Imaging children with ambiguous genitalia and intersex states.
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Child↗
Biomedical subjects
A M Rickwood
Publications and source records attributed to A M Rickwood.
'Congenital' hydronephrosis: limitations of diagnosis by fetal ultrasonography.
OBJECTIVE: To determine whether children presenting clinically with pelvi-ureteric junction obstruction had fetal hydronephrosis. PATIENTS AND METHODS: Forty-three children, born during or after 1985, presented clinically with pelvi-ureteric junction obstruction. Records of the maternal pregnancies were reviewed with reference to the findings of any fetal ultrasonography. RESULTS: In 25 patients fetal ultrasonography was performed at or beyond 30 weeks' gestation (mean 33.2). None had significant fetal hydronephrosis. CONCLUSION: Hydronephrosis due to pelvi-ureteric obstruction is not necessarily congenital and patients presenting clinically may differ inherently from those detected fetally.
Female↗
Congenital testicular maldescent: significance of the complete hernial sac.
OBJECTIVE: To test the hypothesis that testicular maldescent is rarely congenital in the absence of a complete hernial sac. PATIENTS AND METHODS: The study comprised 110 boys undergoing orchidopexy. Operative findings (complete hernial sac versus no hernial sac) were compared with recorded testicular descent at birth. RESULTS: Among 70 testes recorded as maldescended neonatally there was no example without a complete hernial sac at orchidopexy. Among 60 recorded as descended neonatally, 43 had no sac at orchidopexy. CONCLUSIONS: The findings are consistent with the hypothesis, though not with the proposition, that the presence of a complete hernial sac at orchidopexy constitutes proof of congenital testicular maldescent.
Age Factors↗
Prenatally diagnosed pelviureteric junction obstruction: a benign condition?
Renal function in neonates with antenatally diagnosed pelviureteric obstruction is usually well preserved and rarely deteriorates in the short term. To assess if function is maintained in the medium term, and, where not, if any factors are predictive of deterioration, the authors reviewed their cases (1985 to 1992) of antenatally diagnosed unilateral pelviureteric obstruction with renographic confirmation (type II and IIIb curves). Initial renographic assessment was performed at 1 to 3 months. Among the 160 cases, initial differential function exceeded 40% in 140 (87.5%), and these were managed expectantly with renographic follow-up, usually at 24, 48, and 72 months of age. The 20 patients with reduced differential function underwent early intervention (pyeloplasty, or trial of nephrostomy drainage in those with very poor function). Follow-up in those managed expectantly showed good differential function in 135 (96.5%), despite persistence of renographic obstruction in two thirds of the cases, more than half of which have had renographic follow-up beyond 4 years. Differential function decreased to below 40% in five patients (3.5%); this was not related to the type of renographic curve or severity of the hydronephrosis. The natural history of antenatally diagnosed pelviureteric obstruction continues to appear benign, and it may differ from that in older children who present clinically.
Child, Preschool↗
Infection stones in children: a twenty-seven-year review.
OBJECTIVE: The objective of this study was to determine the relationship between urinary tract infection and pediatric urolithiasis and to characterize the pediatric infection stone former. METHODS: Two hundred seventy consecutive pediatric stone formers presenting over a twenty-seven-year period were studied. Of these, 161 children (60%) had infection-related stones. Account was taken of stone composition, anatomic location, associated anatomic lesions, and the rate of stone recurrence over a median follow-up of three years. RESULTS: The mean age of children with infection stones was 4.9 years, with two-thirds being under six years of age. Proteus mirabilis accounted for 82 percent of pure urine cultures. Seventy percent of stones were renal and 30 percent were ureteral or intravesical. One-third of patients had anatomic lesions (pelviureteric obstruction, primary obstructed megaureter, and others) contributing to stone formation. Recurrent stones occurred in 14 percent of cases. CONCLUSIONS: This study reaffirms the predominance of urinary tract infection secondary to P. mirabilis as the leading cause of pediatric urolithiasis in the United Kingdom. The significant recurrence rate suggests the importance of prophylactic antibiotics, surgical correction of congenital anomalies, and long-term follow-up of this patient population.
Adolescent↗
Combined bladder neck suspension and augmentation cystoplasty for neuropathic incontinence in female patients.
OBJECTIVE: To perform bladder neck suspension simultaneously with augmentation cystoplasty in female patients where sphincteric incompetence was not the sole cause of impaired functional bladder capacity. PATIENTS AND METHODS: During an 8-year-period, 26 female patients (mean age 14, range 5-39) were treated with a Marshall-Marchetti plus cystoplasty (Liverpool) or a colposuspension plus clam cystoplasty (Sheffield). All had marked sphincteric incompetence compounded by detrusor hyper-reflexia and/or non-compliance. The patients were followed up for a mean period of 30 months (range 8-80). RESULTS: There were no major complications. At follow-up 23 (88%) were dry by day on a regime of intermittent self-catheterization. Nine patients were taking adjuvant medication, usually for prevention of nocturnal enuresis. CONCLUSION: The results compare tolerably with those of all alternative procedures, including the more elaborate reconstructions (e.g. Kropp procedure) and the expensive artificial urinary sphincter.
Adolescent↗
Urinary incontinence due to unilateral vaginally ectopic single ureters.
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Child↗
Experience with duplex system anomalies detected by prenatal ultrasonography.
We reviewed 39 neonates with prenatally diagnosed duplex system anomalies. Principal diagnoses were ureterocele in 15 patients, ureteral ectopia in 15, lower polar vesicoureteral reflux in 6, lower pole ureteropelvic junction stasis in 2 and yo-yo reflux in an incompletely duplicated system in 1. Several patients had other ipsilateral and contralateral urinary anomalies. Ten patients (26%) had relevant physical signs and only 1 became symptomatic, with urosepsis, neonatally. At initial assessment, before any accounted urinary tract infection, renal polar function as judged by radionuclide examinations almost always was severely impaired in the presence of major ureteral ectopia or severe reflux. By contrast, function was usually well preserved when there was obstruction, or lesser degrees of ectopia or reflux. A total of 19 patients underwent surgery (14 electively and 5 after episodes of urosepsis), while 20 have been managed nonoperatively for 12 to 84 months (mean 34) during which time the appearances and function of the upper renal tracts have remained stable. We conclude that the natural history of these anomalies is often benign and that a policy of routine surgical intervention, developed when most cases presented symptomatically, may not be appropriate in patients who present antenatally.
Female↗
Posterior urethral valves. Does prenatal diagnosis influence prognosis?
Forty-eight boys with posterior urethral valves were reviewed to assess the impact on prognosis of prenatal ultrasonography, which had been the method of diagnosis in 17 of them; the remaining 31 presented postnatally. Renal function before treatment was mildly to moderately impaired in 59% of those presenting prenatally, 42% presenting before 3 months of age and 25% of those first presenting when older than 3 months. All but one of the infants diagnosed prenatally had clinical signs and/or elevated serum creatinine in the early neonatal period. Eight had associated maternal oligohydramnios, of whom 6 presented prenatally and 2 postnatally: this factor was associated with a poor prognosis, with renal impairment persisting in 6 of these patients after treatment. Renal function did not relate consistently to the presence or otherwise of vesicoureteric reflux (unilateral or bilateral). Twelve of the patients who presented postnatally had normal fetal ultrasonography late in pregnancy, of whom 11 had upper tract dilatation when investigated. Six of these patients who currently have impaired renal function did not have maternal oligohydramnios, and it is argued that antenatal detection of the condition would have been beneficial in less than 20% of patients presenting postnatally with posterior urethral valves.
Child↗
Re: Why renography can fail in the diagnosis of upper urinary tract obstruction.
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Humans↗
Current imaging of childhood urinary infections: prospective survey.
OBJECTIVES: To assess whether ultrasonography alone is adequate for routine screening of childhood urinary infection, whether clinical features determine the need for further investigations, and which investigations are most appropriate. DESIGN: Prospective survey of children with proved urinary infection and a preinvestigation record of clinical features. Ultrasonography and intravenous urography were routine, with choice of further studies determined by ultrasonographic findings. SETTING: A children's hospital and two district general hospitals in Mersey region. MAIN OUTCOME MEASURES: Sensitivity and specificity of ultrasonography both generally and in relation to clinical features. Accuracy of intravenous urography compared with radioisotope examinations. RESULTS: Specificity of ultrasonography was good (99% (95% confidence interval 96% to 100%)) but sensitivity modest (43% (32% to 55%)), principally with respect to detecting vesicoureteric reflux and renal scarring. Among older children (aged 2-10 years) with positive ultrasound results and fever or vomiting the sensitivity in detecting reflux (with and without renal scarring) was 78% (62% to 89%) and the specificity 69% (60% to 78%); in detecting renal scarring (with and without reflux) the sensitivity was 100% (80% to 100%) and specificity 65% (56% to 74%). Renal scarring and obstructive uropathies were better assessed by radioisotope examinations than by intravenous urography. CONCLUSIONS: Ultrasonography alone is inadequate for routine screening of childhood urinary infection. Though further investigations remain advisable in infants, in older children they can be restricted to a minority who have positive ultrasound examinations or have had fever or vomiting. Radioisotope examinations largely eliminate the need for intravenous urography.
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Multicystic renal dysplasia detected by prenatal ultrasonography. Natural history and results of conservative management.
In a review of 44 infants with multicystic renal dysplasia diagnosed prenatally by ultrasonography, contralateral anomalies, bilateral disease and other non-urinary congenital anomalies were rare. In approximately two-thirds of infants the lesion was impalpable and in 2 cases involution had occurred prenatally. All but 5 were managed conservatively and without complications, and partial or complete involution of the lesion occurred in more than 50% during follow-up. It was concluded that the natural history of this anomaly is usually benign and that conservative management is advisable.
Female↗
Current management of duplex-system ureteroceles: experience with 41 patients.
Experience is described of 41 infants and children with duplex-system ureteroceles, 25 presenting clinically and 16 by prenatal ultrasonography. Bladder outflow obstruction was rare but lower polar vesicoureteric reflux (VUR), usually of lesser grades, was common. Upper polar function, as assessed by 99mTc-DMSA, was negligible in children with truly ectopic ureteroceles but well preserved in those where the lesion lay wholly intravesically. Lower polar function was good, even in the presence of secondary obstruction, except in 2 infants with major VUR. Twenty-three patients were treated by upper polar nephrectomy plus aspiration of the ureterocele; 2 subsequently required ureterocele excision. Histology of excised specimens indicated that a more conservative approach would not have been rewarded. Where upper polar function was good, conservation was maintained in 3 cases by pyelopyelostomy and in 5 more by excision of the ureterocele plus bipolar ureteric reimplantation. Other operative strategies were employed in 2 cases. Finally, a defined group of 8 children was managed expectantly without untoward results. It was concluded that the variable anatomy and function associated with duplex-system ureteroceles require a flexibile approach to treatment, including, possibly, no treatment at all.
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Natural history of obstructed and pseudo-obstructed megaureters detected by prenatal ultrasonography.
In a series of 38 patients with non-refluxing megaureters detected by prenatal ultrasonography, 89% were males and 16% had associated ipsilateral or contralateral urinary anomalies. By renographic criteria, 36% of ureters were not obstructed; renal function was never impaired initially and, on follow-up, spontaneous resolution of dilatation was common. Infective urinary calculi developed in 3 of the boys. In ureters obstructed by renographic or pressure-perfusion criteria, 79% exhibited normal renal function initially. Most such patients were managed expectantly; on follow-up, functional deterioration occurred in 2 patients, while in the remainder dilatation usually persists but without change in function.
Child, Preschool↗
Incidence of normal micturition in myelomeningocele patients.
Among 108 consecutive patients with myelomeningocele aged 5-12 years initially treated by a selective policy, seven (6.5%) achieved spontaneous urinary continence, five with normal micturition and two with urgency. All had positive conus reflexes and incomplete cord lesions which, with one exception, comprised motor as well as sensory sacral sparing.
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Management of the incontinent child in general practice. The paediatric urologist's viewpoint.
Except for children with neurological disease or major structural anomalies, the burden of managing childhood urinary incontinence in the UK falls predominantly upon general practitioners and local specialists. Because they see relatively few cases and have many other calls upon their attention, their postgraduate education on this topic must be succinct and basic; this article is based upon such advice. The organic causes of childhood urinary incontinence are discussed as also the clinical features and basic investigations (principally ultrasonography) which call attention to them. The various clinically recognisable patterns of functional voiding disorders are described with emphasis on the commonest, urge incontinence. Based on these considerations a scheme is recommended which aims to minimise necessity for secondary or tertiary referral, yet at the same time ensures that organic disease or severe functional voiding disorders are not overlooked.
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Detrusor hyper-reflexia as a factor in spontaneous perforation of augmentation cystoplasty for neuropathic bladder.
In a series of 30 children undergoing cystoplasty for neuropathic bladder, 14 had a combination of a competent sphincteric mechanism and detrusor hyper-reflexia. All 3 cases of spontaneous perforation of the augmentation occurred within this latter group and it is postulated that excessive intravesical pressure due to high pressure hyper-reflexia was the causal factor. Strategies to reduce the risk of perforation are discussed.
Adolescent↗
Features of primary vesicoureteric reflux detected by prenatal sonography.
Primary vesicoureteric reflux (VUR) was detected by prenatal sonography in 34 infants (55 renal units); males accounted for 31 cases. Associated genitourinary anomalies were common, occurring in 29% of the patients. Some element of hydroureteronephrosis was noted at initial cystography in 89% of refluxing renal units, but the degree of renal abnormality at 99Tc DMSA renography was not predicted by the severity of VUR. Overall, 60% of refluxing renal units were renographically abnormal. Although a high rate of urinary infection was encountered during follow-up, most DMSA assessments were carried out prior to infection and hence likely reflect congenital rather than acquired abnormalities. It was concluded that renal impairment associated with high grade primary VUR is frequently present at birth and not secondary to subsequent infection.
Abnormalities, Multiple↗