Common Problems in Pediatric Urology 4

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Comments

By: mhmdlbanna (134 month(s) ago)

thank u ,collective informations

By: sayedeleweedy (137 month(s) ago)

Dr Leithy Thanks for this very illustrative presentation, could you please send me a copy my e-mail is [email protected]

By: sawy_3 (151 month(s) ago)

thanks alot for ur presentation, i like it too much , im dr mohamed pediatric urlogist ik kuwait. could u plz send it to me. bye

By: bisht02 (152 month(s) ago)

presentation is very informative and good for students like me. If possible can you mail it to me.

Presentation Transcript

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Dr. Mohamed Leithy 1 ??? ???? ????? ????? ?????? ??????? ??????? ?????? ??? ??????? ??????? ???? ??????? ?????? ?????? ??????? ??????

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Dr. Mohamed Leithy 2

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Dr. Mohamed Leithy 3 Common Problems Of Pediatric Urology Prenatal To Adult ages By Dr. Mohamed Leithy MD.Urology Student Hospital

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Dr. Mohamed Leithy 4 1-Prenatal Hydronephrosis 2-Epispadias Exstrophy complex 3- Intralbial Masses 4-Hypospadias

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Dr. Mohamed Leithy 5 5- Cryptorchidism (UDT) 6- Voiding Dysfunction 7- Urinary Tract Infection 8- Pediatric Nephrolithiasis 9- Intersex 10- Pediatric Urological Oncology

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Dr. Mohamed Leithy 6

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Dr. Mohamed Leithy 7 1-ANTENATAL HYDRONEPHROSIS • Congenital condition detected by US • Dilatation of pelvicalyceal system • Urinary dilation 1/100 pregnancies • Significant 1 in 500 • Majority resolve by 1 year

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Dr. Mohamed Leithy 8 ANTENATAL US. I HAVE A BABY WITH PRENATAL HYDRONEPHROSIS WHAT SHOULD I DO???

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Dr. Mohamed Leithy 9 - Other anomalies ? - Degree of dilation ? - One or both kidneys ? - Ureteral dilation ? - Status of bladder ? Empty Distended Key hole Gender ? - Amniotic fluid volume?

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Dr. Mohamed Leithy 11 Common causes of antenatal hydronephrosis” UPJ obstruction UVJ Obstruction PUV Ureteric Reflux

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Dr. Mohamed Leithy 13 Postnatal Evaluation Renal Sonogram 48 Hrs -3W -Ve +Ve RUS -6-8WKs -VCUG -Renal Scan Prophylactic Amoxicillin 20 mg/Kg

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Dr. Mohamed Leithy 17 Pelvis

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Dr. Mohamed Leithy 18 NON OPERATIVE management • Transverse Pelvic diameter<20mm • Non Obstructive Drainage Curve • Preservation of Renal Function • Non Palpable Kidney • No Symptoms or Sepsis

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Dr. Mohamed Leithy 19 UPJ OBSTRUCTION Treatment Observation - Serial ultrasounds - 20% deteriorate surgery Surgery RUS - very significant hydro. - Nuc. scan - renal function 35 - 40% - prolonged washout

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Dr. Mohamed Leithy 21 Ureterovesical Junction Obstruction

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Dr. Mohamed Leithy 22 Narrow Segment

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Dr. Mohamed Leithy 25 Management: Excision of Narrow segm. Ureteric reimplantation Nephroureterectomy

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Dr. Mohamed Leithy 26 Posterior Urethral Valve Obstructing membrane from posterior edge of veru,to mem.urethra • 1 in 8000 • 40% ESRD • > 2/3 diagnosed in utero • 50% reflux at presentation • ½ unilateral • ½ bilateral

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Dr. Mohamed Leithy 28 Neonates: Urosepsis Dehydration Electrolyte anomalies Failure to thrive Poor Urinary stream (dribbling) Toddlers UTI and Voiding dysfunction School age boys Voiding dysfunction

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Dr. Mohamed Leithy 29 Dilated P.Ur.

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Dr. Mohamed Leithy 30 Initial Management • Catheter drainage, 5 F or 8 F feeding tube • Stabilize pulmonary, e’lyte fluid problems • Prophylaxis -- circumcise • Vesicostomy in very small infants • Valve ablation

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Dr. Mohamed Leithy 32 - Obstruction effect - permanent Valve bladder syndrome outcome POSTERIOR URETHRAL VALVES Long Term Problems

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Dr. Mohamed Leithy 33 Ureterovesical Reflux • Primary • Antenatal hydronephrosis • Secondary Voiding dysfunction Neuropathic bladder Obstructive uropathy Ureterocele Exstrophy

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Dr. Mohamed Leithy 34 Medical Therapy Principles resolves or becomes less severe as the child grows Complications can be avoided by preventing infection Avoids risks of surgery

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Dr. Mohamed Leithy 35 Medical Management • Septrin, or Macro furan 1/4 - 1/3 dose • Regular, volitional voiding • Bladder instability anticholinergics • UA or C/S if symptomatic • Annual: Ht, Wt, UA; BP if renal scarring • Radionuclide cystogram (or VCUG) and upper tract study q 12 to 18 mo

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Dr. Mohamed Leithy 36 Antireflux Surgery • Intravesical • Extravesical • Endoscopic • Laparoscopic

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Dr. Mohamed Leithy 37 Intravesical bil.Ureteric reimplantation

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Dr. Mohamed Leithy 38 TAKE HOME MESSAGES HN. does not always equate obstruction. Complete obstruction is followed by infection and functional deterioration Ultrasonography must be done for all paediatric Patient complaining of urological symptoms

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Dr. Mohamed Leithy 40 2-Epispadias Exstrophy Complex Improper lower abdominal wall development

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Dr. Mohamed Leithy 41 Total Reconstruction at birth

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Dr. Mohamed Leithy 42 EXSTROPHY / EPISPADIAS Staged Reconstruction a. Closure at birth b. Epispadias Repair c. Bladder Neck Reconstruction Penile Disassembly

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Dr. Mohamed Leithy 45 3-INTERLABIAL MASS 1-Labial adhesion 2-Paraurethral Cysts 3-Imperforated Hymen 4- Urethral Polyp 5-Urethral Prolapse 6-Prolapsed Ureterocele 7-Sarcoma Botryoides

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Dr. Mohamed Leithy 46 Labial Adhesions - Post-void dribbling - Treatment - estrogen cream

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Dr. Mohamed Leithy 54 4-Hypospadias Meatus Chordee Prepuce

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Dr. Mohamed Leithy 55 Phases of surgical repair : Orthoplasty Urethroplasty Meatoplasty and Glanuloplasty Skin cover Scrotoplasty

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Dr. Mohamed Leithy 57 Bladder mucosal graft Buccal mucosal graft The inert collagen matrix Graft of cultured urethral epith. Tissue engineering Laser tissue welding Tissue expanders

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Dr. Mohamed Leithy 59 5-Cryptorchidism UDT Palpable: -80% 1. Retractile 2. Ectopic 3. Intracanalicular Nonpalpable: -20% 1. Intracanalicular 2. Abdominal 3. Absent - Atretic vessels / vas

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Dr. Mohamed Leithy 60 Pre Term 30% Full Term 3.4% 9 months 0.7% Adulthood 0.1 – 1% Current Recommendations Palpable UDT– orchiopexy 7-12 mos. Bilateral nonpalp UDT –HCG testing Atrophic UDT – remnant orchiectomy

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Dr. Mohamed Leithy 61 HISTOLOGIC CHANGES - Deterioration of normal histology – Varies with age, testis location 12 months - delay in germ cell development 24 months - peritubular fibrosis 36-72 mos - Sertoli / Leydig cell dysfunction Adulthood - germ cell aplasia ( as early as 2 yrs. In some reports)

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Dr. Mohamed Leithy 66 Laparoscopy for Bil. UDT

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Dr. Mohamed Leithy 73 Take Home Message Examine the scotum in your pediatric Pt. Refer them if you find any abnormalities

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Dr. Mohamed Leithy 74 Acute Scrotum in Children “Torsion Until Proven Otherwise” No difference in Adult / Child

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Dr. Mohamed Leithy 75 Neglected torsion Gangrene of the testis

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Dr. Mohamed Leithy 77 Site of torsion

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Dr. Mohamed Leithy 79 Blue dot singe

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Dr. Mohamed Leithy 86 6-Dysfunction Voiding Neurogenic Bladder Congenital Spinal Dysraphism Miningiocele Myilominingiocele Spina bifida occulta Sacral agenesis

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Dr. Mohamed Leithy 87 PATTERNS OF ABNORMAL VOIDING Daytime frequency syndrome Giggle incontinence Vaginal voiding Lazy bladder syndrome Nocturnal enuresis

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Dr. Mohamed Leithy 88 Infant Voiding Pattern Reflex spinal Micturition Detrusor Contraction Sphincter. Relax.

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Dr. Mohamed Leithy 89 Development of Control Bl.Capacity increase Bl. Reservoir Voluntary control striated Muscle Sphincter Initiate and terminate stream Volitional control spinal micturition Centrally inhibit detrusor contraction

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Dr. Mohamed Leithy 90 Mature Voiding pattern Inhibit detrusor centrally Initiate voiding Detrusor contraction Sphincter relaxation Void to completion

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Dr. Mohamed Leithy 91 HISTORY Daytime voiding pattern Toilet training history Poor stream/dribbling UTIs Constipation Upper airway obstruction Familial uropathy

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Dr. Mohamed Leithy 92 VOIDING HISTORY How often: Void on wakening? Void at school? Holding maneuvers - squatting, heel into perineum Wetting pattern Spontaneous? Urgency related? / Post void? UTI related?

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Dr. Mohamed Leithy 93 DAYTIME FREQUENCY SYNDROME Sudden onset frequency/urgency Rare incontinence Previously toilet trained No H./of UTIs/neurologic disorder Rare nocturia/enuresis Average duration: 2 .5 months

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Dr. Mohamed Leithy 94 DAYTIME FREQUENCY SYNDROME Treatment Reassurance Behaviour modification Stretch out voiding interval Anticholinergics

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Dr. Mohamed Leithy 95 GIGGLE INCONTINENCE Involuntary wetting with laughter Young female May start at 5 - 7 years Normal voiding pattern - day/night Normal bladder dynamics

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Dr. Mohamed Leithy 96 GIGGLE INCONTINENCE TREATMENT Improves through puberty Alpha-adrenergic agents Phenylpropanolamine Ephedrine Ornade

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Dr. Mohamed Leithy 97 VAGINAL VOIDING Common cause of incontinence Frequent cause of post-void dribbling Treatment Spread labia with voiding Sit backwards on seat with voiding

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Dr. Mohamed Leithy 98 “LAZY BLADDER SYNDROME” Infrequent Voider Void 2-4 times/day Do not void on awakening Do not void at school First void at home after school Presentation Asymptomatic bacteria Dribbling / nocturnal enuresis Constipation / encopresis

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Dr. Mohamed Leithy 99 “I don’t have to go.” “Too busy.” “Don’t like the bathrooms at school.” “I want to hold it so I don’t wet.”

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Dr. Mohamed Leithy 100 DYSFUNCTIONAL VOIDING Counteraction: Functional outlet resistance Detrusor hypertrophy Elevated intravesical pressure Voiding Filling VUR / hydronephrosis Renal damage

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Dr. Mohamed Leithy 101 MULTIMODAL APPROACH Infection control Prophylaxis if indicated Constipation management Behaviour modification Timed voiding schedule Biofeedback therapy Anticholinergics / alpha blockers

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Dr. Mohamed Leithy 102 PHARMACOTHERAPY Anticholinergic---RELAX the bladder Uripan Sympathomimetic---TIGHTEN the sphincter Ephedrine, Alpha-Blocker---RELAX the sphincter Cardura, Diagnosis specific , DDAVP, Imipramine, Antibiotics

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Dr. Mohamed Leithy 103 Nocturnal Enuresis Family History Parental Attitudes Punishment/Reward Child’s Attitude Guilt/Motivated/Carefree Psychological Factors

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Dr. Mohamed Leithy 104 Pathophysiology- A heterogeneous disorder Nocturnal polyuria (Lack of ADH Release) Reduced nocturnal functional bladder capacity Nocturnal enuresis Impaired arousal response to bladder fullness from sleep (70 %) (30 %) (100 %) Pathophysiology- A heterogeneous disorder Nocturnal polyuria (Lack of ADH Release) Reduced nocturnal functional bladder capacity Nocturnal enuresis Impaired arousal response to bladder fullness from sleep (70 %) (30 %) (100 %) Genetics

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Dr. Mohamed Leithy 105 ( A heterogeneous disorder ) Treatment / Pathophysiology Nocturnal Polyuria (Lack of ADH Release) Reduced nocturnal functional bladder capacity Nocturnal enuresis Impaired arousal response to bladder fullness from sleep Desmopressin Anticholinergics (70 %) (30 %) (100 %) Bed alarm combination therapy

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Dr. Mohamed Leithy 106 Inadequate Bladder Capacity Imipramine, , Anticholinergic Excessive Urine Produced - DDAVP Deep Sleep Bed Alarm Combination Therapy Anticholinergic + + DDAVP

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Dr. Mohamed Leithy 108 7-Urinary Tract Infections Epidemiology • First 3 months : male: female 3:1 - Circumcision reduces UTI rates in male infants about 90% • Schoolchildren female: male 30:1

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Dr. Mohamed Leithy 109 Complicated UTIs • Structural or functional voiding abnormalities • Obstruction • Neurological disease • Stones • Diseases predisposing to kidney infection - Diabetes mellitus - Sickle cell disease Polycystic renal disease - Renal transplants

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Dr. Mohamed Leithy 110 PRESENTATION Infants and Toddlers • Non-specific Signs – Irritability– Fever – Failure to Thrive – Nausea / Vomiting – Hematuria

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Dr. Mohamed Leithy 111 School Age Children • Irritability • Listlessness • Unexplained Fever • Pain with Voiding • New Onset Incontinence • Frequency / Urgency • Foul Odor to Urine • Abdominal / Flank Pain

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Dr. Mohamed Leithy 112 Host Defense Factors Voiding Dysfunction • Increased risk of UTI • Associated with VUR • Incomplete emptying • High intravesical pressure • Bladder overdistension • Associated constipation

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Dr. Mohamed Leithy 113 Host Defense Factors Obstructive Uropathy - UPJ, UVJ, PUV - Ectopic ureter Ureterocele Ureteric reflux - <1% of children with first UTI - Slightly higher in males

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Dr. Mohamed Leithy 114 Evaluation of UTI History Frequency and type of UTI A febrile - febrile Symptomatic - asymptomatic Voiding history How many voids/day Urgency, frequency, enuresis Bowel habit history

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Dr. Mohamed Leithy 115 Treatment of UTI in Children Antibiotics Antipyretic Intravenous fluids Follow-up culture after 2 weeks Antibiotic prophylaxis if VUR present Management of underling causes Obstruction- Reflux- Stones Management of voiding dysfunction Neurogenic Bladder

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Dr. Mohamed Leithy 117 8-Pediatric Nephrolithiasis Uncommon Associated with Metabolic disorders: Cystinuria Primary hyperoxaluria Hypercalciuria Renal tubular acidosis Chronic infection Morphological anomalies of UT

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Dr. Mohamed Leithy 118 Multiple stones in lower moieties of Duplex system kidney

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Dr. Mohamed Leithy 119 Conservative Treatment: High fluid intake Dissolution of uric acid stones Antibiotics for infected stones Definite Treatment: ESWL PCNL URS Surgery Management of metabolic disorders

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Dr. Mohamed Leithy 120 9-Intersex Ambiguous Genitalia ?? ???? ???? ?? ??? ????

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Dr. Mohamed Leithy 121 10-Pediatric Urological Oncology ?? ???? ???? ?? ??? ????

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Dr. Mohamed Leithy 122 Thank you. Bye