Dr. Michael P. Leonard MD, FRCSC, FAAP
Professor of Surgery
University of Ottawa
Urinary Tract Infections

 Caused by gut bacteria
 E. coli most common
 Ascend via urethra to bladder and kidneys
 Presentation varies with age:
 Infants – fever, lethargy, diminished feeding, failure to
thrive, diarrhea, vomiting
 Children – frequency, urgency, dysuria, wetting, gross
hematuria, abdominal pain, fever
Urinary Tract Infections

 Incidence
 < 1 yr – more common in males (peak 6 months)
 Increased in uncircumcised males (10x)
 > 1 yr – more common in females (peak 2-3 years)
 School age children:
 1.2% males
 5% females
Urinary Tract Infections
Diagnosis

 Obtain urine sample for urinalysis / culture
 Methods of obtaining urine:
 Infant = bag urine, catheterized urine
 Child = midstream urine, catheterized urine
 Beware contamination!
 Urinalysis:
 +ve nitrite, leucocyte esterase, RBC
 Culture:
 > 108 CFU/l of one organism
Urinary Tract Infection
Treatment

 Antibiotics
 IV ± hospital admission if systemically unwell
(especially infants)
 IV ampicillin / cephalosporin and gentamicin initially
 Oral if reasonably stable and not toxic
 Trimethoprim, TMP-SMX, nitrofurantoin, cephalosporin
 Broad spectrum to cover gram negative and some
gram positive (Staph, Enterococcus)
 No worry regarding anaerobes
 Duration of treatment 7-14 days depending on clinical
scenario
Urinary Tract Infection
Investigation

 AAP Guidelines 2011
 First febrile UTI 2-24 months = renal ultrasound
 VCUG only if abnormal US or second febrile UTI
 “Top down approach”
 DMSA scan to document evidence of APN
 VCUG only if findings APN on DMSA
Urinary Tract Infection
Referral ?

 Consider referring the following to specialist:
 GU anomalies on US and/or VCUG
 VUR, hydronephrosis, ureterocoele
 Concern regarding neurogenic features
 Abnormal lower back exam
 VACTERL syndrome
 Recurrent UTI in the otherwise normal child if not
responsive to timed voiding and management of
constipation
Vesicoureteric Reflux
(VUR)

 Urine washing back to kidneys from bladder = VUR
 Increases risk of renal infection if UTI
 Renal infection may lead to scarring
 Associated with renal dysplasia ± renal scarring
 More common in males < 1 yr and females > 1 yr
 Seen in 35-50% of children with UTI
 Diagnosed by VCUG
VUR - Grading

VUR - Management

 Prevent UTI by antibiotic prophylaxis
 Follow at intervals for resolution
 Follow-up comprises US and Cystogram
 Surgical intervention:
 Breakthrough UTI
 New scarring
 Parental preference
 Surgical options:
 Minimally invasive (STING)
 Open ureteric reimplantation
VUR - Surgery

Nocturnal Enuresis

 If child wets bed at ≥ 5 years of age = NE
 Common developmental issue:
 15% of 5 year olds  1% of 15 year olds
 15% spontaneously resolve annually
 Family history common (genetic component)
 Several theories abound:




Developmental delay of normal maturation
Deep sleep patterns
Bladder over-activity at night
Lack of nocturnal ADH production
Nocturnal Enuresis
Classification

 Primary nocturnal enuresis (PNE)
 No day time symptoms
 No dry interval 6 months or longer
 Secondary nocturnal enuresis
 As above but with dry interval > 6 months at some
time in past
 Complicated nocturnal enuresis
 Day time symptoms ± UTI
Nocturnal Enuresis
Evaluation (Rushton, J Pediatr)

NOCTURNAL ENURESIS
Evaluation
UNCOMPLICATED
Primary onset
Normal daytime habits
Urinalysis / culture
Physical exam
COMPLICATED
Dysfunctional elimination
UTI
+ve
Renal US
VCUG
**
- ve
No further studies
Urodynamics
Neurosurgery consult
** minority of patients
Nocturnal Enuresis:
Treatment

 Three primary treatment modalities:
 Observation:
 fluid restriction, double void at night, star charts
 Conditioning therapy:
 bedwetting alarm system
 Pharmacotherapy:
 DDAVP
Daytime Wetting

 Toilet training complete at 2-3 years
 5% of 5 year olds experience occasional daytime
wetting
 Causes:




anatomical (ectopic ureter, epispadias)
pseudo-incontinence (vaginal voiding)
neurogenic (spina bifida)
dysfunctional elimination (DE)
Daytime wetting - DE

 Bladder problems:
 overactive bladder (OAB)
 hypoactive bladder
 detrusor / sphincter incoordination
 Bowel problems:
 fecal impaction
 colonic distension  hypotonicity
  pelvic floor / sphincter tone
Daytime wetting -Rx

 Anatomical:
 surgery (i.e. hemi-nephrectomy)
 Pseudo-incontinence:
 change of voiding posture
 Neurogenic:
 improve storage (anti-cholinergics)
 improve emptying (IMC)
Daytime wetting -Rx

 Dysfunctional elimination:




improve bowel function (diet)
timed voiding (q 2-3h)
biofeedback
medication:
 anti-cholinergics
 -blockers
 psychotherapy
NORMAL SCROTAL
ANATOMY
Acute Scrotum

 Case study #1:






14 year old boy with right hemi-scrotal pain
Duration of pain = 6 hours
No history of trauma or LUTS
What else do you need to know??
What is your differential diagnosis??
Are any ancillary investigations useful??
TESTIS TORSION
• Clinical Presentation:
– pubertal boy (12-16 years)
– abrupt onset lower abdominal / testicular
pain
– pain usually severe, unrelenting
– associated with nausea, vomiting, anorexia
– prior history of trauma (minor)
– previous episodes which resolved
TESTIS TORSION
• Physical Findings:
– elevated testis with abnormal lie
– “knotting” of spermatic cord
– absent cremasteric reflex
– scrotal erythema / edema
– reactive hydrocoele
– “bell clapper” contralaterally
TESTICULAR TORSION
DIFFERENTIAL DIAGNOSIS
• Emergent:
– Testicular torsion
– Traumatic testicular rupture
– Incarcerated inguinal hernia
– Peritonitis with patent processus vaginalis
– Fournier’s gangrene
DIFFERENTIAL DIAGNOSIS
• Non-emergent
– Torsion of testicular or epididymal
appendage
– Acute epididymo-orchitis
– Idiopathic scrotal edema
– Henoch-SchÖnlein purpura
– Hydrocoele / hernia
– Acute hemorrhage into testicular neoplasm
TESTIS TORSION
• Laboratory Studies:
– urinalysis typically negative, but may
contain WBC’s
– CBC and differential not useful
discriminator
• Radiographic Studies:
– not indicated if typical clinical case with
duration of pain < 12 hours!
TESTIS TORSION
• When should radiographic studies be
considered?
– duration of pain > 12 hours and / or
diagnosis is uncertain
• Which study is indicated?
– Color Doppler ultrasonography
TESTIS TORSION
• Color Doppler ultrasound
– readily available in most locales
– positive finding = no or decreased flow in
affected testis
– sensitivity 91% (range 82-100%)
– pitfalls:
•small (infant) testis = no flow
•peri-testicular flow due to inflammation
around torted testis
TESTIS TORSION
TESTIS TORSION
• Time is of the essence!
– salvage is usually successful within 6-8
hours after onset of pain
– salvage possible up to 24 hours, but rate
declines exponentially
– pain > 24 hr invariably = necrotic testis
(very rare exception!)
TESTIS TORSION
• Surgical Results:
– salvage rates approximate 60-70%
– factors contributing to missed torsion:
•patient delay in presentation = 80%
•physician mis-diagnosis = 20%
– suggests need for education through school
health / physical education programs
TESTIS TORSION
EXTRA-VAGINAL TESTIS
TORSION (NEONATAL)
• Occurs ante-natally (in utero) or in the
first week post-natally
• Testis and tunica vaginalis rotate
together (inadequate scrotal wall
fixation)
• Presents as painless scrotal swelling
with scrotal erythema / bluish
discoloration
• Testis rarely viable - ? need for surgery
TORSION OF TESTICULAR
APPENDAGE

 Case study #2:
 8 year old boy
 2 day history right hemiscrotal pain
 Anything else you want to know??
TORSION OF TESTICULAR
APPENDAGE
• Clinical presentation:
– 7-12 year old (pre-pubertal) boy
– pain more indolent, not as severe as testis
torsion
– pain may resolve with rest
– usually no accompanying nausea or
vomiting
TORSION OF TESTICULAR
APPENDAGE
• Physical Exam:
– early
•testis has a normal lie
•maximal tenderness at upper pole
•tender nodule may be seen (“blue dot”) or felt
– late
•progressive scrotal erythema and edema
•reactive hydrocoele
•more difficult to differentiate from testis
torsion
TORSION OF TESTICULAR
APPENDAGE
• Laboratory investigations:
– urinalysis usually negative
• Radiographic evaluation:
– Color Doppler ultrasound shows increased
flow to upper pole testis / epididymis.
May also see small hypoechoic torted
appendage.
– Radionuclide scan shows increased blood
flow to the affected hemi-scrotum
TORSION OF TESTICULAR
APPENDAGE
• Treatment:
– limit physical activity
– analgesia
– expect an initial increase in swelling /
redness with resolution over 7-10 days
– surgery only necessary if diagnosis in
doubt and / or pain not well managed by
analgesics
– no long term sequelae re: testicular
function
EPIDIDYMITIS

 Case study #3:





10 year old boy
2 day history left hemiscrotal pain and swelling
LUTS for 3 days
Febrile (39.5C)
Any further investigations / information required??
EPIDIDYMITIS
• Bacterial or chemical inflammation of
epididymis
• Rare in pre-pubertal boys
– if occurs, consider urinary tract
abnormality such as ectopic ureter, PUV,
stricture
• Common in sexually active adolescents
– usually Chlamydia, rarely gonococcus
EPIDIDYMITIS
• Clinical presentation:
– pain insidious in onset
– irritative lower urinary tract symptoms
may precede onset of pain
– urethral discharge if STD
– may be septic
EPIDIDYMITIS
• Physical examination:
– elevated temperature
– scrotal edema, erythema, tenderness,
reactive hydrocoele, tender prostate
– early on epididymis may be increased in
size and exquisitely tender
– in later stages, loss of anatomical
landmarks with diffuse tenderness
– Prehn’s sign unreliable!
EPIDIDYMITIS
• Laboratory investigations:
– urinalysis may show pyuria, hematuria,
bacteria
– urine culture may be positive
• Radiographic evaluation
– only necessary in pre-pubertal child with
concurrent UTI
– renal ultrasound and VCUG recommended
– if Color Doppler US obtained will show
increased blood flow to affected side
Scrotal Mass

 Need to distinguish where mass is coming from:
 Processus vaginalis:
 Indirect inguinal hernia
 Communicating or non-communicating hydrocoele
 Testicular adnexae:
 Epididymal cyst / spermatocoele
 Varicocoele
 Testis
 Testicular tumour
Scrotal mass in children

Hernia - Hydrocoele
Embryology

 As testis descends through inguinal canal into
scrotum:
 carries along a tongue of peritoneum (processus
vaginalis)
 normally communication of processus with
peritoneum closes
 leaves potential space (tunica vaginalis) over anterolateral testis
Hydrocoele - Hernia
Anatomy

Hernia - Hydrocoele
Management

 Communicating hydrocoele:
 may resolve spontaneously < 2 yr.
 if persists > 2 yr.  repair
 Indirect inguinal hernia:
 repair at any age
 risk of incarceration small but real
Non-communicating
Hydrocoele

 Localized collection of fluid in tunica vaginalis
 May be secondary to:
 inflammatory process
 trauma, infection, torsion
 tumor
 If concern re: testis  ultrasound
 Surgical intervention is option
Hydrocoele - US

Epididymal Cyst /
Spermatocoele

 Epididymal cyst common in pre-pubertal boys
 Usually seen on scrotal US (non-palpable)
 Benign course
 May grow and become palpable
 Spermatocoele seen in post-pubertal boys
 Blow out of efferent duct  encysted collection of
spermatozoa
 Both conditions may cause cosmetic concerns and
mandate surgical excision
Varicocoele

 15% of adolescents have varicocele:
 rare to have onset prior to adolescence
 >90% left sided
 not likely to spontaneously regress
 Clinical conundrum:
 how can we predict which patients will suffer gonadal
damage from varicocele?
Varicocoele - Anatomy

Varicocoele

 Indications for surgery:
 absolute
 volume difference > 20% on affected side
 caveat re: differential growth and need for more than
one measurement
 relative
 pain
 cosmesis
Varicocoele
Ablation Outcomes

Testicular Tumour

 Rare
 0.5-2/100,000 children
 Presents as painless scrotal mass
 Mass is firm and non-transilluminating
 Caveat re: hydrocoele and inadequate testicular
exam
Testis Tumour
Histology

Testis Tumour

 Obtain serum markers:
 -fetoprotein
  HCG
 Ultrasound of testis:
 confirm diagnosis
 treatment planning
Imaging - Testis Tumour

Surgical Management

Testis Tumour
Radiological Staging

 CXR
 CT abdomen / pelvis
 Bone scan (RMS)
Management - Non RMS

 Orchiectomy and surveillance:
 teratoma / dermoid cyst
 stage I yolk sac tumour
 gonadal stromal tumour (Leydig, Sertoli)
 Chemotherapy (BEP) for yolk sac if:
 stage II-IV disease
 relapse stage I
 Limited role for RPLND in yolk sac
Management RMS

 Radical inguinal orchiectomy
 Children > 10 yr. undergo ipsilateral RPLND before
chemotherapy
 Chemotherapy in all age groups
 Radiotherapy in addition to RPLND in children > 10
yr.
 Higher risk of relapse / spread
Neonatal Abdominal
Mass

 Abdominal mass (75% arise in the GU tract)
 #1-Hydronephrosis (UPJO, VUR, UVJO, PUV)
 #2-Multicystic dysplastic kidney (MCDK)
 #3-Tumours account for 12 %
 Neuroblasoma, CMN and teratoma (sacrococcygeal)
Hydronephrosis
MCDK
Neonatal Abdominal
Mass

 Neuroblastoma is the most common malignancy in
the neonate
 Wilms’ tumour is extremely rare in this age group
 Abdominal mass + hematuria = renal vein
thrombosis
 Girl with abdominal mass + interlabial bulging =
hydrocolpos
 Congenital Mesoblastic Nephroma (CMN) is the
most common renal tumour
Abdominal Mass
After Neonatal Period

 From 1 month to 1 year of age:
 Hydronephrosis – 40%
 Solid masses and tumour – 40%
 Older than 1 year of age:
 Tumour is the most common cause of abdominal mass
Neuroblastoma (NB)

 Most common malignant tumour of infancy
 8% to 10% of all childhood cancers
 Annual incidence 10 cases per 1 million
 Median age at diagnosis: 22 mo
 50% of cases < 2 years of age (75% <4yrs)
(Fortner et al, 1968)
NB - What and Where?

 Tumours of neural crest cell origin:
Cells that form the adrenal medulla and sympathetic
ganglia
 75% are retroperitoneal
50% adrenal
25% sympathetic chain (from neck to pelvis)
NB - Presentation

 Often has systemic symptoms (different from WT)
Fever, abdominal pain or distension, abd mass,
weight loss, anemia, bone pain, proptosis and
periorbital ecchymoses (retro-orbital metastasis)
 Metastases are present in 70% at diagnosis
 VMA (vanillylmandelic acid), HMA (homovanillic
acid)
Elevated in > 90% of the neuroblastomas
24 hr urine collection (catecholamine metabolites)
NB - Imaging

 US is usually the first exam in child with abdominal
mass
 CT or MRI
Both detect extension beyond midline and
hepatic involvement
MRI: better displays the relationship with great
vessels and detects intraspinal extension (tumor
of sympathetic chain)
CT may show calcifications (rare in Wilms
tumor)
NB - Treatment

 Generally based on risk assessment
 Tumour stage
 Grade
 Biochemical risk factors
 Genetic risk factors
 Low-stage favorable
 Higher risk tumor
 Very aggressive tumor
Surgery alone
Adj chemo +/- RT
Autologous bone
marrow transplantation
Wilms' Tumor

 Most common primary malignant renal tumour of
childhood
 Embryonal tumour develops from remnants of
immature kidney
 Annual incidence 7 to 10 cases per million
 Median age 3.5 yrs
 80% diagnosed < 5 yrs of age
 Worldwide sex ratio is close to 1
 (North American girls slightly > boys)
Congenital Anomalies
and WT

 Genitourinary anomalies in 4.5% of WT
 Renal fusion anomalies
 Cryptorchidism
 Hypospadias (Breslow et al, 1993)
 These are common disorders and screening for WT is
not necessary in most children with genital
anomalies
Syndromes and WT

 Without overgrowth:
 Denys-Drash syndrome (DDS)
Male pseudohermaphroditism, renal mesangial sclerosis and
WT ( Drash et al, 1970)
 Aniridia (Found in 1.1% of patients with WT)
 WAGR syndrome
Wilms' tumor, Aniridia, Genital anomalies, mental Retardation
(Clericuzio , 1993)
 Horseshoe kidney (NWTSG found 7 times incidence of WT)
Syndromes and WT

 With overgrowth
 Hemihypertrophy
 May occur alone or with syndromes
 Beckwith-Wiedemann (BWS)
 Perlman
 Soto
 Simpson-Golabi-Behmel
Imaging in WT

 Ultrasound is the first study performed in most
children with an abdominal mass
 Solid nature of the lesion
 CT shows the relationship with other organs
 MRI is the study of choice if extension of tumour into
the inferior vena cava cannot be excluded by
ultrasound
(Weese et al, 1991)
Treatment of WT

 Surgical
Radical nephrectomy
Accurate staging to determine need RT +/- chemo
Exploration of the abdominal cavity
Liver, nodal metastases, peritoneal seeding
Formal exploration of the contralateral kidney
Not necessary with modern imaging
Formal retroperitoneal lymph node dissection not
recommended