This Month in Pediatric Urology

Article Outline

• Antibiotic Prophylaxis for the Prevention of Urinary Tract Infection
• Biofeedback Therapy and Home Pelvic Floor Exercises for Lower Urinary Tract Dysfunction
• Subclinical Varicocele
• Impact of Fellowship on Resident Training in Academic Pediatric Urology Practice
• Copyright

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Antibiotic Prophylaxis for the Prevention of Urinary Tract Infection 

Administration of prophylactic antibiotics in young children found to have vesicoureteral reflux after a urinary infection is widespread. However, the therapeutic benefit is not clearly justified by evidence based medicine. Roussey-Kesler et al (page 674) from France led a multi-institutional prospective French study investigating the effectiveness of prophylactic antibiotic therapy in children 1 month to 3 years old with grades I to III reflux. The 225 boys and girls with similar grades of reflux were equally randomized to receive prophylactic cotrimoxazole (103 patients) or observation (121) and followed for 18 months. The primary end point was infection-free completion of the study or a single urinary infection.

Urinary tract infections occurred in 18 (17.5%) children on prophylactic antibiotics versus 32 (26.2%) in the observed group, and this difference was not statistically significant. The incidence of urinary infections occurred in an increasing fashion from grade I to grade III, but again the difference was not statistical significant. Uncircumcised boys with grade III reflux did have a significantly higher risk for urinary infections compared to the observed group. The authors recognize their findings are limited by the fact that the study was not blinded, there was no placebo group and urine specimens were collected with a bag. They conclude that prophylactic antibiotics for young children with low grade reflux is of limited value except for uncircumcised boys with grade III reflux. Their data may support limitations on the need for imaging young girls with a voiding cystourethrogram.

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Biofeedback Therapy and Home Pelvic Floor Exercises for Lower Urinary Tract Dysfunction 

Lower urinary tract dysfunction (LUTD) manifested by detrusor overactivity, poor bladder compliance, nonrelaxing pelvic floor and bladder sphincter dyssynergia is common in boys with a history of a posterior urethral valve. These changes result in abnormal voiding and have the potential for inducing upper urinary tract deterioration. Ansari et al (page 708) from Lucknow, India report their experience on the effectiveness of biofeedback therapy and home pelvic floor exercise in 30 boys 4.5 to 12 years old with LUTD. Imaging in all boys confirmed effective valve ablation and no abnormal voiding patterns. Of the patients 25 (83%) had had at least 1 prior urinary infection, 18 (60%) had vesicoureteral reflux and 20 (67%) had post-void residual greater than 10% of cystometric bladder capacity. Intermittent catheterization was performed by 25 boys and 2 received alpha blockers. Previous anticholinergic medical therapy failed in all patients.

The boys underwent office biofeedback therapy learning to tense and relax pelvic floor muscles. Pelvic floor activity was monitored with surface electromyogram electrodes, and voiding was assessed for the type of voiding curve, voiding volume and post-void residual. The boys were instructed to continue pelvic floor exercises at school and at home, and returned weekly for office biofeedback reinforcement. Response in voiding dynamics was excellent in 3 (10%) patients and favorable in 18 (60%). Age was not a factor in improved bladder dynamics. Biofeedback did appear to be more effective in boys with a combination of detrusor overactivity, filling pressure less than 20 cm H₂O and cystometric bladder capacities greater than 60% expected for age. Of the 21 boys with a positive response 11 (52%) no longer require anticholinergic therapy and 15 (71%) no longer catheterize. The authors conclude that reeducating pelvic floor muscles using office biofeedback and home pelvic floor exercises for boys with a prior posterior urethral valve can provide relief of LUTD.

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Subclinical Varicocele 

Therapeutic intervention for prepubertal and pubertal boys with grade 2 or 3 varicocele remains problematic. More unsettling is the identification of grade 1 varicoceles noted incidentally when performing scrotal ultrasonography for other pathological conditions. Cervellione et al (page 717) from Manchester, UK studied 2,107 boys 10 to 16 years old in the providence of Verona, Italy. All boys were screened in a standing position with a physical examination and scrotal sonography. The presence of a varicocele was assessed according to the classification of Dubin and Amelar with the authors stratifying patients into prepubertal and pubertal levels of genital development. Of the 2,107 boys 246 (11.7%) were found to have a grade 2 or 3 varicocele and 354 (16.8%) had grade 1 varicocele. Grade 1 varicoceles in 36 boys followed prospectively for 4 years showed no change in 24, progressed to grade 2 or 3 in 10 and resolved in 2 at the end of the study. One boy with progression had documented testicular hypotrophy. The authors conclude that a major screening program for subclinical varicoceles may not be cost-effective. However, progression of subclinical grade 1 varicocele can occur, which should be considered when recommending followup.

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Impact of Fellowship on Resident Training in Academic Pediatric Urology Practice 

There is a long-held perception that subspecialty fellows detract from the operative and overall training experience of residents. In an attempt to determine the impact of fellows on general resident training, Duffy et al (page 720) from Nashville, Tennessee provide a comparative assessment of the operative experience of residents before and after initiation of the Accreditation Council for Graduate Medical Education Pediatric Fellowship Training Program. Recognizing limitations in the accuracy of case log documentation reported by postgraduate years 2 and 4 residents, the authors compared the number of index cases and total cases reported following 6 months of training. Index cases were based on the Accreditation Council for Graduate Medical Education subclassification for pediatric urology. In addition, in-service testing scores were compared to determine the impact on educational experience.

The authors found a statistically significant decrease in index cases related to hypospadias, pyeloplasty, renal surgery, ureteroneocystostomy and urinary diversion, with an increase in the number of hernias and hydroceles, after their fellowship training program was instituted. More importantly, resident performance in each category was still greater than the 50th percentile except for urinary diversion (30th to 50th percentiles), and exceeded the 90th percentile for inguinal surgery, hypospadias and total number of cases. There was no statistical difference in the in-service examination scores before and after fellowship implementation. The authors conclude that while the number of index cases for a specific category may be decreased when a fellow is present, overall the training program continues to expose residents to a high volume of pediatric urology providing a competent background for post-resident training practice.