- •Guide to Pediatric Urology and Surgery in Clinical Practice
- •Preface
- •Contributors
- •Key Points
- •1.1 Introduction
- •1.2 Risk Factors
- •1.3 Presentation
- •1.4 Diagnosis
- •1.5 Common Pathogens
- •1.6 Treatment
- •1.7 Imaging
- •1.8 Indications for Referral
- •Suggested Reading
- •Key Points
- •2.1 Introduction
- •2.2 Pathogenesis
- •2.3 Establishing the Diagnosis
- •2.4 Acute Management
- •2.5 Once the Diagnosis Is Established
- •2.6 Long Term Management
- •References
- •Key Points
- •3.1 Introduction
- •3.2 Aetiology
- •3.3 Pathogenesis and Risk Factors
- •3.4 Classification
- •3.5 Signs and Symptoms
- •3.6 Diagnosis
- •3.7 Imaging Studies
- •3.8 Ultrasound Scan (USG)
- •3.9 Voiding Cystourethrography (VCUG)
- •3.10 Dimercapto-Succinic Acid Scan (DMSA)
- •3.11 Treatment
- •3.12 Prophylaxis and Prevention
- •References
- •Key Points
- •4.1 Epidemiology
- •4.2 Presentation
- •4.3 Diagnosis and Workup
- •4.4 Management
- •4.5 Investigations after First UTI in a Child
- •4.6 Prevention of UTIs
- •4.7 Managing VUR and UTIs
- •References
- •Key Points
- •5.1 Introduction
- •5.2 Common Abnormalities of the Scrotum
- •5.4 Indications for Referral
- •Suggested Readings
- •Key Points
- •6.1 Introduction
- •6.2 Common Foreskin Conditions
- •6.3 Treatment of Conditions of the Foreskin
- •6.4 Indications for Referral
- •References
- •Key Points
- •7.1 Hypospadias
- •7.1.1 Introduction
- •7.1.2 Management Issues
- •7.1.3 Indications and Timing of Referral
- •7.1.4 Complications of Surgery
- •7.2 Epispadias
- •Key Points
- •7.2.1 Introduction
- •7.2.2 Management Issues
- •7.2.3 Surgery, Common complications, and Postoperative Issues
- •7.3 Concealed Penis
- •7.3.1 Introduction
- •7.3.2 Referral and Treatment
- •7.3.3 Complications
- •7.3.4 Benign Urethral Lesions in Boys
- •7.3.5 Treatment
- •7.3.6 Follow-Up After Treatment
- •Key Points
- •References
- •Key Points
- •8.1 Introduction
- •8.2 Common Conditions
- •8.3 Treatment of Undescended Testis
- •8.4 Indications for Referral
- •References
- •Key Points
- •9.1 Natural History of the Prepuce
- •9.2 Benefits of Circumcision
- •9.3 Absolute Indications for Circumcision
- •9.4 Relative Indications for Circumcision
- •9.5 Surgical Options
- •9.6 Contraindications to Circumcision
- •9.7 Complications of Circumcision
- •9.8 Conclusion
- •References
- •Key Points
- •10.1 Introduction
- •10.2 Labial Adhesions
- •10.3 Interlabial Masses
- •10.4 Paraurethral (Skene’s Duct) Cyst
- •10.5 Imperforate Hymen with Hydrocolpos
- •10.6 Prolapsed Ectopic Ureterocele
- •10.7 Urethral Prolapse
- •10.8 Urethral Polyp
- •10.10 Vaginal Discharge and Vaginal Bleeding
- •References
- •Key Points
- •11.1 Introduction
- •11.2 Functional LUTS
- •11.2.1 Overactive Bladder
- •11.2.2 Dysfunctional Voiding
- •11.2.3 Underactive Bladder
- •11.2.4 Uroflowmetry
- •11.2.5 Treatment
- •11.2.5.1 Standard Outpatient Urotherapy
- •11.2.5.2 The Failed Training
- •11.2.6 Giggle Incontinence, Incontinentia Risoria
- •References
- •Key Points
- •12.1 Introduction
- •12.1.1 Definition
- •12.1.2 Prevalence
- •12.1.3 Causes
- •12.1.4 Monosymptomatic Enuresis
- •12.1.4.1 Genetics
- •12.1.4.2 Sleep
- •12.1.4.3 Sleep-Disordered Breathing
- •12.1.4.4 Small Functional Bladder Capacity
- •12.1.4.5 Psychological/Behavioral
- •12.1.5 Nonmonosymptomatic (Organic) Enuresis
- •12.1.5.2 Polyuria
- •12.1.5.3 ADH Secretion
- •12.1.5.4 Food Sensitivity
- •12.2 Investigations
- •12.2.1 History
- •12.2.2 Physical Examination
- •12.2.3 Laboratory Tests
- •12.2.4 Imaging Studies
- •12.2.5 Evaluation of Functional Capacity
- •12.3 Conventional Treatment
- •12.3.1 Behavioral Therapy
- •12.3.2 Alarm Therapy
- •12.3.3 Pharmacologic Therapy
- •12.4 Alternative Treatment
- •12.5 Conclusion
- •12.5.1 Areas of Uncertainty
- •12.5.2 Guidelines
- •References
- •Key Points
- •13.1 Introduction
- •13.2 Definition of Constipation
- •13.3 Evaluation
- •13.4 Treatment of Constipation
- •13.5 Indications for Referral
- •Suggested Readings
- •Key Points
- •14.1 Hematuria
- •14.1.1 Important Points in the History
- •14.1.2 Causes of Hematuria
- •14.1.3 Investigations
- •14.1.4 Management
- •14.2 Proteinuria
- •14.2.1 Quantification of Proteinuria
- •14.2.2 Causes of Proteinuria
- •14.2.2.1 Non-Pathological Proteinuria
- •14.2.2.2 Orthostatic Proteinuria (Postural Proteinuria)
- •14.2.2.3 Pathological Proteinuria
- •14.2.3 Investigations
- •References
- •Key Points
- •15.1 Introduction
- •15.2 Indications for Referral
- •References
- •Key Points
- •16.1 Introduction
- •16.2 Treatment of Angular Dermoid
- •16.3 Indications for Referral
- •16.4.1 Introduction
- •Suggested Reading
- •Key Points
- •17.1 Introduction
- •17.2.1 Thryoglossal Duct Cyst
- •17.2.2 Midline Dermoid Cyst
- •17.2.3 Lymph Nodes
- •17.2.4 Thyroid Nodule
- •17.2.5 “Plunging” Ranula
- •17.2.6 Investigations
- •17.3 Treatment
- •17.3.1 Thryoglossal Duct Cyst
- •17.3.2 Midline Dermoid Cyst
- •17.3.3 Lymph Nodes
- •17.3.4 Plunging Ranula
- •Key Points
- •18.1 Introduction
- •18.2.1 Lymph Nodes
- •18.2.1.1 Infective
- •18.2.1.2 Inflammatory
- •18.2.1.3 Neoplastic
- •18.2.2.1 Investigations
- •Key Points
- •19.1 Introduction
- •19.2 Etiology and Types of Torticollis
- •19.3 Treatment of Torticollis
- •19.4 Indications for Referral
- •Suggested Readings
- •Key Points
- •20.1 Introduction
- •20.2 Common Umbilical Conditions
- •20.4 Indications for Referral
- •20.5 Epigastric Hernia
- •20.5.1 Introduction
- •References
- •Key Points
- •21.1 Introduction
- •21.2 Common Sources of Abdominal Pain
- •21.2.1 Children
- •21.2.2 Infants
- •21.3 Treatment of Conditions
- •21.4 Indications for Surgical Referral in Children with Abdominal Pain
- •References
- •Key Points
- •22.1 Introduction
- •22.2 History
- •22.3 Physical Examination
- •22.4 Laboratory Tests
- •22.5 Diagnostic Imaging
- •Suggested Readings
- •Key Points
- •23.1 Introduction
- •23.2 Investigations
- •23.3 Treatment
- •References
- •Key Points
- •24.1 General Principles
- •24.2 Neonates and Newborn
- •24.3 Infants and Young Toddlers
- •24.4 Older Children
- •24.5 Conclusion
- •References
- •Key Points
- •25.1 Introduction
- •25.3 Neonatal Intestinal Obstruction (Distal)
- •25.4 Childhood Intestinal Obstruction
- •References
- •26.1 Introduction
- •26.3 Initial Management
- •26.4 Causes of Neonatal Bilious Vomiting
- •Key Points
- •26.6 Necrotizing Enterocolitis
- •26.7 Duodenal Atresia
- •26.8 Small Bowel Atresia
- •26.9 Meconium Ileus
- •26.10 Hirschsprung’s Disease
- •26.11 Anorectal Malformations
- •26.12 Conclusion
- •References
- •Key Points
- •27.1 Introduction
- •27.2 Presentation
- •27.3 Investigations
- •27.4 Management
- •References
- •Key Points
- •28.1 Introduction
- •28.2 Presentation
- •28.3 Investigations
- •28.4 Management
- •28.5 Surgical Management
- •References
- •Key Points
- •29.1 Introduction
- •29.2 Types of Vascular Anomalies
- •29.3 Investigation of Vascular Anomalies
- •29.4 Treatment of Vascular Anomalies
- •29.5 Indications for Referral
- •Suggested Readings
- •Index
122 A.M. Behr
Secondary enuresis is the relapse of nighttime wetting in children who have achieved at least 6 months of nighttime dryness. Enuresis is further classified based on the presence or absence of additional symptoms. Monosymptomatic or physiologic enuresis is nighttime wetting in children without any other lower urinary tract symptoms, except nocturia, and without a history of dysfunctional voiding. Children with enuresis and any other symptoms of the lower urinary tract or complicating organic factors are classified as having nonmonosymptomatic enuresis.1
12.1.2 Prevalence
Nocturnal enuresis is a common condition. Of school-aged children aged 5 to 16 years, 6–10% experience nocturnal enuresis.2 Most primary enuresis is thought to be caused by a maturational delay.Therefore, the prevalence should decrease as children mature. Each year 15% of enuretic children cease wetting without intervention.3 Boys tend to be affected more often than girls. About 60% of intermittently enuretic children and 90% of nightly bedwetters are male.4
12.1.3 Causes
The etiology of nocturnal enuresis is unclear and is likely multi-factorial, involving genetic, sleep, urological, neurological, and psychological components. As previously stated, it can be classified as monosymptomatic (physiologic) or nonmonosymptomatic (organic) in nature.
12.1.4 Monosymptomatic Enuresis
12.1.4.1 Genetics
For many families, bedwetting is a familiar disturbance. Research has demonstrated a higher incidence of bedwetting
Chapter 12. Disorders of Elimination: Nocturnal Enuresis |
123 |
in children whose parents were affected when compared to families with no parental history. Geneticists have identified possible markers for primary nocturnal enuresis on chromosomes 12, 13, and 22.5 We know that enuresis is an autosomal dominant trait, so the likelihood of enuresis if both parents were affected is 77% and about 44% if one parent was affected. Children still have a 15% chance of acquiring enuresis even if neither parent was affected.6
12.1.4.2 Sleep
Children with nocturnal enuresis have been shown to have normal sleep patterns; however, parents of bedwetting children report much difficulty awaking the child from sleep, and when awakened, these children are often disoriented. Bedwetting is not caused by deep sleep however and is not considered a sleeping disorder. Nonetheless, it seems as though children with nocturnal enuresis have more difficulty arousing from sleep and are not able to wake up when their bladders are full. Instead, their muscles relax and the bladder empties while they sleep. For instance, a study performed by7 Wolfish demonstrated that children with enuresis awoke to increasing tone intensity 8.5% of the time compared to the control group, who awoke about 40% of the time. For that reason, it is believed that enuretic children have a slow-to-mature sleep arousal mechanism within the central nervous system.
Nocturnal enuresis can occur in all sleep stages, but has shown to be more likely during non-rapid eye movement. Cystometric studies performed on children during sleep have shown that they have more difficulty arousing from sleep during non-rapid eye movement, which predominately occurs during the first two-thirds of the night. If spontaneous bladder contractions occur in that phase, children are less likely to wake and are therefore more likely to have an enuretic episode. Children spend the last one-third of sleep in rapid eye movement and have fewer enuretic episodes during that time.7
124 A.M. Behr
12.1.4.3 Sleep-Disordered Breathing
Obstructive sleep apnea has been studied for its association with nocturnal enuresis. It is well known that regular sleep disruptions due to upper airway obstruction in sleep apnea cause a number of daytime concerns,like sleepiness,decreased school performance, headache, and growth disturbance. Incongruously, these children are very difficult to wake from sleep. It is believed that the brain puts such a high value on sleep integrity that the arousal threshold is actually increased in patients with sleep apnea because of the constant stimuli from the airways. Therefore, these children sleep more heavily and do not wake easily to less obvious stimuli, like bladder fullness. Therefore, in addition to the higher incidence of polyuria in this population, decreased sleep arousal is another cause for the relationship between enuresis and sleep apnea.8
12.1.4.4 Small Functional Bladder Capacity
Though most children with nocturnal enuresis have normal bladder function and a normal structural bladder capacity, they may exhibit small functional bladder capacity that leads to nighttime wetting. Functional capacity is the point at which the brain receives the signal that the bladder needs to empty. This is in contrast to estimated bladder capacity (EBC) which is projected by the formula, [30 + (age in years × 30)] (in milliliters) and structural bladder capacity, which identifies the actual volume of the bladder.
The International Children’s Continence Society (ICCS) has replaced the term functional capacity with voided volume to reflect bladder function versus bladder anatomy. To obtain functional capacity or voided volume, the child should urinate in a measuring container or toilet “hat” at home. Parents should collect about 10 measurements over the course of 3 days to get an average voided volume for the child. Evidence of small functional capacity is primary enuresis, wetting the bed every night, several wetting episodes per