Pediatric urology

Anatomy or system affected: Abdomen, bladder, genitals, kidneys, reproductive system, urinary system

Definition: The treatment or surgical correction of disorders of the urinary tract and associated sexual organs in infants and children

Science and Profession

A pediatric urologist is usually a urologic surgeon who has received extra training in urological procedures on infants and children. In the United States, the full course of training for this type of surgeon requires a medical degree followed by two years of general surgery training. The physician then undergoes four years of urologyresidency and two additional years of training on pediatric cases.

The urinary system is the group of organs responsible for filtering waste chemicals from the blood and excreting them in the urine. It begins in the back of the mid-abdomen with the two kidneys, left and right. As blood passes through the kidneys, water and chemicals are filtered, concentrated, and collected in the central portion of each kidney. This urine is then transported through the ureters, long, thin tubes that run from each kidney to the bladder in the pelvis. Urine is then eliminated from the body through the urethra, which opens in the female’s vulva or at the tip of the male’s penis.

The pediatric urologist is particularly skilled in the repair of congenital deformities of the urinary tract and in the long-term management of the urinary disorders of childhood. Defects of the urinary tract may be present congenitally. Rarely, the bladder may develop a defect of the abdominal wall, appearing inside out at birth. External genitalia that are abnormal in function or appearance may require surgical correction. Males may have an abnormally positioned opening of the urethra. The testes may not be properly positioned in the scrotum. The female urethra may open in an abnormal place, such as the vagina. Such congenital defects may be corrected or improved by urologic surgery.

Many of these abnormalities may lead to frequent urinary tract infections or to backward pressure in the urinary system, eventually damaging the sensitive kidneys. The damage may be severe enough to cause renal failure, necessitating dialysis or kidney transplantation.

Urologists are often involved in the evaluation and treatment of recurrent urinary tract infections. Although surgery faded in importance for treating these chronic infections by the 1980s, urologists continue to be important participants in the management of children who have them.

Another pediatric disorder that requires help from the pediatric urologist is neurogenic bladder. The nerves that control bladder sensations and function come from the spinal cord, leaving the spinal canal in its lowest sacral region. Spinal cord damage anywhere above this level due to injury or congenital defects can result in damage to these nerves, which may cause the child to have no sensation of bladder filling or urination. In addition, the muscles of the bladder wall and the sphincter, both of which permit and control urination, may develop uncoordinated contractions, causing the bladder to retain urine between urinations. This urine repeatedly becomes infected, with eventual damage to the bladder, the ureters, and, most important, the kidneys. The pediatric urologist uses a variety of medications and surgical procedures to treat this serious disorder in an attempt to avoid permanent renal damage.

Family practitioners and pediatricians perform routine circumcisions on newborn males. If routine circumcision is not performed in the first month of life, a pediatric urologist is generally consulted to perform the procedure if it is needed later.

Pediatric urologists may also help parents and children who are suffering from unknown issues with urinary and bowel problems related to toilet training, though by the time a pediatric urologist becomes involved, these issues are quite serious.

Diagnostic and Treatment Techniques

Pediatric urologists usually practice in large cities, often at universities or children’s hospitals. Their day typically is divided between the operating room and the clinic. In the clinic, urinary tract disorders are evaluated and treated medically. Surgery is scheduled when it is indicated or when medical treatment fails. The surgical procedures are often quite difficult. Sometimes, multiple procedures are required to remedy a complicated abnormality. The goal is to achieve as near-to-normal appearance and function of the affected organs as possible.

Common laboratory tests used by the pediatric urologist include complete blood counts, chemistry tests of renal function, and examination of the urine. Urine examination, called urinalysis, involves two steps, both of which are usually performed by a laboratory technician. First, a plastic strip impregnated with chemicals is dipped in the urine to test for acidity, concentration, sugar, protein, and other compounds. Then, after being concentrated in a centrifuge, the urine specimen is examined microscopically to look for indications of urinary tract disease, such as white and red blood cells, bacteria, and crystals of excreted compounds. If there is suspicion of a urinary tract infection, a small volume of urine is placed on a culture medium to allow the growth of any bacteria that might be present. Normal urine should be sterile. A number of imaging studies, such as renal ultrasonography, bladder X-rays, and intravenous pyelography, help assess the urinary tract’s anatomy and function.

Pediatric urologists also perform cystoscopy, the examination of the bladder interior with a scope passed through the urethra. Stones of the kidney or bladder, although rare in children, may require removal using the cystoscope or a wire basket passed through it into one of the ureters.

Perspective and Prospects

General urologists had always performed urologic surgery on children. With the increasing technical complexity of many of these procedures, however, the Society for Pediatric Urology was formed in the 1960s to advance the specialty. Pediatric urology fellowships were instituted in the 1970s.

A major challenge for the specialty has been to correct congenital anomalies in such a way as to result in normal urinary function and, as an adult, normal sexual function for the patient. Improved techniques, including microsurgery, point to increasing success.

Bibliography

Baskin, Laurence S., and Barry A. Kogan, eds. Handbook of Pediatric Urology. 2d ed. Philadelphia: Lippincott Williams & Wilkins, 2005.

Gearhart, John P., Richard C. Rink, and Pierre D. E. Mouriquand, eds. Pediatric Urology. 2d ed. Philadelphia: Saunders/Elsevier, 2010.

Godbole, Prasad P., Martin A. Koyle, and Duncan T. Wilcox, eds. Guide to Pediatric Urology and Surgery in Clinical Practice. London: Springer-Verlag, 2011.

Kliegman, Robert M., et al., eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia: Saunders/Elsevier, 2011.

Lansbury, Janet. “Problems with Potty Training, Constipation, Bedwetting, and Preschool Policies (with Dr. Steven Hodges).” Janet Lansbury, 1 May 2021, www.janetlansbury.com/2021/05/problems-with-potty-training-constipation-bedwetting-and-preschool-policies-with-dr-steven-hodges. Accessed 26 July 2023.

McMillan, Julia A., et al., eds. Oski’s Pediatrics: Principles and Practice. 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.

Martin, Richard J., Avroy A. Fanaroff, and Michele C. Walsh, eds. Fanaroff and Martin’s Neonatal-Perinatal Medicine: Diseases of the Fetus and Infant. 9th ed. 2 vols. St. Louis, Mo.: Mosby/Elsevier, 2011.

Sanghavi, Darshak. A Map of the Child: A Pediatrician’s Tour of the Body. New York: Henry Holt, 2003.

"Urinary Tract Infections in Children." National Kidney and Urologic Diseases Information Clearinghouse, November 16, 2011.