Pediatric Urology

Hypospadias:

Hypospadias (hi-poe-SPAY-dee-us) is a condition in which the opening of the urethra is on the underside of the penis, instead of at the tip. The urethra is the tube through which urine drains from your bladder and exits your body.

Hypospadias is present at birth (congenital).
Complications:-If hypospadias is not treated, a child may have problems learning to use a toilet properly. During adulthood, untreated hypospadias can cause difficulty in achieving an erection.

Surgery:
Best Time- Surgery is best done at an early age — usually between ages 4 months and 12 months. Generally, the earlier the surgery is done, the less traumatic it is for the child. But the procedure can be completed at any age and even into adulthood. Infants should not be circumcised before the procedure because the foreskin tissue may be needed for the surgery.

During surgery, a pediatric urology surgeon uses tissue grafts from the foreskin or from the inside of the mouth to reconstruct the urinary channel in the proper position, correcting the hypospadias. The surgery usually takes from 90 minutes to three hours and is done while the child is unconscious (general anesthesia). Rarely, the repair may require two or more surgeries.

Complications of surgery:
In most cases, surgical repair results in a penis with normal or near-normal function and appearance and no future problems. However, in a small number of cases, a hole (fistula) or scarring may develop along the underside of the penis where the new urinary channel was created. This can result in urine leakage and require an additional surgery for repair.

Ureteric Reimplantation:

Your child has been diagnosed with vesico-ureteric reflux (“reflux”). This is a condition that allows urine to reflux (flow back up) the ureter to the kidney when the pressure in the bladder is increased. This is graded 1 – 5, with one being very minor and 5 being very severe. Grading is done on the basis of the findings at the cystogram, the x-ray procedure where dye is put into the bladder and observed entering the ureters and kidney. Children with reflux are susceptible to urine infections, which can lead to kidney scarring and damage or in more severe cases, the ureter and kidney becomes large, distorted and inefficient.

A ureteric reimplantation is an operation to treat reflux.

The operation is done to correct the faulty “flap-valve” where the ureter enters the bladder and thus prevent reflux from occurring.

The child is anaesthetised and a small bikini line incision is made. Through this the bladder can be approached and opened. The opening of the ureter is found and a small circular incision is made around it. The ureter is dissected free from the bladder muscle. When the ureter can slide in and out of the bladder wall freely, a small tunnel is made for each ureter, approximately 2cm long, with the end opening into the bladder. The ureter is then passed through this tunnel and stitched into place. This is so that in the future, when the bladder muscle contracts to pass urine, the sides of the ureter will be pressed together and stop urine flowing back up to the kidney. The site of the original opening of the ureter is then closed and the bladder is also closed.

Phimosis:

Phimosis is the inability to fully retract the foreskin (or prepuce) over the glans penis due to a narrow opening.
Symptoms:-

Inability to fully retract the foreskin over the glans is the classical feature of phimosis.

The symptoms of phimosis are as follows-

  • Inability to retract foreskin.
  • Straining during urination.
  • Thin stream of urine.
  • Ballooning of foreskin while urinating- A bulge can be seen in the tip of penis as urine accumulates under the foreskin.
  • Recurrent urinary infections.
  • Pus from penis – due to balanoposthitis.
  • Pain during sexual intercourse.

Treatment:
The normal non-retractile foreskin during childhood must be recognized and left alone. In such cases, patients and their parents should be advised against attempting forcible or premature retraction of the foreskin, and avoiding excessive washing of the penis with soap.

Once phimosis is diagnosed, the available treatments include:

Topical corticosteroids- Phimosis can be treated by the local application of topical steroids (betamethasone cream 0.05%) in 80-90% of cases.

Manual stretching:
Surgical methods range from the complete removal of the foreskin to more minor operations to relieve foreskin tightness:

  • Circumcision is sometimes performed for pathological phimosis, and is effective.
  • Dorsal slit (superincision) is a single incision along the upper length of the foreskin from the tip to the corona, exposing the glans without removing any tissue.
  • Ventral slit (subterincision) is an incision along the lower length of the foreskin from the tip of the frenulum to the base of the glans, removing the frenulum in the process. Often used when frenulum breve occurs alongside the phimosis.