Pediatric Urology: Circumcisions, Phimosis, Paraphimosis
The prepuce, or foreskin, is a normal part of the external genitalia, forming a natural covering over the tip of the penis (glans). At birth the foreskin typically is un-retractable, or does not easily glide back and forth over the glans. This is a normal condition and the foreskin will become fully retractable as the child grows. Medical intervention is usually unnecessary. Medical or surgical intervention is necessary when a child has difficulties with urination (for example, the urine pools in the foreskin) or problems with infections.
Circumcision
Circumcision involves the removal of the foreskin from the tip of the glans to the ridge of the glans. Circumcision is often a hotly debated issue in terms of when it should be done and if it should be done. Circumcision should never be done if there is a question as to whether or not the possibility of hypospadias exists.
Phimosis
This is a condition whereby the foreskin is tight and narrow, thus making it impossible or painful to retract. This may cause extreme pain when your child experiences stronger erections. In addition it may cause problems with infections as stated above. Although this is a normal condition in infancy, medical or surgical intervention may be indicated if this persists beyond 4-5 years of age. At this point in time your child should be evaluated by a pediatric urologist who can make the decision whether the need for a circumcision is indicated.
Paraphimosis
This is a condition somewhat opposite of phimosis. Paraphimosis occurs when the foreskin is fully retracted behind the ridge of the glans and is unable to be pulled back over the glans. As the foreskin remains behind the ridge of the glans, it may cause irritation and swelling making it impossible for the foreskin to be pulled back over the glans. This condition requires urgent medical attention.
Abnormal Voiding and Voiding Dysfunction in Children
During normal development children become more aware of their bladders. This maturation process allows the ability to control their bladder and prevent wetting. Children learn to override the normal tendency of the sphincter to relax by contracting their sphincters, thus staying dry. This is a normal reaction of a child to prevent wetting and allows a child time to get to a bathroom. However, an unhealthy situation occurs when a child continues to maintain a contracted sphincter against a full, or straining bladder. This, in essence, sets up two muscles working against each other. Over time, muscle hypertrophy will occur, and the bladder wall will become two to three times its normal thickness because of muscle fiber enlargement. In severe cases damage to the upper urinary tracts can occur.
Bowel Program
In addition to establishing a voiding schedule, every child with diurnal enuresis needs to have a daily bowel movement. Suggested treatments include using stimulants for short-term use (4-8 weeks). Stimulants include Chocolate Ex-Lax 1-2 squares, Senokot Children's Syrup 1-2 tsp. or Dulcolax 1 tablet. All stimulants should be given at bedtime. Children should also be encouraged to sit on the toilet for 5 minutes following meals. Following the use of a stimulant the patient should begin a stool softener and add fiber in the diet. Softeners are safe for long-term use and include Milk of Magnesium 1cc/kg/dose or Mineral Oil 1cc/kg/dose. If mineral oil is used greater than 2 months, vitamins should be supplemented due to malabsorption of fat-soluble vitamins.
Hernia and Hydrocele
In normal testicular development the testicle descends and travels through the abdomen into the scrotum during the last few months of pregnancy. Typically the 'tunnel' from the abdomen to the scrotum (called the processus vaginalis) closes at birth or during the first year of life. However, it is not uncommon for the tunnel to remain open allowing fluid or bowel to enter, which is called a hydrocele or hernia. When there is just fluid in the scrotum it is called a hydrocele and this typically resolves within the first year. If a hydrocele gets larger (rather than smaller), causes pain or discomfort and persists beyond the first year of life, surgical intervention is necessary. If bowel gets down into the inguinal canal or scrotum, it is called a hernia. If this causes discomfort, becomes red and hard, or makes the child ill (that is, vomiting, nausea, fever), surgical intervention is necessary.
Hypospadias
Hypospadias is a relatively common birth defect found in boys whereby the urinary tract opening is not at the tip of the penis. Associated with hypospadias is a foreskin that is only "half" present due to the absence of the lower portion. Children with hypospadias should not be routinely circumcised at birth until they have been evaluated by a pediatric urologist. Different degrees of hypospadias exist -- some quite minor and others more severe. The type of hypospadias is named according to the anatomic location of the defect, but one must always determine whether or not there is associated chordee. On occasion a child may have chordee, or abnormal bend of the penis upon erection, without apparent hypospadias. Like hypospadias, there is a spectrum in the severity and, therefore, repair may be simple or complex.
ACE (Antegrade Continence Enema)
Some children are born with neurogenic bowels, or bowels that don't work properly. This can lead to problems with stool incontinence, or stool accidents. While this may not be much of a problem in a child's younger years, it may become a very difficult and embarrassing issue when your child is older. In addition, it will be more difficult for a parent to manage the neurogenic bowels in an older child. An Antegrade Continence Enema (ACE) is a surgical procedure that will provide a way for your child to be continent of stool.
Surgical Management of Urinary Incontinence in Children and the Mitrofanoff Principle
Children who are born with a neurogenic (non-functioning or poorly functioning) bladder may have problems with urinary incontinence, or wetting. In addition, these children may have difficulty with catheterizing their bladder due to pain or physical limitations. As these children grow older, the wetting problems will become a socially embarrassing issue as other children may start teasing that can result in poor self-esteem and psychological pain. It is crucial that these children have a readily accessible and convenient way to catheterize, or empty their bladders, allowing them to be dry, or continent.
Fecal Incontinence
The Malone Antegrade Continence Enema (MACE) uses the Mitrofanoff principle to allow catheter access to the bowel. Through the catheter a large volume tap water enema is infused to allow stool evacuation. This has become the mainstay of bowel therapy in recalcitrant stool incontinence in children with congenital anatomical and neurological fecal incontinence: spinal bifida, imperforate anus, and cloacal anomalies.
Bladder Surgery in Children
Before any surgery can be performed on the bladder, studies of the bladder and kidneys will be done to accurately evaluate each child's bladder. The information revealed in these studies help determine if surgery is the best option for managing your child's bladder. Once it is determined that surgery is in fact the most beneficial option your child will be scheduled for surgery. The surgical procedure will take approximately 3 hours. Often, however, the Mitrofanoff and MACE operations are done in concert with other major bladder reconstructive surgery. We encourage children to get up and get moving as soon as possible after surgery. After surgery your child will have a foley catheter in the Mitrofanoff to allow it to heal and keep the bladder draining well. In addition, another catheter, called a suprapubic catheter, will help drain the bladder in the more complex reconstructions. The tubes will be left in place for 4-6 weeks to allow the bladder and Mitrofanoff to heal. To help the tubes drain properly they may need to be irrigated, or flushed, with normal saline water to keep the urine clear and to prevent the tubes from clogging.
Undescended Testicle in Children
The testicles are egg-shaped organs that lie in the scrotum. They produce the male hormone testosterone. They also contain reproductive cells called sperm. An undescended testicle occurs when there is failure of the testicle to descend from the abdominal position in the fetus into the scrotum. Orchiopexy is the surgical procedure for an undescended testicle.
Pediatric Dialysis Unit
When kidney function falls below 10% of normal and an immediate kidney transplant is not available, dialysis must be started as a life-sustaining treatment until a kidney transplant can be performed. It is often difficult to accept, but our goal is to make the transition as safe and uneventful as possible. The Pediatric Dialysis Unit at KIMS is one of the finest in the country. It is a recently renovated, state-of-the-art facility with both hemodialysis and peritoneal dialysis modalities available both in the center and at home. The hemodialysis facility has eight individual stations, including an isolation station providing treatment to as many as X children and adolescent of various ages and sizes, X days per week. Patients are monitored for dialysis adequacy, and monthly multi-disciplinary patient reviews are held in accordance with national guidelines. Through personal care and individualized treatment, our staff is able to provide essential support to young patients and their families.
Chronic Renal Failure Clinic
When renal disease strikes a child at any age, from birth to young adulthood, it also impacts a circle of family, friends, and community. KIMS Chronic Renal Failure Clinic is treatment center for all children whose kidney function falls significantly below normal, approximately 75 percent below normal for the child's age. This amount of renal failure indicates a strong likelihood of progression to End Stage Renal Disease (ESRD). The center is designed to recognize those patients in need of special services and intervene early with treatments to avoid progression of the disease and treat the metabolic consequences of kidney failure, such as poor growth and intellectual deficits. From an early stage, the center's team of physicians, nurses, social workers, dieticians, psychologists, and teachers work with the patient and family toward a common goal of sustaining maximum health and preparing for any interventional services necessary for the child's successful treatment.
Pediatric Kidney Transplantation Program
The Pediatric Kidney Transplant Program at KIMS is awell-recognized center of excellence, offering the most advanced surgical and therapeutic modalities. Our long history of transplant innovations and superior outcomes has contributed to our worldwide reputation as leader in the field of transplantation. Kidney transplantation is the ultimate treatment goal for all children with End Stage Renal Disease. The pediatric nephrology and transplantation programs are interdisciplinary partners in the Comprehensive Children's Kidney Failure Center. Specially trained nurse liaisons maintain close supervision over the patient needs and focus on the complex issues that arise. In recent years, transplantation services have extended to multi-visceral transplant, including not only kidney, but liver, heart, and other gastro-intestinal organs that frequently affects kidney function and require Pediatric Nephrology consultation.
The pre-transplant evaluation may require several visits over the course of several weeks or even months. You'll need to have blood drawn and x rays taken. You'll be tested for blood type and other matching factors that determine whether your body will accept an available kidney. The medical team will want to see whether you're healthy enough for surgery. Cancer, a serious infection, or significant cardiovascular disease would make transplantation unlikely to succeed. In addition, the medical team will want to make sure that you can understand and follow the schedule for taking medicines. If a family member wants to donate a kidney, he or she will need to be evaluated for general health and to see whether the kidney is a good match.
