Category: Urology

Categories
Urology

UTI in children: when do you need a surgeon

Recurrent Urinary Tract Infections (UTI) in children are distressing and can lead to an escalating cycle of symptoms. Parents rightly worry about long-term damage to the kidneys and urinary tract. When are surgeons needed?

Paediatric urologists are specialist surgeons trained to perform procedures on children. Children have particular problems of childhood that may not be seen in adulthood. Paediatric urologists can be Adult Urology surgeons with a special interest in children’s problems. They can also be Paediatric Surgeons, with a special interest in urological problems. Both approaches are well established. Surgeons are typically happy to discuss their background and specialist skills, and parents should feel confident to discuss these questions openly.

A surgeon’s role in recurrent UTI risk factors driving infection, and try to identify some reversible causes. Surgeons need to get involved in three general circumstances:

1. Structural anomaly in the urinary tract

2. Dysfunctional voiding

3. Neuropathic bladder

Structural anomalies

These are best considered at three levels i.e. Kidneys, the ureters draining the kidneys, and the bladder. Anatomical problems are detected with ultrasound in children. Extra dynamic information can be obtained from more specialist xray (MCUG study) and nuclear medicine ( DMSA, MAG3) studies.

Kidney: Hydronephrosis, pelvi-ureteric junction obstruction (PUJO), cystic and dysplastic kidneys

Ureter: Hydroureteronephrosis, vesicoureteric reflux

Bladder: Posterior urethral valves, urethral stenosis, meatal stenosis

Dysfunctional voiding

This describes a discoordination between the bladder filling and emptying muscles. This is often an acquired condition that can lead to incomplete emptying of the bladder. This in turn increases risk of recurrent UTI. In addition to ultrasound, paediatric urologists will review voiding patterns using diaries and/ or bladder volume assessment . Parents should expect support investigating the cause, and supporting with bladder training and medications to help return the bladder to a normal pattern.

Neuropathic bladder

This phrase describes a bladder that has lost its nerve supply. More specialist tests are needed to confirm this condition e.g. ultrasound, MRI of spine, urodynamic tests. Once a diagnosis is made, a surgeon is needed to shepherd a child through the various phases of neuropathic bladder. In addition to preventing further urinary tract infection, surgeons are focused in preventing scarring of kidneys. Scarring on kidneys is a long term predicter of hypertension and kidney failure.

Categories
General Urology

The Foreskin : Phimosis

Circumcision referrals are a common feature in general paediatric clinics. Indeed, cicrumcision is the described as the world’s most popular surgery.

Here’s some valuable information to help filter physiological and pathological foreskins, from London Children’s Surgery.

What is the natural history of the foreskin?

This much-quoted study (Gairdner, BMJ 1949) provides a useful summary of the natural history of the foreskin.

Oster’s follow-up paper (Oster, Arch. Dis. Childh, 1968) should be read simply for its cracking opening paragraph. It also contains useful data on phimosis, preputial adhesions and smegma in Danish boys.

We expect partial or full retraction at the following frequencies:

–Birth: 4%

–Up to 6 Months: 20%

–1 year : 50%

–3-11yrs: 90%

–12-13yrs: 95%

–14+yrs: 99%

Therefore, most foreskin reviews will demonstrate physiological phimosis, and parents can be reassured.

Normal / physiological phimosis?

There are various classification systems for retraction of the foreskin. As described by Kayaba et al, retraction progresses from Grade I – V.

What are the features of phimosis?

Balooning

Discomfort

Balanoposthitis

Are steroids useful?

These are frequently used in primary care. The therapeutic goal is making the foreskin more supple. Steroids achieve this by suppresing fibroblast activity, causing thinning of the skin. However, they do have an anti-inflammatory and immunosuppresive effect. This limits their role to pulsed treatments.

Evidence:

-Systematic review, Moreno et al, 2014: Included 12 comparative studies (1395 boys). Compared with placebo, corticosteprids increase the probability of achieving partial or full retraction (RR2.45, 95CI1.84-3.26_

-New South Wales, Wright et al, 1994: 80% retractability achieved in 111 boys completing this betamethasone study

-Barcelona, Orsola et al, 2000: 90% of 137 boys treated with betamathosone with retraction had improvements in retractability

Betamethasone 0.05% applied twice a day over a 4-week period , is a commonly used protocol.

Other steroids favoured include hydrocortisone, clobetasol and triamcinilone.

The steroid effect may wear off, leading to a decline in retractability after a few months, necessitating   a repeated course. 

What about simple emollients?

Golubovic et al, 1996, found a higher frequency of inproved retraction (19/20) in boys treated with betamethasone, compared with boys treated with vaseline alone (4/20 improved).

Preputial stretching

This is described in combination with steroids , at varying frequency e.g. daily or weekly.

Importantly, any stretching should be done by the child, who will limit the stretch to what is comfortable. This will avoid secondary scarring.

What is pathological phimosis?

Pathological or True phimosis occurs when the foreskin is scarred. This is seen in :

1. Balanitis xerotica obliterans

2 Scarred balanoposthitis

Circumcision for UTI of reflux ?

UTI and VUR are described in depth elsewhere.

For the purposes of circumcision, a decision for each patient must be made. However, where surgery is proposed as prophylaxis, keep in mind the numbers needed to treat.

Number needed to treat

rUTI : 111 circumcisions to prevent 11 recurrent UTIs

VUR: 111 circumcisions to prevent 4 UTIs in boys with high grade reflux

What are the surgical options?

There are two options:

1. Dorsal slit procedure

2. Circumcision

Categories
Urology

Foreskin problems

Does my child need a circumcision? This is a question many parents will ask. Where there are no religious or cultural reasons to have a circumcision, parents should get as much information as possible from a specialist source. Here’s some valuable information from London Children’s Surgery.

With foreskins in mind, what is normal and what is abnormal?

The foreskin is usually fixed in place in young children, but it should begin to loosen during early childhood.

The foreskin will normally be able to retract and then move back into place over the head or glans of the penis. However, sometimes this doesn’t happen till much later in childhood. This is called physiological phimosis. This is normal.

In other cases, a problem develops. A foreskin that was retracting well changes, and no longer retracts as it used to do. This is abnormal i.e. pathological phimosis.

What should we expect with normal / physiological phimosis?

It is important to be aware that the foreskin cannot usually be retracted at a young age. The foreskin usually becomes looser during early childhood. The process usually begins by age two to three, but it can take longer for the foreskin to be able to retract completely.

  • Ballooning: One of the most common phimosis symptoms is the bulging or ballooning of the foreskin during urination. This happens because urine builds up inside the foreskin as it makes its way out. If the urine builds up under the foreskin, this can lead to a chemical irritation and balanitis. Teaching your child how to shake off and mop up urine from the foreskin after voiding are essential.
  • Discomfort: Severe phimosis may make it harder to pass urine. Children may complain of a burning sensation or pain in the tip of the penis as they pass urine.
  • Balanitis: This is where the foreskin is inflamed and can progress to an infection. It is also called balanoposthitis.
Should I try to pull back the foreskin?

You should never try to force the foreskin to retract as this could damage it. If the foreskin becomes scarred then it might not be able to retract properly in the future and phimosis surgery may then be required to correct it.

Should my child have circumcision because of phimosis?

Phimosis isn’t usually anything to worry about unless it is causing pain or other phimosis symptoms. In most cases, the foreskin will start to retract between the ages of about 2 and 6. Therefore, the problem will often correct itself in time without the need for phimosis surgery. However, if you are concerned that the foreskin is taking longer than expected to retract, it can be reassuring to see a doctor.

By late adolescence, the foreskin can usually be fully pulled back from the glans and is then able to return into place. Medication or phimosis surgery is only required if this doesn’t happen naturally. It is important not to rush the process by trying to move the foreskin back as this could damage it.

Older boys may also feel self-conscious or anxious about phimosis, so it can be important to talk to them about the condition and enable them to speak to a doctor if they wish.

You should also seek medical advice if your son is experiencing any phimosis symptoms or if the foreskin stops being able to retract later on.

What about abnormal or pathological phimosis?

Phimosis can return later in childhood / adolescence after the foreskin has already been pulled back. This is when the tissue becomes scarred and fibrous and stops the foreskin from retracting properly. When the condition occurs due to scarring it is sometimes known as true phimosis.

The foreskin can be damaged in different ways, including by attempts to force it to retract when it is still too tight. Phimosis surgery may then be needed.

The foreskin may also be affected by a condition called BXO (balanitis xerotica obliterans). This condition is diagnosed by a specialist and requires phimosis surgery as treatment.

Is there medicine I can use?

Most children do not require any treatment for phimosis. Seeing a doctor is useful. The doctor will ask about any phimosis symptoms that you or your child have noticed. The doctor will also examine your child. You should remain present for the examination. This examination will help to rule out balanitis xerotica obliterans, a skin condition that can prevent the foreskin from retracting. The doctor will also check for scarring or damage to the foreskin that could be responsible for phimosis symptoms.

If there are no signs of damage and the foreskin has never been able to retract then it can be best to wait and see if it happens naturally as long as your child is still young enough and isn’t experiencing any phimosis symptoms.

Some children will be successfully treated with a treatment of steroid cream e.g. hydrocortisone. This can be useful even if there is no significant scarring or any evidence of BXO. Steroid cream makes the skin looser and more supple.

Phimosis surgery may also be needed if your child is in pain or having issues such as urinary problems. Surgery is only recommended for phimosis treatment when the condition is unlikely to correct itself, the symptoms are severe or it is associated with scarring or damage

What about phimosis surgery and circumcision?

There are two options:

  • An incision to release the fibrotic scar. This is called a dorsal slit procedure. This retains the foreskin but can have an unsatisfactory cosmetic result.
  • Circumcision: The foreskin is surgically removed. Different surgeons achieve using various methods. The key question to ask are:
    • What procedure would they recommend for younger versus older children? Some methods are only suitable for newborn babies and infants.
    • How is pain controlled? Local or general anaesthetic? Syrups and tablets after the procedure? Pain control must be appropriate to the age of the child. The experience may be unecessarily traumatic if these factors are not considered.
    • What infection rates do they have in their practice? how ill infection be prevented?

It is important to be aware that it will change the appearance of the penis and can affect its sensitivity too. You will need to discuss the risks and benefits of circumcision for phimosis treatment with the doctor.

It is also important to talk to your son about the procedure in an age-appropriate way so that he understands what is happening. 

Categories
Urology

Bedwetting

Bed wetting is really common. It affects up to 20% of 8 years and 1% of 17 years old.

Bed wetting (nocturia) can be a real challenge in any child and impacts both the child and their entire family.

Here is some valuable information for parents from our specialist contributors at London Children Surgery.

When will my child grow out of it?

Most children do improve. However, it can take them a very long time. The length of time required to be cured is related to the length of time with the symptoms and the failure of previous medical therapy.

The child can finding ‘waiting’ to grow out of the condition very frustrating and disempowering.

Why is this still happening?

Again, bed wetting is really common. In a class of 30 children who are 8 years old, 6 children will continue to have wet nights.

Bedwetting is due to a combination of factors:

  • excess urine production at night
  • smaller bladder capacity
  • sleep disturbance

40% of children with bed wetting have a strong family history with a parent having had a similar history as a child.

Is surgery required?

No, most children do not require surgery.

However a very small number of children have a structural problem which requires investigation for better understanding and management. Surgery for this condition is very uncommon.

How can we fix this?

Rarely in life is there a quick fix for anything and the same applies to bed wetting.

Most children require time. Consultation with a specialist can help them get on the right path.

Once they are ‘fixed’ they are cured forever.

What treatments are available?

Thinking about the causes, some contributing factors can be improved:

  • Excess urine production at night: Behavioural changes to drinking and voiding (passing urine) can reduce the bladder load at night. Sometimes, medications can be useful.
  • Sleep disturbance: Many changes can be made to improve sleep patterns and toilet habits around sleep
  • Small capacity bladder: Rarely, this is a cause of night time wetting. Investigations by a specialist can help explain the underlying cause.
What medications can be used?

Our policy is to try and avoid medication and most children not need medication. However medication can be useful. A specialist (paediatrician, paediatric surgeon/ urologist) should be consulted first if you are considering medications for this condition.

What can I do to support my child at home?
  • Daytime voiding pattern: Many children have undiagnosed major daytime issues that are often unknown to family and parents. Ensure your child is voiding every 2-3 hours during the day. It is important to establish regular daytime voiding as part of your child’s routine. Alarms, vibrating watches etc, can be useful aids.
  • Drinking: Lots of children don’t drink enough fluid in the day and fluid restriction is not the way to go. However, consider the timing of the last drink before bed. Encourage your child to drink plenty , up till an hour before bed. Your child should drink mostly water. Fluids that irritate the bladder include caffeine and fizzy drinks.
  • ‘Lifting’ is placing your child on the toilet to void in the middle of the night. This activity does stop the bed getting wet. However unless the child is awake it rarely improves the situation in the long-term.
  • Alarms: Bedwetting alarms can function very well in some children and are a very useful treatment modality in primary care.
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