Pediatric Urology

The pediatric urology unit follows up congenital urological problems that develop in children in the womb before birth, and treats the problems that continue in these children in the early period after birth as well as important urological diseases of childhood.

• Phimosis (narrowing at the tip of the foreskin requiring circumcision)
• Hypospadias (Peygamber sünneti: the urinary opening located lower down instead of at the tip of the penis)
• Undescended testis (the testes not being in the scrotum at birth)
• Hydrocele (congenital fluid accumulation) or swelling in one or both testes.
• UPJ obstruction (narrowing at the end of the canal connecting urine in the kidney to the bladder)
• VUR (backflow of urine from the bladder into the kidney)
• PUV (a membrane in the urinary canal at the bladder outlet)
• Congenital voiding disorders (mostly in children born with a lumbar swelling: meningocele, myelomeningocele, etc.)
• Congenital kidney problems (kidneys not developing in their normal position, kidneys being congenitally large or small, shape abnormalities of the kidneys, congenitally narrow kidney outflow)
• Penis not being of normal size at birth, or having an abnormal penile shape
• Bladder extrophy (congenital development of the bladder open to the outside)

Some of the problems that can develop after birth and can be treated are listed below.

• Urinary stone disease (kidney, urinary canal, bladder)
• Voiding disorders (day or night urinary incontinence, fecal incontinence)
• Neurogenic bladder (voiding disorders and urinary incontinence developing due to diseases affecting the nerves that control the bladder, following trauma or disease)
• Recurrent urinary tract (kidney, bladder) infections
• Testicular torsion is a very urgent condition and requires emergency intervention to save the testis.
• Inflammation of the testis and epididymis
• Vesico-ureteral reflux (backflow of urine from the bladder to the kidneys) is the most common cause of recurrent infections and growth retardation in children.
• Trauma.

Common Urological Conditions in Children

Undescended Testis

When we say undescended testis, in the narrow sense we mean a testis that is hidden or not palpable. A true undescended testis is one that stops at any point along its descent path; it may also be outside the normal path, and this situation is called an ectopic testis, which is rare. Undescended testis is one of the most common congenital genitourinary anomalies. It is seen in 3% of full-term infants and 30% of premature infants. In the first months of life, most undescended testes descend into the scrotum on their own, but by age 1 the rate drops to approximately 0.8–1%. Related to undescended testis, there is a patent processus vaginalis, which prepares the ground for hydrocele and hernia formation. Men with a history of undescended testis have a risk of infertility and testicular cancer. In patients with unilateral undescended testis the risk of infertility is low, whereas in those with a history of bilateral undescended testis infertility occurs at a rate of 50–70%. Undescended testis operations performed early, within the first 6–12 months, contribute positively to fertility. In men with undescended testis, the risk of testicular cancer is increased 5–10 fold compared with the general population. This rate is higher for intra-abdominal testes than for testes located in the inguinal canal. There is no definitive evidence that this risk is reduced after surgery; however, since the testis is easier to palpate, a possible cancer may be diagnosed earlier, enabling early diagnosis. Undescended testis means the testis gets caught along its path during normal descent. Undescended testes are most often palpable in the groin. If bilateral undescended testes are not palpable, they are more often intra-abdominal, and stimulation testing should be performed on them. Various radiological methods are used in the evaluation of undescended testis.

Diagnosis: Diagnosis of undescended testis is based on physical examination. The failure to visualize the testis on ultrasound, CT or MRI cannot guarantee that the testis is absent, and in this case surgical exploration of the area is required. If bilateral undescended testis is accompanied by hypospadias or what we call ambiguous genitalia, it may be life-threatening. In this case, endocrinological evaluation is required.

Treatment: Treatment should begin before age 1. Surgical treatment is the gold standard; however, in some cases hormonal treatment may be applied. Laparoscopy may be performed in patients in whom an intra-abdominal location is suspected. If undescended testis is left untreated, it can lead to significant problems such as infertility, testicular cancer and testicular torsion. In addition, a hernia is usually also present with undescended testis; the hernia is repaired during the operation as well. Sometimes mobile, up-and-down moving testes may be mistaken for undescended testes. This distinction must be made by examination by a urology specialist.

What is a retractile testis?

It is when the testes move up into the groin during examination. Normally these testes have descended into the scrotum on their own, but they can retract backward due to stimulation of the muscles that pull the testis upward (cremaster) during examination. They may move upward especially in cold weather. It is not a disease and does not require treatment.

Hydrocele (Water Hernia)

It forms when the connection of the abdominal lining in the canal between the abdominal cavity and the scrotum remains open after birth. It presents as fluid accumulation around one or two testes, occasionally or continuously. Families usually come in with the expression "the child's testicle/scrotum has swollen."

Two types of hydrocele are seen in the newborn period:

• Communicating hydrocele (connected hydrocele), meaning the abdominal lining extending into the scrotum is completely open,
• In non-communicating type hydroceles, meaning the abdominal side of this lining closes abnormally and peritoneal fluid becomes trapped inside the scrotum.

After diagnosis by careful examination, the swelling is generally expected to disappear and resolve on its own by the end of the first year. If it does not resolve, the problem is corrected with a minor operation.

Hypospadias

Hypospadias is a congenital anomaly. It is the urinary opening (meatus) being located below where it should normally be. Sometimes it is located near the tip of the penis, sometimes on the underside of the middle part of the penis, and sometimes in the scrotum containing the testes. The cause of hypospadias is not fully known. However, low birth weight, preterm birth, maternal hormone use during pregnancy, exposure to various environmental factors and genetic factors play a role.

A classification has been made according to the anatomical location of hypospadias.

• Glanular (coronal)
• Subcoronal
• Distal penile
• Midshaft
• Proximal penile
• Penoscrotal
• Scrotal
• Perineal

Other urinary system anomalies accompanying hypospadias are listed as follows: ureteropelvic obstruction, severe reflux, renal agenesis, renal ectopia or fusion, verumontanum hypertrophy and, less commonly, all anomalies. In severe forms of hypospadias, an intersex investigation must definitely be performed.

Chordee – Penile Curvature

If there is any disturbance in normal development, the external urinary opening remains under the penis. The head of the penis flattens. By restricting the penis during erection, it causes a chordee deformity. The preputium is deficient on the ventral side to the width of the chordee band. Today there are 3 main theories explaining the cause of penile curvature:

• Abnormal development of the urethral plate,
• The presence of abnormal fibrotic mesenchymal tissue at the urethral meatus, and
• Incongruity between the corpora, or differential growth between the normal dorsal corpus cavernosum and abnormal ventral corporal tissue.

Age at Surgery: The American Academy of Pediatrics, by interpreting together the psychological effects of genital surgery on children, the technical aspects of hypospadias surgery and the advances in pediatric anesthesia, concluded that the most appropriate time for hypospadias surgery is between 6 and 12 months. Hypospadias surgery performed at around age 1, if there is sufficient penile tissue, is the current accepted standard. More than 200 techniques have been described for hypospadias repair. In the past, multi-stage operations were applied; today the treatment is performed in a single stage. The advantages of single-stage operations are quite numerous: minimal scarring, minimal hospitalization, minimal anesthesia, minimal cost, maximal functional and aesthetic results, and additionally a lower complication rate. Since foreskin is used for repair in the operations to be performed, children with hypospadias must absolutely not be circumcised.

UPJ Obstruction (narrowing at the end of the canal connecting urine in the kidney to the bladder)

Ureteropelvic obstruction (blockage) is defined as a decrease in urine flow from the renal pelvis (kidney pelvis) into the ureter. If not corrected, it leads to progressive kidney damage. It can be seen in all age groups. Most cases are diagnosed in the perinatal (in-utero) period. It is more common in males, at a ratio of 2:1, and is more dominant on the left side, seen in the left kidney in 67% of cases.

Causes

• Causes originating from the wall of the urinary tube: arrest in the development of the muscles forming the tube and changes in the structure of collagen fibers
• Causes originating from outside the urinary tube: external narrowing of the passage as a result of compression by an abnormally developing vessel from outside
• These two causes may occur alone or together; the underlying cause presents due to the first one.

Findings/Symptoms: Newborns do not complain; children show symptoms, and occasionally complaints can appear at older ages. Growth retardation, feeding difficulty, urinary tract infection, sepsis, kidney stones, pain and blood in the urine may be seen. In older children, episodic pain and associated nausea and vomiting may occur.

Diagnosis: Diagnosis can be made by detecting kidney swelling on prenatal ultrasound follow-ups. After birth, ultrasound should be performed on day 3. Although frequently used in follow-up, ultrasonography alone is not diagnostic for UPJ obstruction. Ultrasonography only visualizes the dilation of the renal pelvis, i.e. hydronephrosis, and the structure and thickness of the renal parenchyma. The anteroposterior diameter of the pelvis is measured, but this neither establishes the diagnosis of obstruction nor shows whether it is worsening or improving. For a definitive diagnosis, a method that functionally evaluates the flow of urine from the kidney into the urinary canal must be used. One of the classic evaluations is intravenous pyelography (IVP), a contrast kidney film. Here the renal pelvis appears enlarged because urine cannot be expelled from the pelvis adequately. In IVP, the contrast dye visualized by X-rays is given into a vein, and this substance is filtered by the kidney. During the serial films taken as this substance is excreted in the urine, kidney function, the renal collecting systems, the passage of the drug into the ureter and the bladder are evaluated. Even if UPJ obstruction is shown on IVP, a diuretic DTPA scintigraphy (diuretic renogram) must be performed for the definitive diagnosis. This is important not only for the definitive diagnosis but also for monitoring recovery after surgery. In the diuretic renogram, while the radioactive substance given intravenously is filtered by the kidney, the function and drainage of the two kidneys are measured and evaluated separately. In this evaluation a drainage curve is obtained for both the right and left kidney. In a UPJ obstruction, the curve shows no drainage and is progressively rising. This rising curve should be seen for the definitive diagnosis of UPJ obstruction. Magnetic resonance imaging has a unique advantage in rapidly evaluating renal blood flow, anatomy and urinary excretion. In particular, the presence of a small vessel causing UPJ obstruction is important in deciding what type of surgery to perform; if there is a crossing vessel that causes the obstruction or further increases the severity of an existing obstruction, the success of procedures performed by cutting from inside the urinary canal (endopyelotomy, see below) is low.

Treatment: Before information about treatment methods is given, it must be kept in mind that in children 18 months old and younger, the poor urine passage due to UPJ obstruction may be temporary and may resolve on its own. However, in cases of obstruction and the kidney damage it causes, the need for surgical treatment may be unavoidable even under 18 months of age. Some babies or children may recover rapidly within months despite a severe UPJ obstruction detected initially, while in others no improvement occurs or they begin to worsen. Therefore, close follow-up of children in this age group is absolutely necessary. The family should be informed about this. This follow-up is generally carried out by periodic ultrasonographic measurement of the degree of dilation of the renal pelvis (hydronephrosis). In patients in whom a definitive diagnosis of UPJ obstruction has been made and spontaneous improvement over time is not expected, surgical treatment is necessary. Open surgical techniques are classified into 3 main groups: flap type, incisional type and dismembered type. The classic UPJ obstruction operation is the removal of the narrowed UPJ segment by open surgery and reimplantation of the ureter into the pelvis (renal pelvis). This operation is called "dismembered pyeloplasty," and its success rate is around 95%. Pyeloplasty operations, which have come to the fore in recent years with laparoscopic surgical technique, are also performed laparoscopically. The same surgical steps as in open pyeloplasty are carried out, but no large surgical incision is made in this application; the operation is performed by entering the body through only 3 or 4 small holes. Pyeloplasty performed with this technique is called "laparoscopic pyeloplasty." Scientific studies have shown no difference in surgical success between laparoscopic and open techniques. However, laparoscopic operations have some advantages over open surgery. Another surgical approach, called "endoscopic incision" or "endopyelotomy," is the cutting of the narrowed part from inside with a small closed-system cutter, entering through the urinary canal with an endoscope. Because this treatment is performed through the urinary canal, the return to daily activities is quite quick. However, there are some factors affecting the success of endopyelotomy, and these factors limit the use of this technique. This procedure can be performed by entering from the urinary canal or from the kidney. Early complications of pyeloplasty are rare, and prolonged urine leakage is frequently seen; if it lasts 10–14 days, a stent must be placed. Fever or flank pain should raise suspicion of urine leakage or infection. In the late period, narrowing due to scar tissue (cicatrix) and recurrences may occur.

Nighttime Bedwetting (Nocturnal Enuresis)

What is bedwetting? How common is it?

It can be defined as involuntary urination. When it occurs at night it is called nocturnal enuresis, and when it occurs during the day it is called diurnal enuresis. Urinary incontinence in children is among the most frequently encountered problems. For the definition of nocturnal enuresis, the criterion is more than two episodes of urinary incontinence per month after the child has reached age 5. Most children achieve control of urination both at night and during the day between the ages of 2 and 4. Urinary control develops in parallel with the maturation of the nervous system. In infancy, urination is entirely reflexive. 40% of three-year-old children wet the bed, and this rate drops to 15% at age 5 and 10% at age 10. Nocturnal enuresis is seen 50% more often in boys than in girls. 85% of children with nocturnal enuresis have normal daytime urination habits and no other abnormalities in their urological history; however, 15% of patients have daytime urination problems. There is a "15s rule" for enuresis: 15% of 5-year-olds are wet; 1% of 15-year-olds are wet; 15% have fecal incontinence; each year 15% become dry; 15% have daytime urinary problems; and 15% have initial dry periods.

How many types of bedwetting are there, and what are the causes?

There are two types of bedwetting. If the child has never remained dry since birth, it is called the primary type; if the child has resumed wetting after remaining dry for at least 6 months, it is called the secondary type. The vast majority of children who wet the bed are in the primary bedwetting group. Sometimes bedwetting may be accompanied by symptoms such as frequent and urgent need to urinate. Nocturnal enuresis is examined by dividing it into two groups according to its causes: physiological and organic. A large group of children with nocturnal enuresis (90–95%) fall into the physiological bedwetting group; this type of bedwetting problem may also be named non-organic enuresis. It is reported that these children feel bladder fullness insufficiently during sleep, have small bladder capacity and very deep sleep. At night, urine output is normally about 50% less than during the day. This is due to the nocturnal increase in plasma arginine vasopressin. In enuretic children there is a similar vasopressin level both during the day and at night, which causes them to produce a larger amount of urine at night. Importantly, bedwetting is largely based on genetic predisposition. If one parent has a history of bedwetting, the child has a 43% chance of having the problem; if both parents have it, 77%; if neither parent has it, 15%. Patients with a history of bedwetting in relatives (maternal uncle, paternal uncle, maternal aunt, paternal aunt) also face this problem. Cases with a family history follow a course similar to their families in terms of the time to recovery.

Is there a sleep-related problem?

The fact that wetting occurs during sleep raises the question of whether there is a sleep disorder that causes very deep sleep or prevents awakening. However, studies have shown no difference from normal children.

What conditions accompany it?

Problems such as diabetes, kidney diseases and bladder diseases are identified in 2–3% of children who wet the bed. In 5–10% of cases, bedwetting is accompanied by complaints such as frequent and urgent need to urinate. These are defined as "polysymptomatic bedwetting." In these children, urinary tract infection, bacteria in the urine, constipation and sometimes food allergy are detected. Additionally, in recent years it has been emphasized that children with adenoid vegetations, known colloquially as "geniz eti" (adenoids), show a high rate of bedwetting, and that these complaints resolve after surgery.

Psychological problems

In general, psychological events do not cause the primary bedwetting problem mentioned earlier. Therefore, in the vast majority of children who wet the bed, there is no need to look for a psychological problem. The misconception that bad children wet the bed is also invalid and should not be overlooked. If bedwetting follows a psychological problem, this is usually a re-emergence of physiological bedwetting. In children with behavioral regression, in addition to nocturnal bedwetting, there are additional findings such as school failure and fear, and these must definitely be evaluated by child psychiatrists.

How should it be approached?

We must state immediately and emphatically that it is the wrong attitudes of families and society, more than bedwetting itself, that harm these children. The most dangerous among these are punitive measures targeting the genital area, such as in news headlines like "Mother seated her bedwetting daughter on a stove." Such attitudes leave effects on children that last a lifetime. It should not be forgotten that children who wet the bed experience a physiological developmental delay (similar to a delay in teething or speech), and that the basic duty of the family is to help the child get through this problem without damaging their self-esteem. Therefore, children who wet the bed must be evaluated at the latest by age 6 by a urology specialist, and after the necessary investigations a treatment plan must be made.

What tests should be done in children who wet the bed?

To make the diagnosis of nocturnal enuresis and to distinguish it from more serious voiding disorders, it should be evaluated by a urologist who is an expert in the subject. Children brought to the physician with bedwetting complaints should be examined for the presence of the organic factors mentioned earlier. For this, it should be investigated whether there are complaints such as daytime wetting, difficulty urinating, constipation, difficult and urgent urination, excessive urination, head trauma, fecal incontinence with urination, snoring and mouth breathing at night. Depending on the information obtained and the general examination results, a series of tests ranging from urinalysis to bladder films should be performed. In 97% of children who wet the bed, there is no physical cause. Therefore, a detailed history often provides information about whether it is physiological bedwetting. At this point, it is important to clarify whether the child who wets the bed has a "small bladder" or an inability to wake from sleep.

• Taking a detailed medical history and questioning
• Keeping a voiding and defecation chart
• Extended physical examination
• A complete urinalysis is generally sufficient.

After these steps, if it is decided that the case is a purely primary bedwetting problem, the treatment phase begins. If the urology specialist decides that the matter is a more complex and comprehensive problem, more detailed investigations are carried out by applying advanced diagnostic methods.

Methods used in treatment

It is generally recommended that treatment interventions be started when children who wet the bed reach 7–8 years of age. At the forefront of these interventions are programs aimed at the child or the family waking the child at night. A program is applied in which the family wakes the child at night and makes them go to the toilet. This program has achieved a 90% success rate.

Use of alarm and drug treatment

Alarm devices are tools that activate as soon as the child starts to wet, helping the child wake up and gain control of the bladder. With this treatment, a recovery rate of 70–84% is achieved in children. Various drugs have been used in bedwetting treatment for many years. There is a recurrence risk of up to 90%. Bedwetting is a common problem in childhood, and it is a subject in which wrong family attitudes persist. First, children who wet the bed should be evaluated by pediatricians who are concerned with the subject, and a long-term treatment approach should be tried with the participation of the family.

Basic principles

• Getting up at night to go to the toilet should be established as a goal
• Access to the toilet should be made easier
• The child should be helped to take on responsibility for staying dry
• Excessive fluid intake should be avoided for the 2 hours before bedtime
• Caffeinated beverages must absolutely not be given
• The toilet should be used before getting into bed
• Diapers should not be put on to keep the child dry at night (this negatively affects the motivation to get up at night)
• The child's participation in morning cleanup should be ensured
• Children's self-esteem should be supported
• Guides explaining to families how they should behave should be prepared
• The days on which children stayed dry should be recorded on a chart
• Children should be checked at least once a month.

Vesicoureteral Reflux (VUR) (Backflow of urine from the bladder into the kidney)

It refers to the backflow into the kidney of the urine contained in the bladder. After urine is produced in the kidney, it is carried to the bladder through tubes called ureters. The bladder stores urine, which is then expelled from the body by the process of urination. Normally, during this urination process, urine does not flow back into the kidney; if it does, it is defined as vesicoureteral reflux. The flap-valve mechanism at the entry of the ureter into the bladder and the pressure dynamics between the bladder and the ureter prevent reflux. The exact rate of VUR is not known. However, in non-symptomatic children the estimated rate is 0.4–1.8%.

Diagnosis: Urinary ultrasound findings are normal in 75% of patients with reflux. A normal urinary ultrasound never rules out VUR. In infants diagnosed with prenatal hydronephrosis, bladder and kidney ultrasound should be used as the first option. In babies diagnosed with hydronephrosis in the prenatal period, there is a 16.2% probability of detecting VUR. For a definitive diagnosis, voiding cystourethrography (VCUG) should be performed. Every child under 2 years of age who has had a febrile urinary tract infection should be evaluated with VCUG. If reflux is detected, scintigraphy (DMSA) is planned.

Treatment: There are two main approaches in this matter: conservative (non-surgical) and surgical.

Endoscopic (Closed) Treatment of Urinary Reflux: Closed, i.e. endoscopic, reflux surgery is a surgical procedure lasting on average 10 minutes and performed without making any incision. After the child is anesthetized, the internal ureteral opening where the reflux occurs is located by entering the bladder through the urethra with a lighted instrument (cystoscope). Below the opening where the internal ureters open into the bladder, a substance containing dextranomer/hyaluronic acid is injected to narrow it. The dextranomer/hyaluronic acid creates a bulge at the point where the internal ureter opens into the bladder, which prevents reflux, and it remains there for life.