Pediatric Urology

Urinary Tract Infections

Urinary tract infections are very common in early childhood, in some studies 15% of boys are affected in the first year of life and up to 50% of all females during a lifetime. The majority of these do not need more than antibiotic treatment and general advice to avoid recurrence such as regular drinking and voiding. When severe, or recurrent, they may indicate the presence of some urinary tract abnormality, and this might warrant further investigation and occasionally surgery. You may contact Dr Ba’Ath for further information about your child’s specific problem.

Dr Ba’Ath produced this video that details non-pharmaceutical methods of prevention of UTIs in children.

Non-pharmaceutical methods for preventing urinary tract infections in children

Hypospadias

A congenital abnormality in the penis that happens in 1 in 200 births so relatively common. In this abnormality, the normal urine opening is along the bottom side of the penis. In most cases it is not far from the normal location but in some cases, it can be further down in the scrotum or even lower. This is usually associated with a hooded foreskin (also called angel circumcision or moon shaped), and a variable degree of bending of the penis.

On the left prior to repair, on the right, post repair. This case done with circumcision

Surgical repair is usually performed at the age of 6-18 months and mostly involves leaving a catheter in for a week and only one stage. Success in less severe cases that requires one stage is in the region of 80-90%. Success means a completely normal looking penis after repair, to the degree that if seen by a non-specialist they would not even recognize the original abnormality or that the child has had surgery. This should achieve the following criteria:

A completely straight penis.
A slit like meatus (urinary opening) in a normal position (not rounded).
Good glans tissue fusion underneath the voiding hole that separates it from the rest of penis shaft.
No visible suture marks.
The foreskin also either needs to be removed (circumcision) or reconstructed according to the family cultural preferences.

Dr Ba’Ath usually does these cases as day case, so you are expected to go home same day. This has been Dr Ba’Ath practice in both the UK and the USA. Many surgeons in the UAE will keep you inpatient for a week. This is culturally driven and might be due to financial motivations on the part of the hospital or the surgeon.

It is important to note that a small percentage of cases might need two or three stage procedures. Complications are possible but usually treatable with another procedure. Below are pictures of cases treated by Dr Ba’Ath. You will be able to see the appearance before and after surgery to know what to expect.

Hydronephrosis

Literally means too much water in the kidney. This usually means that the kidney is swollen with urine. In normal circumstances, the kidney makes the urine slowly at steady rate continuously. As urine is made, it is transported through the ureter straight to the bladder where it is stored. This means that while the kidney is the source of the urine, hardly any urine is stored in the kidney. When the kidney is swollen with urine, this means that either urine is not flowing freely (obstructed), or that it is going back up the ureter from the bladder into the kidney (reflux). It is important to note that it could be neither.

Investigating and managing hydronephrosis is a very large topic and beyond the scope of this website. The condition may need surgery, therefore, it is important to get assessed by a pediatric urologist and that should be done early to avoid kidney damage or other complications.

Pyeloplasty

A procedure done for the treatment of pelviureteric junction obstruction. The procedure can be done open, laparoscopic (keyhole), or with robotics. Laparoscopic surgery offers similar success rates (85%) with less scar, pain and morbidity. Robotic surgery does make the job of the surgeon easier but does not lead to better outcomes. Current instruments in robotic surgery result in a 3-fold increase in incision size. Dr Ba’Ath usually performs this type of surgery laparoscopically.

Urinary Tract Stones

Generally, they are much rarer in children compared to adults. Treatment varies depending on symptoms, size, and location of stones. Two main approaches are usually utilized by Dr Ba’Ath for stone clearance. The first is Extra-Corporeal Shockwave Lithotripsy (ESWL), which is a special machine used to break the stones while they are still inside to smaller pieces so they can come down on their own. The second is using endourology techniques, which utilizes special equipment that goes through the urinary tract to reach, break, and remove the stone. Occasionally, stones can be removed from the urinary tract in the context of another surgery, such as pyeloplasty.

General advice that can be followed to reduce the risk of stone formation is drinking adequate amounts of fluid daily. This is usually between 1200 and 1500 mLs. Reducing salt intake is also helpful. Other measures depend on the type of stone and require special investigations.

Undescended and retractile testicle

Undescended testis (or crypto-orchidism) is a common problem in boys, affecting around 2% of all newborns. It simply means a testis that is not in the right place (scrotum). Often that side of the scrotum is smaller than the normal side. When diagnosed immediately after birth, it has around 50% chance of resolving on its own without any treatment. When persistent, it can lead to reduced testicular growth and fertility potential. Surgery to bring the testis down (orchidopexy or orchipexy) is recommended and should be considered early, at around 6-9 months of age for best results. Around 5-10% require two stage procedures that are usually done laparoscopically (keyhole). The surgery is usually a day case, takes 30-45 minutes and the results are normally excellent.

Retractile testis is a common problem in pediatric urology clinics. The definition of it is a testis that comes in and out of the scrotum but has enough length to reach the scrotum and stay there, at least temporarily. A good hint that this testis is retractile and not undescended is finding the testis in the scrotum during bath time. The testicles should be of normal, symmetrical size. The diagnosis is established by the examination of an experienced pediatric urologist. Retractile testis usually only requires annual checkups and surgery is not required. The most important point when seeking medical attention is differentiating retractile from true undescended testis because the management is very different.

In this video, Dr Ba’Ath explains the difference between retractile and undescended testis.

Other penile abnormalities

Other congenital abnormalities of the penis are commonly seen in children. They include penile torsion (twist), side bends (spiral or lateral chordee), and penoscrotal webbing (a fold of skin between the penis and scrotum that is similar to the web found on duck’s feet) and true buried penis. These are usually discovered in the context of examination for routine circumcision. In such circumstances, it might better to defer the circumcision until later time when the abnormality can be corrected, usually under general anesthesia. This is usually done between 6 and 18 months of age.

Penile torsion is when the penis is twisted around its axis and the hint would be that the dark line on the downside of the penis is not quite in the middle and the slit like urinary hole is not perpendicular on the penis. This is usually skin level problem only and purely of cosmetic concern. Occasionally it can be associated with a side curve in the penis which should be surgically repaired. Repair is recommended at around 6-18 months of age. Routine circumcision is better deferred in such circumstances.

Buried penis is when the foreskin is so large it literally buries the penis under it. This is usually discovered before circumcision. The shape of the foreskin will not be amenable to routine circumcision and therefore it is usually recommended the child undergoes reconstruction and circumcision at around 6-18 months of age. A true buried penis is shown in the picture below. Usually significant ballooning of the area happens when voiding.

Concerns about penis size are also a common complaint. Most of these need reassurance and education only. The penis tends to grow faster than the rest of the body during two stages in life: the first around 3-4 months which is known as “mini-puberty”, and the second at puberty.

Dr Ba’Ath produced this educational video about penis size in children.

Labial Fusion

A common problem in young girls. The two labia minora (the two inside red folds in the female genitalia) are fused together which gives an appearance of one opening instead of two normally (one for urine and one for the vagina). The fusion is completely in front of the hymn, also known as “the membrane of virginity”, which can be culturally significant. The fusion therefore or its treatment does not affect the hymn at all. The difference between genitalia appearance with, and without labial fusion is shown in the picture below (fusion on the left).

It is usually discovered during a routine examination. Sometimes it can present with burning or itching or urinary tract infections. Labial fusion can be safely observed, especially in girls who are still in diapers. Treatment usually consists of applying estrogen or steroid cream and is generally harmless but not always effective. Occasionally mechanical separation or scoping of the tract might be recommended.

Dr Ba’Ath produced this video to explain about labial fusion.