1. Common problems in Pediatric Urology
Dr. Khalid Fouda Neel, FRCSI
Associate Professor of Urology and Consultant Pediatric Urology
College of Medicine and
King Khalid University Hospital
King Saud University

2. Common problems in Pediatric Urology
Hydronephrosis in children
Pediatric Uro-Oncology
UTI
Neuropathic bladder in children
Voiding dysfunction and Nocturnal enuresis
External congenital anomalies
Pediatric Urolithiasis
17 April 2017
Dr. Khalid Fouda Neel

3. Antenatal Hydronephrosis Causes
Pelviureteric junction obstruction (41%)
Ureterovesical junction obstruction (23%)
Vesicoureteric reflux (7%)
Duplication anomalies (13%)
Posterior urethral valves (10 %)
MCDK
Others (6%)
17 April 2017
Dr. Khalid Fouda Neel

4. Evaluation of Hydronephrosis
All patients should be on prophylactic Amoxcicillin 20 mg /kg/Day
17 April 2017
Dr. Khalid Fouda Neel

5. Presentation of UPJO Incidental in Neonates Incidental in Children
Symptomatic:
UTI
Pain
Mass
Hematuria
Stone
17 April 2017
Dr. Khalid Fouda Neel

6. Surgical Treatment of UPJO Indications of Surgery
Symptomatic patients
Incidental finding in neonates:
Worsening hydronephrosis “Pattern”
Reduced differential renal function
Bilateral disease
Poor family compliance
Poor hospital setup******
Incidental finding in children?
17 April 2017
Dr. Khalid Fouda Neel

7. Obstructive pattern in Renal scan and
IVU is not an indication for surgery by
itself
17 April 2017
Dr. Khalid Fouda Neel

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Dr. Khalid Fouda Neel

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Dr. Khalid Fouda Neel

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Dr. Khalid Fouda Neel

11. Ureterovesical Junction Obstruction
Same principle of management of UPJ
IVP might be helpful > 6 months
17 April 2017
Dr. Khalid Fouda Neel

12. Duplication Anomalies
17 April 2017
Dr. Khalid Fouda Neel

13. MCDK
17 April 2017
Dr. Khalid Fouda Neel

14. Posterior Urethral Valves
Presentation:
Antenatal
UTI
Urine retention in neonatal life
Poor urinary stream
Uremia
17 April 2017
Dr. Khalid Fouda Neel

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Dr. Khalid Fouda Neel

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Dr. Khalid Fouda Neel

17. Management Early: Diagnosed bilateral hydronephrosis antenatally:
1. catheterization
2. prophylactic antibiotics
3. confirm diagnosis
4. stabilization
5. cystoscopic fulgration of PUV
17 April 2017
Dr. Khalid Fouda Neel

18. Management Not diagnosed antenatally: 1. catheterization
2. Treatment of infection
3. stabilization
4. cystoscopic fulgration of PUV
17 April 2017
Dr. Khalid Fouda Neel

19. Management
Late:
Management of secondary complications (VUR, valve bladder, CRF...)
17 April 2017
Dr. Khalid Fouda Neel

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Dr. Khalid Fouda Neel

21. Vesicoureteric Reflux
17 April 2017
Dr. Khalid Fouda Neel

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Dr. Khalid Fouda Neel

23. Normal anti-reflux mechanism “flap valve”
1. Oblique course as it enters the bladder.
2. Proper muscular attachments to provide fixation.
3. Posterior support to enable its occlusion.
4. Adequate submucosal length.
17 April 2017
Dr. Khalid Fouda Neel

24. Resolution of reflux 87% of Grade I }
63%5 of Grade II } over 3 y. period
53% of Grade III } of follow up
33% of Grade IV }
Resolution rate is 30 to 35% each year.
17 April 2017
Dr. Khalid Fouda Neel

25. Management Decision depend on:
1. Chance of spontaneous resolution (Age and grade at presentation).
2. Breakthrough infection.
3. Renal scarring and renal function.
4. Compliance with medication.
17 April 2017
Dr. Khalid Fouda Neel

26. Vesicoureteric Reflux Medical Management
In patients with UTI, and VUR can be suspected, the child should be continued on prophylactic antibiotics after Rx till the VCUG is done.
If you decided this patient is for conservative management, he/she is to continue meticulously on prophylactic antibiotic with surveillance with C/S, U/S and DMSA.
17 April 2017
Dr. Khalid Fouda Neel

27. Typical indications of antireflux procedure
1. Breakthrough infection despite prophylactic antibiotics.
2. Noncompliance with medical treatment.
3. Severe reflux (IV and V) especially with renal scarring.
4. Failure of renal growth (renal U/S).
5. New scar formation.
6. Deterioration of renal function (Renal scan).
7. Reflux in girls at puberty.
8. Reflux with congenital anomalies (ureterocele, diverticula).
17 April 2017
Dr. Khalid Fouda Neel

28. Antireflux procedure 1. Sting 2. Intravesical reimplant.
3. Extravesical reimplant.
4. Laparoscopic reimplant.
17 April 2017
Dr. Khalid Fouda Neel

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Dr. Khalid Fouda Neel

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Dr. Khalid Fouda Neel

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Dr. Khalid Fouda Neel

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Dr. Khalid Fouda Neel

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Dr. Khalid Fouda Neel

34. ENDOSCOPIC INJECTION
17 April 2017
Dr. Khalid Fouda Neel

35. Urinary Tract Infections
* After treatment of the acute febrile infection ; the child should receive daily administration of a prophylactic Antibiotic agent until full radiological evaluation of urinary tract is done (****hospital setup****)
17 April 2017
Dr. Khalid Fouda Neel

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Dr. Khalid Fouda Neel

37. Neurovesical Dysfunction Causes
1. Neural tube defects.
2. Anorectal malformation.
3. PUV.
4. High grade neonatal reflux.
5. Non-Neuropathic Bladder Sphincter Dysfunction.
17 April 2017
Dr. Khalid Fouda Neel

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Dr. Khalid Fouda Neel

39. Neurovesical Dysfunction Management
Proactive vs. reactive management
All patients with anomalies which might cause Neurovesical dysfunction showed be periodically screened
If there are any initial signs of bladder dysfunction prompt management should start
RUS, VCUG, C/S, Urodynamic study
17 April 2017
Dr. Khalid Fouda Neel

40. Conservative management should start first
Neurovesical Dysfunction Indications for Surgical Reconstruction & Diversion
Conservative management should start first
Conservative management failed to protect the upper tract
Conservative management failed to gain normal bladder compliance
Poor family/child compliance
Refractory incontinence
17 April 2017
Dr. Khalid Fouda Neel

41. 3 y Female, known with spina bifida was not seen by a urologist before
Came with history of Rec. UTI
Paraplegic, constipated
Normal renal function
17 April 2017
Dr. Khalid Fouda Neel

42. External Congenital Anomalies
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Dr. Khalid Fouda Neel

43. THANK YOU
17 April 2017
Dr. Khalid Fouda Neel

44. Voiding Dysfunction Lazy voider NNBSD
Pseudo-incontinence (vaginal voider)
17 April 2017
Dr. Khalid Fouda Neel

45. Non-Neuropathic Bladder Sphincter Dysfunction NNBSD
Triad of incontinence , UTI, and constipation
Squatting and urge incontinence
Management depend on the severity
Severity start from only mild diurnal incontinence to sever bilateral VUR with CRF
Urodynamic study is helpful
Treatment spectrum from behavior adjustment to major reconstructive surgery
17 April 2017
Dr. Khalid Fouda Neel

46. Nocturnal Enuresis 15% of all children at the age of 5
The incidence is declined by 1-2% /year
2% has NE at the age of 15
1% of adults population
17 April 2017
Dr. Khalid Fouda Neel

47. Nocturnal Enuresis Keys for Effective Management
Child motivation
Monosymptomatic VS multisymptomatic
R/O voiding dysfunction
Small bladder capacity VS normal bladder capacity
Convert the patients to the normal habits
Proper selection of the mode of the management
Following proper steps
The physician should be convinced
17 April 2017
Dr. Khalid Fouda Neel

48. Nocturnal Enuresis
17 April 2017
Dr. Khalid Fouda Neel