- •Hematuria II: causes and investigation
- •Hematospermia
- •Lower urinary tract symptoms (LUTS)
- •Nocturia and nocturnal polyuria
- •Flank pain
- •Urinary incontinence in adults
- •Genital symptoms
- •Abdominal examination in urological disease
- •Digital rectal examination (DRE)
- •Lumps in the groin
- •Lumps in the scrotum
- •2 Urological investigations
- •Urine examination
- •Urine cytology
- •Radiological imaging of the urinary tract
- •Uses of plain abdominal radiography (KUB X-ray—kidneys, ureters, bladder)
- •Intravenous pyelography (IVP)
- •Other urological contrast studies
- •Computed tomography (CT) and magnetic resonance imaging (MRI)
- •Radioisotope imaging
- •Post-void residual urine volume measurement
- •3 Bladder outlet obstruction
- •Regulation of prostate growth and development of benign prostatic hyperplasia (BPH)
- •Pathophysiology and causes of bladder outlet obstruction (BOO) and BPH
- •Benign prostatic obstruction (BPO): symptoms and signs
- •Diagnostic tests in men with LUTS thought to be due to BPH
- •Why do men seek treatment for their symptoms?
- •Watchful waiting for uncomplicated BPH
- •Medical management of BPH: combination therapy
- •Medical management of BPH: alternative drug therapy
- •Minimally invasive management of BPH: surgical alternatives to TURP
- •Invasive surgical alternatives to TURP
- •TURP and open prostatectomy
- •Indications for and technique of urethral catheterization
- •Indications for and technique of suprapubic catheterization
- •Management of nocturia and nocturnal polyuria
- •High-pressure chronic retention (HPCR)
- •Bladder outlet obstruction and retention in women
- •Urethral stricture disease
- •4 Incontinence
- •Causes and pathophysiology
- •Evaluation
- •Treatment of sphincter weakness incontinence: injection therapy
- •Treatment of sphincter weakness incontinence: retropubic suspension
- •Treatment of sphincter weakness incontinence: pubovaginal slings
- •Overactive bladder: conventional treatment
- •Overactive bladder: options for failed conventional therapy
- •“Mixed” incontinence
- •Post-prostatectomy incontinence
- •Incontinence in the elderly patient
- •Urinary tract infection: microbiology
- •Lower urinary tract infection
- •Recurrent urinary tract infection
- •Urinary tract infection: treatment
- •Acute pyelonephritis
- •Pyonephrosis and perinephric abscess
- •Other forms of pyelonephritis
- •Chronic pyelonephritis
- •Septicemia and urosepsis
- •Fournier gangrene
- •Epididymitis and orchitis
- •Periurethral abscess
- •Prostatitis: presentation, evaluation, and treatment
- •Other prostate infections
- •Interstitial cystitis
- •Tuberculosis
- •Parasitic infections
- •HIV in urological surgery
- •6 Urological neoplasia
- •Pathology and molecular biology
- •Prostate cancer: epidemiology and etiology
- •Prostate cancer: incidence, prevalence, and mortality
- •Prostate cancer pathology: premalignant lesions
- •Counseling before prostate cancer screening
- •Prostate cancer: clinical presentation
- •PSA and prostate cancer
- •PSA derivatives: free-to-total ratio, density, and velocity
- •Prostate cancer: transrectal ultrasonography and biopsies
- •Prostate cancer staging
- •Prostate cancer grading
- •General principles of management of localized prostate cancer
- •Management of localized prostate cancer: watchful waiting and active surveillance
- •Management of localized prostate cancer: radical prostatectomy
- •Postoperative course after radical prostatectomy
- •Prostate cancer control with radical prostatectomy
- •Management of localized prostate cancer: radical external beam radiotherapy (EBRT)
- •Management of localized prostate cancer: brachytherapy (BT)
- •Management of localized and radiorecurrent prostate cancer: cryotherapy and HIFU
- •Management of locally advanced nonmetastatic prostate cancer (T3–4 N0M0)
- •Management of advanced prostate cancer: hormone therapy I
- •Management of advanced prostate cancer: hormone therapy II
- •Management of advanced prostate cancer: hormone therapy III
- •Management of advanced prostate cancer: androgen-independent/ castration-resistant disease
- •Palliative management of prostate cancer
- •Prostate cancer: prevention; complementary and alternative therapies
- •Bladder cancer: epidemiology and etiology
- •Bladder cancer: pathology and staging
- •Bladder cancer: presentation
- •Bladder cancer: diagnosis and staging
- •Muscle-invasive bladder cancer: surgical management of localized (pT2/3a) disease
- •Muscle-invasive bladder cancer: radical and palliative radiotherapy
- •Muscle-invasive bladder cancer: management of locally advanced and metastatic disease
- •Bladder cancer: urinary diversion after cystectomy
- •Transitional cell carcinoma (UC) of the renal pelvis and ureter
- •Radiological assessment of renal masses
- •Benign renal masses
- •Renal cell carcinoma: epidemiology and etiology
- •Renal cell carcinoma: pathology, staging, and prognosis
- •Renal cell carcinoma: presentation and investigations
- •Renal cell carcinoma: active surveillance
- •Renal cell carcinoma: surgical treatment I
- •Renal cell carcinoma: surgical treatment II
- •Renal cell carcinoma: management of metastatic disease
- •Testicular cancer: epidemiology and etiology
- •Testicular cancer: clinical presentation
- •Testicular cancer: serum markers
- •Testicular cancer: pathology and staging
- •Testicular cancer: prognostic staging system for metastatic germ cell cancer
- •Testicular cancer: management of non-seminomatous germ cell tumors (NSGCT)
- •Testicular cancer: management of seminoma, IGCN, and lymphoma
- •Penile neoplasia: benign, viral-related, and premalignant lesions
- •Penile cancer: epidemiology, risk factors, and pathology
- •Squamous cell carcinoma of the penis: clinical management
- •Carcinoma of the scrotum
- •Tumors of the testicular adnexa
- •Urethral cancer
- •Wilms tumor and neuroblastoma
- •7 Miscellaneous urological diseases of the kidney
- •Cystic renal disease: simple cysts
- •Cystic renal disease: calyceal diverticulum
- •Cystic renal disease: medullary sponge kidney (MSK)
- •Acquired renal cystic disease (ARCD)
- •Autosomal dominant (adult) polycystic kidney disease (ADPKD)
- •Ureteropelvic junction (UPJ) obstruction in adults
- •Anomalies of renal ascent and fusion: horseshoe kidney, pelvic kidney, malrotation
- •Renal duplications
- •8 Stone disease
- •Kidney stones: epidemiology
- •Kidney stones: types and predisposing factors
- •Kidney stones: mechanisms of formation
- •Evaluation of the stone former
- •Kidney stones: presentation and diagnosis
- •Kidney stone treatment options: watchful waiting
- •Stone fragmentation techniques: extracorporeal lithotripsy (ESWL)
- •Intracorporeal techniques of stone fragmentation (fragmentation within the body)
- •Kidney stone treatment: percutaneous nephrolithotomy (PCNL)
- •Kidney stones: open stone surgery
- •Kidney stones: medical therapy (dissolution therapy)
- •Ureteric stones: presentation
- •Ureteric stones: diagnostic radiological imaging
- •Ureteric stones: acute management
- •Ureteric stones: indications for intervention to relieve obstruction and/or remove the stone
- •Ureteric stone treatment
- •Treatment options for ureteric stones
- •Prevention of calcium oxalate stone formation
- •Bladder stones
- •Management of ureteric stones in pregnancy
- •Hydronephrosis
- •Management of ureteric strictures (other than UPJ obstruction)
- •Pathophysiology of urinary tract obstruction
- •Ureter innervation
- •10 Trauma to the urinary tract and other urological emergencies
- •Renal trauma: clinical and radiological assessment
- •Renal trauma: treatment
- •Ureteral injuries: mechanisms and diagnosis
- •Ureteral injuries: management
- •Bladder and urethral injuries associated with pelvic fractures
- •Bladder injuries
- •Posterior urethral injuries in males and urethral injuries in females
- •Anterior urethral injuries
- •Testicular injuries
- •Penile injuries
- •Torsion of the testis and testicular appendages
- •Paraphimosis
- •Malignant ureteral obstruction
- •Spinal cord and cauda equina compression
- •11 Infertility
- •Male reproductive physiology
- •Etiology and evaluation of male infertility
- •Lab investigation of male infertility
- •Oligospermia and azoospermia
- •Varicocele
- •Treatment options for male factor infertility
- •12 Disorders of erectile function, ejaculation, and seminal vesicles
- •Physiology of erection and ejaculation
- •Impotence: evaluation
- •Impotence: treatment
- •Retrograde ejaculation
- •Peyronie’s disease
- •Priapism
- •13 Neuropathic bladder
- •Innervation of the lower urinary tract (LUT)
- •Physiology of urine storage and micturition
- •Bladder and sphincter behavior in the patient with neurological disease
- •The neuropathic lower urinary tract: clinical consequences of storage and emptying problems
- •Bladder management techniques for the neuropathic patient
- •Catheters and sheaths and the neuropathic patient
- •Management of incontinence in the neuropathic patient
- •Management of recurrent urinary tract infections (UTIs) in the neuropathic patient
- •Management of hydronephrosis in the neuropathic patient
- •Bladder dysfunction in multiple sclerosis, in Parkinson disease, after stroke, and in other neurological disease
- •Neuromodulation in lower urinary tract dysfunction
- •14 Urological problems in pregnancy
- •Physiological and anatomical changes in the urinary tract
- •Urinary tract infection (UTI)
- •Hydronephrosis
- •15 Pediatric urology
- •Embryology: urinary tract
- •Undescended testes
- •Urinary tract infection (UTI)
- •Ectopic ureter
- •Ureterocele
- •Ureteropelvic junction (UPJ) obstruction
- •Hypospadias
- •Normal sexual differentiation
- •Abnormal sexual differentiation
- •Cystic kidney disease
- •Exstrophy
- •Epispadias
- •Posterior urethral valves
- •Non-neurogenic voiding dysfunction
- •Nocturnal enuresis
- •16 Urological surgery and equipment
- •Preparation of the patient for urological surgery
- •Antibiotic prophylaxis in urological surgery
- •Complications of surgery in general: DVT and PE
- •Fluid balance and management of shock in the surgical patient
- •Patient safety in the operating room
- •Transurethral resection (TUR) syndrome
- •Catheters and drains in urological surgery
- •Guide wires
- •JJ stents
- •Lasers in urological surgery
- •Diathermy
- •Sterilization of urological equipment
- •Telescopes and light sources in urological endoscopy
- •Consent: general principles
- •Cystoscopy
- •Transurethral resection of the prostate (TURP)
- •Transurethral resection of bladder tumor (TURBT)
- •Optical urethrotomy
- •Circumcision
- •Hydrocele and epididymal cyst removal
- •Nesbit procedure
- •Vasectomy and vasovasostomy
- •Orchiectomy
- •Urological incisions
- •JJ stent insertion
- •Nephrectomy and nephroureterectomy
- •Radical prostatectomy
- •Radical cystectomy
- •Ileal conduit
- •Percutaneous nephrolithotomy (PCNL)
- •Ureteroscopes and ureteroscopy
- •Pyeloplasty
- •Laparoscopic surgery
- •Endoscopic cystolitholapaxy and (open) cystolithotomy
- •Scrotal exploration for torsion and orchiopexy
- •17 Basic science of relevance to urological practice
- •Physiology of bladder and urethra
- •Renal anatomy: renal blood flow and renal function
- •Renal physiology: regulation of water balance
- •Renal physiology: regulation of sodium and potassium excretion
- •Renal physiology: acid–base balance
- •18 Urological eponyms
- •Index
542 CHAPTER 15 Pediatric urology
Urinary tract infection (UTI)
Definitions
UTI is a bacterial infection of the urine (>105 colony-forming units/ mL of urine), which may involve the bladder (cystitis) or kidney (pyelonephritis).
Classification
Children may be asymptomatic or symptomatic. It may be the first (initial) infection, recurrent UTI due to persistence of the causative organism and reinfection, or an unresolved infection due to inadequate treatment.
Incidence
Up to age 1 year, the incidence in boys is higher than in girls (males 2.7%: females 0.7%). Thereafter, the incidence in girls becomes greater (school age: males 1%; females 1–3%).
Pathology
Common bacterial pathogens are Escherichia coli (E. coli), Enterococcus, Pseudomonas, Klebsiella, Proteus, and Staphylococcus epidermis. Bacteria enter via the urethra to cause cystitis, and ascending infection causes pyelonephritis.
Alternatively, there can be hematogenous spread from other systemic infections.
Risk factors
•Age: Neonates and infants have increased bacterial colonization of the periurethral area and an immature immune system.
•Vesicoureteric reflux (VUR).
•Genitourinary abnormalities (UPJ obstruction; ureterocele; posterior urethral valves)
•Voiding dysfunction (abnormal bladder activity, compliance, or emptying).
•Gender (female > male after 1 year old)
•Foreskin: Uncircumcised boys have a 10-fold higher risk of UTI in the first year from bacterial colonization of the glans and foreskin.
•Fecal colonization (contributes to perineal bacterial colonization)
Presentation
UTI patients present with fever, irritability, vomiting, diarrhea, poor feeding, suprapubic pain, dysuria, voiding difficulties, incontinence, and flank pain.
Investigation
Diagnosis is made on urinalysis and culture. In young children, a catheterized urine specimen or a suprapubic aspirate is most accurate (bag specimens are less reliable because of skin flora contamination).
In toilet-trained children, a mid-stream specimen can be collected.
URINARY TRACT INFECTION (UTI) 543
Imaging
UTI in children <5 years, febrile UTI, infection in non–sexually active boys, and girls (>5 years) with two or more episodes of cystitis require renal tract imaging.
•Ultrasound identifies bladder and kidney abnormalities.
•Voiding cystourethrogram (VCUG) demonstrates urethral and bladder anomalies, VUR, and ureteroceles.
•DMSA (dimercaptosuccinic acid) renogram can demonstrate and monitor renal scarring.
Management
Empirical treatment should be started if infection is suspected. Children <3 months old with severe infection or pyelonephritis should receive broad-spectrum intravenous antibiotics (gentamicin and ampicillin) until antibiotic sensitivities are available.
Older children, and infants tolerating feeds can be given oral antibiotics (cephalosporins, or nitrofurantoin and trimethoprim-sulfamethoxide after 2 months old).
Complications
Neonates and young children have an increased risk of associated renal involvement and subsequent renal scarring, which can result in hypertension and renal failure.
544 CHAPTER 15 Pediatric urology
Vesicoureteric reflux (VUR)
Definition
VUR results from abnormal retrograde flow of urine from the bladder into the upper urinary tract.
Epidemiology
Overall incidence in children is >10%, with younger children affected more than older children, girls more than boys (female–male ratio 5:1). VUR occurs more often in Caucasian than in Afro-Caribbean children.
Siblings of an affected child have a 40% risk of reflux, and routine screening of siblings is recommended.
Pathogenesis
The ureter passes obliquely through the bladder wall (1–2 cm), where it is supported by muscular attachments that prevent urine reflux during bladder filling and voiding. The normal ratio of intramural ureteric length to ureteric diameter is 5:1.
Reflux occurs when the intramural length of ureter is too short (ratio <5:1). The degree of reflux is graded I–V (see Fig. 7.1, p. 345). The appearance of the ureteric orifice changes with increasing severity of reflux, classically described as stadium, horseshoe, golf-hole, or patulous.
Classification
•Primary reflux (1%) results from a congenital abnormality of the ureterovesical junction.
•Secondary reflux results from urinary tract dysfunction associated with elevated intravesical pressures. Causes include posterior urethral valves (reflux seen in 50%), urethral stenosis, neuropathic bladder, and detrusor sphincter dyssynergia (DSD).
•VUR is also seen with duplex ureters. The Weigert–Meyer rule states that the lower-pole ureter enters the bladder proximally and laterally, resulting in a shorter intramural tunnel, which predisposes to reflux.
Complications
VUR associated with UTI can result in reflux nephropathy with hypertension and progressive renal failure.
Presentation
Patients have symptoms of UTI, fever, dysuria, suprapubic or abdominal pain, failure to thrive, vomiting, and diarrhea.
Investigation
•Urinalysis and culture to diagnose UTI
•Urinary tract ultrasound scan and VCUG to diagnose and grade reflux and establish reversible causes (Fig. 15.2)
•Urodynamic assessment if suspicious of voiding dysfunction
•DMSA scan to detect and monitor associated renal cortical scarring.
VESICOURETERIC REFLUX (VUR) 545
Management
Correct problems contributing to secondary reflux. Most primary VUR grade I–II cases will resolve spontaneously (~85%), with 50% resolution in grade III. Observation and medical treatment are initially recommended.
Medical treatment
Low-dose antibiotic prophylaxis should be given to keep the urine sterile and lower the risk of renal damage until reflux resolves. Anticholinergic drugs are given to treat bladder overactivity.
Surgery is indicated for severe reflux, breakthrough UTIs, evidence of progressive renal scarring, and VUR that persists after puberty. Techniques of ureteral re-implantation include the following:
•Intravesical methods involve mobilizing the ureter and advancing it across the trigone (Cohen repair) or reinsertion into a higher, medial position in the bladder (Politano–Leadbetter repair).
•Extravesical techniques involve attaching the ureter into the bladder base and suturing muscle around it (Lich–Gregoir procedure).
•Alternatively, endoscopic subtrigonal injection of Deflux into the ureteral orifice has 70% success, and 95% with repeated treatments.
Figure 15.2 Massive bilateral reflux is seen on cystogram in young child.