Paediatric urology
A surgical medicine subspecialty that is concerned with the diseases of the genitourinary tract in children. A paediatric urologist and surgeon examines, treats and manages urological disorders in children.
Different from adult urology
The focus is on the urological and reproductive organs of children from infancy to teenage. We look at genetic and developmental concerns in this area, and while planning treatments we look at the age and growth of the child.
Adult urology is concerned with the urinary tract and adult reproductive organs, addressing conditions such as prostate disease, kidney stones and cancers that occur in adults.
An interactive specialty
Paediatric urology frequently includes interaction with other subspecialists, including nephrologists, neonatologists, endocrinologists and obstetricians-gynaecologists. It is also a constantly changing field with continuous research and development to ensure better outcomes in patients. Most of the paediatric urological procedures involve long-term follow-up. Parents must not shy away from this and must be committed to bringing their children for follow-ups.
The genitourinary system in children
The system consists of two kidneys, two ureters (tubes that carry urine from kidney to bladder), one urinary bladder, and one urethra (tube that carries urine from bladder to outside the body). In addition, it includes the reproductive organs: the prostate gland, testicles and epididymis in males; and the uterus, fallopian tubes, ovaries, vagina and external genitalia in women. They are the same as adults with some progressing differences.
Common conditions in children that need medical help
Structural anomalies that can impede the urine flow from kidney to ureter or into the bladder. These, if untreated, can lead to urine blockage, infection and kidney damage. These issues are within the genitourinary tract that occur during birth and after birth, infections of the urinary tract, such as bladder infections and kidney infections, and even trauma or tumours in the genitourinary system.
And then some more
Undescended testicles: When one or both testicles have failed to descend to the scrotum.
Hypospadias: Wherein the urethra opening is on the lower side of the penis, rather than on the tip.
Vesicoureteral reflux (VUR): When urine tends to flow back into the ureters from the bladder.
Hydronephrosis: Where one or both kidneys fill up with urine, it becomes infectious and causes damage. Children also get kidney stones, kidney and bladder tumours, and urinary tract infections.
Urinary tract infections
Can happen often in children, especially in girls. Antibiotics help. At times, we suggest additional tests to understand if there are any specific causes. Having UTIs repeatedly can lead to kidney scarring and it can become a larger risk factor in adulthood.
Renal cysts
These are fairly common, occurring in approximately one in 1,000 children. Most of the cysts are benign, though a few can be malignant; early detection is essential.
Kidney stones in children
Becoming more common. Some primary causes are dehydration, metabolic disorders, urinary tract abnormalities and genetic conditions. Also, changing lifestyle and children’s attraction to high-sodium and high-sugar foods.
Certain conditions more common in Indians
The incidence of urological disorders can be determined by several factors, such as genetics, environmental conditions and health care access.
UTIs are very prevalent in children in India, as they are all over the world. Hygiene and access to clean water can be contributing factors. Recurrent UTIs may be an indicator of underlying urological disorders such as VUR. This and hydronephrosis are the conditions that, if untreated, may result in kidney damage. Availability of prenatal care and early diagnosis can significantly influence treatment.
Most common causes
Genetic and environmental factors. In many cases, the cause is unknown.
The expectant mother’s condition
The child can be at risk at birth if the mother is hypertensive or diabetic. Some factors could be family history, certain conditions like VUR might be inherited, and so the risk is more for a newborn. During pregnancy, a foetus’s structural abnormalities can be a result of genetics. This would mean an absent kidney, an abnormal opening of the urethra, kidney diseases or UPJ (ureteropelvic junction obstruction is a blockage where the kidney meets the ureter), causing the urine to flow back up into the kidney.
The role of the environment
Chemical, pollutant and toxin exposure during pregnancy could heighten the risk of issues at birth. As a child grows, the possibility of UTIs can depend on hygiene habits. In hotter climates, kidney stones can become common, especially if the child’s water intake is poor.
The spinal cord-bladder connect
The nerve signals between the brain and the bladder travel through the spinal cord. The contraction and emptying of the bladder are regulated by these signals. If there are any issues in the spinal cord, during birth, it can lead to neurogenic bladder (impaired bladder control due to damage to nerves). That causes complications like UTIs, urine retention, involuntary urination, renal damage, etc.
Injuries that children get
Active children are susceptible to injuries that might impact the urinary tract. There could be kidney contusions or lacerations due to direct blows to the flank or abdomen. Although less frequent, ureteral injuries can be caused by major trauma, while bladder ruptures can occur with pelvic fractures. There can be testicular trauma that could be caused by blows to the scrotum. Children can also be subject to surgical emergencies like that for testicular torsion (loss of blood flow to scrotum).
Your approach to treatment
A few core things I keep in mind during treatments are: minimally invasive surgeries, that too only if needed; being compassionate; and, most important, establishing clear and efficient communication with the child and family. My treatment plans are designed uniquely to each child. I tend to look at methods with minimal invasion because it reduces discomfort in the child and has shorter recovery time. Surgeries are only considered if essential. I also schedule follow-up meetings to keep tracking progress. I prefer using fewer medical terms with children; I want them to be relaxed and trusting of me. Their parents get detailed understanding of the child’s medical issues, the severity, treatment plans and post care. There I keep the conversation open and transparent. At the end of the day, the child must be given the best care, not just medically, but also psychologically and emotionally.
Common misconceptions
Bed-wetting is not simply laziness; it is usually a medical condition that can be cured. Any testicular pain may not be a mere bruise; in rare cases it could be testicular torsion. Mild UTIs in children can cause scarring in the kidneys if they are left untreated. Children will not outgrow all urological problems; certain conditions need to be treated. Remember, children are not adults, they have different physiology and pathology, and the natural history of diseases is much different. They need to be taken care only by professionals.
Latest advancements and research
Robotic surgery: Procedures with better precision and fewer invasions.
Advanced imaging: Enhanced diagnostic precision with MRI and ultrasound.
Genetic testing: Finding underlying genetic reasons for urological disorders.
Tissue engineering: Cultivating new tissue for reconstructing the urinary tract.
Enhanced treatment protocols: Improved handling of advanced conditions such as VUR and congenital kidney abnormalities.
Common diagnostic tools
Blood tests, urine tests, ultrasound, MRI, blood tests and CT scans. Then there is VCUG or voiding cystourethrogram. It is an X-ray to see the bladder and urethra when the patient urinates. It helps diagnose VUR. We also use cystoscopy, where we insert a camera to look inside the bladder and urethra. Urodynamics for study of the bladder. Renal scan for assessment of kidney function and drainage.
Surgical options
For undescended testes, there are open and laparoscopic orchiopexies (surgical procedures that replace the undescended testicle into the scrotum). For VUR, too, based on the need, there can be laparoscopic and open surgery. Other surgical procedures are ureteral reimplantation (repositioning of the ureters), hernia and hydrocele (a condition where fluid accumulates in the scrotum) repairs, and hypospadias repair. Ureteropelvic junction can be treated with pyeloplasty, which can either be done robotically or laparoscopically. There are procedures like ureteroscopy (a minimally invasive procedure used to examine and treat conditions within the ureters and kidneys), percutaneous nephrolithotomy (minimally invasive procedure to treat kidney stones) and shockwave lithotripsy (non-invasive procedure used to break down kidney stones into smaller pieces so that they can be passed in urine).
The role of counselling in preparing a child for surgery
Counselling can address the psychological and emotional needs of the child as well as the parents. Young children need simple language, play and visual aids. If the child is told beforehand about what they could feel during the procedure, what they would see or smell in the operating room, then it can help them with possible anxiety.
Common post-operative complications
There can be infections that are treated by antibiotics and dressing. In case of any unexpected bleeding, we take up extra procedures or blood transfusions. If there is urinary retention, it might need to be catheterised (insertion of a latex/polyurethane/silicone into the bladder through the urethra to allow urine to drain from the bladder). There could be complications with the wound, which can delay healing. With reconstructive or abdominal surgeries, there could be an ureteral obstruction or bowel obstructions, which we treat with stents, nasogastric tubes (thin, flexible tube inserted through the nose, down the throat and into the stomach) or further intervention.
The use of AI
It helps with analysing images while planning surgical procedures. We can utilise predictive analytics to understand if there can be any complications post-surgery. It cannot replace the surgeon, only assist them in doing a better job.
Parental vigilance
Regularly check the site where the surgery has been performed, as well as the incision. Check for redness/swelling/if the area is warmer than the rest of the body/any fluid or blood drainages around the wound. Any such irritations must be informed to the doctor without delay. Sometimes children can have chills or come down with a fever. Parents should also check the child’s urinary output―has it decreased/is there blood in it? Children could have pain while urinating, and it may not change even after medication. Some children also tend to have vomiting, diarrhoea or constipation.
Strategies for promoting healthy bladder and bowel habits
Children should be trained to practise regular toilet habits. Start such habits when they are small, and to make it a practice, start by rewarding or complimenting them when they keep up with a routine. Motivate them to drink water during the day. Add fruits, vegetables and whole grains to avoid constipation, and more important, reduce processed food intake. For children with bladder or bowel dysfunction, pelvic floor exercises can tighten muscles. When a child has recurring constipation or incontinence, a doctor must be consulted to exclude any underlying medical condition.