastic kidney,
posterior urethral valves, prune-belly syndrome, and megacystis microcolon syndrome.
• Certain conditions require more immediate intervention, espe- cially when bladder outlet
obstruction is present. If posterior ure- thral valves are considered, the bladder should be drained
with a feeding tube and a VCUG performed at an appropriate interval. Conversely, if prune-belly
syndrome is considered, urethral cath- eterization should be avoided, if possible, to minimize the
risk of urinary tract infection. Additionally, a ureterocele may obstruct the bladder outlet and result
in bilateral upper tract dilatation. This situation can be ameliorated by placement of a urinary
catheter.

34. • An increasing number of pregnant mothers carrying a fetus with
hydronephrosis seek prenatal evaluation with the urologist. These
visits are scheduled within the week unless the following
conditions exist: (1) there is bilat- eral hydronephrosis or
hydronephrosis in a single system kidney, (2) there is
oligohydramnios, and (3) there is evidence of significant cystic
renal disease in a fetus younger than 22 weeks’ gestation. In
certain circumstances, termination of pregnancy may be
considered. Conversely, fetal intervention may be indicated. These
difficult decisions are often precipitated by oligohydramnios and
the risk of severe pulmonary and renal insufficiency. The decision
for discontinuation of the pregnancy is dependent on the
gestational age of the fetus; thus prompt evaluation may be
required.

35. • 12. Congenital Anomalies in the Neonate
• Patients with major abdominal defects, such as bladder or cloacal
exstrophy, require direct admission to the neo- natal nursery for
stabilization and surgical planning. In many cases, a team is assembled and
provides orthopedic, general surgi- cal, and urologic care during the
surgery (Jeffs, 1978; Lattimer et al, 1979; Gearhart, 1999). Patients with
imperforate anus and variants, such as a cloacal anomaly, require
decompression of the intestinal tract, usually within the first 24 to 48
hours (Chen, 1999). At the time of the colostomy, the urologist may
evaluate the perineum and perform endoscopy to further assess the
urinary anomalies. Procedures to correct these major defects must be
planned by surgeons who are familiar with the potential risks and
complications associated with the reconstruction of the urethra, vagina,
and colon. The anesthesia team must be skillful in the management of the
complex metabolic changes that may occur in infants who are under
anesthesia for long periods. The neona- tologists must be expert in the
management of infants who have undergone major surgical procedures.

39. • Today, many newborns with spinal dysraphisms are diagnosed in utero
(Babcook et al, 1995). These infants are referred by direct admission to the
neonatal intensive care nursery. Most of these children are not in urinary
retention initially, but many develop spinal shock after neurosurgery in the
newborn period and have a transient period of overflow urinary drainage.
As soon as possible after closure of the spinal defect, a baseline renal and
bladder ultrasonogram is performed to evaluate for evidence of bladder or
upper tract abnormalities. Initial urody- namics investigation is performed
after resolution of the spinal shock to ensure that bladder storage
pressures are not excessive (McGuire et al, 1977, 1983; Bauer, 1998;
Tarcan et al, 2001). High- risk infants (those with a detrusor leak-point
pressure greater than 40 cm H2O or detrusor-sphincter dyssynergia) are
started on anti- cholinergic therapy and intermittent catheterization
(Snodgrass and Adams, 2004). Even those infants with normal urodynamic
findings require close follow-up due to the risk for subsequent
neurourologic deterioration resulting from spinal cord tethering (Tarcan et
al, 2001).

41. II. Past Medical and Surgical History
• A patient’s past medical and surgical history are always germane to the patient history and often
provide insight into the current condition. Many pediatric congenital syndromes include urologic
anomalies (see Tables 115–2 and 115–3), and the pediatric urolo- gist should be aware of these
associations. Additionally, an assess- ment of the child’s developmental progress may impact their
urologic development, especially in the context of potty training and enuresis. A brief description of
developmental milestones is provided in Table 115–4.
• Other pediatric conditions impact the timing of surgical inter- vention and affect the level of risk
from anesthesia. In healthy children, a recent history of a respiratory illness or asthma increases the
risk of reactive airway disease and therefore the risk of general anesthesia (Schreiner et al, 1996;
Parnis et al, 2001). Preterm infants are also at increased risk of anesthetic complications and
postoperative apnea. As a result, many of these infants require postoperative cardiopulmonary
monitoring. Neonates with a history of apnea are at highest risk (Murphy et al, 2008). A history of
recent upper or lower respiratory tract infection increases the risk of reactive airway disease and
anesthetic-related complica- tions (Stasic, 2004). Infants with significant cardiac anomalies may
benefit from a pediatric anesthesiologist with cardiac experience. Although the pediatric
anesthesiology team will assess the child for anesthetic risk, the pediatric urologist should be aware
of these conditions as well. Finally, all bleeding dyscrasias, such as von Willebrand disease, should
be evaluated by pediatric hematology prior to operative intervention.

42. III. Medications and Allergies in the
Pediatric Patient
• Medications are typically dosed based upon weight, such as mil- ligrams per
kilogram. Therefore an accurate weight must be obtained prior to prescribing most
medications to pediatric patients. Additionally, many adult medications are
contraindi- cated in children, and pediatric guidelines should be consulted. For
example, aspirin has been associated with Reye syn- drome in children and
adolescents and is not recom- mended for the treatment of fever in children.
Acetaminophen (10 to 15 mg/kg every 4 hr) and ibuprofen (5 to 10 mg/kg every 6
hr) are not associated with significant adverse effects. However, overdoses of
acetaminophen can lead to hepatic failure. Trimethoprim-sulfamethoxazole is
contraindicated in preterm infants and full-term infants less than 2 to 3 months of
age due to the risk of hyperbilirubinemia and kernicterus. Sulfon- amide
medications can be initiated after 2 to 3 months of age (Fefer and Ellsworth, 2006).
• Allergies should be recorded for all patients and be clearly docu- mented. In the
pediatric urology population, children with myelo- meningoceles are at increased
risk for latex allergies, and latex precautions should be instituted in these patients.
Children with an increased number of operations and operative intervention in the
neonatal period are associated with an increased risk of latex sensitivity in this
population (Pires et al, 2002).