Parent and Patient Information System - ESPU

Parent & Patient Information System 06/09/2015 Page1 / 51 Parent and Patient Information System Second Edition published on 06/09/2015 ©2015 - European Society for Paediatric Urology ALL RIGHTS RESERVED. This book contains material protected under International Copyright Laws and Treaties. Any unauthorized reprint or use of this material is prohibited. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system without express written permission from the author / publisher.

Parent & Patient Information System 06/09/2015 Page2 / 51 Main summary Chapter 1 - Urinary Tract Infection - a common problem in children................... 3 Chapter 2 - Hydrocele, Hernia and Undescended Testis....................................... 7 Chapter 3 - Testicular torsion - a serious cause of scrotal pain......................... 11 Chapter 4 - Diagnotic Tools Used in Pediatric Urology....................................... 16 Chapter 5 - Structure, Development and Function Of Urinary System.............. 27 Chapter 6 - Ultrasound - a noninvasive diagnostic tool ...................................... 31 Chapter 7 - Penile Problems................................................................................... 33 Chapter 8 - A Child´s Kidneys and Urinary Tract ................................................. 38 Chapter 9 - Bedwetting (Enuresis)......................................................................... 43 Chapter 10 - Bladder problems/daytime incontinence ........................................ 45 Chapter 11 - Constipation....................................................................................... 49

Parent & Patient Information System 06/09/2015 Page3 / 51 Chapter 1 - Urinary Tract Infection - a common problem in children Urinary tract infections (UTIs) are common in kids. By 5 years old, about 8% of girls and about 1-2% of boys have had at least one. In older kids, UTIs may cause obvious symptoms such as burning or pain with urination. In infants and young children, UTIs may be harder to detect because symptoms are less specific. In fact, fever is sometimes the only sign. Most UTIs are caused when bacteria infect the urinary tract. An infection can occur anywhere along this tract, but the lower part — the urethra and bladder — is most commonly involved. This is called cystitis. If the infection travels up the ureters to the kidneys, it's called pyelonephritis and it's generally more serious. Although bacteria aren't normally found in the urine, they can easily enter the urinary tract from the skin around the anus (the intestinal bacteria E. coli is the most frequent cause of UTIs). Many other bacteria, and some viruses, can also cause infection. Rarely, bacteria can reach the bladder or kidneys through the blood. Bacterial UTIs are not contagious. UTIs occur much more frequently in girls, particularly those around the age of toilet teaching, because a girl's urethra is shorter and closer to the anus. Uncircumcised boys younger than 1 year also have a slightly higher risk of developing a UTI. Other risk factors for developing a UTI may include an abnormality in the structure or function of the urinary tract, an abnormal backward flow (reflux) of urine from the bladder up the ureters and toward the kidneys. This condition, known as vesicoureteral reflux (VUR), is present in about 30% to 50% of children with a UTI. Furthermore poor toilet and hygiene habits, the use of bubble baths or soaps that irritate the urethra, and family history of UTIs are additional risk factors. UTIs are highly treatable, but it's important to catch them early. Undiagnosed or untreated UTIs can lead to kidney damage. Signs and symptoms of UTIs vary depending on the child's age and on which part of the urinary tract is infected. In younger children and infants, the symptoms may be very general. The

Parent & Patient Information System 06/09/2015 Page4 / 51 child may seem irritable, begin to feed poorly, or vomit. Sometimes the only symptom is a fever that seems to appear for no reason and doesn't go away. In older kids and adults, symptoms can reveal which part of the urinary tract is infected. In a bladder infection, the child may have pain, burning and stinging sensation when urinating. An increased urge to urinate or frequent urination is another sign. Wetting problems, even though the child is toilet trained may occur. Low back pain or abdominal pain in the area of the bladder are additional symptoms. Last but not least urine may look cloudy or contain blood and foulsmelling. Many of these symptoms are also seen in a kidney infection, but the child often appears more ill and there is more likely to be fever with shaking chills, pain in the side or back, severe fatigue, or vomiting. In infants and toddlers, frequent diaper changes can help prevent the spread of bacteria that cause UTIs. When kids begin to self-care, it's important to teach them good hygiene. After every bowel movement, girls should remember to wipe from front to rear to prevent germs from spreading from the rectum to the urethra. Kids should also be taught not to "hold it in" when they have to go because urine that remains in the bladder gives bacteria a good place to grow. School-age girls should avoid bubble baths and strong soaps that might cause irritation, and they should also wear cotton underwear instead of nylon because it's less likely to encourage bacterial growth. Other ways to decrease the risk of UTIs include drinking enough fluids and avoiding caffeine, which can irritate the bladder. In case of a child diagnosed with VUR the doctor's treatment plan to prevent recurrent UTIs should be followed strictly. Most UTIs are cured within a week with proper medical treatment. Recurrences are common in certain kids with urinary abnormalities, those who have problems emptying their bladders (such as children with spina bifida), or those with very poor toilet and hygiene habits. Diagnosis After performing a physical exam and asking about symptoms, your doctor may take a urine sample to check for and identify bacteria causing the infection. How a sample is taken depends on how old your child is. Older kids might simply need to urinate into a sterile cup.

Parent & Patient Information System 06/09/2015 Page5 / 51 For younger children in diapers, a plastic bag with adhesive tape may be placed over their genitals to catch the urine. However, urine that comes in contact with the skin may become contaminated with the same bacteria causing the infection, so a catheter is usually preferred. This is when a thin tube is inserted into the urethra up to the bladder to get a "clean" urine sample. The sample may be used for a urinalysis (a test that microscopically checks the urine for germs or pus) or a urine culture (which attempts to grow and identify bacteria in a laboratory). Knowing what bacteria are causing the infection can help your doctor choose the best medication to treat it. Most children with a UTI recover just fine, but some of them — especially those who are very young when they have their first infection or those who have recurrent infections — may need further testing to rule out abnormalities of the urinary tract. If an abnormality is suspected, the doctor may order special tests, such as an ultrasound of the kidneys and bladder or X-rays that are taken during urination (called a voiding cystourethrogram, or VCUG). These tests, as well as other imaging studies, can check for problems in the structure or function of the urinary tract. Treatment UTIs are treated with antibiotics. The type of antibiotic used and how long it must be taken will depend on the type of bacteria that is causing the infection and how severe it is. After several days of antibiotics, your doctor may repeat the urine tests to confirm that the infection is gone. It's important to make sure the infection is cleared because an incompletely treated UTI can recur or spread.

Parent & Patient Information System 06/09/2015 Page6 / 51 Give prescribed antibiotics on schedule for as many days as your doctor directs. Keep track of your child's trips to the bathroom, and ask your child about symptoms like pain or burning on urination. These symptoms should improve within 2 to 3 days after antibiotics are started. Take your child's temperature once each morning and each evening, and call the doctor if it rises above 101° Fahrenheit (38.3° Celsius), or above 100.4° Fahrenheit (38° Celsius) rectally in infants. Encourage your child to drink plenty of fluids, but avoid beverages containing caffeine, such as soda and iced tea. Kids with a simple bladder infection are usually treated at home with oral antibiotics. However, those with a more severe infection may need to be treated in a hospital to receive antibiotics intravenously (delivered through a vein right into the bloodstream). This may be especially the case when there is an additional abnormality of the urinary tract like obstruction or vesicoureteral reflux.

Parent & Patient Information System 06/09/2015 Page7 / 51 Chapter 2 - Hydrocele, Hernia and Undescended Testis Hydrocele and hernia Hydrocele: It is the painless scrotal fluid collection around the testis. Mainly there are 2 types of hydroceles:  Communicating: The membrane surrounding the testis is in continuity with the abdominal cavity. The fluid in the abdominal cavity drains into the scrotum via this open connection. This abnormality is also the main underlying pathology for development of hernia.  Non-communicating: There is no connection between abdominal cavity and scrotum. This type is mostly seen in adult patients. Testis normally develops in the abdominal cavity and within time migrates downwards into the scrotum. The descent mostly is completed before birth. During its travel, testis sweeps a part of peritoneum (membrane covering the organs in the abdominal cavity) into scrotum that is covering the outer surface of testis. This peritoneal connection between abdominal cavity and scrotum mostly becomes closed before the birth or till the end of the first year of life. In children in whom this connection failed to close, the abdominal fluid can drain into the scrotum by gravity in upright position. This is why the swelling is not so evident in sleeping period but becomes significantly visible in physically active children. If the connection is narrow allowing only passage for fluid, it causes a scrotal swelling which is the finding of fluid collection around testis. Besides this, if the neck of the connection is wider that is allowing the small intestines move forward to scrotum, this is called the hernia. Diagnosis is done by physical examination. The scrotal or inguinoscrotal swelling increasing significantly by crying, abdominal straining is the typical finding. Transillumination method is used to differentiate the hydrocele from hernia. A hand lamp is held beneath the scrotum in a dark room. If the light is clearly seen, it reveals the presence of fluid around testis. If the light is prevented to pass through that means the intestinal segment is present in the scrotum, namely indirect inguinal hernia. In some instances with a doubt in diagnosis, ultrasonography may be helpful.

Parent & Patient Information System 06/09/2015 Page8 / 51 The hernia does not frequently cause problem. However, if the intestine segment which moves to the scrotum is squeezed at the neck of the hernia sac, it becomes an emergent case. Intestine cannot be pushed back into its place, the blood source of this intestine segment becomes strangulated, the intestine becomes obstructed, the scrotum of the child becomes reddish, stretched and tender. The child starts to vomit. This situation must be corrected in a very urgent way. Therefore, not to face with this emergent situation, hernias should be repaired as they are diagnosed. The hydroeceles mostly resolve at the end of the first year of life secondary to the closure of connection. Therefore, newborns those were diagnosed with hydroceles should be followed up to 1 years of age. In children whom scrotal swelling persist, surgical correction should be considered. The diagnosis of hernia is a more serious situation that the closure of connection should not be waited. In children with diagnosis of hernia, surgery should be performed at the earliest time when the medical status of child allows an operation. Surgical success is 99%. However, in emergent surgeries, complication rates increase. Another issue is the presence of hernia on the other side. There is a probability of presence of occult hernia on the contralateral side. The surgical exploration of the other side is a controversial subject and depends on the surgeons’ preference.

Parent & Patient Information System 06/09/2015 Page9 / 51 Undescended testis Testis forms and develops in the abdominal cavity and it migrates downwards to the scrotum. In 3% of newborns, testis is not completely located in the scrotum. In most of these children, testis descends to the scrotum within the first 6 months and in a little percent between 6-12 months. The incidence of undescended testis after the first year of life is approximately 1%. Undescended testis describes the situation that testis is not present in the scrotum. However, if the testis sometimes descends into the scrotum and sometimes moves upwards to inguinal region, it is called ‘retractile (shy) testis’ which is different from ‘true undescended testis’. If a testis cannot be palpated in the scrotum, several scenarios are available: testis may be arrested on its way (inguinal canal) during the descent (true undescended), it may be directed to another location (ectopic testis), may be hanged in abdominal cavity (intraabdominal testis), may be affected in development (atrophic) or it may truly be absent due to intrauterine torsion of the vessels of testis (vanishing testis). In majority of the cases, physical examination is adequate to have the diagnosis. In 20% of cases, the testis can not be palpated. The use of the modern imaging tests as ultrasonography, magnetic resonance imaging and computerized tomography unfortnately do not have additional benefit. Therefore, in cases of nonpalpable testis, laparoscopy is used with the aim of both for diagnosis and a treatment. Laparoscopy, is the investigation of testis in the abdominal cavity by placing a telescopic lens through the umbilicus. Undescended testis may cause problems if left untreated. It may cause fertility (fathering a child) problems. The risk of testicular cancer development is higher than the normal population. Early intervention decreases these risks of infertility and cancer development. In most of the patients with undescended testis, a patent (nonclosed) connection between adominal cavity and scrotum (patent processus vaginalis) is present which has a potential to cause hydrocele or hernia. During operation, this opening is also repaired and testis is fixed to scrotum to prevent torsion. The feeling of an empty scrotum additionally may cause anxiety in cosmetic and psychological aspects.

Parent & Patient Information System 06/09/2015 Page10 / 51 The surgical intervention should be done and completed around the age of 1 (after 6 months). However, if the child has an accompanying hernia, there is no need to wait until this age and child should be operated at the earliest possible time for anesthesia. The most accepted and exact treatment of undescended testis is surgery. An incision made in the inguinal region, testis is released from the attachments around, the present patent processus vaginalis is repaired and testis is placed into the scrotum. In very well selected patients, hormonal treatment may be used for 3-4 weeks. The children in whom hormonal treatment worth to trying have mobile palpable testicles which could be brought to scrotum easily. The success rate of hormonal treatment in true undescended testis is very low. In patients with hydrocele or hernia and who have previous inguinal surgery history, hormonal treatment is not indicated. Hormone treatment may be used before or after the surgery to increase the fertility index. Side effects are enlargement of penis and scrotum, pubic hair growth, darkening of the scrotum skin and increased activity. These side effects are mild and transient.

Parent & Patient Information System 06/09/2015 Page11 / 51 Chapter 3 - Testicular torsion - a serious cause of scrotal pain For most boys, talking seriously about their private parts can be a little embarrassing. And for teen boys, the topic is strictly off-limits — especially in front of their moms. But if you have a son, it's important that he knows to tell you or a health care provider if he ever has genital pain, especially his scrotum or testes. Genital pain is usually nothing more than a mild and fleeting discomfort. But when it's more painful, it can be caused by a very serious condition called testicular torsion. Testicular torsion is a medical emergency that usually requires immediate surgery to save the testicle. About Testicular Torsion Testicular torsion, or testis torsion, occurs when the spermatic cord that provides blood flow to the testicle rotates and becomes twisted, usually due to an injury or medical condition. This cuts off the testicle's blood supply and causes sudden and severe pain and swelling. Testicular torsion requires immediate surgery to fix. If it goes on too long, the testis can be permanently damaged and a boy can risk losing the affected testicle. This problem can happen to males of any age, including newborns and infants, but is most common in 10- to 25-year-olds and teens who have recently gone through puberty. Causes The scrotum is the sack of skin beneath the penis. Inside the scrotum are two testes, or testicles. Each testicle is connected to the rest of the body by a blood vessel called the spermatic cord. Testicular torsion occurs when a spermatic cord becomes twisted, cutting off the flow of blood to the attached testicle. Most cases of testicular torsion occur in males who have a genetic condition called the bell clapper deformity. Normally, the testicles are attached to the scrotum, but in this condition the testicles aren't attached, and therefore are more likely to turn and twist within the scrotum.

Parent & Patient Information System 06/09/2015 Page12 / 51 Testicular torsion also can occur after strenuous exercise, while someone is sleeping, or after an injury to the scrotum. Often, however, the cause isn't known. Symptoms If your son experiences sudden groin pain, call a doctor and get him to a hospital or doctor's office as soon as you can. Testicular torsion is considered a surgical emergency, meaning that when it happens, immediate surgery is needed to save the testicle. Because surgery may be necessary, it's important to not give a boy with testicular pain anything to eat or drink before seeking medical care. If your son has testicular torsion, he'll feel a sudden, possibly severe, pain in his scrotum and one of his testicles. The pain can get worse or subside a bit but generally won't go away completely. Other symptoms may include swelling, especially on one side of the scrotum, nausea and vomiting, and abdominal pain, respectively. Up on inspection one testicle appears to be higher than the other. Sometimes, the spermatic cord can become twisted and then untwist itself without treatment. This is called torsion and detorsion, and it can make testicular torsion more likely to occur in the future. If your son's spermatic cord untwists and the pain goes away, it might be easy to dismiss the episode, but you should still call a doctor. Surgery can be performed to secure the testicles and make testicular torsion unlikely to occur in the future. Diagnosis When you arrive at the hospital or doctor's office, a doctor will examine your son's scrotum, testicles, abdomen, and groin and might test his reflexes by rubbing or pinching the inside of his thigh. This normally causes the testicle to contract, which probably won't happen if he has a testicular torsion.

Parent & Patient Information System 06/09/2015 Page13 / 51 The doctor also might perform tests to determine if the spermatic cord is twisted, including ultrasound to make images of the testicle and to check its blood flow. Urine and blood tests might help in determining whether symptoms are being caused by an infection instead of a torsion. Sometimes, it will be necessary for the doctor to perform surgery to make a diagnosis of testicular torsion. Other times, when the physical exam clearly points to a torsion, the doctor will perform emergency surgery without any other testing in order to save the testicle. Saving a testicle becomes more difficult the longer the spermatic cord stays twisted. The degree of twisting (whether it's one entire revolution or several) determines how quickly the testicle will become damaged. As a general rule, after 6 hours, the testicle can be saved 90% of the time; after 12 hours, this drops to 50%; after 24 hours, the testicle can be saved only 10% of the time. Treatment Testicular torsion almost always requires surgery to fix. In rare cases, the doctor may be able to untwist the spermatic cord by physically manipulating the scrotum, but surgery will generally still be needed to attach one or both testicles to the scrotum to prevent torsion from happening again. Usually, if your son has a torsion, he'll be given a painkiller and a general anesthetic that will make him unconscious for the procedure.

Parent & Patient Information System 06/09/2015 Page14 / 51 Surgery consists of making a small cut in the scrotum, untwisting the spermatic cord and stitching the testicles to the inside of the scrotum to prevent future torsions. Moreover the contralateral side will be fixed as well because of the probability of torsion on that side as well. When that's finished, the doctor will stitch up the scrotum, and your son will be taken to a recovery room to rest for an hour or two. Following the surgery, your son will need to avoid strenuous activities for a few weeks, and if he's sexually active, he'll need to avoid all sexual activity, too. Talk to the doctor about when it will be safe for your son to resume his normal activities. If a torsion goes on too long, doctors won't be able to save the affected testicle and it will have to be removed surgically, a procedure known as an orchiectomy. Most boys who have a testicle removed but still have a viable testicle can father children later in life. However, many also opt for a prosthetic, or artificial, testicle a few months after surgery. This can help make some boys feel more comfortable about their appearance. With newborn boys, saving the testicle is dependent upon when the torsion occurs. If it takes place before a boy is born, it may be impossible to save the testicle. In this case, the doctor may recommend a surgery at a later date to remove the affected testicle. If the symptoms of a torsion appear after a boy is born, the doctor may recommend emergency surgery to correct the testicle.

Parent & Patient Information System 06/09/2015 Page15 / 51 Don't Ignore Symptoms Boys need to know that genital pain is serious and shouldn't be ignored. Ignoring pain for too long or simply hoping it goes away can result in severe damage to the testicle and even its removal. Even if your son experiences pain in his scrotum that goes away, he still needs to tell you or a doctor and get checked out. A torsion that goes away makes him more likely to have another one in the future. Doctors can greatly reduce the risk of another torsion by performing a simple surgical procedure that secures the testicles to the scrotum. If your son had a torsion that resulted in the loss of a testicle, it's important to let him know that he can still lead a normal life, just like anyone else. The loss of one testicle won't prevent a man from having normal sexual relations or fathering children.

Parent & Patient Information System 06/09/2015 Page16 / 51 Chapter 4 - Diagnotic Tools Used in Pediatric Urology Laboratory tests 1.1 Urinalysis Urinalysis is used from very old times for diagnosis of several diseases. Although, it provides very useful information, in cases of inadequate sample collection or improper analysis may give erroneous results. It is usually wanted by your doctors in cases of probable urinary tract infection. However, besides this, it also gives information about the presence of red blood cells, white blood cells, microorganisms, glucose (sugar), cells lining the urinary system, status of acidity (urinary pH) and density (SG: specific gravity). Collection method of urine specimen shows difference regarding the age groups. In children who are toilette trained, it can be collected in a clean container as a midstream sample (some urine is voided and sample is taken at the middle of voiding). In small children, urine bags covering the external urethral meatus (most outer part of the urethra) may be used, but it is sometimes difficult to hold this bag in place or to prevent contamination with the stool. In these cases, urine sample may be obtained by urethral catheterization or suprapubic puncture (taking the urine directly from bladder at a level below than umbilicus by a very thin needle). The macroscopic appearance of urine may give clues about the disease. Several drugs may cause changes in urine color. Red color mostly is a finding of presence of blood in urine which may be caused by several diseases. Turbidity in urine may be a sign of infection or the presence of large amounts of amorph phosphate crystals. Density (specific gravity) of urine may be between 1003 and 1030. It gives information about the secretion of a hormone (anti-diuretic hormone) which regulates the water amount of the body. Also, specific gravity reflects the status of oral intake of water. Dipsticks are strips that have several indicators on it. By this strip, we can have a quick evaluation of urine in terms of the acidity of urine, contents of protein, glucose, hemoglobin, presence of red and white blood cells, bacteria, leukocyte esterases and nitrites. All these

Parent & Patient Information System 06/09/2015 Page17 / 51 parameters give clues about many diseases including infection, renal tubular disease, stone disease and other systemic diseases. Findings of crystalluria may be helpful for diagnosis and follow-up of stone disease. 1.2 Urine culture Obtaining samples for urine culture in children sometimes may be difficult. In toilette trained children, midstream urine voided to a sterile container may be used for this purpose. However, we must keep in mind that penile skin in uncircumcised children may cause contamination. In children who are not toilette trained, urine bag, urethral catheterization and suprapubic puncture techniques may be used. The results are obtained 48-72 hour after sample delivery. Bacterial growth more than 100000 colony forming units is generally considered clinically significant, however in some conditions lower numbers may be accepted as infection. 1.3 Kidney function tests Serum creatinine levels: Creatinine is a metabolite of creatine which is found in skeletal muscles and it is excreted by the kidneys. Since, the daily production of creatinine is stable, it is a direct indicator of renal function. Children have a lower muscle mass and therefore the serum creatinine levels are lower than adults. Creatinine clearance: Clearence of a substance reflects the amount of plasma cleaned from this substance per time. The creatinine clearance is the most reliable measurement of kidney function. Twenty-four hour urine collection and serum creatinine levels are needed to make this calculation. Blood urea nitrogen: Urea is the by-product of protein degradation. It is also an indicator of kidney function; however it can be affected by the dietary protein and water intake.

Parent & Patient Information System 06/09/2015 Page18 / 51 Imaging modalities 2.1 Plain abdominal X-ray graphy It is the first graphy of intravenous urography. It should cover all the urinary system. It gives a gross idea about the structure of the bones, presence of stone, calcifications and other causes of opacities. 2.2 Intravenous urography (IVU) IVU is an imaging tool that iodinized material is given into the vessel of the patient (1 ml/kg of body weight) and then serial X-ray films are obtained. This iodinized material is filtered through the kidneys and it makes an opacification that the kidneys become visible. In this test, position, outer contours of the kidneys, shape of the calyces, any mass effect on kidneys, the shape of the ureters and bladder are evaluated. It is used in order to evaluate the whole urinary system, show the collecting system, presence of obstruction and calcifications. It is preferred since it is not expensive, does not necessitate special instruments and easy to perform. However, it has some disadvantages as the radiation exposure, risk of allergic reaction to contrast material and limited ability to show the qualitative and quantitative dynamic renal functions.

Parent & Patient Information System 06/09/2015 Page19 / 51 2.3 Ultrasonography Ultrasonography is an imaging modality working by sound waves. The produced sound waves are sent from the probe to inside of the body and organs reflect these waves. Every organ has its specific reflection capability called ‘echogenicity’. This modality is a cheap, easy and quick way of imaging the organs. By this imaging tool, we are able to evaluate the dilatation, abnormal structural pathologies (tumor, cyst), abscess and stones of all the urinary tract. However, ultrasonography is a real-time test, dependent on the operator and does not give information about the function of kidneys. 2.4 Voiding cystourethrography (VCUG) This test evaluates the lower urinary tract (bladder and urethra). A catheter is placed into the bladder via the urethra and contrast material which makes the lower urinary tract visible under the X-ray graphies. Patient is asked to micturate and serial X-ray graphies are taken. Normally, the urinary stream of human beings is one-sided. The urine in the bladder does not pass to upper urinary tract (ureters and kidneys) during storage or even during voiding. There is a mechanism at the level of bladder-ureter junction which prevents the up-sided leakage. However, in some individuals, this mechanism does not work properly and a leakage from bladder to upper

Parent & Patient Information System 06/09/2015 Page20 / 51 urinary system happens which is called ‘vesicoureteral reflux (VUR)’. Presence of recurrent urinary tract infections (UTI) is one of the most frequent results of this disease. VCUG is mostly performed in children with suspicion of VUR. Moreover, obstructions in the bladder outlet, incomplete emptying of bladder, voiding with high pressures are the other probable causes of VUR. Besides presence of VUR, VCUG also demonstrates the anatomic abnormalities and gives clues about the functional problems regarding the bladder and urethra. 2.4.1 Preparing the child for the test Since the VCUG is a test which is done under X-ray, metal objects may affect the quality of the test. The child’s clothes should not carry metal buttons or zips. The test carries the risk of propagating an infection in bladder to upper system. Therefore, it is not performed when an active UTI is present and absence of UTI should be documented by a urinary culture before the test. Parents should know that informing the child prior to the test will help to be relaxed, make them feel in safety and to perform the procedure under more comfortable conditions. Also, mothers with suspicion of pregnancy or who are pregnant should be aware of radiation exposure. 2.4.2 Performing the test The technician may ask you for helping during the placement and immobilization of child to the examination table. A plain film is taken before the catheterization. Then, the external genitalia of the child is rinsed with a special solution to get a microorganism free area before catheterization. A catheter (sterile, thin and flexible tube) is inserted through urethra into the bladder. The outer tip of the catheter is connected to a packet containing the mixture of physiologic serum and contrast material. The contrast material is let dripping under natural

Parent & Patient Information System 06/09/2015 Page21 / 51 gravity into the bladder until it is full. During the filling period, several films are taken to investigate the presence of VUR or other probable abnormalities. When the bladder becomes full, the catheter is taken out and several films are obtained during the voiding. A last film is taken to see whether there is residual urine in the bladder. Although, the procedure itself is painless, restriction of the movements, feeling of cold due to the special solution which is used to rinse the genitalia, insertion of the catheter and fullness of bladder can disturb the children. Parents may stay with child during the procedure by wearing the radiation protective shields. The whole procedure normally lasts about 15-20 minutes. No special instructions are needed after the test. There is no need to restrict diet or physical activities. Your doctor will evaluate the test and may request for additional tests if necessary. 2.4.3 Concerns During the procedure, the child receives a little amount of radiation. The effective radiation dose which a 5-10 years old child is exposed to is 1.6mSv which is equivalent to the natural background radiation in 6 months. In newborns, it is 0.8mSV which is equivalent to a natural radiation of 3-months. However, the benefits of the test overcome the radiation risk. To decrease this risk of radiation, new fluoroscopy machines have been developed, number of films may be limited and protective shields may be used on the genitalia. Another risk which is extremely rare is the probable allergic reactions to the contrast material used in the test. You should contact to your doctor if an adverse effect happens. After the test, some children may complain about some burning feeling during their voiding. It should nearly always fade away. On the other hand, the change in the color and odor of the urine and fever following the test may be the signs of UTI. In these occasions, you should contact your doctor as soon as possible. 2.5 Computerized tomography (CT) It is a test which the X-rays are directed in a surrounding manner with a special technology. It can be used to investigate the pathologies inside the cavities (skull, chest, abdomen) of the body. Contrast material is also used in this test in order to investigate the organs and related pathologies in details. It lets to investigate all the organs within the slices of the imaging. Slices are taken

Parent & Patient Information System 06/09/2015 Page22 / 51 with 5-10 mm intervals. The radiologists make the interpretation of the test. In evaluation of urinary stone disease, contrast material is not used and it is the most accurate test in this regard. It has some disadvantages as the child must be immobilized and sometimes should be sedated in this respect. The use of contrast material and relatively higher radiation dose are other disadvantages. The spiral CT technology decreases the time of immobilization and applications with low-dose aim to decrease the radiation exposure. In some instances, the CT is not sufficient in imaging of the soft tissues where a further MRI (Magnetic Resonance Imaging) may be needed. 2.6 Magnetic Resonance Imaging (MRI) It is a modality that achieves images by using the hydrogen atoms in the body. It is widely used to image kidney, bladder, prostate, testis and penis pathologies. It is the most accurate test for evaluation of congenital abnormalities. Use of various contrast material during MRI expanded its area of indication. Injection of gadalonium (contrast material used in MRI) and obtaining quick images give information on both anatomy and functions. MRI images can be reconstructed in any angle or plane. It is the most accurate test for soft tissues and patients are not exposed to ionizing radiation. However, the long test duration makes the sedation of children obligatory. In some patients who had prosthesis are not suitable for this test.

Parent & Patient Information System 06/09/2015 Page23 / 51 2.7 Scintigraphic studies 2.7.1 Static renal scintigraphy It is an imaging modality showing the distribution of the radioactive substance (Dimercaptosuccinic acid=DMSA) which is given into the vessels over the kidney. Its indications are mostly the recurrent UTI and presence of VUR. It shows the comparative contribution of each kidney to the overall kidney functions and demonstrates the affected areas on the kidney. There is no special preparation before the test. One to three hours after the injection of the radioactive substance, the images are obtained. Patient should drink as much water as he/she can during this waiting period. After the waiting period, images are taken within 30 minutes. During image capture, patient should be off the clothes and immobile.

Parent & Patient Information System 06/09/2015 Page24 / 51 2.7.2 Dynamic renal scintigraphy In this test, DTPA (Diethylene triamine pentaacetic acid), MAG-3 (mercaptoacetyltriglycine) or EC (ethylenedicysteine) are used as the radioactive substances. The perfusion, concentration and excretion functions of the kidney are evaluated. Also, the comparative (split) renal functions may be assessed. Two hours before the test, children should drink as much water as they can (11.5 liters of water for older children, as much milk, mama as they can get for smaller ones). A catheter can be inserted in order to empty the bladder. Some medication as diuretics can be given during the procedure and it lasts about 40 minutes.

Parent & Patient Information System 06/09/2015 Page25 / 51 2.8 Uroflowmetry and Urodynamic study 2.8.1 Uroflowmetry It is a test that gives information about the urinary flow rate, voiding pattern and voided volume. Child will urinate to a special designed toilette which has connected to a computer. It is a noninvasive test. However, it does not give data about the bladder dynamics. By this test, maximum urinary flow rate, mean flow rate, voiding duration, time to reach to the maximum flow rate and voided volume are measured. The computer draws a pattern of voiding. As a result several conclusions about the presence of lower urinary tract obstruction and voiding problems can be made. This test is also used to evaluate the response to the treatments in patients with neurologic or non-neurologic voiding problems. 2.8.2 Urodynamic study Urodynamic study is done to evaluate the lower urinary tract functions. It gives information about the storage and emptying phases of the voiding activity. In a normal individual, bladder stores the urine in a low pressure. During emptying bladder contracts, urethral sphincter relaxes and all urine is expelled without residue. The patient should be informed prior to the test. The routine and urologic examinations must be done. A voiding diary must be filled. In the presence of UTI, test should be postponed. Therefore, a urine analysis is mandatory.

Parent & Patient Information System 06/09/2015 Page26 / 51 Before the test, genitalia is cleaned with a special solution. Then, a special catheter which has 2 lumens (one lumen for serum physiologic instillation, one lumen for pressure measurement) is inserted to the bladder, another catheter is inserted to rectum to measure the abdominal pressure and finally 3 electrodes are stuck to the perineal area to measure the sphincteric activity. By these catheters and electrodes, the behavior of bladder and urethral sphincter during filling and emptying are investigated. During the test, child will be asked several questions to understand the different filling phases: first sensation (the first sensation that the child feels bladder is being filled), first desire to void (the first point that the child can void but can postpone this feeling) and strong desire to void (continuous feeling of voiding without the fear of urine leakage). If a contrast material is put into the instilled liquid, it will be able to visualize the bladder under fluoroscopy during the test. This is called ‘videourodynamic study’. The fluoroscopic images and pressure studies are recorded simultaneously. It helps to investigate the relation between bladder and sphincter in details, the presence of VUR, the pressure during the initiation of VUR and anatomic abnormalities in the bladder.

Parent & Patient Information System 06/09/2015 Page27 / 51 Chapter 5 - Structure, Development and Function Of Urinary System What is the urinary system Urinary system means the sum of the organs which take role in production, propagation, storage and emptying of urine that is the liquid waste product of our body. Upper urinary tract includes the kidneys and ureters. Kidneys are the organs which produce urine, filter the necessary materials, discharge the waste product. Ureters are the organs which have tube-like structure draining urine to the bladder (urinary sac). Bladder and urethra constitute the lower urinary tract. Bladder is an organ made of muscle which can enlarge as the urine volume increases in it and the urethra is the tube like organ from bladder to outside. How is urine produced? We have 2 kidneys and both of them function together. In some of the population, one kidney is not formed, however one single kidney, either from birth or taken out by surgery later in life, can supply the demands of the body. Twenty percent of the blood pumped by heart goes to the kidneys. The main function of kidneys is to filter the blood and discharge the waste products in a dissoluted state in urine. Kidneys make the water and salt balance of the body. Also by producing different hormones, it sets the blood pressure, stimulates and controls the production of red blood cells which carry the oxygen to the tissues. Moreover, kidneys have an important role in managing the acid-base balance of our body. How does the urinary system function? Kidneys have a shape like bean and located at the back of the body under the chest cage on both sides. Right kidney is placed under the liver and therefore it is in a lower level than the left kidney. Size of one kidney is as the fist of the person. The outer side of kidney is called cortex and includes the filtration units. The most outer surfaces of kidneys are surrounded by a fat tissue which is protective against traumas. The inner side is called medulla and 10-15 fan-shaped structures called pyramids are located in here. Urine is drained from pyramids to goblet-like tubular structures called calyx.

Parent & Patient Information System 06/09/2015 Page28 / 51 Blood is transported to kidneys by renal artery (the vessel carrying the clean, oxygenated blood from heart to peripheral organs). Renal artery enters to the kidneys from the notch of the bean in the middle and gives lots of branches within the organ. Each arteriole (the small sized artery) reaches a unit called nephron. Nephron is the single unit of filtration which is enveloped by the arterioles. Each kidney has about 1 million nephrons. When the capillaries (the smallest vessels) enter the nephron unit, they form a clump and this structure is named as glomerule. Blood is filtered through these capillaries and the filtered fluid moves along very thiny tubes called tubules. Within these tubules, the contents of urine (salt, water, waste products) are regulated. The filtered blood exits the kidney by renal vein (vessels carrying the deoxygenated blood from peripheral organs to heart). Kidney has a very dark red color because of its rich vascularity. Urine, as a final product, is a solution containing water, urea (end product of protein degradation), salt, aminoacid, by-products of bile, ammonia and all the substances which couldn’t be absorbed back. The color of urine is due to the presence of a substance called urochrome, a blood product. The urine draining from the calyces begin to collect in a place called renal pelvis which is located at the behind the renal vessels at the level of the notch of the bean. Out of the kidney

Parent & Patient Information System 06/09/2015 Page29 / 51 border to downside, renal pelvis turns into the tubular structure called ureter. Normally, we have one ureter for each kidney. The travel of ureter ends in urinary bladder. The bladder is composed of mostly muscular tissue and has the capability of enlarging as the volume of stored urine increases. In adults, it can store upto 500 ml.s. An adult person produces 1500 ml of urine in a day. Excessive or decreased volume of urine may be a sign of kidney diseases. As the volume increases, the bladder via the nerve fibers sends signals to brain about its fullness. When the person finds a convenient social environment for micturation, the bladder contracts, the sphincter (a structure made of circular muscle fibers at the outlet of bladder which is providing continence) relaxes and whole stored urine is emptied without residue through a tubular structure which is called urethra. The most outer part of urethra opens to the tip of penis in man and just above the vaginal opening in woman. How did the urinary system develop? The first 10 weeks of the baby in mother’s uterus is called embryo and this period is very important for the development of organs. After this period till birth, baby is called as fetus. In mother’s uterus, the kidney functions are carried out by the placenta (the connection between baby and mother). However, after birth baby needs perfectly working kidneys to survive.

Parent & Patient Information System 06/09/2015 Page30 / 51 The urine producing part of kidney (parenchyma) and urine transporting part (collecting system) develop from different origins. Parenchyme starts to develop in the groin region of the embryo and then it starts to migrate to higher position and it should connect with the collecting system at the right place at the right time. The first urine is produced around 11th weeks. Problems of migration end up with the formation of horse-shoe (fusion abnormalities) or ectopic (misplaced) kidneys. Problems in the formation of ureteric bud structure which will form the future collecting system cause duplication, ureterocele, ectopic ureter and vesicoureteral reflux. If the timing of the convergence of parenchyma and collecting system is not proper, a nonfunctioning kidney with a bunch of grapes shape called multicystic dysplastic kidney.

Parent & Patient Information System 06/09/2015 Page31 / 51 Chapter 6 - Ultrasound - a noninvasive diagnostic tool A renal ultrasound is a safe and painless test that uses sound waves to make images of the kidneys, ureters, and bladder. During the examination, an ultrasound machine sends sound waves into the kidney area and images are recorded on a computer. The black-and-white images show the internal structure of the kidneys and related organs. Renal ultrasounds help to clarify certain issues like the size of the kidneys, signs of injury to them, abnormalities present since birth, presence of blockages or kidney stones, complications of a urinary tract infection, and cysts or tumors to name a few. Usually, there is no need for any special preparation for a renal ultrasound. Parents are usually welcome to accompany their child to provide reassurance and support. The child will be asked to lie on a table. The room is usually dark so the images can be seen clearly on the computer screen. The sonographer will spread a clear, warm gel on the child's abdomen over the kidney area. This gel helps with the transmission of the sound waves. Subsequently a small wand (transducer) will be rubbed over the gel. The transducer emits high-frequency sound waves and a computer measures how the sound waves bounce back from the body. The computer changes those sound waves into images to be analyzed. The procedure usually takes less than 30 minutes.

Parent & Patient Information System 06/09/2015 Page32 / 51 It is important to notice the child that the renal ultrasound test is painless. The child may feel a slight pressure on the abdomen as the transducer is moved over it and the child has to lie still during the procedure so the sound waves can reach the area effectively. Finally the doctor will go over the results with the family. If the test results appear abnormal, further tests may be required. No risks are associated with a renal ultrasound. Unlike X-rays, radiation isn't involved with this test.

Parent & Patient Information System 06/09/2015 Page33 / 51 Chapter 7 - Penile Problems Circumcision Circumcision is excision of a part of the skin (prepucium) which is covering the distal part of the penis (glans). It is performed regarding the cultural, religious or medical reasons. Glans and prepucium are attached to each other during the normal penile development. Most the newborns have these attachments. 75% of the boys younger than 5 years old have adhesions and the frequency decreases with the increasing age. Between the glans and prepucium, white nodular structures, which can be seen and palpated, are called as ‘smegma’. Smegma is a physiologic formation which is secondary to the collection of fatty secretion by the inner side of prepucium. It resolves within the time and parents should not show an effort to clean this structure by releasing the attachments between glans and prepucium. Because, this manoeuver causes tearing of the surface of glans which heals with secondary adhesions. Circumcision is one of the most speculative surgical procedures which is performed for centuries. Circumcision is thought to be having a beneficial preventive effect against penile and cervix cancer, sexually transmitted diseases (including AIDS) and urinary tract infection. Except the cultural or religious reasons, the relative indications for circumcision are: balanitis (inflammation of glans), balanoposthitis (inflammation of glans and prepucium), phimosis, paraphimosis, very long prepucium, as a preventive measure in the geographical regions which AIDS and similar diseases are frequent, as a preventive measure against penile cancer, children with recurrent UTI, after penile traumas. The absolute indications are the balanitis xerotica obliterans (BXO) and pathological phimosis caused by recurrent episodes of balanitis/balanopostitis. BXO is a chronic skin disease characterized by the scarring of prepucium, glans and outer opening of the urethra. It can be seen in 1.5% of the children and the cause couldn’t be exactly explained. The timing of the elective circumcision is controversial. However, it should be performed whenever it is indicated. The cultural or religious circumcision should not be performed between 1.5-5 years of ages which is a critical period for the psychological development of the child. If circumcision will be done within this age interval, sedation or general anesthesia should be used.