PEDIATRIC UROLOGY

TOPICS RELATING TO
INFANTS & TODDLERS
DANIELLE BRADY, PGY-2
 Ultrasound

Voiding Cystourethrogram (VCUG)

Nuclear Cystogram (RNC)

Renal Scan (Mag-3 Lasix scan)

MOST COMMON IMAGING MODALITIES FOR

PEDIATRIC UROLOGY
 ULTRASOUND

• USED MOSTLY FOR EVALUATING KIDNEY AND BLADDER

• FIRST IMAGING MODALITY
• GREAT FOR EVALUATING HYDRONEPHROSIS
• CAN EVALUATE HEALTH APPEARANCE OF KIDNEY SHOWING:
▪ SCARRING
▪ CYSTS
▪ OTHER ABNORMALITIES
ULTRASOUND
 VOIDING CYSTOURETHROGRAM (VCUG)

• X-RAY FLUOROSCOPY
• CATHETER USED TO FILL BLADDER WITH IODINATED CONTRAST
• AS THE BLADDER FILLS, THE CONTRAST SHOWS THE SHAPE OF THE
INTERIOR OF THE BLADDER AND THE URETERS
• WHEN VOIDING, CONTRAST SEEN COMING OUT OF THE URETHRA,
BUT CAN ALSO SHOW CONTRAST REFLUXING UP TO THE KIDNEYS
VOIDING CYSTOURETHROGRAM (VCUG)
 RADIONUCLIDE CYSTOGRAM (RNC)

• LESS DETAIL BUT ALSO LESS RADIATION THAN VCUG

• RADIOPHARMACEUTICAL
• NOT TYPICALLY USED FOR INITIAL STUDY (INSTEAD, USE VCUG)
• USED FOR SUBSEQUENT IMAGING TO MONITOR PATIENT
• LESS DETAILED VUR GRADING
RADIONUCLIDE CYSTOGRAM (RNC)
 RENAL SCAN (MAG3)

• ASSESSES OVERALL KIDNEY FUNCTION AND EVALUATES

OBSTRUCTION
• TECHNETIUM-99M MAG3 RADIOISOTOPE WITH BLADDER CATHETER
• LASIX GIVEN ONCE BLADDER IS FILLED
• T ½ TIME

• MEASURES BLOOD FLOW TO THE KIDNEYS, UPTAKE AND EXCRETION

OF THE ISOTOPE, AND EXCRETION OF URINE
• COMPARES FUNCTION BETWEEN KIDNEYS
• PROVIDES FURTHER DIAGNOSTIC INFORMATION ABOUT SCARRING OR
OBSTRUCTIONS
RENAL SCAN (MAG3)
 HIGH YIELD TOPICS IN
INFANTS AND TODDLERS
HYPOSPADIAS
 HYPOSPADIAS

• URETHRAL OPENING ON UNDERSIDE

OF PENIS
• IN UTAH MORE COMMON, IN 1:125
BABY BOYS
• ASSOCIATED WITH CHORDEE
• CORRECTIONS BETWEEN 6 MONTHS
TO 18 MONTHS
 HYPOSPADIAS
PATHOGENESIS, DIAGNOSIS, AND EVALUATION

DUE TO COPYRIGHT PLEASE VISIT UPTODATE FOR MORE INFORMATION ON THE TOPIC
 • SEVERE HYPOSPADIAS NEED REPAIRS
• NO CIRCUMCISIONS BY PEDIATRICIANS; FORESKIN MAY BE NECESSARY
FOR NEOURETHRA OR PENILE SHAFT SKIN COVERING (COVERING
BOTTOM OF SHAFT FROM CHORDEE REPAIR)
• GOAL FOR NORMAL CIRCUMCISED PENIS WITH NORMAL URETHRAL
OPENING AT TIP OF GLANS
• STAND TO VOID
• STRAIGHT ERECT PENIS (FOR REPRODUCTION)

REPAIRS
HYPOSPADIAS
THE MOST COMMON GU
DISORDER IN BOYS…
UNDESCENDED TESTES
 • MORE COMMON AMONG PRETERM (UP TO 30%), LOW
BIRTH WEIGHT, AND TWIN BOYS
• IMPORTANT TO DIFFERENTIATE BETWEEN RETRACTILE TESTES
• MOST DESCEND BY 3 MONTHS (TESTOSTERONE SURGE)
• REFER IF NOT DOWN BY 6 OR 9 MONTHS TO UROLOGY
• ORCHIOPEXY BETWEEN 12 TO 24 MONTHS IDEALLY
• COMPLICATION IF NOT ADDRESSED
• REDUCTION IN VIABLE SPERM
• MALIGNANT DEGENERATION OF TESTICLE
• INCREASED RISK FOR TORSION

UNDESCENDED
TESTES
 • GOOD EXAM TECHNIQUES
• LOOK FIRST; LYING DOWN IS EASIEST
• USE SOAP
• ONE HAND IS PLACED NEAR THE ANTERIOR SUPERIOR
ILIAC SPINE AND THE OTHER ON THE SCROTUM. THE
FIRST HAND'S FINGER TIPS ARE SWEPT ALONG THE
INGUINAL CANAL TO GENTLY EXPRESS ANY RETAINED
TESTICULAR TISSUE INTO THE SCROTUM
• TRUE UNDESCENDED  YOU MAY FEEL THE TESTIS
“POP”
• SQUATTING OR CROSS LEGGED POSITION
• FATIGUE THE CREMASTERIC MUSCLE
• AT LEAST 1 MINUTE
• WARM COMPRESS ALONG INGUINAL CANAL
DIFFERENTIATION BETWEEN • AT HOME, BATH TUB SOAK
RETRACTILE TESTES
&
TRUE UNDESCENDED
• PHENOTYPICALLY MALE NEWBORN INFANTS
• BILATERAL NONPALPABLE TESTES
• UNILATERAL NONPALPABLE TESTIS WITH HYPOSPADIAS
• SUSPECTED DISORDER OF SEXUAL DEVELOPMENT

• ASCENDING TESTIS IN BOYS BEYOND INFANCY (WHENEVER THE EXAMINATION CHANGE IS

NOTED)

• CONCERN FOR ATROPHIC TESTIS

• DIFFICULTY DIFFERENTIATING BETWEEN UNDESCENDED, RETRACTILE, AND ECTOPIC (AT ANY AGE)

REFERRING IDEALLY BETWEEN

6-12 MONTHS OF AGE
MOST COMMON UROLOGIC
ABNORMALITY IN CHILDREN…
 VESICOURETERAL REFLUX (VUR)

Retrograde flow of urine from the bladder into the ureter and
potentially up to the renal collecting system  can cause
hydronephrosis

Associated with increased likelihood of pyelonephritis with UTIs

• Can lead to renal scarring, HTN, renal failure

Reflux can also be an indication of higher pressures in the bladder

from obstruction such as posterior urethral valves, or other outlet
obstructions such as neuropathic bladder or dysfunctional voiding

If not diagnosed prenatally, usually diagnosed at age 2-3 and usually girls
• Prevalence in healthy infants about 1-3% (up to 8% in girls); up to 10-20% in infants
with antenatal hydronephrosis, and for those with 1 or more UTIs it increases to 30 to
40%
VESICOURETERAL REFLUX (VUR)
 • ULTRASOUND TYPICALLY DONE FIRST

• FOLLOWED BY VCUG

• MONITORED WITH RNC

• UTI CONNECTION…
• RENAL AND BLADDER US RECOMMENDED BY
AAP FOR INFANTS/TODDLERS TO 24
MONTHS AFTER FIRST FEBRILE UTI
• VCUG NOT ROUTINELY DONE AFTER 1ST
FEBRILE UTI IN THIS AGE GROUP UNLESS THEY
HAD AN ABNORMAL US
• VCUG RECOMMENDED AFTER 2ND FEBRILE UTI
DIAGNOSIS
VESICOURETERAL
REFLUX (VUR)
 PRIMARY VS. SECONDARY
VESICOURETERAL REFLUX (VUR)
PRIMARY
DUE TO INCOMPETENT OR
INADEQUATE CLOSURE OF THE
URETEROVESICAL JUNCTION (UVJ),
WHICH CONTAINS A SEGMENT
OF THE URETER WITHIN THE
BLADDER WALL (INTRAVESICAL
URETER).
SECONDARY
ASSOCIATED WITH
ANATOMIC (SUCH AS POSTERIOR
URETHRAL VALVES) OR FUNCTIONAL
BLADDER OBSTRUCTION SUCH AS
BLADDER BOWEL DYSFUNCTION AND
NEUROGENIC BLADDER
 VUR SEVERITY
INTERNATIONAL REFLUX STUDY COMMITTEE

1 2 3 4 5
Grade 1: reflux into the Grade 2: Reflux that Grade 3: Reflux into the Grade 4: Reflux into the Grade 5: Reflux into the
distal ureter without extends to the proximal kidney with mild kidney with moderate kidney with severe
dilatation ureter without dilatation dilatation of the ureters dilatation of the ureters dilatation of the ureters
(can be tortuous) and and renal pelvis with and renal pelvis with
renal pelvis blunting of fornices but loss of papillary
preserved papillary impressions and fornices
impressions
 VUR Severity
International Reflux Study Committee
Case courtesy of Radswiki, Radiopaedia.org, rID: 12076
Case courtesy of Radswiki, Radiopaedia.org, rID: 12076
Case courtesy of Radswiki, Radiopaedia.org, rID: 12076
Case courtesy of Radswiki, Radiopaedia.org, rID: 12076
Case courtesy of Radswiki, Radiopaedia.org, rID: 12076
• TYPICALLY RESOLVES ON ITS OWN
• OVER 80% OF GRADE 1 AND 2 RESOLVED BY AGE 5

• US AND VCUG OR RNC DONE EVERY FEW MONTHS TO YEARS TO CLOSELY MONITOR
• SCREEN FOR BOWEL DYSFUNCTION; TOILETING BEHAVIORS OPTIMIZED
• HIGH GRADE VUR OR HISTORY OF MULTIPLE UTIS WILL BE STARTED ON ANTIBIOTIC
PROPHYLAXIS
• AMOXICILLIN IN INFANTS
• SEPTRA OR NITROFURANTOIN IN TODDLERS
• SURGICAL REPAIR  URETERAL REIMPLANTATION AND ENDOSCROPIC REPAIR
• FOR OLDER KIDS WITH REPEATED UTIS (ESPECIALLY DESPITE PPX ABX), SCARRING,
AND/OR HIGHER GRADE VUR (GRADE 4 AND 5)

TREATMENT
VESICOURETERAL REFLUX (VUR)
 Webbing Webbed angle connection between scrotum and
base of the penis

Phimosis Inability to fully retract the foreskin (whether on

uncircumcised male or post circumcision
complication from scarring)
Megameatus Enlarged meatus (associated with hypospadias)

DEFINITIONS…
Epispadias Opening of urethra at the top of the head of
the penis (can be associated midline defect
bladder exstrophy)
Meatal Usually diagnosed with abnormal stream once
stenosis
toilet trained; from scar tissue/adhesions as a
complication from circumcision
Webbing
Ureteropelvic Blockage of the flow of urine in the area where
junction
obstruction the ureter meets the kidney pelvis (can lead to
(UPJ) hydronephrosis)
 REFERENCES
• UPTODATE

• IVUMED WITH PCMC AND UTAH PEDIATRICS UROLOGY GUIDE

• HTTPS://WWW.IVUMED.ORG/WPCONTENT/UPLOADS/2012/10/EVERYBODYSGUIDETOPEDIATRICUROL
OGY.PDF

• HTTP://UROLOGY.UCLA.EDU/BODY.CFM?ID=478&REF=14&ACTION=DETAIL

• HTTPS://WWW.AAFP.ORG/AFP/2012/1115/P940.HTML
S
• HTTPS://WWW.NCBI.NLM.NIH.GOV/PMC/ARTICLES/PMC2145675/PDF/CANFAMPHYS00134-0083.PDF

• HTTPS://RADIOPAEDIA.ORG/CASES/VESICOURETERAL-REFLUX

• HTTPS://UROLOGY.UCSF.EDU/PATIENT-CARE/CHILDREN/ADDITIONAL/VESICOURETERAL-REFLUX

• HTTP://PEDIATRICS.AAPPUBLICATIONS.ORG/CONTENT/PEDIATRICS/EARLY/2016/11/24/PEDS.2016-
3026.FULL.PDF

• PEDIATRICS IN REVIEW FEB 2007, 28 (2) E6-E8; DOI: 10.1542/PIR.28-2-E6

• PEDIATRICS IN REVIEW JUN 2001, 22 (6) 205-210; DOI: 10.1542/PIR.22-6-205

• PEDIATRICS IN REVIEW JAN 2018, 39 (1) 3-12; DOI: 10.1542/PIR.2017-0007

• PEDIATRICS IN REVIEW NOV 2000, 21 (11) 395; DOI: 10.1542/PIR.21-11-395