Dr. A.K. Singal MBBS (Gold Medalist), DNB, MNAMS
M.CH (AIIMS, Gold Medalist)
Stecker Scholar Pediatric Urology (USA)

Knowledge Bank

Common symptoms of Pediatric Urological disorders

Consultation and counseling by a Pediatric Urologist is very important for these disorders as the parents are very anxious and worried. They would want to know about the eventual outcome and the problems the baby may face after birth. A Pediatric Urologist given his expertise in the field is ideally suited for this counseling and he also provides a continuum of care right from antenatal diagnosis and its proper interpretation to management after birth.

  1. Antenatally diagnosed Hydronephrosis- Hydronephrosis refers to Swelling of the kidney. Fetal Hydronephrosis is the most common structural abnormality seen on antenatal sonogram, occurring in 1% of all pregnancies. Many of these mild hydronephrosis subside during the pregnancy while others may subside after birth. A follow-up with an expert pediatric urologistis mandated to ensure that this happens and no child with persistent hydronephrosis is missed. The common disorders manifesting with antenatal hydronephrosis are:
    1. Pelviureteric junction (PUJ) obstruction: There is a partial blockage at the site where the pelvis of the kidney joins the ureter (see About Genitourinary system to understand anatomy). As a result, the urine collects under pressure and produces swelling of the kidney. During pregnancy estimation of the diameter of the pelvis can give a rough idea of the chances of requirement of surgery after birth. Kids with PUJ Obstruction are best investigated after birth with ultrasonogram (at one week of age) and a renal scan at 4-6 weeks of age. On the average about 70% of the babies having antenatal or fetal hydronephrosis may not require anything more than observation after birth. Only 30% of the children have a worsening hydronephrosis or fall in renal function mandating surgery. Click here to see the cases

      1. A newborn baby with PUJ Obstruction treated with pyeloplasty

      2. PUJ obstruction in a child managed with Laparoscopic Pyeloplasty surgery

    2. Vesicoureteric Reflux (VUR): In normal human anatomy, urine flows one way from the kidney, down the ureter and into the urinary bladder. At the junction of the ureter and the bladder- the body has in place “an Anitreflux mechanism” . In children with Vesico-ureteric reflux (VUR)- this mechanism is defective, allowing the urine to go back up the ureter and kidneys from the bladder. This happens on a full bladder and worsens during the voiding phase. As s result, there is swelling of the kidney and ureter – a condition called Hydroureteronephrosis. In children with VUR, the antenatal hydronephrosis is generally mild and the degree varies between different scans. Management begins after birth by confirming the diagnosis with USG and MCU. After birth, these kids are put on low dose antibiotics to prevent infections which can cause kidney damage. An ultrasonogram and a special test called Micturating Cystourethrogram (MCU) is performed at one month of age to confirm or rule out VUR. After grading of VUR, a pediatric urologist can advise the next course of action whether medical or surgical treatment of VUR.

      Endoscopic Management of VUR

    3. Posterior urethral valves (PUV): In this condition there is a block in the urethra, as a result urine is stored in bladder at high pressures which is not able to empty properly. The bladder becomes thick and distended. Both the ureters and kidneys may be swollen. Posterior urethral valves is a very serious condition as upto 30% of the children will have eventual renal failure at some point after birth even after adequate therapy. This is especially true for those cases where oligohydramnios sets in during pregnancy. Oligohydramnios signifies severe obstruction and decreased urine production by the developing child. These children are to be investigated as soon as possible after birth may be on day 1 of life as this is a semi emergency to treat them. An ultrasonogram and a special test called Micturating Cystourethrogram (MCU) is performed to confirm or rule out PUV. Once confirmed, best treatment for PUV includes endoscopic surgery under care of a pediatric urologist.

      Newborn with Posterior urethral valves

    4. Vesicoureteric junction (VUJ) obstruction: There is a block at the point where the ureter joins the bladder. As a result, the ureter and the kidney get swollen up- Hydroureteronephrosis. This can be evaluated after birth with a USG and a renal scan. A MCU is also recommended to rule out VUR. MCU tests are done at MITR Hospital Navi Mumbai for best results and diagnosis.
    5. Duplex system:There is double collecting system of the kidney leading to double urinary pipes in one kidney and generally the upper pole may be swollen due to abnormal junction of the ureter with the bladder. Children with duplex system may need treatment under care of a Pediatric Urologist after birth for best outcomes.
  2. Absent Kidney: Also called Renal Agenesis. If both kidneys are absent- the child will be born with renal failure and will soon succumb to it. Unilateral or one-sided renal agenesis is a common condition and does not have many long-term issues in most children. After birth, these children should be investigated under care of a pediatric urologist surgeon to rule out problems in other kidney like VUR or PUJO, which are seen in upto 20-30% of children. Abnormalities of female reproductive organs are also common in girls and these kids merit further investigation after birth.
  3. Polycystic kidney:In this disease, there are multiple fluid filled cysts in the kidney generally on both sides. There are further two types of this disease. Infantile variety which generally presents soon after birth as renal failure and Adult Variety which is diagnosed later in life. Infantile variety can be diagnosed easily during pregnancy and a therapeutic termination of pregnancy should be recommended for these babies and such counselling is done by pediatric urologists in india.
  4. Multicystic kidney disease (MCKD): In this disorder there are multiple non-communicating cysts in the kidney. This disease generally occurs on one side and the other kidney is usually normal. The side having MCKD is generally non-functioning in nature and may require surgery after birth once the diagnosis is established. Some of these kidneys may disappear automatically during pregnancy or first 2-3 years of life, thus a surgery to remove such kidneys may not be required in all the cases. But the diagnosis must be confirmed with a USG and a renal scan after birth and also to see that the other kidney is normal. Sometimes it may be difficult to distinguish a severe hydronephrosis from MCKD even after renal scan, then a Cystoscopy and retrograde pyelogram may be required to confirm the diagnosis and proceed with appropriate surgery in care of an expert pediatric urologist.

    Laparoscopic surgery for multicystic kidney

  5. Oligohydramnios: Inadequate renal function in a fetus may lead to shortage of amniotic fluid or oligohydramnios. Oligohydramnios is the single most important prognostic indicator for renal anomalies during pregnancy. Fetuses with oligohydramnios tend to develop renal failure soon after birth. Some of these may even have inadequate lung development and difficulty in breathing soon after birth. Most common condition causing oligohydramnios is PUV followed by bilateral renal agenesis and infantile variety of polycystic kidney disease. Such children are best seen by top pediatric urologists immediately after birth for best treatment.

Common causes for Dysuria in children are

  1. Urinary tract infection (UTI)
  2. Calculus disease- stones in urinary system
  3. Balanoposthitis

Newborn babies- most common cause is Posterior Urethral valves and newborn should be admitted and investigated immediately. Sometimes a Ureterocele which is jutting out into urethra can cause similar symptoms. We have also seen a newborn who had out pouching of the bladder called diverticulum leading to these symptoms. All these can be easily diagnosed on a MCU and a USG.

Older children may have thinning of stream and the above symptoms due to

  • Phimosis: Very tight foreskin can sometimes cause this problem. This can be easily diagnosed on examination by a Pediatric Urologist.
  • Meatal stenosis:Tight urinary opening can cause these symptoms. This condition can be easily diagnosed on clinical examination and treated by a minor surgery.
  • Urethral stricture:Sometimes, there is narrowing of urethra due to infection, injury or after catheterization. This can be very well seen on X-ray study called retrograde urethrogram and if possible a MCU.
  • PUV: Rarely, older children may present with a variant of PUV called Mini-valves where small fold of tissue in urethra cause mild obstruction to urine flow. These can be diagnosed on MCU and treated easily cystoscopically.
  • Stone impacted in urethra or bladder neck

Frequency signifies irritation or small bladder capacity. Common causes are:

  1. Urinary tract infection
  2. Urinary calculi or stones
  3. Overactive bladder
  4. Small bladder capacity

A good chat with the patient, a thorough examination by a pediatric urologist and a few investigations can sort out the issue.

Pyuria signifies serious urinary tract infection and a Pediatric urologist should be consulted immediately as this is potentially serious condition. Pyuria can be because of VUR, PUV, PUJ Obstruction, neuropathic bladder, bladder outlet obstruction etc. and needs to be managed with admission and antibiotics. Also tests are done to diagnose the underlying conditions for the cause of urinary infection.

Blood in urine can come either from the kidneys, ureters, bladder or urethra. Generally, blood which comes from kidneys makes the urine look like cola (brownish) and is well mixed with urine, there are no symptoms of irritation like frequency. There may be clots also if the bleeding is occurring from the kidneys. Common causes of such an occurrence are Nephritis, calculi (stones) or malignancies and these can be differentiated by certain tests. Patients who have nephritis are further treated by Nephrologists while others by Pediatric Urologists.

Blood in urine from bladder occurs commonly due to infection or stones. Generally, there are associated symptoms like fever, pain in lower abdomen, Pyuria, frequency etc when there is either of these. Bladder tumors are very rare in childhood. Further work-up like Ultrasonogram, X-rays may be required to deal with such problems.

Bed wetting or Nocturnal enuresis is a very common problem and affects upto 10% of normal children. Classically, the child has no daytime symptoms and wets the bed at night. Such kids do not need further investigation once a Pediatric Urologist has seen and examined the patient in detail. Generally, some behavioral modification and adjustments in life style are enough to help these children. In 1% of these children, especially if the wetting continues beyond 7 years of age a proper re-evaluation and therapy is recommended. It is important to remember that bed wetting though may be very common and not harmful to the child as such, but it exerts a harmful psychological effect on the developing children. These children may have a lowered self-esteem because of bed wetting and may be afraid to go to a relative’s place or a friend’s place to stay overnight.

There is other group of children who have bed wetting at night along with some day time symptoms like urgency, frequency with occasionally wetting the undergarments. Some of these children try to assume a squatting posture with heel pressed into the perineum- this phenomenon is called Vincent’s Curtsy. These are all signs of an overactive bladder and such children need proper evaluation and therapy by a Pediatric Urologist.

If the child is continuously wetting his clothes and lacks control over the urination, the condition is called incontinence of urine. This is a very distressing condition for the family as well as for the child. Common causes are:

  1. Neurogenic bladder
  2. Exstrophy bladder
  3. Overactive bladder
  4. Non-Neurogenic Neurogenic bladder
  5. Epispadias

A Pediatric Urologist would be able to differentiate these conditions based on a good examination of the patient. Nowadays we have newer therapies and approaches to these conditions. The prime goal is to offer dryness to the patient by medical or surgical means and is a very much attainable goal. The family and the treating Pediatric Urologist must be committed to spend time and energy in arriving at correct formula which works for the patient. This means a very individualized approach and frequent visits.

Fever in urological disorders generally signifies upper tract or kidney involvement in the presence of other symptoms of urinary infection in a child. In newborn babies and infants, fever may be the only symptom of a severe urinary tract infection as other symptoms like frequency, urgency or Dysuria may be absent or missed in a small child who passes urine in a diaper. If clinically, the other systems are not involved and the child had fever, it may be worthwhile to rule out a urinary tract infection by submitting a urine examination.

Abdomen or tummy houses a lot of organ systems like stomach, intestines, liver, spleen, kidneys, pancreas and other glands. Resultantly, abdominal pain can arise from any of these organ systems. Though the causes are diverse, still there are some generalizations. Pain arising from the kidneys is generally in the flank, is deep seated, may be associated with some urinary symptoms (like frequency, dysuria, Hematuria) and there may be no vomiting or diarrhea (associated with stomach or intestinal problems). Jaundice is commonly associated with diseases of liver. Common causes of pain arising from the kidneys:

  1. Acute Pyelonephritis: Urinary infection which has involved the kidney.
  2. Abscess: Pus collection inside or outside the kidney.
  3. Pelvi-ureteric junction obstruction:There is an obstruction to urine flow from the kidney to the ureter and bladder leading to swelling and pain.
  4. Stones:Renal or ureteric calculi generally present with pain in the flank. Classical pain in such cases is Colicky in nature- meaning which comes and goes.

A detailed history and examination would be recommended for any child for such symptoms.

Common causes are:

  1. Hypospadias: Birth defect in which the urinary opening is not present at the tip of the penis but on the underside anywhere along the midline. These can be corrected with surgery at 9 months- 1 year of age. Some of these babies with severe defects may require further investigation to rule out other abnormalities. Hypospadias are best treated by expert pediatric urologist surgeons who have great interest and experience in managing children with hypospadias- More information on Hypospadias , see cases of Hypospadias managed by Dr A.K.Singal,
  2. Epispadias:This is reverse of Hypospadias and the urinary opening is present on the top of the penis. These can also be easily corrected with surgery.
  3. Intersex:Earlier called Intersex- more scientific term for this condition is Disorders of Sex Development of DSD. DSD should be suspected is there is any doubt about the sex of the baby or so called "Ambiguous genitalia". Other situations are severe Hypospadias, Hypospadias with undescended testis, both sided undescended testes, a young girl with a large clitoris or bilateral inguinal hernias. If there are any of the above conditions, then these patients should be thoroughly investigated to learn more about their reproductive organs and sex of rearing. The investigations are karyotype (tells about chromosomes and DNA), Ultrasound, Genitogram and hormonal analysis. See cases of DSD managed by Dr Singal

Undescended testis is one of the most common congenital anomalies in newborn males and can be seen in upto 3-5% of these babies. Some of these will descend to scrotum in first 3-4 months of life, so it is wise to wait for this time before any decision is made. The further planning depends whether the testis can be felt clinically or not. The testis which can be felt clinically can be easily operated on outpatient basis by a surgery called orchidopexy. The ones which cannot be felt clinically are called Non-palpable undescended testis and they may require laparoscopic surgery to find their position and to facilitate their placement in the normal position. It is important to mention here that in such babies’ upto 10-15% may have an absent testis on laparoscopy. This is where laparoscopy is better than USG or MRI scan as it is 100% diagnostic when compared to USG and MRI where chances of missing a small testis are always there. So personally, we don’t recommend any imaging for such babies and prefer to do laparoscopy to decide and counsel for once and all. This is important as the testis left inside the tummy can develop into a cancer later.

See a case: A Boy with undescended testis (cryptorchidism )

Common causes of testicular swelling are:

  1. Hernia- out pouching of intestine from the abdomen into the scrotum. Hernia is very common in children and read more about Hernia in children here.
  2. Hydrocele- collection of fluid around the testis, read more details about Hydrocele here
  3. Cyst
  4. Tumors
  5. Infections- epididymo-orchitis

Dr A.K.Singal is an expert and top pediatric urologist based in Navi Mumbai India. Dr Singal is renowned diagnosis, treatment and expert care of children having urinary disorders. Children from all over India and more than 20 countries come to Mumbai for treatment under his care at MITR Hospital in Kharghar, Navi Mumbai India. To contact him- pls fill up this form or contact MITR Hospital.

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