Ramirez Urology

Pediatric Urology

Most urological problems in children are very different from urological diseases in adults. They require specific knowledge and experience in the field. In addition, the vision of a specialist in pediatric urology allows to make the diagnosis and timely treatments, with a long-term view, because the child with urological pathology may carry it into adulthood with different disorders that will need to be evaluated and followed over time.

The 5 most frequent urological pathologies in children

Congenital obstructive uropathy

What is Congenital Obstructive Uropathy (congenital hydronephrosis)?

Hydronephrosis is a dilatation of the dilatation of the renal collecting system due to an alteration of the urine transport mechanism from the kidney to the bladder. It may be due to functional or mechanical functional or mechanical. The severity of dilatation is not always proportional to the degree of obstruction.

The hydronephrosis maintained over time causes parenchymal renal parenchymal lesions secondary to increased pressure in the urinary tract and decreased blood flow. The persistence of hydronephrosis increases the risk of chronic infantile nephropathy, urinary tract infections and the formation of lithiasis in the upper urinary tract.

It is essential to to evaluate the specific cause and administer the appropriate treatment for each case.

Urological specialty

What symptomatology does it produce?

Clinical presentation is variable, many remain asymptomatic asymptomaticespecially if the obstruction is partial. In those cases in which symptoms appear, the most frequent are: abdominal mass palpable during lactation, abdominal painpresence of blood in the urine, urinary tract infections y growth retardation.

Diagnosis

It is essential to make a correct diagnosis as early as possible to avoid the potential risk of developing obstructive nephropathy (a frequent cause of chronic kidney disease in childhood). In this aspect, the generalized use of ultrasound ultrasound in the prenatal period makes it possible to identify both kidneys as early as the 16th week of gestation.

Treatment

Mild or severe unilateral dilatations can be checked by ultrasound. monitored ultrasonographically during pregnancy until delivery. Some never need to be treated, but if an obstructive pattern is demonstrated, surgical intervention is necessary. surgical intervention is necessary..

Congenital obstructive uropathy

Vesicoureteral Reflux

What is vesicoureteral reflux (VUR)?

Vesicoureteral reflux (VUR) is the backward flow of urine. retrograde flow of urine from the bladder into the ureter and renal pelvis. It can be uni or bilateral. It is both an anatomical and functional disorder with consequences including urinary tract infections, the hypertension and the appearance of renal scarring that can lead to the alteration of the alteration renal function. The main objective of its treatment is to prevent the appearance of these complications.

The cause or causes are not completely clear. Basically it has been accepted as a congenital alteration in the development of the vesicoureteral junction.

Reflux can also be an acquired pathology and there is sufficient scientific evidence demonstrating an association between reflux and various types of bladder function disorders such as neurogenic overactive bladder.

vesicuroteral reflux

The prevalence of VUR in asymptomatic children is estimated to be 0.4-1.8%. The natural history of primary VUR is of spontaneous resolutionwhich explains its high incidence in children compared to adults. Spontaneous resolution of VUR depends on age at presentation, sex, grade, laterality, mode of presentation and anatomical factors. It is more likely before the first year of lifeIn low grade, asymptomatic patients with antenatal ureterohydronephrosis (UHN) or sibling VUR.

The presence of renal cortical abnormalities, bladder dysfunction or febrile urinary tract infections are negative predictors for resolution of reflux.

Diagnosis

The imaging tests are the basis for the diagnosis and management of reflux. For this purpose, imaging tests such as ultrasound, cystography, etc. are performed.

Treatment

The main objective of VUR treatment is to prevent the acute morbidity of febrile infections and acute pyelonephritis, with the consequent aim of reducing renal damage. Basically, two therapeutic options are considered: a management conservative management non-surgical management and the surgical approach.

Medical treatment consists of prophylactic administration of an antibiotic agent at one-fourth to one-third of the usual therapeutic dose. It is administered at night. Surgical treatment is preferred to medical treatment in patients with febrile infections, despite medical treatment, in patients with poor compliance, in patients with renal parenchymal anomalies and high grade reflux. Parental preferences should also be taken into account.

physician performing ultrasound scan of kidneysq

Enuresis

What is enuresis?

Enuresis is defined as the presence of involuntary urination that occur during nocturnal sleepin children older than 5 years of age.

The importance of enuresis lies in its high prevalence. This is particularly significant in the preschool age, so it represents a very frequent reason for consultation during the pediatric age. On the other hand, it is also important to highlight the psychological impact it can have on the child and/or the family.

Monosymptomatic enuresis (MSE) is classified into primary and secondary:

Primary

That in which the child at no time in his life has remained without enuretic episodes for a period of more than 6 months.

Secondary

When they have presented a period of nocturnal continence (dry) equal to or greater than 6 months, relapsing

Enuresis

Epidemiology

The incidence is higher in boys than in girls, approximately in a 2:1 ratio. It is estimated that the prevalence of enuresis ranges from 10-15% by the age of 5 years, with about 80% of the cases occurring in boys. 80% of these cases belong to the EMS primary. Generally it is a self-limited disease in time, and in most patients it disappears with age.

Enuresis is probably not due to a single mechanism of production, but several of them must concur in the participation for the clinical fact of urine loss in bed to occur.

Enuresis is often associated with the presence of psychological disorders such as: low self-esteem, feelings of stigmatization, guilt, behavioral disorders or learning and cognitive disorders, derived from poor quality sleep. These disorders represent a problem of added concern for both the patient and his family. Enuresis must be treated. This decision must be made on an individual basis and will be made according to the presence of emotional involvement, alteration in the quality of life and/or demand for treatment by the parents.

Hypospadias

What is Hypospadias?

Hypospadias is a congenital defect produced by incomplete fusion of the urethral folds and presents as:

Hypospadias is the most common most common congenital anomaly of the penis.. Cryptorchidism and inguinal hernia are the anomalies most frequently associated with hypospadias.

Hypospadias

The standard classification is that proposed by Duckett:

Distal hypospadias

The urethral meatus is located on the glans penis, balanopreputial sulcus or distal part of the penis (60-65%).

Hypospadias media

The meatus is located in the middle or proximal part of the penis (20-30%).

Proximal hypospadias

The meatus is located in the penoscrotal junction, scrotum or perineum (10-15%).

Treatment

The optimal timing of surgical treatment is between 6 and 18 months of age. Early surgery has many advantages: The child will not remember the surgical intervention and will join school with the malformation corrected. Post-surgical care is easier at this age. Emotional alterations are less.

The objective is the correction of all defects associated with the malformation. The incurvation will be corrected, a urethra of adequate length and caliber, glanduloplasty and adequate skin coverage will be performed.

Phimosis

By the third year of life, 90% of foreskins can be retracted, and less than 1% of males have phimosis by the age of 17. Early forced retraction is not recommended (de-epithelialization and secondary phimosis).

The application of topical corticoid creams topical corticosteroid creams from 4 - 5 years of age. In our opinion, only non-physiological phimosis, secondary to other processes or that which produces disorders (urination, pain and/or local infections) should be treated surgically.

Phimosis surgery

Cryptorchidism

What is cryptorchidism?

Cryptorchidism, etymologically "concealed testicle", defines the testicular absence in the scrotum. The absence of the testicle in the scrotum can signify the following entities:

Anorchia or testicular absence

Due to testicular agenesis or atrophy secondary to intrauterine vascular compromise, a situation defined as testicular regression syndrome or evanescent testis.

Congenital undescended testicle

Testicle that is located outside the scrotum somewhere in the normal path of descent: abdomen, inguinal canal or scrotal root.

Ectopic testicle

Testicle that is outside the normal path of descent.

Retractile testis or cremasteric hyperactivity

Testicle that is located in a suprascrotal position and that spontaneously or with manual maneuvers descends to the scrotal cavity. This situation is due to the activity of the cremasteric reflex, involves normal testicles and does not require treatment.

Acquired undescended testicle

Situation that defines the testicle with normal descent and subsequent ascent to suprascrotal positions.

cryptorchid

Cryptorchidism occurs in 2-5% of term infants and 30% of preterm infants.

The 70% of congenital undescended testicles spontaneously descend descend spontaneously in the first months of life. The prevalence at one year of life is 1%, similar to the adult population. Eighty-five percent of cryptorchidism are unilateral and in 80% of them the testicle is located in the inguinal tract.

Diagnosis

Although cryptorchidism usually presents as an isolated entity, a general examination should be performed to rule out the presence of endocrine, genetic or metabolic disorders that may be associated. It will be essential to differentiate palpable from non-palpable testes, the presence of other associated disorders, as well as the time of diagnosis.

Treatment

The objectives of the treatment are to place the testicle in a normal scrotal position and to fix it if it is viable, or to remove the remaining tissue if it is not. The benefits of placement in a correct location are based on the improvement of testicular function, the possible reduction of the risk of malignizationThe benefits of placement in the correct location are based on improved testicular function, possible reduction in the risk of malignancy, as well as ease of diagnosis should it occur, aesthetic reasons and prevention of complications such as the development of a hernia or torsion. It can also improve body self-image.

If spontaneous descent does not occur by 12 months of age, surgery is recommended. surgerysurgery is recommended, as it is unlikely to resolve spontaneously after that time and hormonal therapy does not appear to be effective.

Medical (hormonal) treatment of cryptorchidism is controversial, not being recommended by all groups, due to its low efficacy and lack of evidence of long-term effects.