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Pediatric Urology
1
How should we evaluate a patient with febrile urinary tract infection (UTI)?
After treatment of the infection, the patient should undergo a urinary tract evaluation with a renal-bladder sonogram and ± voiding cystourethrogram (VCUG). Approximately 50% of children under the age of 12 presenting with a UTI are found to have abnormalities of the genitourinary (GU) tract. The most common abnormalities identified are vesicoureteral reflux (VUR), obstructive uropathies, and neurogenic bladder. In the absence of anatomic abnormalities, the most common causes of UTI in children are constipation and dysfunctional voiding.
2
What is VUR disease?
The reflux of urine from the bladder into the upper urinary tract. Primary VUR is caused by an inadequate valvular mechanism at the ureterovesical junction, presumably related to a shortened submucosal ureteral tunnel. One-half of children with culture-documented UTIs have VUR.
3
Is VUR damaging to the kidney?
VUR increases the likelihood of renal scar by 2.5-fold. Reflux of infected urine can lead to pyelonephritis and subsequent renal scarring. Currently, renal scarring is the fourth leading cause for renal transplantation in children. The combination of VUR and elevated bladder storage pressures (e.g., neuropathic bladder or bladder outlet obstruction) is harmful to the kidney, and a concurrent UTI makes this situation particularly dangerous.
4
What are the indications for surgical correction of VUR?
Reflux resolves spontaneously in many children; however, high-grade reflux, especially when bilateral, is unlikely to resolve. Most children with high-grade reflux or breakthrough UTIs despite antibiotic prophylaxis should be managed surgically. Surgical management may also be appropriate in children with reflux persisting into late childhood or adolescence. Bulking agents have been evaluated, but long-term results and durability remain unclear.
5
What is the most common cause of antenatal hydronephrosis?
Ureteropelvic junction (UPJ) obstruction. Hydronephrosis is the most common abnormality detected on prenatal ultrasound and accounts for 50% of all prenatally detected lesions. Fifty percent of prenatal hydronephrosis, in turn, is caused by UPJ obstruction. UPJ obstruction is bilateral in approximately 20% of cases and associated with VUR in 15% of cases.
6
What is the most common cause of UPJ obstruction?
Intrinsic stenosis. Less common causes include a lower pole (renal) crossing vessel, anomalous ureteral insertions (high in the renal pelvis), and peripelvic fibrosis.
7
Can UPJ obstruction resolve spontaneously? What are the indications for pyeloplasty?
Yes. Ultimately, only about 25% of children with findings consistent for UPJ obstruction require pyeloplasty. The indications for surgical intervention include worsening hydronephrosis, poor or declining renal function, pain, infection, and the presence of a solitary kidney or bilateral hydronephrosis.
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