Pediatric Urology Basics

CAKUT & Antenatal Hydronephrosis - Kidney Quirks & Womb Woes

• CAKUT (Congenital Anomalies of Kidney & Urinary Tract): Spectrum of structural malformations.
  • Common types: Ureteropelvic Junction Obstruction (UPJO), Vesicoureteral Reflux (VUR), Posterior Urethral Valves (PUV), Multicystic Dysplastic Kidney (MCDK).
• Antenatal Hydronephrosis (ANH): Dilation of fetal renal collecting system (pelvis AP diameter >4mm <28wks, >7mm ≥28wks).
  • SFU Grading: Grades 1-4 assess severity.
  • Causes: Transient (most common), UPJO, VUR, PUV, MCDK.
  • Postnatal Evaluation: Ultrasound (USG) initial. Further: Voiding Cystourethrogram (VCUG), renal scan (DTPA/MAG3).
  • Management: Observation, prophylactic antibiotics (VUR), or surgical correction for obstruction.

⭐ Most common cause of neonatal hydronephrosis is transient hydronephrosis, followed by UPJ obstruction.

Postnatal ANH Management Flow:

Obstructive Uropathies - Plumbing Problems Pronto

• Posterior Urethral Valves (PUV):

  • Embryology: Wolffian duct remnant.
  • Diagnosis: Antenatal USG ('keyhole' sign); postnatal VCUG (gold standard).
  • Management: Endoscopic valve ablation.

  ⭐ Posterior Urethral Valves (PUV) are the most common cause of bladder outlet obstruction in male neonates.

• Ureteropelvic Junction Obstruction (UPJO):

  • Causes: Intrinsic (aperistaltic segment) or extrinsic (crossing vessels).
  • Symptoms: Antenatal hydronephrosis, flank pain, UTI.
  • Diagnosis: USG, diuretic renography (MAG3/DTPA). Surgery if symptomatic / DRF < 40%.
  • Management: Anderson-Hynes pyeloplasty.

• Ureterovesical Junction Obstruction (UVJO):
  • Types: Primary (congenital) or secondary.
  • Leads to megaureter (ureter > 7mm).
  • Management: Ureteral reimplantation if symptomatic or ↓ renal function.

VUR & Pediatric UTIs - Reflux Ruckus & Bug Battles

• VUR (Vesicoureteral Reflux): Retrograde urine flow (bladder → kidney).
  • Primary: Congenital UVJ incompetence. Secondary: ↑ Bladder pressure (e.g., PUV).
  • Grading: International Reflux Study I-V.
  • Dx: Voiding Cystourethrogram (VCUG).

    ⭐ Voiding Cystourethrogram (VCUG) is the gold standard for diagnosing Vesicoureteral Reflux (VUR).

  • Complications: Recurrent UTIs, renal scarring, HTN.
• VUR Management:
  • Conservative: Continuous Antibiotic Prophylaxis (CAP) for Grades I-III / symptomatic.
  • Surgical: Breakthrough UTIs on CAP, new/worsening scars, persistent high-grade (IV/V) >1-2 yrs. Options: Deflux, ureteric reimplantation.
  • Flowchart:

• Pediatric UTIs:
  • Risks: VUR, obstruction, female, uncircumcised males <1yr.
  • Bugs: E. coli (most common), Klebsiella, Proteus.
  • Dx: Urine culture. Tx: Antibiotics.
  • Scarring: DMSA scan (4-6 months post-UTI). 📌 DMSA: Detects My Scarring Always.

Genital & Testicular Anomalies - Bits & Bobs Basics

• Hypospadias: Urethral meatus opens on ventral aspect of penis.
  • Classification: Glandular, coronal, penile, scrotal.
  • Associated: Chordee (ventral curvature), hooded prepuce (dorsal redundancy).
  • Repair: Surgical correction at 6-18 months; aims for normal voiding & cosmesis.
• Epispadias: Urethral meatus on dorsal aspect of penis; often associated with bladder exstrophy.
• Undescended Testis (UDT)/Cryptorchidism: Failure of testis to descend into scrotum.
  • Types: Palpable (approx. 80%), non-palpable (approx. 20%).
  • Complications: ↓Fertility, ↑Malignancy risk (seminoma 4-10x higher).
  • Management: Orchiopexy, ideally between 6-12 months of age.

> ⭐ The optimal timing for orchiopexy in Undescended Testis (UDT) is between **6 and 12 months** of age to maximize fertility potential and allow for early detection of malignancy.

• Testicular Torsion: Twisting of spermatic cord leading to vascular compromise; a urological emergency.
  • Neonatal: Extravaginal; often presents as a firm, painless scrotal mass.
  • Pubertal: Intravaginal; associated with 'bell clapper' deformity; acute onset of severe testicular pain.
  • Management: Urgent surgical exploration, detorsion, and bilateral orchiopexy.

High‑Yield Points - ⚡ Biggest Takeaways

• PUV: Commonest male neonatal bladder outlet obstruction; "keyhole" sign USG.
• VUR: VCUG for diagnosis & grading; risk of renal scarring.
• Hypospadias: Ventral meatus, chordee; no circumcision pre-repair.
• Cryptorchidism: ↑ risk malignancy/infertility; orchiopexy by 6-18 months.
• Wilms' Tumor: Commonest pediatric renal cancer; painless abdominal mass.
• UPJ Obstruction: Commonest cause antenatal hydronephrosis; pyeloplasty.
• Testicular Torsion: Surgical emergency; absent cremasteric reflex; immediate detorsion.