Pediatrics [UROLOGY]

Posterior Urethral Valves = Urethra This is a duplicate from the surgery content in case you are
If a newborn male presents with low or no urine output +/- studying pediatrics only
palpable bladder suspect an obstructive renal failure caused by
posterior urethral valves. This is caused by redundant tissue
within the urethra. Think of it as the pediatric equivalent to
Kidneys
bladder outlet obstruction from prostate hypertrophy in older Malignancy
men. Perform a catheterization to relieve the pressure on the Hematuria (glomerular)
bladder. Failure to do so will cause pressure within the bladder to
rise leading to reflux up the ureters (which can lead to
hydronephrosis and renal dysfunction). There may be a history
of oligohydramnios. Confirm the diagnosis with a VCUG.
Ureters
Surgical intervention is typically needed.
Vesicoureteral Reflux
Ectopic Ureter
Hypospadias / Epispadias = Urethra
Ureteropelvic Junction Obstruction
Think of the erect penis. Hypospadias is hypo, on the bottom, and
therefore the urethral opening is on the ventral surface of the
penis. Epispadias is epi, on top of, and so the urethral opening is Bladder
on top dorsal surface. This is clinical and cosmetic. You must Hematuria (non-glomerular)
not do a circumcision; that skin is needed to rebuild the penis
correctly. Repair is purely cosmetic; epispadias may present with
incontinence.

Ureteropelvic Junction Obstruction = Ureter Urethra

The ureter at the ureteropelvic junction has been narrowed Posterior Urethral Valves
which limits the flow of urinary volume. During normal flow Hypospadias
states, this usually doesn’t cause problems. However, during a Epispadias
high flow state (such as diuresis from an alcohol binge) the lumen
is too narrow to handle the flow; the patient develops colicky
pain. This resolves when the flow returns to normal. Diagnose
with an ultrasound (hydronephrosis without hydroureter).

Infants should also have a VCUG to evaluate for contralateral
reflux.

Ectopic Ureter = Ureter
One ureter puts urine where it belongs (in the bladder) so the child
senses, voids, and empties the bladder the way they’re supposed
to. Males maintain continence as the ureter is implanted proximal
to the external sphincter. In females there’s a constant leak in
addition to the “normal function.” There will be no history of dry
periods despite adequate toilet training. Check with ultrasound,

VCUG, and radionuclide scan to evaluate anatomy and renal
function. Reimplant the bad one.

Vesicoureteral Reflux = Ureter

This involves retrograde urine flow from the bladder back into
the ureters. The severity of ureter dilatation and distance of reflux
determine the stage. The reflux can lead to recurrent urinary
tract infections and renal scarring. Antibiotic prophylaxis can
be used in mild stages but ultimately surgical correction may be
needed. Diagnose with VCUG.

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 Pediatrics [UROLOGY]

Overview of Urologic Testing
Voiding cystourethrogram (VCUG) puts some dye in the Use… To see…
bladder via a catheter. Then the child voids which causes the VCUG Retrograde flow (reflux)
bladder to contract. The dye should not go to the ureters. If it ends Ultrasound Obstruction (hydro)
up in the ureters, it’s retrograde flow (vesicoureteral reflux, or Cystoscopy Direct visualization (mass)
CT scan Stones, Trauma
VUR). That’s not normal. This is most commonly used in
IV pyelogram Anatomy (outdated study)
evaluating pediatric patients with urinary tract infections.



Ultrasound looks at the tubes. It can see how large they are - not
where they go or where they come from. That is, they can see
hydronephrosis and hydroureter. Hydro is caused by obstruction.
It’s often the place to start because of accessibility, lack of
radiation, and low cost.


Cystoscopy gets a camera into the bladder and the ureters. It's like

a colonoscopy for the bladder instead of the colon. It allows direct
visualization from inside the lumen. It also allows for biopsy of a
mass and placement of stents.



CT scan has a large radiation burden. Its use should be minimized
in children. A contrasted scan shows the GU anatomy well, and
includes the rest of the peritoneal contents. It’s the test of choice
if assessing hematuria in the setting of trauma. A NON-contrasted
CT scan is required for kidney stones (both are radio-opaque).

Intravenous pyelogram is an injected material that moves into
the kidneys and down into the GU system. Imaging is captured
via X-ray. It’s unlikely to be the correct answer for any question
– it’s old and outdated.

Hematuria = Almost anywhere along genitourinary tract

You need to differentiate between microscopic vs macroscopic
and glomerular vs non-glomerular. Isolated microscopic is
usually benign and transient. Macroscopic has a broad differential
ranging from infection to stones to pseudohematuria (such as
discoloration from medication).

The morphology of the red blood cells can help points towards a
cause. Glomerular causes of bleeding typically have
dysmorphic urinary RBCs, RBC casts, and cola-colored urine.
Post-glomerular (such as urethra or bladder) sources present
with red/pink urine with clots and normal appearing RBCs.

History is important. If a child presents with true hematuria after

a traumatic injury, further diagnostics with imaging (CT scan)
should be obtained. With smoky-colored urine, eval for nephritic
syndrome (urinalysis with microscopy) should happen. Source of Hematuria
Glomerular Non-glomerular
Cryptorchidism Dysmorphic RBCs Normal-appearing RBCs
An undescended testicle will atrophy if not brought down to the Smokey or “cola” urine Red/pink urine +/- clots
scrotum. It can be given 6 months of age before considering Presence of RBC casts No casts present
orchiopexy. Development will be normal (1 is enough), but these
patients are at a 10x testicular cancer risk for life.

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