This Month in Pediatric Urology

Article Outline

• Flow Patterns of Healthy Male Newborns
• Buried Penis After Newborn Circumcision
• Natural Fill Urodynamics and Conventional Cystogram for Neurogenic Bladder
• The ALARA Concept and Serial Imaging Studies After Blunt Renal Trauma in Children
• Copyright

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Flow Patterns of Healthy Male Newborns 

Uroflowmetry is an effective noninvasive study to assess and follow the urinary flow patterns of children. However, uroflowmetry requires the child to void either sitting or standing into the flow meter, which limits usefulness of the study in nontoilet trained subjects. Olsen et al (page 1857) from Skejby, Denmark investigate the use of an ultrasound flow probe designed to measure arterial flow patterns to assess urinary flow in 23 healthy male newborns. The neonates were categorized as having one of several flow curves with 57% showing a bell shaped and 18% an interrupted curve. Dyscoordinated voiding was identified in 34% of the subjects. Arousal during the 4-hour study period was assessed by a visual analog scale and averaged 90%. The authors conclude that ultrasound flow probes can be used successfully to monitor the voiding pattern in newborns. Continued assessment of this cohort is planned to investigate dynamic changes of voiding that may occur with age. A successful noninvasive tool for evaluating voiding patterns could be beneficial when determining treatment outcomes for various disorders including posterior urethral valves, urethral strictures and hypospadias.

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Buried Penis After Newborn Circumcision 

A disproportionate amount of clinic time can be spent counseling families regarding the appearance of the penis following circumcision. Often parents are uncomfortable with the lack of a protruding phallus and demand a revision of the circumcision to limit the potential of a poor self-image as the child ages. Eroğlu et al (page 1841) from Istanbul, Turkey followed the progress of 88 infants who had undergone neonatal circumcision and were subsequently diagnosed with a buried penis within 6 months. Followup at ages less than 1 year (16% of patients), 1 to 3 years (67%) and greater than 3 years (17%) revealed a buried penis in 100%, 32% and 7%, respectively. Regardless of the etiology of the buried penis, the authors recommend a conservative approach in the asymptomatic child until after age 3 years. While clearly some children will benefit from release of a buried penis, the authors do provide support for conservative management, particularly for the child with a substantial suprapubic and inguinal fat pad.

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Natural Fill Urodynamics and Conventional Cystogram for Neurogenic Bladder 

Urodynamic assessment in neonates and infants has an important role in the proactive management of neurogenic bladder dysfunction. It is recognized that conventional cystometrogram analysis fills the bladder artificially and may impact diagnostic assessment. Jorgensen et al (page 1862) from Skejby, Denmark evaluated the differences between natural fill urodynamics and conventional cystometrograms in 11 male and 8 female infants with the diagnosis of neurogenic bladder. Both studies were assessed through suprapubic catheters placed 24 hours before testing. Natural fill urodynamics testing was performed in a 24-hour period and conventional cystometrogram was performed at a filling rate of 10% of the estimated bladder capacity. In infants who voided spontaneously the cystometric bladder capacity was larger than the average voided volumes seen with natural filling. A discrepancy between overactive contractions was also noted with natural fill urodynamics appearing more sensitive to overactive contractions. The authors appreciate that natural fill urodynamics has the added burden of being invasive, time-consuming and more expensive than conventional cystometrograms but believe that valuable information can be obtained in a more sensitive fashion, particularly in regard to overactive contractions. It must also be appreciated that the larger bladder capacity determined by the cystometrogram may not be consistently seen in the natural environment. The authors conclude that while natural fill urodynamics can provide more sensitive information, this may not be enough to mandate routine use. This report brings to light that regardless of the technique used, multiple variables exist which influence the results and, therefore, maintaining internal consistency from one test to the next is likely more important than the specific technique used.

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The ALARA Concept and Serial Imaging Studies After Blunt Renal Trauma in Children 

Technological advancements in computerized tomography have resulted in a rapid and precise diagnostic tool that provides detailed pathological information particularly in a trauma situation. However it is recognized that the required ionizing radiation exposes the young child to the potential of malignant risks during their lifespan. Therefore, most pediatric radiologists are adopting the ALARA (as low as reasonably achievable) principle when imaging children. Using that philosophy, Eeg et al (page 1834) from Toronto, Ontario, Canada evaluated whether the loss of precise imaging when using ultrasonography as a followup study would unfavorably impact the acute care of children who have had blunt renal trauma. They identified 73 children with a mean age of 10.4 years of whom 31% had high grade renal lesions of which 45% sustained complications. Intervention was required in 6 of 10 children. Low grade lesions were documented in 69% and only 1 child required intervention. The authors report that they were able to evaluate 74% of patients with high grade injury after the initial imaging using only ultrasonography and encountered no clinically important missed injuries or complications. They salvaged 96% of the kidneys using this conservative approach. They noted that low grade injuries rarely required intervention which places in question the need for any followup imaging for those lesions unless clinical symptoms change. The authors recommend reserving followup computerized tomography for cases in which a rapid precise answer is required due to a change in clinical stability or when the renal sonogram inconclusively directs further management. They conclude that ultrasonography can be performed as surveillance in the acute management of pediatric blunt renal trauma. It is important that all urologists are aware of the ALARA philosophy.