Clinical Profile, Management, and Outcome of Posterior Urethral Valves in Children - Experience from a Tertiary Care Hospital.

Background: Posterior urethral valves (PUV) are the most common obstructive anomaly of the lower urinary tract in children. End-stage renal disease (ESRD) in 17% of the children is due to PUV. The present study helps know the spectrum of the disease, management options, and the outcome in these children. Methods: The present study is a descriptive type of study by review of medical records of all the children presented to the hospital from 2015 to 2019. Profile of PUV includes any abnormality in antenatal ultrasonography (USG), age at presentation, presenting complaints, general condition at the time of presentation, biochemical investigations like serum creatinine and electrolytes at admission, clinical progression during hospital stay and the type of intervention. Outcome variables studied were improvement in the stream and overall well-being of the child, renal function, recurrent urinary tract infections (UTIs). Follow-up period varied from 1 to 6 years. Results: A total of 73 patients were included in the study. The mean age of presentation was 3.4 years. The most common presenting complaints were poor urinary stream and dribbling of urine. Antenatal USG showed abnormality in 23 patients. Renal function was abnormal in 28 patients. Out of 73 patients, 51 underwent endoscopic ablation of valves, 19 underwent vesicostomy, and three patients underwent supravesical diversion. During the follow-up recurrent UTI was observed in 11 patients, 15 patients progressed to chronic kidney disease, and 15% of patients were hypertensive. Mortality in the present study was 4%. Conclusion: PUV includes a spectrum of diseases from mild form to lethal conditions. Early intervention by relieving obstruction may prevent or delay the ESRD; hence, timely intervention is necessary in these children.

Pediatric urethrovaginal reflux: an underestimated cause of urinary incontinence and its successful management.

INTRODUCTION AND HYPOTHESIS: Urethrovaginal reflux (UVR) secondary to vaginal urine entrapment is an unnoticed cause of daytime urinary leakage in toilet-trained girls. Our aim is to emphasize the diagnosis of UVR as a cause of urinary incontinence, its predisposing factors, early detection, and treatment. METHODS: A total of 25 girls aged between 9 and 14 years presented with mixed daytime urinary incontinence from 2019 to 2021. They were evaluated by detailed history, vaginal examination, focused neurological examination, bladder diaries, urine analysis, uroflowmetry, and residual urine assessment. Micturating cystourethrography was also performed in those girls who did not show improvement with a conservative line of management. RESULTS: The parents of these girls were educated about the cause of leakage. They were treated with behavioral modifications, urotherapy, correcting toilet postures, and reverse sitting on the commode. Urethrovaginal reflux was found in 6 of the 25 girls (24%). Their ages were 9, 10, 10, 11, 12, and 14 years respectively. Two girls (10 and 14 years old) had a body mass index more than 25. They all had a typical history of a small quantity of urine leakage 5-10 min (post-micturition dribble) after every void. At follow-up after 12 months, all of them were free from urinary incontinence. CONCLUSIONS: Urethrovaginal reflux should be considered in the differential diagnoses of girls with day-time incontinence. The key to diagnosis is an appropriate and detailed history as it is common for parents or girls to ignore symptoms or fail to report them. Proper voiding instructions and behavioral therapy often resolve the problem.

Retrograde urethrogram - a novel approach to diagnosing a posterior urethral polyp in a neonate.

We present a case of antenatally detected fetal megacystis caused by an obstructing posterior urethral polyp. Antenatal and postnatal ultrasounds showed bladder wall thickening and bilateral hydroureteronephrosis, most marked antenatally. A working diagnosis of posterior urethral valves was therefore made. However, further postnatal assessment with a micturating cystourethrogram (MCUG) combined with a retrograde urethrogram identified a pedunculated urethral polyp as the cause. The addition of a retrograde urethrogram as an adjunct to the MCUG in the diagnosis of posterior urethral polyp has not previously been reported, and in this case provided diagnostic confidence of this rare condition, allowing for definitive surgical planning.

Culture-positive urinary tract infection following micturating cystourethrogram in children.

Objective: To determine the incidence of culture-positive urinary tract infection (UTI) after micturating cystourethrogram (MCUG). We further wanted to identify risk factors for developing a culture-positive UTI following MCUG. Methods: A retrospective review of the available medical records of 500 paediatric patients who underwent MCUG in Perth, Western Australia was performed. Results: Seven (1.4%) patients comprised of four females and three males developed a febrile, culture-positive UTI within 14 days following MCUG. Significant association was found for female patients, patients with neurogenic bladder, and patients with previous culture-positive UTI as developing a culture-positive UTI following MCUG. Multivariate logistic regression determined that patients were more likely to develop culture-positive UTI within 14 days following MCUG if they had a known history of UTI (odds ratio: 5.0, 95% confidence interval: 1.5-17.3, p=0.010) or had a neurogenic bladder (odds ratio: 4.2, 95% confidence interval: 1.0-17.9, p=0.049). Conclusion: The incidence of patients who developed a febrile, culture-positive UTI following MCUG was low at 1.4%. Statistically significant and independent associations for the development of culture positive UTI were found in patients with neurogenic bladder and patients with previous culture-positive UTI. Further prospective studies are necessary to determine necessity of prophylactic antibiotics for high-risk patients, e.g., patients with neurogenic bladder or previous culture-positive UTI.

Radiology reporting of micturating cystourethrograms (MCUGs): What the paediatric urologists want to know.

BACKGROUND: Micturating cystourethrograms (MCUGs) are commonly requested to exclude vesicoureteric reflux (VUR) and bladder outlet obstruction (BOO). Useful additional information including timing and bladder volume at the start of reflux, urethral anomalies and post-void drainage can be obtained from the cystograms, but are not routinely reported by radiologists. OBJECTIVE: The study aim was to retrospectively review MCUG reports against a proposed reporting proforma, and then re-analyse the effect of the proforma on report quality. STUDY DESIGN: A retrospective analysis of paediatric MCUG reports was undertaken from two patient cohorts. Cohorts A (41 reports) and B (51 reports) comprised reports written before (2011-12) and following (2016-17) distribution of the standardised reporting proforma, respectively. Reports were assessed with respect to the parameters outlined on the standardised MCUG reporting proforma, including presence, grade and timing of VUR amongst others. Findings from both cohorts were compared and statistically analysed (p < 0.05 significant) to establish if the proforma influenced the content of reports. RESULTS: Statistically significant improvements were demonstrated in the reporting of: bladder outline normal/abnormal - reported in 92% after the proforma vs 56% before (p < 0.001); urethra normal/abnormal - 87% vs 68% (p = 0.033); contrast volume instilled - 84% vs 61% (p = 0.011); bladder emptying - 69% vs 17% (p < 0.001). In patients with VUR, reporting of VUR timing - 96% vs 33% (p < 0.001) and VUR grade - 91% vs 40% (p = 0.002) were also significantly improved. CONCLUSION: Implementation of a standardised MCUG reporting proforma produced substantial improvements in report quality and consistency, with statistically significant improvements noted in six of seven key features.

The results of different diagnostic imaging studies used in children with urinary tract infection.

Urinary tract infections (UTI) can cause significant renal scarring, which can be complicated by hypertension and renal impairment. This study describes the outcome of different imaging modalities in children with UTI and its relation to age, sex and type of UTI. Our objective was to describe the frequencies of different imaging studies, which were used to investigate children with UTI at King Fahad Hospital (KFH) between the years 2003 and 2008. This is a descriptive study of all children presenting with UTI at KFH from 2003 to 2008. The study population, 100 children , were divided into 3 age groups; first group (> 1 month to 2 years); second group (> 2 to 5 years) , third group (> 5 to 12 years). All enrolled children were confirmed to have had UTI via urinary cultures. Ninety seven (97%) patients underwent renal ultrasonography (US), 77 (77%) had a 99mTc-dimercaptosuccinic acid (DMSA) scan within 2 months of presentation, and 60 (60%) patients underwent micturating cystourethrogram (MCUG), mainly those with an abnormal DMSA scan. A total of 100 patients screened, 10 (10%) were males and 90 (90%) were females, first age group constituted 10%, second age group was 25% , third age groups was 65%. E-coli was isolated in 84% of patients, 60% had recurrent UTI, 45% had pyelonephritis, 48.4% had abnormal renal US, 61% had an abnormal DMSA scan, and 26.6% had abnormal MCUG. UTI can cause significant morbidity in children if not managed properly. Imaging studies are useful in identifying children who require advanced medical intervention; however, such studies should be performed only when indicated.

Displasia renal multiquística: curso clínico y evaluación del riñón contralateral / Multicystic dysplastic kidney: clinical course and prognosis of the contralateral kidney

Introducción: La displasia renal multiquística (DRM) unilateral es una malformación frecuentemente encontrada en el ultrasonido obstétrico. En Colombia no existen publicaciones sobre las características clínicas y el comportamiento de esta enfermedad que permitan sugerir el tipo de estudios que se deben practicar en la fase inicial y en el seguimiento de estos niños. Objetivos: Describir las características clínicas de 40 pacientes con DRM unilateral con énfasis en la evaluación del riñón contralateral (RC) con respecto a sus funciones, tamaño y frecuencia de malformación urológicas asociadas. Metodología: Estudio descriptivo de pacientes menores de 18 años con diagnósticos pre o postnatales de DRM unilateral, atendidos en la consulta externa de nefrología pediátrica del Hospital Infantil Club Noel entre julio de 1997 y diciembre de 2007. Resultados: Se encontraron 40 pacientes. En ellos 88% el diagnóstico se hizo antes de nacer; 55% eran de sexo masculino, con una edad promedio al ingreso de 2 meses (rangos, 1 y 42 meses). En el RC se descubrió hidronefrosis (HN) en 2 casos (5%) y reflujo vesicoureteral (RVU) grados I yII en 3 casos (9%). El cálculo de la filtración glomerular fluctuó entre 81 ml/min/1.73 y 193 ml/min/1.73 (media, 105). Sólo uno de los 38 renogramas fue anormal e informó la presencia de una cicatriz renal. En el control ecográfico de 31 pacientes los quistes desaparecieron en 13 y persistían en 18, con una media de 60 meses (rango, 24 y 132 meses). El tiempo de seguimiento promedio fue 60 meses con un rango entre 15 y 132 meses. Conclusiones: En este grupo de pacientes se encontró buen pronóstico del RC: ninguno presentó disminución de la filtración glomerular y la frecuencia de malformaciones urológicas como la HN y el RVU fue muy baja. El ultrasonido renal (UR) es indispensable en la evaluación inicial y seguimiento de los casos.

Introduction: The multicystic dysplastic kidney (MDK) is a frequent malformation discovered in obstetrical ultrasound. In Colombia, there are no publications on clinical characteristics and follow up studies suggesting initial evaluation and follow up in these children. Objectives: To describe the clinical characteristics of 40 patients with unilateral MDK, with emphasis in the evaluation of the contra-lateral kidney (CK) regarding function, size, and associated urological malformations. Methodology: A review of cases of patients under 18 years of age with prenatal or postnatal diagnosis of unilateral MDK that attended the Pediatric Nephrology outpatient clinic at Hospital Infantil Club Noel in the city of Cali from July 1997 to December 2007. Results: A total of 40 patients were found. In 88% of these, diagnosis of unilateral MDK was done prenatally; of these, 55% were males with a mean age of 2 months of age (range 1 to 42 months). Evaluation of contra-lateral kidney showed: hydronephrosis (HN) in 2 cases (5%), vesicouretheral reflux (VUR) grades I and II in 3 cases (9%). Glomerular filtration fluctuated between 81 ml/min/1.73 and 193 ml/min/1.73 (mean 105). Radioisotope renography was performed in 38 patients and only one patient was reported with renal scar. Follow up with renal ultrasound revealed that renal cysts disappeared in 13 patients and persisted in 18 with a media of 60 months (range 15 to 132 months). Conclusions: In this group of patients, a good prognosis of the CK was found: none presented decline of the glomerular filtration rate and frequency of urological malformations as HN and VUR was very low.