Pediatric urological diseases

⚠️ Why Is PUV a Problem?

The valve-like tissue causes partial or complete blockage of urine flow, which can lead to:

Bladder distension and dysfunction

Hydronephrosis (swelling of kidneys due to backed-up urine)

Kidney damage or failure

Recurrent UTIs

Pulmonary hypoplasia (underdeveloped lungs if severe bladder backup affects amniotic fluid during pregnancy)

👶 Symptoms (in newborns and children)

Prenatal:

Detected by ultrasound: enlarged bladder, low amniotic fluid (oligohydramnios), bilateral hydronephrosis

Postnatal (after birth):

Poor urinary stream

Difficulty urinating or dribbling

Urinary tract infections

Abdominal distension

Signs of kidney failure (e.g., poor growth, lethargy, electrolyte issues)

🧪 Diagnosis

Prenatal ultrasound

Postnatal tests:

Voiding cystourethrogram (VCUG) – key diagnostic test to see reflux and obstruction

Renal ultrasound

Blood tests for kidney function (creatinine, BUN)

🛠️ Treatment

Initial Management:

Catheterization to relieve bladder pressure

Antibiotics to prevent/treat infection

Stabilization of kidney function

Definitive Treatment:

Endoscopic valve ablation – minimally invasive surgery using a cystoscope to remove the obstructing valve tissue

Severe Cases:

Vesicostomy – temporary surgical opening in the bladder to allow drainage

Renal support – if kidneys are severely damaged (may require dialysis or kidney transplant later in life)

🔁 Long-Term Follow-Up

Many children with PUV require long-term care due to:

Bladder dysfunction

Chronic kidney disease (CKD)

Growth and developmental concerns

Multidisciplinary care is often needed (pediatrics, urology, nephrology).

VUR stands for Vesicoureteral Reflux, a condition where urine flows backward from the bladder into the ureters and sometimes all the way up to the kidneys.

In healthy individuals:

Urine flows one-way: kidneys → ureters → bladder → urethra (out).

The bladder's valve mechanism prevents backward flow.

In VUR, that valve is either congenitally defective or damaged, allowing urine to reflux back toward the kidneys.

👶 Who Gets VUR?

Most common in infants and young children, especially those with urinary tract infections (UTIs).

Can be inherited (family history increases risk).

More common in girls, except in newborns where it's more common in boys.

📊 Grades of VUR (I to V)

Grade	Description
I	Reflux into ureter only
II	Reflux into ureter and kidney without dilation
III	Mild dilation of ureter and kidney
IV	Moderate dilation and blunting of calyces
V	Severe dilation and twisting of ureters; loss of kidney structure

⚠️ Why VUR Matters

Can lead to recurrent UTIs

Risk of kidney scarring, especially in high-grade reflux

Can result in hypertension and chronic kidney disease over time

🧪 Diagnosis

Voiding cystourethrogram (VCUG) – gold standard; contrast dye + X-ray to observe reflux during urination

Renal ultrasound – detects hydronephrosis or kidney damage

DMSA scan – checks for kidney scarring or function loss

💊 Treatment Options

Depends on the grade of VUR and age:

Observation (for low-grade VUR):

Many children outgrow grades I–II

Regular monitoring with ultrasounds and urine cultures

Antibiotic prophylaxis:

Low-dose daily antibiotics to prevent UTIs

Surgical treatment (for higher-grade or persistent VUR):

Ureteral reimplantation – corrects the valve mechanism surgically

Endoscopic injection (Deflux) – less invasive, injects bulking agent to block reflux

👨‍⚕️ Long-Term Outlook

Most low-grade cases resolve over time.

Preventing UTIs and kidney damage is the key goal.

Some children need long-term follow-up by pediatric urology or nephrology.

PUJO stands for Pelvi-Ureteric Junction Obstruction (also called Ureteropelvic Junction Obstruction or UPJO). It is a condition where the junction between the renal pelvis and the ureter is narrowed or blocked, which impedes the flow of urine from the kidney to the ureter.

Congenital (most common):

Abnormal development of the PUJ before birth

Presence of a crossing blood vessel compressing the junction

Intrinsic narrowing due to muscle or fibrous tissue

Acquired (rare in children):

Post-surgical scarring

Infections

Stones or trauma

🧒 Who Gets PUJO?

Most often diagnosed in infants and young children

Can be unilateral or bilateral

Sometimes found before birth via prenatal ultrasound

⚠️ Symptoms

Prenatal:

Detected as hydronephrosis (fluid-filled dilation of the kidney) on routine prenatal ultrasound

Postnatal:

Abdominal/flank mass

Urinary tract infections (especially with fever)

Hematuria (blood in urine)

Pain in the side (especially after fluid intake)

Poor growth or failure to thrive in severe cases

🧪 Diagnosis

Renal Ultrasound – initial test to assess kidney size and hydronephrosis

Diuretic Renogram (MAG3 or DTPA scan) – key functional test to assess drainage and kidney function

Voiding Cystourethrogram (VCUG) – done to rule out VUR

MRI Urography or CT Urography – for complex or uncertain cases

📊 Severity Assessment

Based on degree of hydronephrosis and differential renal function

If function drops below 40%, intervention is more strongly considered

🛠️ Treatment Options

1. Observation

For mild cases with preserved kidney function

Regular ultrasounds and renal scans to monitor

2. Surgical Treatment

Pyeloplasty (typically Anderson-Hynes dismembered pyeloplasty) – the gold standard surgery:

Removes the obstructed segment

Reconnects the healthy pelvis and ureter

Can be done open or laparoscopic

3. Temporary Drainage (rarely needed):

Nephrostomy tube or double-J stent for decompression in acutely ill infants

🩺 Prognosis and Follow-Up

Excellent outcomes after surgery in most children

Regular follow-up with imaging to confirm drainage and monitor kidney growth

Early diagnosis and treatment help prevent permanent kidney damage

Circumcision is a surgical procedure that involves the removal of the foreskin — the skin covering the tip (glans) of the penis. It is most commonly performed in newborn males, but can also be done in older children or adults for medical, cultural, or religious reasons.

Neonatal circumcision – Done in the first few days or weeks of life, usually under local anesthesia.

Pediatric circumcision – Performed in older children, often under general anesthesia.

Adult circumcision – Typically done for medical reasons.

📌 Reasons for Circumcision

✅ Medical Indications:

Phimosis: Tight foreskin that can't be retracted

Recurrent balanitis (inflammation of the glans)

Recurrent UTIs

Paraphimosis: Trapped retracted foreskin

Balanitis xerotica obliterans (BXO)

🌍 Cultural and Religious Reasons:

Common in Jewish, Islamic, and some African and Indigenous cultures

🧼 Hygienic or Preventive Health Reasons:

Reduced risk of:

Urinary tract infections (especially in infants)

Penile cancer (very rare)

Sexually transmitted infections (including HIV)

Cervical cancer in female partners (linked to lower HPV transmission)

⚙️ How It's Done

In newborns:

Often done in an outpatient setting using:

Plastibell device

Gomco clamp

Mogen clamp

Takes about 10–20 minutes

In older children/adults:

Requires general or local anesthesia

Surgical removal of foreskin with suturing

Recovery takes longer than in newborns

⚠️ Risks and Complications

While generally safe, potential risks include:

Pain and bleeding

Infection

Poor cosmetic result

Meatal stenosis (narrowing of urethral opening, especially if circumcision is done too early)

In very rare cases, injury to the penis

🧑‍⚕️ Post-Operative Care

Keep the area clean and dry

Apply petroleum jelly or antibiotic ointment as directed

Watch for signs of infection (redness, swelling, pus, fever)

Healing time: 5–10 days in newborns, 2–3 weeks in older individuals