Bullying has a potential role in pediatric lower urinary tract symptoms.

PURPOSE: National statistics estimate that a quarter of American school children are regularly bullied, making this issue the main parental concern and the leading form of school violence. To our knowledge no study in the literature has examined the association of bullying with lower urinary tract symptoms. We evaluated the relationship between being bullied and lower urinary tract symptoms in the pediatric population. MATERIALS AND METHODS: We accrued 100 patients from a pediatric urology practice in prospective case-control fashion. The degree of lower urinary tract symptoms was determined by the voiding severity score obtained by a single pediatric urologist. Using the Peer Relations Questionnaire and a thermometer scale we surveyed participants for evidence of victimization from bullying and school related anxiety. We then correlated voiding symptom severity with the degree of bullying. RESULTS: After applying our study exclusion criteria we examined and analyzed data on 38 control children without lower urinary tract symptoms and on 38 children with lower urinary tract symptoms. Mean age was similar in the 2 groups. There were more females in the group with lower urinary tract symptoms (22 vs 13). Mean case voiding severity score was 3.82 (range 2 to 5). As measured by Bullied Index Score the degree of being bullied was significantly higher in the case group (4.76 vs 1.95, p <0.001), as was the anxiety level estimated by the thermometer score (3.68 vs 0.97, p <0.001). We also found that physical forms of bullying accounted for worse voiding severity scores (4.56 vs 3.67, p <0.01). CONCLUSIONS: To our knowledge our study is the first to show that 1) bullying is significantly associated with pediatric lower urinary tract symptoms and 2) physical forms of bullying accompany worsened symptoms.

Untethering an unusual cause of kidney injury in a teenager with Down syndrome.

Acute kidney injury (AKI) is characterized by the acute nature and the inability of kidneys to maintain fluid homeostasis as well as adequate electrolyte and acid-base balance, resulting in an accumulation of nitrogenous waste and elevation of serum blood urea nitrogen and creatinine values. Acute kidney injury may be a single isolated event, yet oftentimes, it results from an acute chronic kidney disease. It is critical to seek out the etiology of AKI and to promptly manage the underlying chronic kidney disease to prevent comorbidities and mortality that may ensue. We described a case of a 16-year-old adolescent girl with Down syndrome who presented with AKI and electrolyte aberrance.Abdominal and renal ultrasounds demonstrated a significantly dilated bladder as well as frank hydronephrosis and hydroureter bilaterally. Foley catheter was successful in relieving the obstruction and improving her renal function. However, a magnetic resonance imaging was pursued in light of her chronic constipation and back pain, and it revealed a structural defect (tethered cord) that underlies a chronic process that was highly likely contributory to her AKI. She was managed accordingly with a guarded result and required long-term and close monitoring.

Chemotherapy Refractory Spindle-Cell Rhabdomyosarcoma of the Bladder Treated With Consolidative Ovarian-Sparing Radical Surgery.

We present a case of chemotherapy refractory spindle cell rhabdomyosarcoma of the lower urinary tract in a 15-month-old female that ultimately required consolidative surgery with cystectomy, urethrectomy, ovarian-sparing hysterectomy, bilateral salpingectomy, anterior vaginal wall resection, and bilateral pelvic lymph node dissection. Genitourinary reconstruction was performed by ileal conduit creation and vaginoplasty. After completion of her maintenance postoperative chemotherapy regimen, the patient has remained disease-free for approximately 27 months.

Survival of nonseminomatous germ cell tumors in pediatric patients and young adults - A stage group stratified analysis.

INTRODUCTION: Testicular germ cell tumors, particularly nonseminomatous germ cell tumors (NSGCT), comprise the most common solid malignancy in male children and younger adults. While these patients experience excellent survival outcomes, few studies have characterized their survival by age. Thus, we aimed to characterize the relative survival of NSGCT by age, stratifying patients by stage group. METHODS: Using the Surveillance Epidemiology and End Results (SEER) database, we divided patients with NSGCT into pediatric patients and adolescents (<19 years), young adults (19-30 years), and older adults (>30 years). Survival analysis, using Cox proportional hazards models and Kaplan Meier curves, described overall and cancer-specific survival (CSS) of each age category for Stage I-III NSGCT by stage group. RESULTS: A total of 14,786 patients met inclusion criteria and comprised the age groups <19 years (N=1,287), 19 to 30 years (N=7,729), and >30 years (N=5,770). Stage group distribution at presentation was similar between each group. Survival analysis demonstrated no differences in cancer-specific survival (CSS) among Stage I or II NSGCT. However, among Stage III tumors, multivariable models noted worse CSS in patients >30 years (HR=3.35 (95%CI: 1.45-7.73), P=0.005) and those 19-30 years (HR=2.28 (95%CI: 0.99-5.21), P=0.053) compared to pediatric and adolescent patients. CONCLUSIONS: Younger NSGCT patients experience excellent oncologic outcomes compared to their older counterparts. These survival differences by age group are largely driven by differential survival among Stage III neoplasms. Furthermore, our report lends additional evidence that age is an important prognostic factor in advanced NSGCT, including pediatric and adolescent patients.

Evaluation of consistency between physician clinical impression and 3 validated survey instruments for measuring lower urinary tract symptoms in children.

PURPOSE: Since many children with lower urinary tract symptoms are treated based on history and physical, it is important to know which symptom survey correlates best with the physician clinical impression. We evaluated 3 tools that have been demonstrated to predict severity of lower urinary tract symptoms, the Dysfunctional Voiding Symptom Score, the Akbal survey and the Nelson survey. Total scores from each survey were compared to clinical impression. MATERIALS AND METHODS: Participants consisted of 36 males and 35 females referred to our pediatric urology center for lower urinary tract symptoms. A total of 37 children 4 to 10 years old completed the Dysfunctional Voiding Symptom Score with the help of their parents, and 34 of these parents completed the Akbal survey. A total of 35 children 11 to 17 years old completed the Nelson survey. Scores from the 3 instruments were compared to the clinical impression of a pediatric urologist using rank correlation (Kendall's tau-b test). RESULTS: Mean total symptom scores were increased relative to physician rating for all 3 surveys. Symptoms reported by younger children using the Dysfunctional Voiding Symptom Score correlated better with physician rating of symptom severity (tau-b 0.43) compared to symptoms reported by parents using the Akbal survey (tau-b 0.41). Older children reporting symptoms using the Nelson survey had the strongest correlation with physician clinical impression (tau-b 0.48). CONCLUSIONS: All 3 surveys were statistically significantly correlated with the physician impression of severity for lower urinary tract symptoms, with the Nelson survey being the most accurate.

Persistent motor deficits predict long-term bladder dysfunction in children following acute transverse myelitis.

PURPOSE: We determined whether motor and bladder recovery are correlated in children with acute transverse myelitis. MATERIALS AND METHODS: From 1995 to 2004, 14 children (8 males and 6 females) with acute transverse myelitis were retrospectively evaluated to determine if there was a correlation between motor and bladder recovery following disease onset. RESULTS: During the acute phase of the disease, all patients experienced lower extremity motor deficit and bladder dysfunction. Full motor recovery was associated with full bladder recovery, and no motor recovery was related to no bladder recovery. Partial motor recovery was associated with either no or partial bladder recovery. CONCLUSIONS: Motor and bladder recovery were related in our patients with transverse myelitis. Children with no motor recovery did not experience bladder recovery. No significant bladder recovery was seen beyond 4 months in our patients.

Urinary ascites secondary to forniceal rupture in a child with the Prune Belly Syndrome.

Despite adequate bladder catheterization, a neonate with Prune Belly Syndrome developed urinary ascites secondary to forniceal rupture. Treatment consisted of bilateral cutaneous pyelostomies. Even though most children with Prune Belly Syndrome respond to lower urinary tract drainage, a cutaneous pyelostomy may be necessary when the ureters are tortuous and do not drain adequately following bladder decompression.

Management of urethral catheter knot in a neonate.

To accommodate the small size of the infant urethra, finer, more flexible tubes are often used for urinary catheterization in the pediatric intensive care units. These tubes have the ability to knot in the bladder, occasionally requiring surgical removal. The mechanism of knotting appears to result from excessive intravesical catheter coiling, and as the bladder decompresses the catheter tip can migrate through a coil thereby creating a knot. Review of the literature from 1975 to 2000 identified 19 cases of urethral catheter knotting in the pediatric bladder with two reports of prostatic urethral involvement. Herein, we describe the first reported instance of catheter knotting within the penile urethra and describe the surgical technique employed for its removal.

Genital hair strangulation in an uncircumcised boy.

Penile strangulation injury due to a coil of hair acting as a tourniquet is an uncommon injury in boys that has severe potential complications if diagnosis is delayed. We report the first such case in an uncircumcised boy. The purpose of this report is to call attention to hair as a potential source of injury in the pediatric population. The pathophysiology and management of these injuries are presented.

Urodynamics in a patient with Werdnig-Hoffman disease.

Werdnig-Hoffman Disease (WHD) is a rare type of spinal muscular atrophy which causes progressive deterioration of the lower motor neurons of the spinal cord and the brainstem. To our knowledge we report the first case of neurogenic bladder documented on urodynamic studies of a patient with WHD.

Anatomic variants associated with newborn circumcision complications.

OBJECTIVE: Circumcision is one of the commonly performed procedures on males in the United States, Canada, Australia, and the United Kingdom. The association of minor anatomic variations of the newborn genitalia in patients with minor circumcision complications has not been previously examined. In this study, we looked for an association between subtle genital anatomic variations and newborn circumcision complications. MATERIALS AND METHODS: Over an 18-month period, children presenting for circumcision revision were examined for minor variations in genital anatomy. Children referred for other urological problems during the same period comprised the control group. The same physician evaluated all of the children. RESULTS: During this period, 68 children were evaluated for possible circumcision complications. A confirmed complication was present in 57 infants. Patients with a minor circumcision complication were found to have a 9-fold higher incidence of a prominent suprapubic fat pad, penoscrotal webbing, or being a premature infant as compared to the control group. CONCLUSIONS: Subtle anatomic variations may be associated with a higher incidence of circumcision complications. Physicians performing newborn circumcisions should thoroughly examine the genitalia for these anatomic variations prior to the procedure in order to reduce potential complications.

Urethral prolapse: four quadrant excisional technique.

BACKGROUND: Urethral prolapse is a condition that occurs when urethra mucosa evaginates beyond the urethra meatus, resulting in vascular congestion and edema of the prolapsed tissue. Young females with this clinical entity often present with peri-vaginal bleeding and swelling. Urethral prolapse can be diagnosed by its typical clinical appearance and should not be confused with other causes of peri-vaginal bleeding, most importantly, sexual abuse. CASE: We retrospectively evaluated the charts of three girls, ages 4, 6, and 8, who presented complaining of vaginal blood spotting. On examination, a ring of congested, edematous tissue was seen prolapsing through the urethral meatus in each patient. All patients did not respond to medical management and required surgical removal of the tissue. We herein discuss and evaluate their management and our four quadrant excisional technique. CONCLUSION: Urethral prolapse can be definitively diagnosed without laboratory or radiographic evaluation by demonstrating that the edematous tissue surrounds the meatus circumferentially. Initial treatment consists of parental reassurance, observation, and warm soaks. If the prolapse does not demonstrate improvement, excision of the prolapsing tissue may be necessary. We believe that our surgical technique facilitates removal of the prolapsed tissue and anastomosis of the residual urethral mucosa.

The surgical treatment of labial adhesions in pre-pubertal girls.

STUDY OBJECTIVE: A review of our experience with the surgical treatment of labial adhesions refractory to medical treatment. DESIGN: Retrospective review. SETTING: University tertiary care hospital same-day surgery center. PARTICIPANTS: Nine prepubertal females, age 3-6 yrs, presenting with thick, symptomatic labial adhesions refractory to medical management. INTERVENTION: All patients underwent surgical lysis of labial adhesions under general anesthesia. Adhesions were incised sharply and the cut edges were reapproximated with 7-0 chromic suture by a pediatric urologist (JGB). MAIN OUTCOME MEASURES: Duration of recurrence-free follow-up. RESULTS: No patient had recurrence in an average of 8.6 months of follow-up. Surgery was well tolerated in all cases. CONCLUSION: This technique effectively treats and prevents the recurrence of moderate to severe labial adhesions that are unresponsive to medical therapy.

Urinary dysfunction in children is associated with exposure to environmental tobacco smoke.

OBJECTIVE: Environmental tobacco smoke (ETS) is known to cause significant morbidity across a wide variety of organ systems. The purpose of this study was to examine the relationship of ETS exposure with pediatric urinary dysfunction. PATIENTS AND METHODS: Participants were drawn from a university-based pediatric urology practice throughout the first half of 2011. All patients who presented with a chief complaint of urinary dysfunction were approached to participate (N = 184). Exclusion criteria eliminated all but 71 subjects. Of these, 68 subjects and their parents completed age-appropriate questionnaires on ETS exposure and symptom severity. Data were analyzed using descriptive statistics and relationship between exposure and outcome was evaluated via Spearman correlation analysis. RESULTS: A total of 68 children with no known etiology for their urinary dysfunction were evaluated for symptom severity and ETS exposure. Participants demonstrated a significant positive correlation (rho = 0.592 for those 4-10 years; rho = 0.415 for those 11-17 years) between ETS exposure and severity of their urinary symptoms. CONCLUSIONS: These data indicate a positive relationship between ETS exposure and urinary dysfunction among children with no other obvious etiology for their symptoms. Physicians should inform parents of the potential dangers of childhood ETS exposure, including the possible relationship with urinary dysfunction.

Benign testicular enlargement due to diffuse interstitial fibrosis associated with cryptorchid testis in 11-month-old boy.

Benign testicular enlargement secondary to diffuse interstitial fibrosis is a rare clinical entity, especially in pediatric patients. To our knowledge, this is the first pediatric case reported of benign testicular enlargement due to interstitial fibrosis in a cryptorchid testis. We report a rare case of an 11-month-old boy with a cryptorchid testis found intraoperatively to have an asymmetrically enlarged testis secondary to diffuse, benign interstitial fibrosis of the testis. Additionally, we discuss previous case reports of testicular enlargement due to interstitial fibrosis, the potential etiology and the management.

Laparoendoscopic single site orchiopexy.

We report a laparoendoscopic single site orchiopexy in a 2-year-old boy with a right nonpalpable testis. Diagnostic laparoscopy using a 5-mm port revealed a right intraabdominal testis. The 5-mm port site was extended to accommodate the smallest commercially available triport, and orchiopexy was performed. The operative time was 55 minutes, and the estimated blood loss was minimal. There were no complications, and surgical and cosmetic results were excellent. Laparoendoscopic single site surgery is a feasible technique for orchiopexy of the nonpalpable testis.

Laparoendoscopic single-site varicocele repair in adolescents-initial experience at a single institution.

BACKGROUND AND PURPOSE: Laparoendoscopic single-site (LESS) varicocele repair is a modification of standard laparoscopic varicocele repair that uses a single port. We describe our initial experience with LESS varicocele repair. PATIENTS AND METHODS: During a 1-year period, all patients who presented for varicocele repair underwent LESS repair. We evaluated our initial experience by determining operative time, operative and postoperative complications, and overall cost of the procedure. RESULTS: A total of 11 adolescents underwent LESS varicocele repair. There were no intraoperative complications, and there were no conversions to open surgery or traditional laparoscopy. Estimated blood loss was minimal, and mean operative time was 66.9 minutes (range 48-91 min). The varicocele was corrected in all cases. During the 4 to 14 month follow-up, there was no recurrence, testis atrophy, or hernia in any patient. One subclinical hydrocele developed postoperatively that has not been repaired. CONCLUSION: Our experience with LESS varicocele repair in adolescents suggests it to be a safe and effective method for varicocele repair in adolescents.